It is hard to find studies regarding catch up growth during rehabilitation from hospitals in India due to centrality of curative medical care, which takes most of the time of the doctors. In addition, there is also heavy workload on the hospital staff and standardized weighing scales are not available in many hospitals. As a result, infrastructure for documentation of catch up growth in nutrition rehabilitation with various diets (due to diverse food habits across the country) is lacking.

We therefore examined the catch up growth in children suffering from severe malnutrition using energy dense local foods.

The study was carried out at Niloufer Hospital, Hyderabad where National Institute of Nutrition manages a nutrition ward to provide nutrition support to the children who suffer from severe mal-nutrition. Severely undernourished children who get admitted to the hospital for various reasons are referred to the nutrition ward by the clinicians attending to these patients after the initial treatment. This includes necessary investigations, treatment of infections, correction of electrolyte imbalance, and administration of broad-spectrum antibiotics and this is carried out at other wards. The usual practice is to provide potassium chloride if the child has symptoms suggestive of hypokalemia. This initial phase of treatment usually requires a week and thereafter a child is transferred to the nutrition ward for nutrition rehabilitation.

Criteria for admission to the nutrition ward is presence of severe wasting (weight for height Z [WHZ]score <-3) or nutritional edema or risk of severe wasting due to faulty feeding practices(2). Once transferred to the ward, the child is examined and necessary investigations including Mantoux test, hemoglobin estimation, chest X-ray etc are carried out. Routine massive vitamin A administration is done and iron is withheld for the first week as per the WHO guidelines(1). Nursing staff is available round the clock for supervised feeding. Broad spectrum antibiotics are administered to the children who have not received antibiotics in other wards.

The diet provided to the children follows the WHO recommendations regarding calories and proteins. However, it is modified to include the local foods so that it is possible for families to maintain it at home. This diet has been derived based on previous studies by National Institute of Nutrition at this centre(3). The child is initially put on a maintenance diet of about 100 kcal/kg/day, which is slowly increased up to 170-220 kcal/kg/day. A typical diet of a child weighing 7kg consists of 350ml of milk (fortified with oil to increase the energy density), 250g of khichdi (rice and dhal in 2:1 ratio with added oil), 1-2 slices of bread, 2 eggs and a banana, which provides around 170 to 200 kcal/kg/day and 3 to 4 grams of protein/kg/day. Micronutrients are provided in the form of multivitamin-multimineral syrups containing zinc sulphate, nicotinamide, thiamine hydrochloride, riboflavin, pyridoxine, copper sulphate, potassium iodide, selenium, cyanocobalamin, Vitamin A, cholecalciferol and calcium. Folic acid is given regularly but iron is withheld during the initial phase of rehabilitation. Iron supplementation is started once the child starts gaining weight. Children are fed every 2 hours initially and once appetite improves, they are fed ad libitum. Foods consumed by the children were recorded in a sub sample of 80 children who participated in another study(4).

Rate of weight gain was also calculated for the entire period of hospital stay (rate of weight gain for the entire duration of the hospital stay).

Weight for height Z (WHZ) score, weight for age Z (WAZ) score and height for age Z (HAZ) score were calculated at the beginning of each week using WHO anthro (v2.0.4) software. Height was assumed to be the same in all the weeks, as catch up growth in height in the first few weeks of rehabilitation is usually not seen.

All analyses were performed with the statistical package for social science (SPSS) statistical software for windows, 11 (SPSS Inc. USA). Mean and SD were calculated for continuous variables and frequencies were calculated for categorical variables. One-way ANOVA with Scheffe’s post-hoc tests for more than two groups and student’s t test for two groups were calculated to see significant differences. Simple regression analyses were used to assess the association of baseline WHZ score with the rate of weight gain for the entire duration of the hospital stay. Significance was tested at <0.05 level.

Children admitted for nutrition rehabilitation belonged to the lowest socioeconomic strata of the society. A total of 309 consecutive records were available for analysis. Out of these, 15 children were readmitted to the ward. However, this number is likely to be an underestimate of the true relapse rate, as children may not get admitted to the same hospital or may not have been referred to the nutrition ward from other wards.

Information on few variables was missing in the records in some cases and available numbers are mentioned in parentheses in tables. Mean age of the children was 25 months (range 2-60 months). Baseline HAZ, WAZ and WHZ scores were –3.8 (range -11.1 to 1.1), -4.8 (range -8.1 to 1.0), and –4.1 (range -8.1 to –1.2), respectively. Among them, 53% were boys, 18% had edema and 20% had severe anemia (hemoglobin<7g/dL). The calorie and protein intakes calculated in a sub sample during nutrition rehabilitation were (mean ± SD) 178 ± 54 kcal/kg/day and 4.1 ± 1.9 g/kg/day, respectively.

TABLE I



Weight Gain (g/kg/day) in Malnourished Children

Table I depicts the general characteristics and rate of weight gain (g/kg/day) in children with and without edema. Overall, the mean rate of weight gain calculated for the total duration of the hospital stay in the entire sample was 5g/kg/day. Eight percent of the children did not gain weight, 44% of the children had poor catch up growth (<5g/kg/day), 35% of the children had moderate catch up growth (5-10g/kg/day) and 12% had rapid catch-up growth (>10g/kd/day). Mean rate of weight gain in each week appeared to decrease with increasing age (Table II), but the difference was not statistically significant.

TABLE II



Weight Gain (g/kg/d) in Each Week in Relation to Baseline 

Most of the children had 1-2 days of fever during admission and about 10-12% children had diarrhea. Longer duration of fever worsened the rate of weight gain in each week. Similarly, higher morbidity score was associated with lower rate of weight gain.

In simple linear regression analysis with rate of weight gain for the total duration of the hospital stay as dependent variable and baseline WHZ score on day 1 as an independent variable, baseline WHZ score was significant determinant (P<0.001) of weight gain explaining 12 % of the variation in total weight gain (Fig. 1).

Fig. 1 Linear regression plot with (weight for height Z) WHZ score as independent variable and total weight gain (wgt) as dependent variable in children without edema.

The study provides a database on catch up growth in weight during nutrition rehabilitation of severely undernourished children when treated with energy dense local foods. The mean rate of weight gain at our center was 5g/kg/day (Table 1). Despite staying in the ward for 5 weeks, mean WHZ scores of 40% of children were <-3 due to severity of baseline wasting and moderate rates of catch up growth. Rapid catch up growth of >10g/kg/day in hospital-based rehabilitation was seen in centers from Jamaica and Bangladesh(5-7). Studies reporting catch up growth during hospital based nutrition rehabilitation in India are not available for comparison.

WHO recommends caloric intake of 170-220 kcal/kg/day for rapid catch up growth during nutrition rehabilitation. The mean calorie and protein intakes at the ward calculated in a sub sample of children were about 180 kcal/kg/day and 4 g/kg/day, respectively, which may be considered adequate. Zinc was found to be a limiting factor despite high calorie diets in a study from Bangladesh(8). However, zinc and other micronutrients are routinely supplemented at our center. Milk based diets were found to be superior to plant based diets for catch up growth(9,10) and regenerating serum albumin(11,12). The diet at our center can be considered as a mixed diet with average milk intakes of about 350mL per day (range 50mL to 850mL). Rapid catch growth was possible with local staples consisting of meat, fish, vegetables and palm oil in a study from Nigeria(13). With the advent of ready to use therapeutic food (RUTF), much more rapid catch up growth (15g/kg/day) was observed as compared to the WHO recommended milk based diet (F-100) in a therapeutic feeding center in Senegal(14).

Although the calorie-protein intakes of the children at our center appear to be adequate, the intakes of potassium and magnesium may be inadequate. WHO guidelines advocate supplemental potassium and magnesium for at least 2 weeks for all severely malnourished children. At our center, these supplements were provided when the child had clinical symptoms suggestive of hypokalemia. These supplements were not provided routinely at the ward because magnesium is not commonly available as an oral supplement, and the children received a variety of foods which were rich sources of potassium and magnesium. However, the intakes of potassium and magnesium in these children were less than the WHO recommendation and this may have contributed to the low rates of weight gain. Better adherence to the WHO guidelines may help improving the rate of weight gain during nutrition rehabilitation of severely malnourished children.

The high prevalence of fever and presence of other morbidities is not entirely unexpected, as mal-nourished children are susceptible to infections due to poor immune status(15-17). Therefore, despite efforts to prevent infections, the morbidities such as fever were high. In this study, weight gain was 7g/kg/day when there was no morbidity, which was 40 % higher than the average weight gain of 5g/kg/day.

Apart from the caloric intake, the severity of wasting is known to influence the rate of weight gain(18). Interestingly in the regression plot of our study, weight gain decelerated to zero when the child’s baseline WHZ score approached the median (Fig. 1). With increasing age, there was a decrease in weight gain though statistically not significant. But such pattern is expected since growth rates are much higher in the first two years of life compared to the next three years.

All the limitations of a retrospective study are applicable to this study but since our center is a research unit, the staff is well trained and experienced and records are well maintained. Moreover, as this study included data collected for 5 years, sample size was large and it was possible to carry out sub-group analyses.

Management of severely undernourished children as per the WHO guidelines aims at achieving weight gain of >10g/kg/day and it needs to be examined whether a better adherence to WHO guidelines would improve the rate of weight gain.

Dr B Sesikeran, Director, National Institute of Nutrition, Hyderabad, India for administrative support, and Ms Pramodini, Ms Rajkumari and other nurses for preserving the records.

Contributors: All the authors conceived and designed the study. RSM analyzed the data and wrote the paper. BK, KVR and VS guided data analysis and interpretation of data, and helped editing the paper. All the authors were involved in providing clinical care to the children involved in the study. All the authors approved the final manuscript.

Funding: None.

Competing interests: None stated.