Archives of Disease in Childhood 1994; 71: 297-303

Community based, effective, low cost approach tothe treatment of severe malnutrition in ruralJamaica

Maria T Bredow, Alan A Jackson

AbstractModerate and severe malnutrition areendemic in much of the developing worldand in association with pockets of depri-vation in the developed world. The cost interms of individual and social develop-ment is high. The principles of effectivemanagement are clearly documented. Alow cost, community based treatmentprogramme for moderately and severelymalnourished children under 3 years ofage was established at a health centre inrural Jamaica. Children were followed upmonthly and defaulters were rigorouslyrecalled. Management consisted of care-fully delivered dietary advice, antibiotics,anthelminthics, and vitamin supple-ments. All children improved and theresponse of 36 children, who were treatedin the first year, showed an acceleratedweight gain, with catch-up growth and themaintenance of length gain. There was asignificant increase in the weight for age,at 1.9% per month over six months, whichexceeds the rate reported with food sup-plementation programmes and nutritionrehabilitation centres.(Arch Dis Child 1994; 71: 297-303)

Department ofCommunity ChildHealth, Bristol RoyalHospital for SickChildrenM T Bredow

Department ofHumanNutrition, UniversityofSouthampton,Bassett Crescent East,SouthamptonS016 7PXA A Jackson

Correspondence to:Professor Jackson.Accepted 1 July 1993

Over the years the approach to the manage-ment of severely malnourished children haschanged. The high mortality associated withhigh costs of hospital based treatment led to a

period when outpatient management in nutri-tion rehabilitation centres, matched with pre-ventive programmes, gained widespreadsupport.1-4 One consequence of this was theperception that severe malnutrition was

primarily caused by a simple shortage of foodand that the provision of adequate amounts offood, in the form of supplementationprogrammes, would resolve the problem.Nutritional rehabilitation centres were devel-oped for this purpose but had only limited suc-

cess.2-6 In part the indifferent outcome mighthave been because the provision of food alonefailed to acknowledge a wider range of socialand clinical problems. If all malnourishedchildren are managed in a similar way, insuffi-cient importance tends to be attached to thedifferent approaches best suited to childrenwith different degrees of severity.7 8 This shiftof focus, and the implication that the problemhad been solved as an issue of relevance toclinicians, resulted in a loss of interest in thedevelopment of more effective approaches tomanagement.9 Thus, although in 1981 the

World Health Organisation (WHO) hadpublished recommendations on The Treatmentand Management of Severe Protein-energyMalnutrition,'0 because the practical applica-tion of the advice failed to gain wide recogni-tion it was never critically evaluated in thefield.

In reviewing the situation, C Schofield andA Ashworth (personal communication) haveobserved that mortality rates have changedlittle over the past 40 years (case fatality ratesof at least 20 to 30%), despite increase inknowledge and understanding. They concludethat the high mortality from severe malnutri-tion among children in most areas of the worldcan be directly attributed to faulty case man-agement. As, in principle, the ability to managea child with severe malnutrition is identical tothe approach required for management insituations of famine, caused either by war ornatural disasters, and also the management ofdepleted patients with nutritional support inthe developed countries, there is a major causefor concern. The implications are that theinappropriate management is a reflection of ageneration of doctors who have been trainedwith an incorrect understanding of the diseaseprocess and a wrong approach to manage-ment.°0 All the evidence would suggest that thepractices most often adopted are unnecessarilyexpensive as well as being ineffective (CSchofield, A Ashworth, personal communica-tion). The lessons learnt over years ofexperience in the developing countries havenot been incorporated as an essential part ofmedical knowledge and understanding in thedeveloped countries.9The most successful treatment programmes

have been those in which regular follow up ofmalnourished children continues until fullrecovery has taken place and where goodsupervision of staff and patients is main-tained. 1 2 8 The establishment of such nutritionprogrammes linked to child health clinicsunder the guidance of well trained staff hasbeen frequently recommended." II

The author (MTB), having been trained inthe management of severe malnutrition in aspecialised centre, sought to reproduce theexperience in the setting of a normal ruralclinic, with the objective of identifying howfeasible it was to put into practice the recom-mendations in the WHO report. In this way itwas hoped to obtain a clearer understanding ofthe practicality of the approach recommended,the level of experience and skill needed by staffto run the programme and hence the level oftraining and supervision that would be needed

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Age (months)

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Age (months)

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Age (months) Age (months)Individual weight charts for 20 boys (A and B) and 16 girls (C and D) with malnutrition for each time of review afterregistration. The centiles are derivedfrom the NCHS reference data16 and the ranges for the Gomez classification (normal,I, II, and III) are shown (WIA =weightfor age).

for effective widespread implementation of therecommendations. The setting of the studywas a health clinic in rural central Jamaicaduring the late 1980s.

MethodsBACKGROUNDJamaica is a subtropical island with a popula-tion of 2-5 million. Malnutrition of somedegree is a persistent problem in preschoolchildren and, despite an overall fall in preva-lence with time, the pattern of improvement isnot even. There are localities in both urbanand rural areas where the prevalence is eitherconstant or increasing. Based on the classifi-cation of Gomez et al,12 the overall prevalenceof moderate to severe malnutrition in childrenunder 3 years of age has varied between 7%and 14%,51314 which is comparable with theprevalence in other countries in theCaribbean. 15The Balaclava Health Centre, in the parish

of St Elizabeth, is a rural clinic in the sugarcane plantations of central Jamaica. The clinicserved a population of over 14 000, of whom

just over 1000 were under 3 years of age. Adoctor provided clinical cover through an out-patient clinic twice a week, but most of theclinical work was undertaken by nurses andcommunity health aides (people selected fromthe community and trained with basic skills inidentification of clinical problems and healthpromotion).The progress of individual children was

followed with a 'growth chart', with weightbeing used as the main criterion. The nutri-tional status of each child was formally identi-fied according to the Gomez classification.'2 Inthis classification the 50th centile for weight istaken as the reference standard, that is, 100%'weight for age' (50th centile derived fromNational Center for Health Statistics (NCHS)data).16 The child's weight is determined as apercentage of the 50th centile with normalbeing >90%; Gomez grade I mild malnutri-tion, 75 to 89%; Gomez grade II moderatemalnutrition, 60 to 74%; and Gomez grade IIIsevere malnutrition, <60%. Children on the3rd centile using NCHS data are approxi-mately 80% weight for age, that is, withinGomez grade I (see figure). The annual report

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of the Department of Health showed that forSt Elizabeth in 1986, of all the children under3 years of age who were weighed at theBalaclava Health Centre, 66% were within thenormal range of weight for age and there were3% with severe malnutrition (Gomez gradeIII), 9%/o with moderate malnutrition (Gomezgrade II), and 22% with mild malnutrition(Gomez grade I).

DEVELOPMENT OF THE PROGRAMMEBefore the introduction of the programmethere was no defined plan in the clinic for themanagement of malnourished children. Largenumbers attended the clinic and not allchildren were weighed on every visit, especiallyif they appeared relatively well, thus stuntedchildren were sometimes overlooked. When amalnourished child was recognised, theapproach to management was to give generalnutritional advice and where appropriate toencourage breast feeding. Although medica-tion provided at the clinic was free or at anominal charge, the stocks were inadequateand the cost for purchasing at the privatepharmacy were prohibitively expensive. Therewas no system for detecting those children whodefaulted from follow up. In June 1987, aprogramme for managing children withmalnutrition was established at the BalaclavaHealth Centre, and was based on the manage-ment received by malnourished children at aspecialist nutrition unit (Tropical MetabolismResearch Unit, University of the West Indies,Jamaica) that was broadly in line with theWHO guidelines.'0From the start of the programme emphasis

was placed upon ensuring that all childrenunder 3 years of age should be weighed oneach visit to the clinic, and that the weightshould be plotted on a growth chart thatshowed the Gomez grades. All children wereweighed to the nearest 50 g. Those in Gomezgrades II and III and all children with nutri-tional oedema were considered malnourishedand were entered into the treatment protocol.They were recorded in a special register andtheir notes were marked so that childrenmaking unscheduled visits could be easilyidentified. The register was checked on aregular basis and any child who had defaultedfrom an appointment was recalled by letter ortelegram. The recumbent length of eachmalnourished child was measured to thenearest 0-5 cm. Where possible the weight andheight of the mother of each child was taken.Every malnourished child was seen by a doctoror nurse and a history and examination wereundertaken to look for underlying disease. Thechild was then started on the treatmentprotocol which entailed specific dietary advice,medication, and regular follow up until thechild reached 3 years of age.

TREATMENT PROTOCOL(1) Dietary adviceBreast feeding was encouraged and an energyand protein enriched diet, based upon dried

skimmed milk and either coconut oil ormargarine was prescribed. All the ingredientswere cheap and readily available in Jamaicaand the mothers were expected to use theirown resources to obtain them. The instruc-tions on how to make up the feed were basedupon two formulations: a maintenance formu-lation for the initial period of rehabilitation anda recovery formulation that would satisfy theneeds for catch up growth.7

Maintenance formulation (from first visit):140 ml/kg/day skimmed milk plus 30 g fat perlitre of milk or 140 ml/kg/day full cream milk.

Recovery formulation (for catch up growth):140 ml/kg/day skimmed milk plus 90 g fat perlitre.The mother was given simple but explicit

instructions. For example, a 10 kg child wasgiven 1-5 packs of milk powder (making 1-5litres) and four to five soup spoons ofmargarine (30 g/spoon) daily. This could betaken as a drink or made into porridge withcornmeal. Emphasis was placed on the import-ance of giving the child the special formulationas, in general, the family food would be oflower energy density. Therefore, if familyfood was to be offered, this should only be aftereach milk and fat meal, so as not to suppressthe appetite of the child for the high energyformulation.

For the first week the maintenance formula-tion was to be given, as this provided sufficientenergy (about 376 kJ (90 kcal)/kg/day) andprotein to facilitate the return of normalmetabolic function, without placing a meta-bolic stress on the system.7 During this timethe child became accustomed to regular feeds,infections were treated, and vitamin supple-ments enabled the replenishment of specificdeficiencies. An increase in appetite after aboutone week marked a general improvement in thechild's condition. The formulation of higherenergy (627 (150 kcal)/kg/day) and proteindensity was introduced at this time to facilitateincreased rates of weight gain.7 17

(2) MedicationThe milk and fat feeds were considered to bethe most important part of the management.Therefore, even if medications were notimmediately available, the child was startedon the dietary regimen. Medications wereprescribed as follows:

Antibiotics - Silent infections may be themajor reason for failure in response in anymalnourished individual.18 In Gomez grade IIany obvious infection was given appropriatetreatment. In Gomez grade III and any childwith oedema a broad spectrum antibiotic wasgiven, even if there was no clinically apparentinfection.

Anthelminthic - All children over 6 months ofage were given mebendazole 100 mg twicedaily for three days. (Piperazine was con-sidered to have a spectrum that was toonarrow.)

Small bowel colonisation - A high index ofsuspicion existed for the presence of smallbowel overgrowth and/or giardiasis and

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Table 1 Characterisation of36 undernourished children(20 boys and 16 girls), according to the Gomezclassification, at initial registration and at review after aperiod ofmanagement

No of children No of childrenGomez grade at registration at review

Normal 0 3I 1* 14II 24 15III 11 4Total 36 36

*This child had nutritional oedema.

therefore metronidazole 50 mg/kg/day wasgiven electively for five days.

Micronutrients - All children were presumedto require supplemental vitamins and a multi-vitamin preparation and folic acid were givendaily for one month.

Iron supplements - Excess iron can be damag-ing in malnutrition, but during catch upgrowth, reserves might become depleted.Therefore, iron (2 mg/kg/day) was given forone month once weight gain was established.At the front of each child's notes a tally was

maintained of which medications had beenreceived. In this way any medication that wasnot immediately available, at the time when thechild was registered, could be dispensed whenit came into stock. In those children whoremained in Gomez grade II or III malnutri-tion after six months, the course of medicationwas repeated, or in any child where the clinicalneed arose. All the children received acomplete course of immunisations and all themothers were given advice on contraception.

(3) Follow upChildren in Gomez grade II malnutrition wereseen one week after the initial registration andthen at monthly intervals if they were well.Children in Gomez grade III, those withnutritional oedema, and those who wereclinically ill were seen at least weekly at first,then monthly once improvement had becomeestablished. Children who were severely ill andthose who did not thrive on the protocol werereferred to hospital.When a child achieved Gomez grade I on the

high energy feed, a normal mixed diet wasintroduced. The guardian was encouraged tocontinue mixing some fat into the child's foodto prevent deterioration. The child continuedto be monitored at intervals of one to twomonths until 3 years of age. If any child showeddeterioration by dropping to Gomez grade II orIII malnutrition the programme was recom-menced. Beyond 3 years of age the childrenwere seen according to clinical need only anddefaulters were not sought specifically.

ResultsThe programme was reviewed at the end of thefirst year (June 1988). At that time there were45 children on the malnutrition register: 28boys and 17 girls. Children had entered theprogramme throughout the year and treatmentperiods ranged from less than one month to 12months. Four children had presented withnutritional oedema and in each case theoedema had resolved within two weeks of start-ing the programme. Only one child had beenreferred to hospital; this was a boy aged 4weeks who was Gomez grade II. He presentedwith fulminant meningitis and died in hospitaltwo days later. At the time of the review ninechildren, including the child with meningitis,had only made one visit to the clinic and there-fore were excluded from the analysis of thechanges in weight and height. All nine childrenwere Gomez grade II.

(1) WEIGHT AND WEIGHT FOR AGEAll 36 malnourished children (20 boys, 16girls), who attended the clinic more than once,gained weight. The individual growth chartsare shown in the figure and it is obvious thatfor the most part there was catch-up in weight.Table 1 shows the overall changes in theGomez grade. On average, weight hadincreased by 2-03 kg over a period of 5-6months. It is not easy to determine the rele-vance of these values, because it is normal forchildren to gain weight. If the change isexpressed as weight for age, however, thennone of the children deteriorated, threeremained at the same weight for age, while 33showed an improved weight for age, henceaccelerated weight gain. The mean increase inweight for age of about 11% over 5-6 monthswas significant (p<0.01, Student's t test)(table 2). There was no evidence that theenhanced rate of weight gain was slowingdown as the 10 children who had been in theprogramme for over eight months were stillimproving over the last four months (1 -6% permonth, 033 kg/month) compared with thefirst four months of their treatment (1l. 3% permonth, 0 30 kg/month).

Comparing the sexes, there was no signifi-cant differences in age of presentation, severityat presentation or response to treatment asdetermined by weight gain (table 2). However,if Gomez grades were compared, the childrenin Gomez grade III were much younger(mean 8-7 months) than those less severelymalnourished in Gomez grade II (mean 16-3)months) (table 3). The severely malnourishedchildren showed a mean increase in weight forage of 15.3%, almost twice that of the moder-ately malnourished children (8-9%) over the

Table 2 Changes in the age, weight, and weightfor age of36 malnourished children (20 boys and 16 girls) betweeninitial registration and review. Values are means (SD)

At registration At review ChangeBoys Girls Total Boys Girls Total Boys Girls Total

Age (months) 13-5 (6 3) 14-6 (9-5) 14-0 (8 0) 19-2 (6 9) 20-1 (10) 19-6 (8-4) 5-8 5-5 5-6Weight (kg) 6-2 (1-8) 6-2 (2 5) 6-2 (2-1) 8-3 (2 2) 8-2 (1-8) 8-2 (2 0) 2-1 2-0 2-03Weight forage (%) 61 (10) 64 (12) 62 (11) 71 (12) 75 (7-0) 73 (10) 10 6 10-8 10-7

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Table 3 Changes in the age, weight, and weightfor age of36 children (20 boys and 16 girls) with malnutrition betweenregistration and review in relation to the ornginal severity of disease based upon the Gomez classification, 25 children wereoriginally Gomez I and II, and 11 children were originally Gomez III. Values are mean (SD)

At registration At review Change

Gomez Gomez Originally Originally Originally OriginallyI and II III Gomez I and II Gomez III Gomez I and II Gotnez III

Age (months) 16-3 (7-3) 8-7 (6-5) 21-8 (7 3) 14-6 (9-0) 5-5 5-8Weight (kg) 7-2 (1-5) 3-9 (1-5) 9-1 (1-5) 6-3 (1-6) 1-9 2-4Weight for age (%) 68 (4.5) 48 (7) 77 (8) 64 (9) 8-8 15-3

same period. This difference was significant(p<0-01).Most of the children attended the clinic at

least monthly. Of a total of 201 clinic visits,only 23 were at intervals beyond two monthsfrom the previous appointment, and only twowere longer than three months. There was agood response from the defaulters to the letteror telegram that was sent as a reminder. Meanweight gain per month during absences ofmore than two months (281 g/month) wassignificantly less than that during visits amonth or less apart (641 g/month, p<001).

(2) RECUMBENT LENGTHAt registration all but four of the 36 childrenshowed evidence of stunting and 10 wereseverely stunted according to the Waterlowcriteria (Waterlow, 1973; relative to the NCHS50th centile height reference: 95 to 90%, mildstunting; 89 to 85%, moderate stunting;<85%, severe stunting). The mean height forage was 87% (range 74-98%). The dataenabled assessment on the change in length of16 children (nine boys and seven girls, table 4).There was a significant increase in length overthe period of follow up, which was about thatwhich would have been expected for childrengrowing normally, with no evidence of catch-up in length. Hence, the group as a wholeremained moderately stunted with length forage about 88%. This meant that the increasein weight over the same period of timerepresented an increase in weight for lengthand therefore a significant decrease in thedegree of wasting.19

(3) MATERNAL WEIGHT AND HEIGHTThe mean (SD) height of 21 mothers was 159(7.1) cm and their weight was 51-4 (6-6) kg(they had an average body mass index (BMI)of about 20 3). The mean value lies close to the25th centile for adult females in the NCHSreference data.16

Table 4 Changes in age, recumbent length, length for age,weight, weightfor length (calculated as a percentage of theexpectedfor the actual height of the child based upon theNCHS reference data'6), and weightfor age in 16 children(nine boys and seven girls) between registration and review.Values are mean (SD)

At registration At review Change

Age (months) 13-1 (7-2) 17-3 (8-2) 4-2Length (cm) 66-6 (10-3) 70 3 (10-2) 3-7**Length for ageQ/%) 89-5 (5 3) 87-9 (5-1) -0-6Weight (kg) 6-1 (2-0) 7-5 (2-2) 1-3**Weight for age (/) 63 (11) 69 (10) 6*Weight for length (%) 83 (11) 89 (7) 6*

By Student's t test: *p<0.05, **p<0.01.

DiscussionMalnutrition occurs in environments that aredeprived materially and in terms of the avail-able services. Therefore, it is important todetermine the minimum level of resourcewhich is required to create and sustain aservice that can effectively manage the dis-order. It has been shown that intervention inthe form of food supplementation can exert asignificant effect, and in carefully designedstudies significant improvements in stuntingand mental function can be achieved duringthe first six months of a supplementationprogramme.20 21 Similarly, the relative benefitof each element of the clinical intervention hasbeen carefully assessed, with the experience ofa metabolic ward being translated into apreventive programme22-24; therefore, weknow what to do. What has not happened withany formality has been an assessment of howthese approaches can be effectively integratedinto standard care for severely malnourishedchildren in the community, in a way thatensures that the beneficial effect is protectedwithout great additional cost. The extent towhich the health and other services have failedto adequately address the problem isemphasised by recent international meetings ofthe International Dietary Energy ConsultativeGroup of the United Nations (I/D/E/C/G, inpreparation) and Medicins Sans Frontieres.25There is a misperception that simple, effectiveapproaches are not available, or that theapproaches that work may be too complex andexpensive to be applied in the context of aroutine clinic in a village health centre.Therefore, the objective of the present studywas to explore the extent to which recom-mended practice is realistic and feasible as anintegral part of the standard clinic care offeredin a rural community without any specialresource or facilities.The nutrition programme that was devel-

oped was run by the regular staff of a ruralhealth centre with no extra funding andwithout the provision or distribution of foodsupplements of any kind. Emphasis was placedupon the mother's own understanding of whatwas needed for the child and the provision toher of adequate support in the form of adviceand guidance when problems arose. The effec-tiveness of the approach can be assessed by theoutcome.When improvement is measured in terms of

catch-up growth, the results for gain in lengthand weight, or gain in weight relative to length,compare very favourably against otherprogrammes in the Caribbean and CentralAmerican region and elsewhere.2 7 The aver-age gain in weight for age that was achieved

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was 10-7% over 5 6 months (1 ./9% per month),which compares with results reported for nutri-tion rehabilitation centres in Haiti andGuatemala of less than I1% per month oversimilar periods.2 A community based supple-mentation programme in Trinidad achieved anincrease of 4 5% in 3 9 months (1-1% permonth).6 In Tanzania, children treated inhospital for malnutrition were followed up inthe community through an integrated primarycare programme, without any food supplemen-tation. A year or more after discharge fromhospital the mean gain in weight for age was8.7%.4As in general paediatric practice, it is

important to recognise early children at risk of,or suffering from, malnutrition. Youngerchildren have a higher mortality26 and tend tobe more severely malnourished, but they alsoshow a greater potential for recovery.2 26 27 Inthese respects the children of Balaclava wereno different, the severest children were theyoungest, yet the response in terms of weightgain was the greatest (table 5). In general thechildren tended to be younger than describedin other studies2 4 6 and basing the programmeat a primary care clinic contributed to enablingopportunistic recognition and treatment earlierthan can be achieved at a referral centre. Theclinic facilities could also be used to good effectin maintaining contact with the children forfollow up. Those children who were not seen atthe clinic for several months tended to dopoorly and did not gain much weight. Beghinand Viteri evaluated the effectiveness ofnutrition rehabilitation centres and firmlyemphasised the need for effective supervisionand follow up.3 Frequent supervision has beenshown to result in a faster rate of recovery.6Mothers are likely to need encouragement tocontinue to follow the clinic advice and theyneed to have their problems addressed in atimely fashion. Further, the factors associatedwith missed clinic appointments might inthemselves be directly related to poorer weightgain: the illness of a mother or child, change ofguardian, shortage of money, or distrust ofmedical treatment.

Stunting is the most widely prevalent formof malnutrition and is most directly associatedwith long term functional impairment.21 28 Itis more resistant to correction in the shortterm than wasting, and it is far from clear howit can best be corrected in the longer term.29For children treated for severe malnutrition inhospital it appears that improvement in lengthor height tends not to take place until therehas been substantial improvement in wasting.Therefore, the observation that the childrenwere able to maintain a normal rate of lengthgain at the same time as wasting was beingcorrected, is potentially very important. Atthis age children in developing countrieswould be expected to be falling behind inlength,29 and therefore the ability to maintainlength growth is a significant observation. Itsuggests that the quality of recovery with suit-able management in the community is at leastas good as for hospitalised children and insome respects might even be superior. The

anthropometry of the mothers shows that theytended to be short and they had a BMI at thelower end of the normal range. Thesemothers, therefore, had a lifetime of marginalnutrition and the state of food currently avail-able in the households probably only borderedon the adequate. The fact that they couldidentify the resource to treat their childrenappropriately when they were properly guidedand advised, would argue that the problem layin the delivery of health care of an appropriatequality, rather than poverty or lack of healthresource being the primary determinant.Given the opportunity, they did what wasrequired and did it well.The intervention was of course not without

cost of any kind. The programme representedan increase in workload for the staff:

(1) Increased administration: setting up theregister, writing in the follow up appointments,checking the register on a regular basis for non-attenders, writing letters/telegrams to non-attenders.

(2) More frequent attendance at clinic bymalnourished children than previously.

(3) Increased weighing and measuring of allchildren. The community health aides found itparticularly time consuming to measure therecumbent length at every visit and for thisreason some of the records were incomplete.

It is perhaps important to appreciate thatsome of this extra effort was associated withthe setting up of the system and the specialneeds of the study itself. In the longer term, asthe problems are identified and handled at anearlier stage, one would expect the load tolighten. There is probably little benefit inmeasuring length at every visit, and a less fre-quent measurement, such as every threemonths, would probably be adequate.

In financial terms, the extra costs for theclinic were those related to extra work, thecosts of the medications, the costs of thetransport, and the costs of the feed. The extrawork was funded largely by goodwill; successbreeds encouragement and enthusiasm. At thetime of the review the medication cost US$14per child for every six months of treatment.The costs of transport fell on the mother andwere variable, whereas the milk and fat for thefeed came to about US$2 per child per week.These costs are not insubstantial for themothers and not all could afford to spend eventhis amount on a single child on a regular basis.This undoubtedly contributed to the slow andchequered progress of some of the children,but the mothers can take full credit for theexcellent progress that did take place.Without the need to distribute supplements

to all the children on a regular basis, the smallsupplies of food that were occasionally avail-able at the clinic could be given selectively tothose families who were most in need. Therewas no question that the progress of the pro-gramme might be endangered, or have to stop,for lack of supplements. In general the mothersaccepted the programme very well. The major-ity kept to their appointments and appreciatedthe regular interest that was shown in thewelfare of their children.

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ConclusionThe results of this programme clearly showthat it is possible to treat even severelymalnourished children successfully in the com-munity and that this can be achieved through a

low cost, simple, but specific programme

organised by the regular staff of a rural healthcentre. The nutritional self reliance of themother can be maintained by avoiding hand-outs of supplements, while generating a

positive attitude to long term surveillance byboth the staff and the parents. This is con-

sidered to be a fundamental requirement forthe success to be sustained. The malnutritionregister was of critical importance to ensure

that those children at particular risk could befollowed up, even when they defaulted. Asthose who were not seen for several months didnot do well, the setting up, and maintaining ofthe register is considered essential. A pro-

gramme of this kind depends upon the good-will and long term cooperation of the clinicstaff: they have to know what to do, how to doit, and to be motivated to do it well. Theirsupervision and encouragement should be a

very high priority for a senior nurse or a doctor.This senior person should have responsibilityand enthusiasm for the programme as a whole.

The contributions of all members of staff at the BalaclavaHealth Centre are gratefully acknowledged.

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3 Beghin ID, Viteri FE. Nutritional rehabilitation centres: anevaluation of their performance. Trop Pediatr 1973; 19:404-16.

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