Malnutrition and Illness Management is a core objective of the creche initiative, as ensuring the health and well-being of young children is central to quality creche services. Regular monitoring of children’s growth and health helps us understand whether children are growing as expected and allows us to respond early when concerns arise.

As explained in the previous section, weight and height measurements of every enrolled child are collected at regular intervals. These measurements are entered into the Shishu Ghar Management Information System (MIS), which uses WHO growth standards Click here to assess each child’s nutritional status. Through these reports, we are able to identify early signs of growth faltering, wasting, underweight, and stunting.

Early identification is critical in the creche context, as it allows caregivers, supervisors, and program staff to take timely and appropriate action. This includes providing special nutrition care at the creche, informing and counselling parents, and facilitating referrals to health facilities or nutrition services when required. Follow-up actions are also tracked to ensure that children receive continuous care and their condition is monitored over time.

This section of the guidelines outlines the standard protocols for malnutrition and illness management for children enrolled in our creches. It provides clear guidance on identification, referral, follow-up, and documentation processes, enabling teams to respond systematically and consistently to children’s nutrition and health needs.

Growth Faltering

Any weight loss or poor weight gain in children below three years of age is not considered normal and requires immediate attention. Early childhood is a critical period for development, and even small changes in a child’s growth pattern can signal underlying nutritional health concerns.

Growth faltering should not be viewed as a programmatic burden or a failure of care. Instead, it must be understood as an early warning sign of nutritional insecurity, illness, or inadequate feeding and care practices. Identifying growth faltering at the earliest stage allows timely action, preventing children from slipping into moderate or severe malnutrition.

Timely identification followed by appropriate Special Nutrition Care (SNC) and necessary medical intervention can effectively arrest further nutritional decline and support recovery. Early response not only improves child health outcomes but also reduces the need for intensive interventions at later stages.

A child is considered to be experiencing growth faltering when there is a noticeable decline in weight compared to the previous month or stagnation, relative to the child’s age. For uniform assessment and accuracy, Weight-for-Age Z-scores, as per WHO Growth Standards, will be used to identify and monitor growth faltering among children.

Decision Tree - Growth Faltering

Role of Supervisors & Caregivers - Process Flow

For SNC protocols - Please click here

Underweight (Weight for Age)

Underweight children are at serious risk for illness and poor development. Creches provide daily access to these children, allowing us to detect low weight early through monthly monitoring and immediately intervene with extra nutrition (SNC) and medical intervention before the problem becomes severe. Early action at creche level saves lives and prevents the need for hospitalization.

Underweight means a child's weight is much lower than what is expected for their age. We measure this using Weight-for-Age Z-scores (WAZ), which compare each child's weight to the WHO standard for healthy children of the same age and sex. Underweight children have inadequate body reserves - not enough fat and muscle to fight illness, support growth, or fuel brain development. This makes them vulnerable to infections, delays their physical and mental development, and in severe cases, can be life-threatening.

Decision Tree - Underweight

Role of Caregivers & Supervisor - Process Flow

Wasting (Weight for Height)

Wasting or Acute malnutrition refers to a child being too thin for their height, usually due to recent lack of adequate food or illness. It is seen when a child’s weight is very low compared to their height, indicating rapid weight loss or failure to gain weight. Such children often appear visibly thin with loose skin folds. Wasting is a serious condition that needs immediate attention, as affected children are more vulnerable to infections and poor health outcomes. Early identification helps ensure timely nutritional support and medical care, preventing further deterioration and supporting recovery.

Visual Signs

• Very thin arms and legs
• Ribs clearly visible
• Loose, baggy skin
• Loss of muscle and fat
• Face may look thin and drawn

In wasting, the children are classified using Weight-for-Height Z-score (WHZ) based on WHO Child Growth Standards as follows:

Decision Tree - Wasting

Role of Supervisors & Caregivers - Process Flow

Multiple Nutritional Conditions

Children attending creches often present with overlapping nutritional conditions rather than a single, isolated diagnosis. For example, a child may simultaneously exhibit Severe Acute Malnutrition (SAM) and Growth Faltering Stage 2 (GF2) combined with Severe Underweight (SUW). When multiple nutritional conditions coexist, it is critical to prioritize treatment based on the most severe and life-threatening condition first.

The guiding principle is to always follow the protocol for the most severe condition present. This ensures that the child receives the most intensive level of care, monitoring, medical and nutritional intervention appropriate to their highest-risk condition.

The following table provides clear decision rules for determining which treatment protocol to follow based on the combination of conditions present in a child.

Once the Creche Supervisor identifies which protocol to follow using the table above, all aspects of care, including treatment intensity, monitoring frequency, home visit schedule, and referral pathways must follow that protocol exclusively. As the child improves and graduates from the severe condition, the Supervisor should reassess and determine if a lower-level protocol is still required for remaining conditions.

Regular reassessment is essential, as children may move between categories as they improve or, in some cases, deteriorate. Documentation of all nutritional assessments and category assignments must be maintained in the Shishu Ghar app to track progress over time and ensure appropriate protocol adjustments.

Linking with the Public Health System

Children identified with severe underweight and severe acute malnutrition require medical assessment and nutritional support. The public health system, through the Anganwadi Worker (AWW), Auxiliary Nurse Midwife (ANM), RBSK (Rashtriya Bal Swasthya Karyakram), Primary Health Centre (PHC), and Community Health Centre (CHC), provides essential medical services and supplementary nutrition programs designed specifically for malnourished children.

This section details out the systematic process for the Creche Supervisor to link severely malnourished children with appropriate government health services. The focus is on two priority categories: Severe Underweight (SUW) children and Severe Acute Malnutrition (SAM) children, as these conditions carry the highest risk of mortality and require immediate medical intervention alongside nutritional rehabilitation.

Follow up & Home Visit Protocols

This section details out the systematic follow-up mechanism for children who have been identified with malnutrition, acute medical emergencies and chronic medical conditions. The Creche Supervisor is solely responsible for conducting all follow-up activities to ensure continuity of care, treatment adherence, and recovery monitoring. This protocol applies to all children who have been sent home with treatment or admitted to hospital, as well as children diagnosed with various categories of malnutrition (GF1+, GF2, Zig Zag, SUW, SAM).

The Creche Supervisor initiates follow-up immediately after a child is referred for medical care. The follow-up pathway differs based on whether the child receives home management or requires hospitalization.

Pathway 1: Child Sent Home with Treatment (Home Management)

When a child is sent home with treatment for a chronic medical condition or mild illness, the Creche Supervisor ensures:

Immediate Actions (Within 24 Hours):

• Parents have received prescribed medicines from the health facility
• Parents understand the correct dosage, timing, and duration of medication
• A specific follow-up date is scheduled for consultation with the doctor
• Parents know when to contact the supervisor if the child shows any worsening symptoms

Step 1: Follow-Up During Home Care Period–The Creche Supervisor conducts home visits and maintains regular phone contact with parents to:

• Monitor if the child is improving
• Verify that treatment is being followed correctly
• Assess if the child or family needs any additional support (transportation, medicines, nutrition)
• Document the child's progress

Step 2: Before Child Returns to Creche–Before allowing the child to return to creche, the Creche Supervisor:

• Understands any special care needs the child may have at creche (rest periods, dietary restrictions, activity limitations)
• Confirms which medicines need to be administered at creche, including exact timing
• Plans additional monitoring protocols if needed for the specific condition
• Briefs creche caregivers on what signs or symptoms to watch for
• Ensures two consecutive weekly home visits have been completed before the child's return

Step 3: When Child Returns to Creche–Upon the child's return, the Creche Caregiver (under Supervisor's guidance):

• Monitors the child very closely during the first week back
• Administers medicines exactly as prescribed
• Watches for any recurring signs or symptoms
• Reports progress daily to the Creche Supervisor
• Informs parents daily about how the child is doing

Pathway 2: Child Admitted to Hospital (Hospital Care)

When a child requires hospitalization for an acute medical emergency or chronic condition, the Creche Supervisor provides intensive support:

During Hospitalization:

• Conducts daily phone checks with parents to monitor the child's condition
• Makes physical visits to the hospital every two days
• Coordinates with hospital staff to understand treatment plan and prognosis
• Informs the ANM and ASHA worker about the hospitalization
• Provides emotional and logistical support to the family
• Assists with discharge planning and ensures parents understand post-discharge care

Post-Discharge Follow-Up: The Creche Supervisor follows the same three-step process outlined in Pathway 1 (Home Management) once the child is discharged from hospital.

Homevisit Frequency

Different health conditions require varying intensities and durations of follow-up. The table below specifies home visit frequency, duration, and exit criteria for each condition category-