Menu ENN Search

Sensory stimulation and play therapy: A tool to combat severe wasting in India?

View this article as a pdf

Nisha Kamble is an Occupational Therapist working with the State Centre of Excellence in Paediatric Nutrition at the B.J. Wadia Hospital for Children, Mumbai.

Radhika Mathur is a Paediatrician and Senior Project Medical and Research Officer working at the State Centre of Excellence in Paediatric Nutrition at the B.J. Wadia Hospital for Children in Mumbai.

Vrushabh Gavali is a Consultant Paediatric Neurologist working in the Department of Paediatric Neurology at B.J. Wadia Hospital for Children, Mumbai.

Sanjay Prabhu is a Senior Paediatric Consultant in charge of the State Centre of Excellence in Paediatric Nutrition at the B.J. Wadia Hospital for Children, Mumbai.

Bhaskar Krishnamurthy is an Assistant Professor in the Department of Clinical Pharmacology at Seth GSMC and KEM Hospital, Mumbai.

Minnie Bodhanwala is the Chief Executive Officer of the Wadia Group of Hospitals

Background

Across the globe, an estimated 45.4 million children under the age of five are affected by wasting (UNICEF/WHO/World Bank, 2021). Those children suffering from severe wasting are at an exceptionally high risk of poor growth outcomes and are also thought to be at a high risk of motor and cognitive delays as brain development is further inhibited with increasing severity of malnutrition (Prado & Dewey, 2014). Children are particularly vulnerable to malnutrition in their first two years of life when growth velocity and brain development are especially high.

As per the World Health Organization (WHO) guidelines (WHO, 2013), the management of complicated severe wasting in inpatient settings is divided into three phases: stabilisation, transition and rehabilitation. Once children with severe wasting have recovered their appetite and have been treated for medical complications, they enter the rehabilitation phase which aims to promote rapid weight gain, stimulate emotional and physical development and prepare the child for normal feeding at home. Following those recommendations, Indian healthcare guidelines include the provision of sensory stimulation and play therapy as detailed in Step Nine of the inpatient treatment of children with severe wasting (Government of India, 2011).

Sensory stimulation and play therapy for children with severe wasting

Sensory stimulation integrates various ways to promote expressive behaviours. It helps babies and children to learn and reach developmental milestones through the activation of one or more of our five senses: seeing, hearing, touching, tasting and smelling.

Play therapy is an interactive method used to interact with children. This model includes developmental play capacities (cognitive, physical and social play skills) and individual play styles (internal control, freedom to suspend reality and intrinsic motivation). Play reflects the child’s cognitive, motor, language and social skills. Physical play helps the children to refine locomotion, hand-eye coordination and manipulation skills (Cooper, 2000). Play therapy is used to achieve optimal arousal and to develop cognitive and social skills (Gardner et al, 1999).

According to Kerac et al (2010), there is a lack of data on the current practice of the basic WHO recommendations for play and stimulation activities for children with severe wasting at hospitals and healthcare centres and there is need to better document the feasibility of conducting sensory stimulation and play therapy. A few, more recent studies have begun to document the subject.

A study in Ethiopia found that, for children with severe wasting, sensory stimulation and play therapy enhances the improvement of gross motor functions when combined with standard nutrient-rich diets but it can enhance these gross motor functions even when such standard dietary care is not available (Abessa et al, 2019). Hence, family-based sensory stimulation and play therapy in a low-income setting have the potential to improve the development, linear growth and nutritional outcomes in children with severe wasting.

In Malawi, the provision of a four-day programme of counselling and psychosocial stimulation to primary caregivers and their children who were hospitalised with severe wasting did not result in improved developmental or nutrition outcomes, likely due to the programme's short duration. Other studies of psychosocial stimulation interventions for children with severe wasting, which showed positive effects on child development, were more rigorous and continued beyond discharge from inpatient care. (Daniel et al, 2021).

Our study

To understand the developmental outcomes resulting from sensory stimulation and play therapy in patients with severe wasting, we conducted a short-term observational study at the Nutritional Rehabilitation Centre (NRC) at Bai Jerbai Wadia Hospital for Children, an urban tertiary paediatric care centre in Mumbai. This article aims to share our results with the hope that our learnings will inform other practitioners and, in turn, benefit children from high-burden countries.

The NRC at Bai Jerbai Wadia Hospital for Children is a referral site for a large catchment area surrounding the city of Mumbai with an increased population density of lower- and lower middle-income groups which contributes to relatively high numbers of child admissions with severe wasting. This study was conducted to understand the developmental outcomes after sensory stimulation and play therapy in various developmental domains in patients with severe wasting admitted to the NRC and to identify any difference between children with co-morbidities as compared to those without co-morbidities. Being a tertiary care centre, many of our patients have co-morbid conditions such as cerebral palsy, congenital cardiac defects, chronic respiratory illness or abnormal anatomical conditions such as a cleft lip/palate which can affect overall improvement in neurodevelopmental outcomes after play therapy. Moreover, there is no literature available that differentiates the developmental outcomes between these two groups. We excluded children with congenital deformities, uncontrolled epilepsy and a history of recent surgery as it was not possible to provide interventions to those children at the time.

After the stabilisation phase, the children were assessed by the occupational therapist and given sensory stimulation in conjunction with structured play therapy. The Vineland Social Maturity Scale (VSMS) was used to assess the initial developmental parameters in five domains, namely: gross motor, fine motor, language (expressive and receptive), socio-emotional and cognition. VSMS is a scale used to measure the adaptive abilities, or social competence, in a purposeful manner in various social settings in each domain. It therefore assesses the child’s ability to adapt to various social challenges which in turn is termed social adaptive behaviour. Social adaptive behaviour is measured in the form of social age in the various domains in VSMS. The social quotient in each domain can then be calculated by representing the social age as a proportion of the chronological age. The scoring is often interpreted as 90-100% being normal, 80-90% as low-normal and less than 80% as inadequate.

A minimum of 10 play sessions each lasting 40 minutes were held in the presence of the caregiver in the playroom only, or both in the playroom and the playground, depending on the age and health status of the child. By attending play sessions, the parents were actively included and were encouraged to continue these activities at home after discharge. Children were reassessed using VSMS post-intervention.

Our observations

Out of 86 admissions in the NRC from January 2020 to March 2021, 50 patients (58.1%) aged between one month and five years were recruited for sensory stimulation and structured play therapy. Amongst those admitted, we excluded children with deformities, uncontrolled epilepsy and a history of recent surgery.

There were 12 patients enrolled in the study who had co-morbidities and 38 who did not have co-morbidities. The developmental outcomes were summarised in terms of pre- and post-intervention social age. Statistical significance was set at p < 0.05.

Table 1: Paired t-test comparing social age pre and post intervention

Domain

Pre intervention

Mean ± SD

Post intervention Mean ± SD

Difference (Change)

t value

p value

Gross motor

61.33 ± 27.23

69.78 ± 26.08

-8.45 ± 16.94

-3.526

0.001*

Fine motor

65.90 ± 26.39

71.28 ±25.73

-5.38 ± 13.79

-2.760

0.008*

Language

64.44 ± 29.78

68.16 ± 27.10

-3.71 ± 18.87

-1.391

0.170

Social

59.53 ± 26.72

75.64 ± 23.69

-16.11 ± 20.66

-5.517

< 0.001*

Cognition

19.38 ± 22.67

19.64 ± 19.49

0.26 ± 24.00

-0.076

0.939

n=50

* indicates a statistically significant difference

There was a significant difference in gross motor, fine motor and social development pre- and post-intervention which indicates that the intervention was successful.

When comparing the changes of social quotient observed between the two groups (children with co-morbidities and those without co-morbidities), we observed no statistically significant difference in any of the domains (Table 2). There was no difference in the milestone improvement, post-intervention, between children with pre-existing co-morbidities and those without.

Table 2: Comparison of the change in social quotient pre- and post-intervention for children with co-morbidities and those without co-morbidities

Domain

With co-morbidity

(n=12)

 

Mean ± standard deviation

Without co-morbidity

(n=38)

 

Mean ± standard deviation

p-value

Gross motor

7.78 ± 7.85

8.66 ± 19.02

0.818

Fine motor

9.63 ± 9.66

4.04 ± 14.71

0.139

Language

5.48 ± 9.19

3.16 ± 21.10

0.594

Social

10.49 ± 9.58

17.90 ± 22.90

0.117

Cognition

0.49 ± 1.96

0.19 ± 27.60

0.970

Discussion

In this experience, we observed that children treated for severe wasting benefited from the sensory stimulation and play therapy that was provided in addition to the nutrition rehabilitation in the gross motor, fine motor and social domains, Similar findings were seen in a pilot study conducted across 10 NRCs in India where it was concluded that sensory stimulation and play therapy are an integral part of the management of inpatient severe wasting and that maternal involvement in play therapy is crucial (Kumar et al, 2021). This benefit was independent of the presence or absence of co-morbidities.

Currently, the treatment of severe wasting in the NRC is primarily to provide medical nutrition therapy. The inability to provide sensory stimulation and play therapy has been a neglected aspect of the holistic management of severe wasting. Children who are wasted also suffer from delays in motor and cognitive milestones so a focus on this area of development appears to be warranted in order for all children to thrive and achieve their potential. After the stabilisation phase, there is a window of opportunity to provide sensory stimulation and to involve the child in play activities which may in turn make their stay in the NRC an enriching experience. Although not explored in this study, there may be particular benefit for children who are wasted and have nutritional oedema who otherwise tend to remain either withdrawn or are irritable.

In our NRC, we have a dedicated occupational therapist who offers this service to all patients admitted for treatment. As per the WHO recommendation, and based on our experience, we strongly advise regular sensory stimulation and play therapy for a severely wasted child by either an occupational therapist or a health care worker who is trained by an occupational therapist to provide the same at each nutrition centre. The approximate cost for the equipment, which includes toys, games, etc., would be around USD500 (£420) per centre which does not have an occupational therapy department or a linked District Early Intervention Centre (DEIC). However, if the latter is available then the cost would further reduce to around £85 which can be considered value for money.

Nevertheless, we identified certain challenges during our implementation of this intervention including a lack of maternal motivation and determination as well as the occasional lack of family support. This leads to a discontinuation of continued stimulation at home after discharge. We were able to gather this information based on regular post discharge follow-ups and reviews which were initially maintained weekly followed by bi-monthly.

Further to this, we do understand that home-based management of uncomplicated severe wasting is important and for that reason it is important to have a strong home-based Early Child Development component as well (Kumar et al, 2021).

The main limitation of this study was that there was no control group in this setting. Due to the standards of care recommended by the WHO, it would be unethical to deprive any patient of the therapy so the inclusion of such a control group was unfeasible. Without a control, it is difficult to determine whether the positive impacts were attributed to the intervention alone, hence a strong recommendation for introducing sensory stimulation and play therapy cannot be made at this point despite these promising findings.

Conclusion

The results of our study suggest that receiving sensory stimulation and play therapy benefits children who have severe wasting, especially in the gross motor, fine motor and socio-emotional domains. The presence or absence of co-morbidity did not affect the outcome which indicates that sensory stimulation is as beneficial when children have co-morbidities as when they do not.

Based on both our clinical experience and these findings, we believe that sensory stimulation should preferably be included in all NRCs via occupational therapists, trained health care workers or linkage to DEIC. The components of this therapy should also be integrated in the follow-up programme and carried out by frontline health workers. Stating this, we also think that more research should be conducted across multiple centres in various countries to develop concrete guidelines for this promising intervention.

For more information, please contact Radhika Mathur at dr.radhikamathursharma@gmail.com

 

References

Abessa T, Worku B, Wondafrash M et al (2019) Effect of play-based family-centered psychomotor/psychosocial stimulation on the development of severely acutely malnourished children under six in a low-income setting: a randomized controlled trial. BMC Pediatrics, 19, 1, 336.

Cooper, R (2000) The impact of child abuse on children’s play: a conceptual model. Occupational Therapy International, 7, 4, 259-276.

Daniel A, van den Heuvel M, Voskuijl W et al (2017) The Kusamala Program for primary caregivers of children 6–59 months of age hospitalized with severe acute malnutrition in Malawi: study protocol for a cluster-randomized controlled trial. Trials, 18, 550.

Daniel A, Bwanali M, Tenthani J et al (2021) A Mixed-Methods Cluster-Randomized Controlled Trial of a Hospital-Based Psychosocial Stimulation and Counseling Program for Caregivers and Children with Severe Acute Malnutrition. Current Developments in Nutrition, 5, 8.

Gardner J, Grantham-McGregor S, Himes J et al (1999) Behaviour and development of stunted and nonstunted Jamaican children. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 40, 5, 819–827.

Government of India (2011) Operational Guidelines on Facility-based Management of Children with Severe Acute Malnutrition. Ministry of Health and Family welfare; Government of India. http://rajswasthya.nic.in/MTC%20Guideline-%20MOHFW.pdf

Kerac M, Mcgrath M, Grijalva–Eternod C et al (2010) Management of Acute Malnutrition in Infants (MAMI) Project Technical Review: Current evidence, policies, practices & programme outcomes.

Kumar P, Rohatgi S, Singh P et al (2021) Strengthening Psychosocial Stimulation in the Management of children with Severe Acute Malnutrition: Experience from a Nutritional Rehabilitation Centre. Indian Pediatrics, S42-S45.

Prado E and Dewey K (2014) Nutrition and brain development in early life. Nutrition Reviews, 72, 4, 267–284.

UNICEF/WHO/World Bank (2021) Levels and trends in child malnutrition: key findings of the 2021 edition of the joint child malnutrition estimates. Geneva: World Health Organization.

WHO (2013) Guideline: Updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization.

More like this

FEX: Editorial

View this article as a pdf Dear readers, A warm welcome to the 68th edition of Field Exchange. As we bring you this edition, the world is facing a series of challenges:...

FEX: Emotional Stimulation for acutely and severely malnourished children in SNNPR

By Dr. Alessandro Conticini and Mrs. Valérie Quéré Dr. Alessandro Conticini joined Play Therapy Africa as Co-Director after having headed the Child Protection, Adolescent...

FEX: Integration of management of children with severe acute malnutrition in paediatric inpatient facilities in India

View this article as a pdf Lisez cet article en français ici By Praveen Kumar, Virendra Kumar, Sila Deb, Arpita Pal, Keya Chatterjee, Rajesh Kumar Sinha and Sanjay...

FEX: Mental Health among Children in Severe Food Shortage Situations

A paper on the 'Mental Health and Psychosocial Well-Being among Children in Severe Food Shortage Situations' has been prepared in a WHO inter-departmental collaboration. Food...

FEX: Role of nutrition in integrated early child development

Research Location: Global What we know already: Early child development (ECD) is a key predictor of future social capital and national productivity. Worldwide, 250 million...

FEX: Generalised Oedema in COVID-19 Positive Children - A Case Series

View this article as a pdf Experiences on COVID-19 and nutrition captured to date in Field Exchange have been at a programme level rather than at individual case management...

FEX: Scalable integrated early child development programme using a conditional cash transfer programme in Colombia

Summary of research1 Location: Colombia What we know: Poverty and the associated poor nutrition and lack of psychosocial stimulation are associated with poor child...

FEX: Nutritional rehabilitation of infants < 6 months with severe acute malnutrition

Summary of published research1 Location: India What we know: There is a significant burden of acute malnutrition in infants under 6 months of age in nutritionally vulnerable...

FEX: Development of a maternal service package for mothers of children with severe acute malnutrition admitted to nutrition rehabilitation centres in India

View this article as a pdf Lisez cet article en français ici By Vani Sethi, Praveen Kumar and Arjan De Wagt Vani Sethi PhD is a public health nutritionist in the...

FEX: Managing at risk mothers and infants under six months in India – no time to waste

View this article as a pdf Lisez cet article en français ici By Praveen Kumar, Sila Deb, Arjan de Wagt, Piyush Gupta, Nita Bhandari, Neha Sareen and Satinder...

FEX: Sally Mugabe Children’s Hospital: A Snapshot

View this article as a pdf This article offers insight into the provision of inpatient treatment of complicated wasting at the Sally Mugabe Children's Hospital,...

Resource: Emotional Stimulation in the Context of Emergency Food Interventions, Final Report, Addis Ababa, August 2009

Play Therapy Africa embarked in the mission of designing an effective methodology for the delivery of emotional stimulation easy to be adopted during emergency food crisis,...

FEX: Supporting healthy growth in infants in low-resource settings in Mumbai, India

View this article as a pdf Lisez cet article en français ici By Rupal Dalal, Shruthi Iyer, Marian Abraham and Lahari Yaddanapudi Rupal Dalal MD FAAP IBCLC is a...

FEX: Nutrition and brain development in early life

Summary of review1 Location: Global What we know: It is likely that nutrition deficiency during pregnancy and early childhood affects individual cognition, behaviour, long...

FEX: The Paediatric Development Clinic: A model to improve medical, nutritional and developmental outcomes for high-risk children aged under-five in rural Rwanda

By Kathryn Beck, Catherine M Kirk, Jessica Bradford, Christine Mutaganzwa, Evrard Nahimana and Olivier Bigirumwami View this article as a pdf Kathryn Beck is the Nutrition...

FEX: Mortality and causes of mortality in children 6-59 months of age admitted to inpatient therapeutic feeding centres in Niger

By Florence Tapié de Céleyran, Kerstin Hanson, Cecilia Ferreyra, Nuria Salse, Didier Tshialala, Cristian Casademont, Rebecca Grais and Helena Huerga View this...

FEX: Continuity of information in nutrition interventions in India: Experiences from Jharkhand

View this article as a pdf Lisez cet article en français ici By Ipsha Chaand Ipsha Chaand is pursuing a PhD at the Centre of Social Medicine and Community Health,...

FEX: Community management of acute malnutrition in Rajasthan, India

View this article as a pdf Lisez cet article en français ici By Daya Krishna Mangal and Shobana Sivaraman Daya Krishan Mangal is Professor and Dean of Research at the...

FEX: NRC shelter programme in Lebanon

By the Norwegian Refugee Council, Lebanon and Jordan This article represents the combined efforts of many members of the NRC teams both in Lebanon and Jordan. The arrival of...

FEX: Community-based management of severe malnutrition: SAM and SUW in children under five in the Melghat tribal area, central India

By Dr Vibhavari Dani, Dr Ashish Satav, Mrs Jayashri Pendharkar, Dr Kavita Satav, Dr Ajay Sadanshiv, Dr Ambadas S Adhav and Dr Bharat S Thakare Dr. Vibhavari Dani is a...

Close

Reference this page

Nisha Kamble, Radhika Mathur, Vrushabh Gavali, Sanjay Prabhu, Bhaskar Krishnamurthy and Minnie Bodhanwala (). Sensory stimulation and play therapy: A tool to combat severe wasting in India?. Field Exchange 68 , November 2022. p10. www.ennonline.net/sensorystimulationandplaytherapycombatseverewastinginindia

(ENN_7462)

Close

Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.