Authors of the recent publication [1] need to be commended for documenting the experience of management of severe acute malnutrition (SAM) in public sector. Low mortality or high survival at discharge from Nutrition Rehabilitation Centers (NRCs) is noteworthy. Equally important is the documentation of social determinants of SAM which is considered to be a bio-psycho-social-disorder [2].

This paper reports that nearly two-third children having complicated SAM were discharged without recovery [1]. Organic causes like tuberculosis can lead to development of SAM and using IMNCI protocols (as stated in the paper) for detecting presence or absence of tuberculosis is a major flaw in NRC protocols. All children with SAM should be screened appropriately (or be referred) for detecting organic causes, especially when they do not have expected recovery in NRC. Since this paper [1] also had an objective of informing future design and implementation of program for care of children with SAM, the readers also expect comments on the strategies other than community based programs to use ready-to-use-therapeutic food (RUTF). This becomes more important in view of a recent Cochrane systematic review [3] which did not found enough evidence favouring RUTF over standard diets. Indian Academy of Pediatrics also recommended RUTF only for a limited time period (4-8 weeks) until child recovers from SAM [4]. Several strategies need to be implemented simultaneously to tackle this bio-psycho-social-disorder (i.e. SAM).

It is surprising to find that a small trial [5] on 70 study subjects comparing liquid and solid RUTF has been referenced as global evidence on effectiveness of RUTF in supporting catch-up growth. The ‘survival 6 months after discharge’ from NRC is likely to be a better program performance indicator as it incorporates the care both during NRC stay and in community. NRC protocols should incorporate this or other similar performance indicators.

1. Singh K, Badgaiyan, Ranjan A, Dixit HO, Kaushik A, Kushwaha KP, et al. Management of children with severe acute malnutrition: experience of nutrition rehabilitation center in Uttar Pradesh, India. Indian Pediatr. 2014; 51:21-5.

2. Elizabeth KE. Nutrition rehabilitation centers and locally prepared therapeutic food in the management of severe acute malnutrition. Pediatrician’s perspective. Indian Pediatr. 2014;51:19-20.

3. Schoonees A,　Lombard M,　Musekiwa A,　Nel E,　Volmink J. Ready-to-use therapeutic food for home-based treatment of severe acute malnutrition in children from six months to five years of age. Cochrane Database Syst Rev.　2013;6: CD009000.

4. Sachdev HPS, Kapil U, Sheila Vir S. Consensus Statement: National Consensus Workshop on Management of SAM Children through Medical Nutrition Therapy. Indian Pediatr. 2010;47:661-5.