Indian Pediatr 2010;47: 651-653
Management of Children with Severe Acute
Malnutrition: A National Priority
Umesh Kapil and HPS Sachdev*
From Department of Public Health Nutrition, All India
Institute of Medical Sciences, New Delhi 110 029; and *Department of
Pediatrics and Clinical Epidemiology, Sitaram Bhartia Institute of Science
and Research, B-16, Qutab Institutional Area,
New Delhi 110 016, India.
Correspondence to: Dr Umesh Kapil, Professor Public
Health Nutrition, All India Institute of Medical Sciences, Ansari Nagar,
New Delhi 110 029, India.
Severe acute malnutrition (SAM) among
children below five years of age remains a major embarrassment, and
impediment to optimal human capital development in India. The World Health
Organization (WHO) and United Nations Children’s Fund proposed diagnostic
criteria for severe acute malnutrition in children aged 6 to 60 months
include any of the following: (i) weight for height below –3
standard deviation (SD or Z scores) of the median WHO growth reference
(2006); (ii) visible severe wasting; (iii) presence of
bipedal edema; and (iv) mid upper arm circumference below 115
mm(1). The Indian Academy of Pediatrics recommended diagnostic criteria
(2007), adapted from the earlier WHO guidelines, are weight for
height/length below 70% or
of NCHS median and/or visible severe wasting and/or bipedal edema; mid
upper arm circumference criteria may also be used for identifying severe
Estimates from the most recent Nationally
representative survey indicate that 6.4% of children below 60 months of
age have weight for height below –3 SD(3). In the current Indian
population of 1100 million, there would be about 132 million under five
children (~12% of population), of which 6.4% or roughly 8 million can be
assumed to be suffering from SAM. This colossal burden creates suspicion
whether the anthropometric cut-off, primarily based on African experience,
should be lowered in our setting. However, evidence suggests that this
definition is not inappropriate.
Eight data sets from low-income countries (Ghana,
Guinea Bissau, Senegal, the Philippines, Nepal, Pakistan, India, and
Bangladesh) were used for analysis of disease risks associated with
childhood undernutrition(4). The risk of death increased with descending
SD scores for wasting (weight for height) and quite steeply so below -3SD.
In SAM children, confounder adjusted odds ratio for overall mortality were
9.4 (95% confidence interval 5.3, 16.8); the corresponding estimates for
death due to diarrhea, pneumonia and measles were 6.3 (2.7, 14.7), 8.7
(4.8, 15.6), and 6.0 (4.3, 8.2), respectively. The number of global deaths
and Disability Adjusted Life Years (DALYs) in children less than 5 years
old attributed to stunting, severe wasting, and intra-uterine growth
restriction constituted the largest percentage of any risk factor in this
age group(4). SAM was responsible for 0.45 million deaths and 6% of DALYs
for children younger than 5 years. The disease burden attributable to
stunting, severe wasting, and intrauterine growth restriction together was
the highest in south-central Asia, where India alone had 0.6 million
deaths and 24.6 million DALYs attributable to these conditions. In
addition to these mortality and disease burden considerations, other
factors supporting the choice of weight for height below -3SD for defining
SAM include(1): (i) in a well-nourished population there are
virtually no children below -3 SD (<1%); (ii) these children have a
higher weight gain when receiving a therapeutic diet compared to other
diets, which results in faster recovery; and (iii) there are no
known risks or negative effects associated with therapeutic feeding of
these children, applying recommended protocols and appropriate therapeutic
Urgent Action is Warranted
India weathered the recent global fiscal crisis
impressively and is relentlessly marching forward on the economic and
development fronts. However, these economic gains have not translated into
substantial nutritional benefits, which is acutely embarrassing and
disconcerting. Protecting lives and promoting optimum development of
undernourished children is a human rights issue that can no longer be
swept under the carpet. Considering the serious biological consequences,
particularly the extremely high risk of mortality, it is unethical to
delay institution of urgent measures for prevention and treatment of SAM.
The Millennium Development Goal targets of under-five mortality also
cannot be achieved without according a high priority to treatment of SAM
children. Finally, optimally treated survivors of SAM recover without any
residual sequelae and can achieve their full genetic potential; thus the
likely returns on this intervention are immense.
There is considerable unanimity about the urgent
necessity of instituting public health interventions for tackling the
menace of SAM. Also, there is little debate about the need to urgently
universalize, further refine, and research the local adaptation(2) of the
WHO recommended inpatient management for SAM(5), which has been shown to
reduce mortality. According to the current recommendations, SAM children
should ideally be treated in a facility. Considering the burden of SAM and
the availability of hospital beds, this is not operationally feasible;
thus community- or home-based management is an unavoidable alternative for
a proportion of these subjects(6). However, philosophical differences are
evident regarding the choice of interventions to be adopted in the
community. One view favors the sole adoption of the preventive and
promotive aspects (ensuring basic nutrition and health care for all
infants and children, especially promotion of breast feeding and
appropriate complementary feeding) with no special emphasis on active
detection and nutritional therapy of SAM children. There is some merit in
arguments that emphasis on the latter process will: (i) present an
opportunity for commercialization of malnutrition through multi-national
companies’ product based nutrition therapy, (ii) erode progress in
efforts to address the underlying determinants of SAM, and (iii)
only result in transient alleviation, as the inevitable return to deprived
environments will cause a relapse.
In this context, we cannot ignore historical lessons
from the success story of diarrhea management in developing countries. A
major reduction in diarrhea related morbidity and mortality is ascribed to
the successful treatment of acute episode in the community through Oral
Rehydration Solution and continued feeding. Inaction based on arguments
similar to those above could have prevented this success story.
Fortunately, institution and universalization of these therapeutic
measures did not await diarrheal disease control through preventive and
promotive interventions including breast feeding; water, sanitation and
hygiene measures; and health education. We firmly believe that public
health interventions for SAM must simultaneously focus on preventive and
promotive aspects, and therapeutic interventions in the community. The
Consensus Statement published in this issue(7) illustrates that all the
above mentioned legitimate concerns regarding active detection and
nutritional therapy of SAM children can be adequately addressed through
multiple mechanisms and safeguards.
A valid impediment to the urgent operationalisation of
community management of SAM is the paucity of local evidence, which
precludes clarity about the possible therapeutic protocols and their
practical implementation. Evidence related to other settings and cultures
(for example, Africa) cannot be directly translated and operationalized in
a diverse country like India. Some priority researchable issues in our
context include: (i) formulation and validation of criteria for
identifying the subgroup of subjects who can be safely managed in the
community; (ii) devising and testing practical algorithms for
community management within the ambit of ongoing public health programs
like the Integrated Child Development Services and Integrated Management
of Neonatal and Childhood Illnesses; (iii) assessing alternative
operational mechanisms and algorithms; (iv) comparing recovery and
compliance with protocols based on home available foods or other
indigenously manufactured medical nutrition therapy products constituted
on recommended nutritional principles(8,9); and (v)
biotechnological innovations to formulate locally acceptable, efficacious,
safe and cheap medical nutrition therapy products and mineral
There is unprecedented political and bureaucratic will
to address the national embarrassment of SAM, a silent life threatening
emergency. The national funding agencies and Indian scientists also
perceive the need for priortising this area for research. In this milieu,
arguments against product based nutritional therapy in community settings
should not obstruct urgent evidence creation to feed national policy. This
is the opportunate moment for all stakeholders to consciously bury their
individual differences and collectively make concerted efforts for
addressing a national calamity. We cannot succeed without active
contribution from each and every stakeholder.
Contributors: Both authors conceived and discussed
the content of the commentary. UK produced the first draft, which was
modified by mutual agreement. Both will act as joint guarantors.
Conflict of interest: None stated.
1. WHO Child Growth Standards and the Identification of
Severe Acute Malnutrition in Infants and Children. A Joint Statement by
the World Health Organization and the United Nations Children’s Fund,
2009. Available from http://www.who.int/nutrition/publications/severemalnutrition/9789241598163/en/index.html.
Accessed on June 15, 2010.
2. Bhatnagar S, Lodha R, Choudhury P, Sachdev HPS, Shah
N, Narayan S, et al. IAP Guidelines on Hospital Based Management of
Severely Malnourished Children (adapted from WHO guidelines). Indian
Pediatr 2007; 44: 443-461.
3. International Institute for Population Sciences.
National Family Health Survey 3, 2005-2006. Mumbai, India: International
Institute of Population Sciences, 2006.
4. Black RE, Allen LH, Bhutta ZA, de Onis M, Ezzati M,
Mathers C, et al. Maternal and child undernutrition: global and
regional exposures and health consequences. Lancet 2008; Published Online
January 17, 2008 DOI:10.1016/S0140-6736(07)61690-0.
5. Ashworth A, Khanum S, Jackson A, Schofield C.
Guidelines for the inpatient treatment of severely malnourished children.
Geneva: World Health Organization; 2003.
6. Gupta P, Shah D, Sachdev HPS, Kapil U.
Recommendations: National Workshop on Development of Guidelines for
Effective Home Based Care and Treatment of Children Suffering from Severe
Acute Malnutrition. Indian Pediatr 2006; 43: 131-139.
7. Sachdev HPS, Kapil U, Vir S. Consensus statement:
National Consensus Workshop on Management of SAM Children through Medical
Nutrition Therapy. Indian Pediatr 2010; 47: 661-665.
8. Kapil U. Ready to Use Therapeutic Food (RUTF) in the
management of severe acute malnutrition in India. Indian Pediatr 2009; 46:
9. Community-based management of severe acute
malnutrition. A Joint Statement by the World Health Organization, the
World Food Programme, the United Nations System Standing Committee on
Nutrition and the United Nations Children’s Fund, 2007. Available from
http://www.unicef.org/search/search.php? querystring=Management +of+Severe+Acute+Malnutrition&hits=&is
News=. Accessed on 16 January, 2010.