In the recent past, there has been a welcome,
if late, development of interest in technical issues related to the
management of malnutrition, especially through public programs such
as the National Rural Health Mission (NRHM) and the Integrated Child
Development Services (ICDS)1.
However, management of severe malnutrition continues to be a huge
gap area in public policy in the country. Apart from issues related
to actual implementation such as poor coverage and quality of care,
there are significant programmatic gaps and confusions that are
confounding efforts to tackle severe malnutrition effectively as a
public health problem as well as treatment of individual children.
This is specially exacerbated by the inconsistencies between the
approaches of the two primary agencies (ICDS and NRHM) leading to
considerable lack of clarity on the ground on criteria for screening
and identification, treatment protocols, and the role of different
agencies for these activities as well as for rehabilitation and
follow up.
The focus of the interventions under the NRHM has
primarily been on the treatment of Severe Acute Malnutrition (SAM)
through Nutrition Rehabilitation Centers (NRCs). According to the
WHO, Severe Acute Malnutrition (SAM) is defined by a very low weight
for height (below –3Z scores of the median WHO growth
standards), by visible severe wasting, or by the presence of
nutritional edema [1]. SAM children have a mortality risk that is
substantially higher than that of normally nourished children2.
The median under-five case-fatality rate for SAM typically ranges
from 30% to 50% [2]. NFHS 3 data for India shows that 6.4% children
under five years of age have a weight-for-height Z-score
(WHZ) which is less than -3SD i.e. about 8 million children in India
are at any time severely acutely malnourished.
Traditionally, within India and internationally,
SAM has been treated in institutional (hospital-based) settings with
the use of therapeutic foods using the F-100 formula. Until recent
interventions by some health departments, there was no special,
large-scale public program for the identification and management of
SAM in India. Under the NRHM, different states have now set up
Nutrition Rehabilitation Centers (NRCs) for treatment of SAM [3].
Although there are no central guidelines for the management of SAM,
the broad programmatic interventions being adopted in most states
are more or less similar and throw up many issues for discussion.
The ICDS, through the anganwadi centers and
anganwadi workers (AWWs) is currently responsible for regular growth
monitoring of all children under six, identification of children who
are malnourished and to also provide follow up care (including
referrals). In states/districts where there is an NRC program, the
AWW is supposed to refer children who are severely underweight as
per WHO standards for weight for age, to the NRC.
Once the child is referred to the NRC, he/she is
screened for SAM by weight for height/length, MUAC and presence of
edema. Those children referred by the AWW who fit the entry criteria
(i.e. are SAM) are admitted into the NRC. The rest are sent
back, occasionally with treatment for any current illness, but
little more. Further, analysis of NFHS and other data sets reveals
that this approach leads to two further kinds of errors: firstly, it
misses identifying a substantial proportion of SAM; secondly, the
number of severely underweight children who would potentially be
referred to referral centers only to be sent back as non-SAM is
substantial. Further, this approach self-evidently fails to refer
cases of recent acute weight loss that are not yet below the cut-off
to qualify as severely underweight.
As seen in Table I, using
anthropometric data from NFHS-3 and also comparable data collected
by CARE as part of the Integrated Nutrition and Health Program (INHP
data), simply relying on weight for age measures for identification
of children for referral to NRCs would leave out a substantial
proportion of SAM children (36% to 44%) since they fall in the
moderate or normal weight-for-age categories. Thus, screening for
severely under-weight children is simply not a sensitive enough test
for identifying SAM.
TABLE I Proportion of Children With Severe Acute Malnutrition (SAM) by Different Data Sets
Parameters |
NFHS 3 data
|
NFHS 3 data
|
INHP data, 2009
|
|
(0-59 months) |
(6-23 months) |
(6-23 months) |
Proportion of all SAM children who are: |
Severely underweight |
55.6 |
64.1 |
57.1 |
Not
severely underweight |
44.4 |
35.9 |
42.9 |
moderately underweight |
25.1 |
22.2 |
29.3 |
‘normal’ (not underweight) |
19.3 |
13.7 |
13.6 |
|
100.0 |
100.0 |
100.0 |
% of all severely underweight children who are having: |
Severe acute malnutrition (SAM) |
25.5 |
37.8 |
42.4 |
Severe stunting and SAM |
8.2 |
12.9 |
11.9 |
Severe stunting but not SAM |
60.5 |
46.9 |
41.9 |
% of all severely stunted children who are: |
Not
severely underweight |
59.3 |
55.8 |
55.5 |
Not
having SAM |
5.3 |
8.8 |
9.9 |
This analysis uses WHO Child Growth Standards, 2005, and
standard classification norms. |
Conversely, among those who do get referred to
the NRC for treatment, most (58% to 75%) are not SAM and hence do
not fit the entry criteria for admission to NRCs. Thus, the
specificity of the severe underweight cut-off in identifying SAM is
very poor. These children need additional attention, but not in the
form of referral to NRC. At the AWC, they are currently offered
"double rations", but little more. Because of the lack of
consistency between the referral criteria of the AWW (weight for
age) and the entry criteria for the NRC (SAM or nutritional edema),
many children are needlessly referred to and sent back from the NRC.
This could create a poor impression for the AWW at the village level
de-motivating her as well as parents towards referrals.
There are also gaps in the current exit criteria
for NRCs, leading to a waste of resources. As per WHO and IAP
guidelines, a child is considered fit for discharge from the NRC
only once the weight for length /height is more than -1 SD
(approximately 90% of NCHS median weight for height) [4-6]. However,
the children who are admitted at the NRC are usually kept for a
fixed period of 14 days for nutritional rehabilitation, medical
treatment and nutritional counseling unless the physician decides to
extend their stay at the facility. Effectively the child is sent
back from an investment of Rs 50 per day for food plus drugs, to
whatever the household can manage plus food worth Rs 6 per child per
day from the AWC. This ‘conveyor belt’ approach of discharge after
14 days, in the absence of community based management of
malnutrition, may seriously compromise the investment that has been
made during the 14 days of admission. Past international experience
exists to show NRCs have a limited role precisely for this reason
[7]. NRCs are just one link in a chain of well conceived
comprehensive strategies for prevention and cure that are likely to
lead to success.
There are also problems with the entry criteria.
In current practice, it is seen that the entry criteria for NRCs do
not include an appetite test and all children who are SAM are
automatically admitted. However, not all SAM children require
institution-based treatment. Malnourished but well children who have
an appetite need not be treated in NRCs but can be managed through
community based programs. Recent studies [8-9] show that RUTF can be
used in community settings as an effective instrument to treat SAM.
It is estimated that 80% of SAM children can be treated in the
community [10]. So even amongst those children who are SAM and do
get referred to the NRC, most in fact can be managed in the
community itself. In turn, such an approach would free up scarce
institutional resources for more intensive care for sick SAM
children, who need such care.
A community based program for management of SAM
children in India seems to be a task that can be led by the ICDS,
since an anganwadi centre is present in every village. The AWW can
be trained to identify children who are SAM affected, and further to
screen children who require to be referred to the NRC and those who
can be managed in the community. A strategy combining therapeutic
food, nutrition counseling, regular monitoring and community
mobilization can then be adopted (through the AWWs) for the
community based management of SAM affected children. Thus, there is
an urgent need to bring the ICDS program for malnutrition into
coherence with the NRC program for malnutrition. Protocols for
community-based management need to be developed as well as recipes
and production arrangements for locally produced therapeutic foods.
It is also important that the program for
management of SAM must be placed in the framework of prevention and
treatment of all kinds of malnutrition. For instance, there are a
large number of children who are not SAM but severely stunted and it
is equally important that this problem is addressed. Stunting is an
indicator of long neglected inadequate growth that should have been
attended to. Stunting has significant implications on the
intergenerational propagation of malnutrition with maternal stunting
resulting in greater risk of IUGR and low birth weight. Studies have
also linked childhood stunting with short adult stature, reduced
lean body mass, less schooling, diminished intellectual functioning
and reduced earnings [11-13]. A focus on SAM has no direct impact on
stunting, whereas a simultaneous focus on stunting would greatly
help the prevention of SAM in coming generations through reducing
low birth weight.
Moreover, there are children who are ailing and
in the moderate (weight for age) category but have not yet reached
the criteria for entry to the NRC. In the experience of the authors
[14], such children could also die before ever reaching the NRC and
need urgent attention. In such a context, a percentage weight loss
might be a better criterion for referral to the NRC rather than
waiting for the child to reach a universal cut off in weight-for-age
terms.
Conclusions
The current operational criteria for identifying
children for referral, admission to and discharge from the NRC
appear inadequate to meet the larger goal of managing children with
SAM. They tend to leave out as many as 36% to 44% of children with
SAM. Simultaneously, the majority of children referred to NRC on the
basis of weight-for-age are not SAM, while many children with SAM
who can be managed at the community level are needlessly admitted to
the NRC.
In addition, there is a lack of focus on other
children who need attention: children with severe stunting as well
as children who are showing significant growth faltering but have
not yet reached cut off levels for SAM. The management of sick
versus hungry children is not clearly distinguished, and there
is no identified role or provision for community based therapeutic
feeding for the latter. Finally, a protocol for the transition to
normal feeding with home-available foods is yet to be spelt out.
A comprehensive policy for SAM must lay down a
credible roadmap for reducing the prevalence of SAM over time, and
eventually eliminating it. This will involve articulation of both
curative and preventive strategies. There is a need for a proper
system of identification to be put in place with appropriate
protocols for follow up care and treatment based on different
categories of malnutrition.
Recommendations
Anthropometric measurements: Measure heights
and MUAC: Internationally, for easy identification of children who
are SAM at the community level, the Mid-Upper Arm Circumference
(MUAC) is used in large public programs. It is argued that such a
strategy is not only easy to implement and affordable, but also
identifies most of SAM children. Therefore, one route would be to
re-introduce MUAC in India as well, through the ICDS.
However, two caveats are important here. Firstly,
while MUAC is good for one-time detection, it is not so for
monitoring and follow up. On the other hand, weight-for-height is
good for both. Further, it is too easily assumed that measuring
height/length of children is too difficult for AWWs, or is too much
of an additional burden. Judicious use of height measurements do not
have to be burdensome, and the little additional effort would be
worthwhile to make anthropometric measure-ments more meaningful. We,
therefore, recommend measurement of heights to be introduced in the
ICDS. It would also be useful to explore criteria based on
percentage weight loss rather than universal cut-offs.
NRC Criteria: The criteria for referral to an
NRC need to be rectified and expanded. All sick malnourished
children, including malnourished children without appetite need to
be referred to a designated NRC. PHC level doctors may be more
accessible than the NRC (which may only be at district level to
start with), and primary screening for acute infections and
infestations and treatment are feasible. AWWs should be trained to
conduct appetite tests for severely malnourished children, based on
which they can decide whether the child needs institutional care or
can be managed in the community.
The child needs to stay at the NRC till free of
illness and recovery of appetite; these can be the exit criteria,
provided there is a program for community based management for
severe malnutrition, including home-based therapeutic feeding and
transition to home-available food.
Community-Based Management for SAM: All
children with SAM who do not need to be referred to NRC need to be
receiving community based management of malnutrition. This includes
the children who have been discharged from NRC.
Community based management for SAM should include
intensive breast feeding and nutritional counseling, monitoring
through home visits by ASHA/ second anganwadi worker on a weekly
basis, weekly growth monitoring with referral to PHC/NRC whenever
the child meets the criteria above. Special calorie dense
supplementary food needs to be provided which can be organized in a
decentralized way through the expertise of a nutrition specialist
placed at district level. Production needs to be local, culturally
acceptable, safe and decentralized, preferably to village level.
Micronutrient supplementation is important and should be organized
through the health system at district level.
Severely stunted children should continue to
receive extra food supplementation and intense effort needs to be
made to rule out underlying chronic illness through referral to the
PHC. Simultaneously, the general food security of the family needs
to be investigated; and action taken, through the Village Health
Nutrition and Sanitation Committee and the Panchayats, for
implementation of relevant food security schemes for the household.
While laying out a strategy the roles of each
agency – PHC, NRC, AWWs, ASHAs etc. must be clearly defined.
In summary, a comprehensive strategy needs to be
developed that covers all categories of malnutrition as well as
prevention, promotion and treatment. This requires the elements of
maternal and child care, maternity protection, nutrition counseling,
community mobilization for nutrition, good quality supplementary
nutrition, community based management of severe acute malnutrition
(including therapeutic feeding), NRC-level care, and high quality
pediatric services. A consistent and logical operational approach
that brings convergence and coordination between the two essential
services of ICDS and NRHM would go a long way in achieving this. We
believe this is entirely possible within the resources of this
country.
Acknowledgments: The authors would like to
acknowledge CARE-India and USAID for access to the raw data of INHP
analyzed in this study.
Funding: None; Competing interests:
None stated.
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