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

This is a summary of a Field Exchange field article that was included in issue 63 – a special edition on child wasting in South Asia. The original article was authored by Praveen Kumar, Sila Deb, Arjan de Wagt, Piyush Gupta, Nita Bhandari, Neha Sareen and Satinder Aneja.

Praveen Kumar is Director Professor at the Department of Paediatrics, Kalawati Saran Children’s Hospital (KSCH), Lady Hardinge Medical College, New Delhi and is also the Lead Coordinator of the National Centre of Excellence (NCoE) for severe acute malnutrition (SAM) management.

Sila Deb is an Additional Commissioner of the Child Health Division (Nutrition in charge), Ministry of Health and Family Welfare (MoHFW), Government of India, overseeing the National Child Health Programme for Child Health and Nutrition.

Arjan de Wagt is Chief of Nutrition Section, UNICEF India country office, New Delhi.

Piyush Gupta is the President-Elect of the Indian Academy of Pediatrics (IAP) and Chairperson of the Nutrition Chapter of IAP (PAN).

Nita Bhandari is Senior Scientist and Director of the Centre for Health Research and Development, Society for Applied Studies, New Delhi.

Neha Sareen is a Senior Consultant in NCoE on SAM and supports the MoHFW, Nutrition Division in management of children with SAM.

Satinder Aneja is a Professor and Head of the Department of Paediatrics, School of Medical Sciences and Research, Sharda University, Greater Noida, India.

The authors would like to acknowledge Dr Vishal Kumar, Shivani Rohatgi, Purnima Arora, Deepika Choudhary and Prachi Singh who supported the work highlighted in this article at various stages, as well as the Child Health Division, MoHFW, Government of India, New Delhi.

Background

Malnutrition in infants under six months in India – a significant public health problem

Adequate nutrition during the first six months of life is crucial for appropriate growth and development. Malnutrition in infants under six months old (U6m) is a global public health problem – a problem that is particularly acute in India where approximately 31.9% are wasted and 14.9% severely wasted in this age group. As in other South Asian countries, such as Bangladesh, the prevalence of wasting is highest at birth (37%) and declines with age. This pattern highlights that the origins of early-life undernutrition often begin in utero.

In South Asia, 9.8 million infants are born with low birth weight (LBW) each year, 75% of whom live in India. Being born LBW increases a child’s risk of death in infancy and, for those who survive, the risk of morbidity and acute malnutrition during infancy and early childhood. Individuals born with intrauterine growth restriction (IGR) who experience rapid weight gain in infancy are also at greater risk of non-communicable diseases such as hypertension, diabetes and dyslipidaemia in adulthood. The need to address growth failure in early life in South Asian countries is a focus of the recently launched POSHAN Abhiyaan programme in India which aims to improve antenatal care and breastfeeding practices nationwide with a target to reduce LBW by 2% per annum.

Current state of care for vulnerable infants in India

To manage vulnerable infants, the Government of India (GOI) has established special newborn care units (SNCUs) under the National Health Mission (NHM). SNCUs provide specialised care to infants who are born preterm (<34 weeks) or at a birth weight of <1,800g, as well as other sick neonates under 28 days of age. To date, 844 SNCUs have been established across India, treating nearly one million newborns per year and resulting in almost one million fewer newborn deaths in 2017 than in 2000.

At community level, the Home Based Newborn Care (HBNC) programme targets remote, rural areas where care would otherwise be inaccessible. Accredited social health activists (ASHAs) conduct seven follow-up visits of infants during the first 42 days of life. Follow-up continues to 18 months for LBW and 12 months for non-LBW preterm infants. ASHAs support mothers to sustain exclusive breastfeeding for six months and perform regular growth monitoring and screen for signs of sickness in mothers and infants for early referral. The Home Based Care for the Young Child (HBYC) programme follows HBNC through which ASHAs provide an additional five follow-up visits to infants between 3 and 15 months of age to support continued nutritional growth and development and prevent childhood illness and death. Some nutrition rehabilitation centres (NRCs) also manage acutely malnourished infants U6m according to national severe acute malnutrition (SAM) protocols.

A weakness of the current system is the lack of clarity on how to identify infants at nutrition risk (not just those already severely acutely malnourished) and to provide appropriate management of this vulnerable group.

Management of ‘at risk’ Mothers and Infants (MAMI) U6m approach in India – the opportunities

A Community-MAMI (C-MAMI) tool,¹ developed at global-level by the MAMI Special Interest Group (MAMI SIG),² supports the identification and management of uncomplicated, nutritionally at-risk mother-infant dyads in the community. This is consistent with the recommendations of the updated 2013 World Health Organization (WHO) guidelines. Encouraging results of C-MAMI pilots in Ethiopia and Bangladesh sparked interest among Indian experts and, as a result, two expert group consultation meetings were held to discuss its application to the India context.

At the first consultation in October 2018, the MAMI SIG shared global learning and experience of using the C-MAMI tool. A training package was subsequently developed to strengthen inpatient care of U6m infants with severe malnutrition which has since been piloted in 10 NRCs in India. At the second consultation in October 2019, discussions and presentations from multiple stakeholders fed into the development of operational and technical guidelines on Early growth failure: identification and management through existing Government platforms. The guidelines recommend the use of existing government health platforms (HBNC and HBYC programmes and Village Health Sanitation and Nutrition Days (VHSNDs) and health workers (ASHAs, anganwadi workers (AWWs) and auxiliary nurse midwives (ANMs)) for the management of this vulnerable group. The guidelines have been agreed in principle by the Ministry of Health and Family Welfare (MoHFW) but no official order for their implementation has been issued as yet.

Pilot MAMI programme

MAMI training programme

The new training package on inpatient management of U6m infants with severe malnutrition was piloted in New Delhi in November 2018 by the National Centre of Excellence on Severe Acute Malnutrition (NCoE SAM) with support from UNICEF and MoHFW. The training was attended by 27 paediatricians, medical officers, nutritionists and staff nurses from NRCs in 10 states and covered the identification, management, discharge and follow up of severely malnourished infants U6m.

MAMI implementation experiences

Following the pilot training, staff from the 10 selected NRCs implemented the new protocol. Infants were screened and classified as not at nutrition risk, at moderate nutrition risk or at severe nutritional risk. Following the proposed new guidelines, infants U6m at moderate and severe risk were admitted to NRCs for management. Of the 890 children presenting during the pilot period (February to May 2019), 29% were infants U6m. Of these infants, 69% were identified as having severe nutritional risk and were admitted for inpatient care. The remaining 31% were at moderate nutritional risk and were also admitted for care, given that community-based services were not yet available.  

According to a monitoring checklist, the majority of NRCs adhered to inpatient treatment protocols. Deviations from protocols occurred in a few cases, for example due to lack of clarity on the need for electrolyte supplementation in breastfed infants and operational challenges such as stock shortages of antibiotics and micronutrient supplements and a lack of personnel to manage evening and night shifts. Temperature recording and antibiotics were administered correctly but blood glucose testing was irregular in three NRCs.

Out of 258 infant U6m admissions, 80% had prospects of breastfeeding (mother present and breastfeeding or had stopped breastfeeding within the last two months). Of these, 79.8% had incorrect breastfeeding attachment and positioning. Following counselling and support from NRC staff, breastfeeding was corrected in 55.4% of cases with the remaining mothers receiving support via the supplementary suckling technique (SST). Relactation by SST was unsuccessful in only 30% of cases with lower success occurring in NRCs with less skilled manpower available, particularly during evening and night shifts.

Key learnings from the pilot programme

The pilot programme demonstrated that, with training support, most NRCs can successfully identify and manage infants U6m at nutrition risk and breastfeeding support is effective in correcting feeding problems in over half of cases. Successful management of these cases in the community is possible if trained support from health workers is available.

For U6m infants who require NRC admission due to medical complications or to implement SST, the success of treatment depends on the availability of a paediatrician and adequate supervision. This will need to include skilled support during evening and night shifts. It was noted that relactation is less successful after breastfeeding has ceased for more than three months, highlighting the importance of early breastfeeding support.

Maternal health and nutrition services in India

The wellbeing of an infant is largely determined by the wellbeing of their mother. The MAMI approach therefore considers the mother-infant pair and includes a maternal mental health care component. In India, several programmes exist to support mothers, including Janani Shishu Suraksha Karyakaram (JSSK) to support women in pregnancy, and others that provide nutrition support and social determinants that influence women’s uptake of existing health services. MAMI facility and community-based programmes must link with these services to ensure success.

A lack of existing services for maternal psychosocial assessment and support is a challenge in India. Maternal mental health has only recently been recognised as important for the wellbeing of at-risk mothers and infants and dedicated services are largely deficient in health facilities. Health workers similarly lack training in mental health issues and the availability of specialists is limited in peripheral healthcare facilities. Urgent linkages are also therefore needed between psychiatry, medicine, child development and maternal and social development to provide effective management services for mothers and infants.

MAMI in India – the way forward

In India, the high prevalence of severe wasting makes it impossible to provide inpatient care to all affected infants U6m. Inpatient care may also be inappropriate in many cases. Use of existing government platforms in India to test the utility and feasibility of community-based management of infants U6m at moderate risk of malnutrition could provide a step forward in preventing growth failure and malnutrition in this vulnerable group. Linkages with the recently launched government POSHAN Abhiyaan programme and Mother’s Absolute Affection (MAA) programme provide further opportunities for the rollout of this approach. The pilot study described here demonstrates the utility of providing skilled, facility-based support to infants at high nutrition risk, including the use of SST. This level of support should be incorporated into NRCs and paediatric facilities across India. By implementing support through both platforms (community and inpatient), malnutrition in infants U6m in India can be comprehensively addressed at scale so that inpatient care is only required for those either at severe nutritional risk or who do not improve with community-based interventions.

For more information please contact Prof. Praveen Kumar.