Integrated programme achieves good survival but moderate recovery rates among children with severe acute malnutrition in India

Victor Aguayo et al.
American Journal of Clinical Nutrition 2013; 98:1335-42

At any point in time, an average 8 million Indian children suffer from severe acute malnutrition (SAM). In the state of Madhya Pradesh, an estimated 1.26% of children under five years of age have SAM. The response to SAM is an integrated programme where children are initially admitted to a facilitybased phase in a Nutrition Rehabilitation Centre (NRC) and after the facility-based phase, children are transitioned to the community-based phase at home. This article assesses the effectiveness of an integrated model for the management of SAM in India comprising facility and community-based care using locally adapted protocols to inform the future design and implementation of programs for the delivery of services for children with SAM in India.

Detection of SAM is conducted at the community level by Anganwadi workers, the frontline workers of India’s Integrated Child Development Services (ICDS) programme. Severe wasting is defined by a MUAC < 115 mm and/or a weight-for-height z-score (WHZ) less than -3 of the median WHZ in WHO Child Growth Standards. All children 6-59 months with bilateral pitting edema, and/or WHZ less than -3 and/or MUAC < 115 mm were admitted to the NRC. Children were treated as per WHO protocols, consisting of stabilization, transition and rehabilitation phases. Children with normal appetite and free of medical complications entered the rehabilitation phase from the day of admission. All children completed a mandatory 14-day stay in the NRC and then were transitioned to the community phase where they were followed up by community workers and returned for a follow-up visit at the NRC every 15 days after discharge.

Results and discussion

Children admitted were very young, 78.7% were 6-23 months; 55.7% were girls and 64.1% were from scheduled caste or scheduled tribe families. The authors recommend that programmes for children with SAM in Madhya Pradesh need to give priority to children younger than two years of age, particularly girls, from socioeconomically disadvantaged groups.

The following overall outcomes were recorded:

• Deaths: two children (0.1%) died while in the NRC
• Defaulters: 531 children (19.8%) defaulted (left the NRC before completing 14 days)
• Discharged: 2151 children (80.1%) were discharged from the NRC to the community-based phase of the programme.

The authors underscore the importance of the low death rate comparable to national and international standards of care. However the proportion of defaulters (32.0%) was higher than national and international standards of care. It is thought that the high default was due to the high opportunity cost to the family from their child being in a facility for 14 consecutive days. The proportion of children discharged from the programme (67.6%) was below national and international standards of care, mostly because of the significant proportion of children who defaulted the programme before completing the required length of stay. The mean weight gain in the facility-based phase was below national and international minimum standards, suggesting the quality of the therapeutic food used in the NRC is suboptimal. The mean weight gain in the community-based phase of the programme was lower than observed in CMAM programmes elsewhere indicating that the nutrient density of the foods used in this phase was less than adequate to ensure appropriate weight gain and timely recovery.

The authors conclude that the current protocols and therapeutic foods need to be improved. Considering the burden of SAM in India, treating all children with SAM in NRCs is not operationally feasible. The experience in Madhya Pradesh demonstrates that existing health systems can be strengthened with feasible adjustments to provide effective care for children with SAM through an integrated model that comprises facility and community-based therapeutic care.