As per the Global Nutrition Report 2020, India has 17.3 per cent of children under 5 years of age who are wasted, higher than the average for the Asia region (9.1 per cent) and highest in the world(1). In 2018, World Health Organization (WHO) report on child nutrition states that globally 21.9 percent (149 million) U5 children are stunted, followed by 7.3 percent (49 million) U5 children are wasted and 5.9 percent (40 million) U5 children are overweight (2). According to National Family Health Survey (NFHS) the percentage of wasted and severely wasted children has increased from 19.8 percent and 6.4 percent in NFHS-3, 2005-06 to 21 percent and 7.5 percent in NFHS-4, 2015-16.(3) Especially states like Jharkhand (29 percent), Gujarat (26.4 percent), Karnataka (26.1 percent), Madhya Pradesh (25.8 percent), Maharashtra (25.6 percent), Rajasthan (23 percent), Chhattisgarh (23.1 percent) and Haryana (21.1 percent) contribute to the major burden of wasting in India. (3–5) Severe wasting is also termed as Severe Acute Malnutrition (SAM). SAM is a life-threatening factor for children because of their lack of immunity to infections and diseases. Severely wasted children show poor growth and cognitive developmental delays. They also reflect the poor nutritional status of women during pregnancy, poor breastfeeding and complementary feeding practices, poor dietary intake and lack of adequate health services.(6) Children with SAM are 11.6 times more likely to die and children with MAM are three times more likely to die than the normal children.(7)
As per WHO guidelines children with SAM are identified using Weight for Height Z score (WHZ) below – 3 Standard Deviation (SD) and or Mid Upper Arm Circumference (MUAC) less than 11.5cm.(8,9) Treatment guidelines for SAM has evolved from facility-based to Community Management of Acute Malnutrition (CMAM).(8,10) It was found that inpatient or facility-based engagement of SAM children required skilled health personnel and expensive treatments. In addition, accessibility to Malnutrition Treatment Centers (MTC) or Nutrition Rehabilitation Centers (NRC) is a challenge in rural areas.(11,12) Also, often community and families are not aware that the severely wasted children require immediate medical attention to prevent them from further morbidity and mortality.(4,12) With this background, many countries adopted community-based management for uncomplicated cases of SAM.(13–15)
CMAM is an evidence-based approach implemented in more than 70 countries to manage and treat SAM and MAM U5 children.(16) CMAM categorizes SAM into children with medical complications and children without medical complications.(17,18) Children without an appetite and/or with any medical complications are treated using inpatient facility.(17,18) Children without medical complications and with appetite fall under uncomplicated cases. Such uncomplicated SAM cases are treated using Ready to Use-Therapeutic Food (RUTF)[1] with a weekly or biweekly visit to a nearby health facility.(17,18) CMAM follows a decentralized approach, empowering the community health workers by increasing the availability and accessibility for effective treatment of acute malnutrition.(18,19) In 2000, CMAM was first tested as a pilot study in humanitarian emergencies.(20) Later in 2007, it was supported and recommended by the United Nation (UN) agencies that CMAM could be used as a standard procedure for treating and managing severe acute malnutrition in emergency and developmental contexts.(8)
In India, Community Management of Acute Malnutrition (CMAM) is adopted by many states and the outcomes were tested in pilot studies.(21) Initially, in 2009, CMAM was introduced in India as an emergency response in Bihar during Kosi floods. (4) Later, pilot studies were conducted in Maharashtra, Rajasthan, Odisha and Jharkhand to treat SAM children either community based or combination of both facility and community-based management.(4,11,12,22,23) In 2015, National Health Mission, Government of Rajasthan implemented CMAM by adopting POSHAN (Proactive and Optimum care of children through Social Household Approach for Nutrition) strategy to treat SAM children without medical complication using Medical Nutrition Therapy (MNT) Kit[2].(24,25) The community-based intervention was implemented in two phases. The CMAM POSHAN-I was implemented from 2015-16 covering 10 High Priority Districts (HPD) and 3 tribal districts of Rajasthan. Around 234,404 children aged 6-59 months were screened and 9,640 children were identified as SAM and enrolled for treatment.(24,25) After treating the enrolled SAM children using Energy Dense Nutrition Supplement(EDNS) for 8 to 12 weeks, 88 percent of children recovered 7 percent did not recover and were referred to MTCs.(24,25) With this achievement of internationally comparable success rate, the second phase of POSHAN-II was implemented in 2018, covering 20 districts of Rajasthan.(24) In Integrated Management of Acute Malnutrition (IMAM), POSHAN-II around 375,533 children were screened and 10,344 children were identified and enrolled for treatment.(24,26) This research study is aimed to evaluate the effectiveness of IMAM POSHAN-II with respect to the percentage of cured, non-recovered and defaulted children and rate of weight gain. We have also attempted to examine the factors associated with cured, non-recovered and defaulted SAM children.
IMAM POSHAN-II
Under IMAM POSHAN-II, treatment services were provided through Subcenters[3] at block level through frontline health workers such Auxiliary Nurse Midwife (ANM)[4], Accredited Social Health Activist (ASHA)[5] and Anganwadi Workers (AWW).(27) Before implementation, ASHAs, AWWs and ANMs were trained intensively for anthropometric measurements at the district level to ensure quality delivery of health services. During this intervention, Subcenters were designated as POSHAN centres and ASHA’s were called POSHAN Prahari. (27)
Process of diagnosing Severe Acute Malnutrition (SAM) under IMAM POSHAN-II
The process to diagnose Severe Acute Malnutrition included screening, identification and enrollment. The process flow is illustrated in figure 1.
- POSHAN Prahari’s carried out the screening process which also known as active case finding by visiting all the households with children aged 6-59 months in their respective operational geographies.(27) POSHAN Prahari’s measured the Mid Upper Arm Circumference (MUAC) for all the children aged 6-59 months.(27) The children with MUAC<12.5cm were short-listed for validation by ANM at the nearest Subcenter.(27)
- During identification, the shortlisted children with MUAC<12.5cm were brought to nearest sub-centre by POSHAN Prahari where ANM measured for weight, height or length and MUAC. Children were also checked for bilateral pedal oedema and any medical complications. Later, ANM along with mother or caregiver conducted appetite test for the screened children using EDNS[6].(27) If the child was diagnosed with bilateral pedal oedema and or identified with any medical complication and or failed in appetite test, then he or she was referred to the nearest Malnutrition Treatment Center (MTC) irrespective of the anthropometric measurements.(27) If WHZ<-3SD and or MUAC<11.5cm, then the child was identified as SAM. Identified SAM children without any medical complications with adequate appetite were enrolled in the program for treatment.(27)
- The children with MUAC between 11.5 to 12.4 cm and WHZ -3SD to <-2SD were categorized under Moderate Acute Malnutrition (MAM). They were referred to Anganwadi Center (AWC) for treatment through Integrated Child Development Services (ICDS) Supplementary Nutrition Program (SNP).(27)
Table 1. Admission and discharge criteria, POSHAN-II(27)
Anthropometric measurement
|
Enrollment criteria
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Discharge criteria
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MUAC
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MUAC <11.5 cm
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MUAC ≥12.5 cm
|
WHZ
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WHZ < -3SD
|
WHZ ≥ -2SD
|
WHZ and MUAC
|
WHZ < -3SD and
MUAC < 11.5cm
|
WHZ ≥ -2SD
|
Treatment of Severe Acute Malnutrition (SAM) children
Under POSHAN-II SAM children were identified and enrolled as per the program guidelines (table 1). Albendazole and amoxicillin were provided to all the enrolled children before initiating treatment with EDNS (additional file 1).(27) During treatment, the enrolled children were provided with Energy Dense Nutrition Supplement (EDNS), weekly according to their weight (additional file 1).(27) The child consumed EDNS every day as per the prescribed dosage along with regular home-based food. Every Tuesday, children with their mother or caretaker, reported to subcenter. These Tuesdays were called POSHAN Divas(days). On POSHAN Divas, ANM measured for weight, height and MUAC of the enrolled children to track their nutritional status.(27) After measurements, ANM provided EDNS packets to the mothers or caretakers for the following week.(27) Caregivers were informed that EDNS packets was specially made for the malnourished children and should not be shared with other family members. Caregivers were also educated about the method of feeding EDNS inadequate portions. Children with ≤ 24 months were encouraged for continued breastfeeding. They were also counselled on minimum meal frequency, handwashing practices and immunization. They were advised to seek medical care or reach out to ASHA (POSHAN Prahari) immediately if the child became unwell during EDNS consumption. Throughout the treatment phase, POSHAN Prahari’s visited the households of the enrolled children every day. During home visits, POSHAN Prahari’s monitored for regular consumption of EDNS by the SAM children and counselled the mother for adequate dietary intake and hygiene practices.(27) As the anthropometric measurements of the child improved (table1) they were further observed for one more week for consistent improved nutritional status. In the following week, if the nutritional status of the child did not deteriorate, the child was categorized as cured and discharged from POSHAN program.(27) The cured children were followed up for four months, and the non-recovered children were referred to MTC. In the follow-up phase, POSHAN Prahari’ s made home visits of cured children to track their nutritional status and dietary intake.(27) The detailed process flow of the treatment phase is shown in figure 2.
[1] Ready to Use-Therapeutic Food (RUTF): It is a high energy fortified ready to eat food suitable for treatment of severely malnourished children. This food should be soft or crushable, palatable and easy for children to eat without any preparation. At least half of the proteins contained in the product should come from milk products.(33)
[2] Medical Nutrition Therapy (MNT) kit consist of Energy dense Nutritional Supplement (EDNS), antibiotics and albendazole which is used for the treatment of SAM children in POSHAN-II.(24)
[3] In Indian rural health system, a subcenter is the peripheral and first point of contact between the community and primary health center system serving 5000 population in plains and 3000 population in hilly region.(44)
[4] ANM is key field level health functionary who are posted in Subcentre for maternal and child health besides treatment of common illnesses and are viewed as replacement of professional cadre of midwives in Primary Health Center (PHC).(44)
[5] ASHA is a community level health activist whose primary task is to create awareness, counsel, mobilize and facilitate the community in accessing health services from subcenters or Primary Health Center (PHC). (45)
[6][6] Energy Dense Nutrient Supplement (EDNS): In IMAM POSHAN-II, Ready to Use-Therapeutic Food RUTF was called as EDNS.(24)