The case of severe acute malnutrition

When we are yet to come to terms with malnutrition, here is the new enemy: severe acute malnutrition which kills infants


Geetanjali Minhas | September 15, 2015 | Mumbai

Ten-month-old Yash was born premature at 7.5 months and weighed only 1 kg. His mother Radha Sathe was only 20 when she gave birth to him. Beaten and abused regularly by her alcoholic husband, Sathe had no knowledge about hygiene or the benefits of breast feeding.
During pregnancy, she suffered from nausea, had no appetite and was unaware about nutrition for herself and her baby.

What’s more, she realised that she was pregnant only after six months after which she went to the primary health centre (PHC) for health check-ups. Hailing from Ambedkar Vasahat, Duttanagar village in Ahmednagar district of Maharashtra, Sathe delivered Yash at a hospital 30 km away. Though she went through sonography, no blood test was done before the delivery. The baby was severely malnourished at birth, had extremely low immunity and suffered a severe skin infection.

At the anganwadi she received take-home ration (THR) of a multi-grain, fortified mixture, but the THR was given without any directions and she was unable to cook it. Only after she came in contact with health workers at Shrimati Malati Dahanukar Trust (SMDT), an NGO working in the area, she was counselled on nutrition, breast feeding and hygiene habits.

Multi-vitamins were administered to Yash while Sathe was given calcium and iron supplements followed by regular monitoring and home visits. Slowly, the baby started getting healthy, weighing 6.6 kg and Radha’s health also improved. Yash’s skin infection is being treated and he weighs a near healthy 6.640 kg.

Sarthak Sadeep Thombare (23 months) was not only severely malnourished but also suffered from tuberculosis and had a cleft palette. After getting treated for cleft palette he was brought to the SMDT centre and administered energy-dense fortified food for four months along with multivitamins. As he slowly started becoming healthier, his mother too was given nutrition counselling and provided with iron and calcium supplements. “Sarthak now comes for regular follow-ups. He now weighs 8.5 kg and is 71 cm tall,” says SMDT nutritionist Deepali Fargade.

Though the severe malnutrition scare is behind him, Thombare has speech problems due to his cleft palette for which he needs speech training. Besides, it will take some more time and effort for him to become healthy. 

Malnutrition – comprising undernutrition as well as overnutrition – is hardly talked about in India, despite about half of the population suffering from it as estimated by several domestic and international agencies.

While no recent official figures are available at the central level, as per National Family Health Survey (NFHS) (2005-06), 6.4 percent children under 5 years of age in India suffered from severe acute malnutrition (SAM) – from which young Yash Sathe and Sarthak Thombare have successfully been pulled out. Yet, there are so many others who continue to suffer from it and more often than not die of it. What’s worse, the cause of such deaths is rarely attributed to SAM. 

“For long, the ministry of women and child development did not recognise SAM and later didn’t come to a consensus on SAM criteria. As a result, hospitals are not identifying or assessing SAM children and their deaths are registered as due to diarrhoea or pneumonia and not due to nutritional status,” says Dr Raj Bhandari, who has advised UNICEF on health and nutrition​.

SAM is defined by weight-for-height measurement of 70 percent or less below the median or 3SD (standard deviations) or more below the mean National Centre for Health Statistics reference values or presence of nutritional oedema and in children aged 6-59 months or arm circumference less than 115 mm.

It is a life threatening condition and results from a relatively short duration of nutrition deficit and is often complicated by concurrent infective illnesses. Such children are highly vulnerable to infections and face high mortality risk. As per the World Health Organisation (WHO) standards, children below -3SD are severely stunted and those below -2SD are moderately stunted.

These children have to be viewed as severely malnourished, and complications and changes in their organ functions have to be noted at the start of their treatment. Common illnesses like diarrhoea and pneumonia increase fatality in children, which can be prevented by 7-10 percent through SAM management protocol, says Dr Rupal Dalal, founding director, Foundation for Mother and Child Health (FMCH) India.
“Almost 85-90 percent of them can be treated in the community by WHO-recommended special food without the need of admission in the specialised feeding centres called Nutrition Rehabilitation Centres. This is called Community Management of Acute Malnutrition (CMAM),” Dr Dalal adds.

Food security and malnutrition, however, do not figure high on the governance agenda.

As per a FLAIR [Forum for Learning and  Action with Innovation and Rigour] policy paper on malnutrition, the government of India allocated a mere 8.7 percent share to food and nutrition schemes in the budget, though it was increased marginally to 9.60 percent in 2014-15.

In 2014-15, there was a gap of Rs 2,966.56 crore in the fund requirement and the actual allocation for the mid-day meal scheme and a gap of Rs 6,627.53 crore between fund requirement and actual allocation for Supplementary Nutrition Programme (SNP) under the Integrated Child Development Services (ICDS) scheme, the report adds.

Further, 14 percent of the ICDS budget and 9 percent of the mid-day meal budget under the tribal sub-plan (TSP) is still unspent from 2012-13. Between 2011-12 and 2012-13, there is +0.8 percent underutilisation of special component plan (SCP). (These plans were introduced to channel funds for SCs and STs in proportion to their share in the total population.)

States like Madhya Pradesh, Bihar and Jharkhand have the highest child malnutrition rates and others like Kerala, Manipur, Mizoram and Sikkim, where 80 percent or more of rural population have access to toilets, have the lowest levels of child malnutrition, as per the FLAIR report.

Although India currently does not have an active national nutrition policy/strategy, it has had some nutrition specific policies over the years: Guidelines for Enhancing Optimal Infant and Young Child Feeding Practices (2013), Food Security Bill (2013), National Rural Health Mission (NRHM 2008-12), Infant and Young Child Feeding Guidelines (2010, revised from 2004), National Plan of Action on Nutrition (1995-2000), Infant Milk Substitutes, Feeding Bottles and Infant Foods Act (1992, amended in 2003; regulation of production, supply, and distribution).

Other nutrition-specific programmes/interventions mainly include programmes under the National Health Mission (NHM) and state-specific interventions under NRHM + RMNCH plus flexi-pool of state project implementation plans.

India receives loans from the World Bank for nutrition-related activities, technical assistance to strengthen the nutrition policy framework and health system, and capacity strengthening to improve nutrition. India also receives funding from the Bill and Melinda Gates Foundation which will implement a programme through a partnership with the Bihar government to improve key health, nutrition and sanitation indicators in the state.

Several UN agencies, including Unicef, World Food Programme and Food and Agriculture Organisation, also provide nutrition-related funding. Unicef provides support at the central and state levels for strategic planning and implementation of activities to contribute to reduction of the stunting rate and an improved infant and young child nutrition situation.

“Measures like the food security law are not enough. We need to draw attention of our policymakers to prevent deaths of malnourished children. There is evidence that 50 percent of children (under 5) are dying due to malnutrition. Is our health system equipped to detect these children?” asks Dr Bhandari, who is involved in state-level initiatives in Maharashtra for malnutrition treatment centres and is a former consultant with UNICEF and the Indian government.

The infrastructure to raise the nutritional levels of children (0-6 years) has so far remained inadequate. On April 27, a parliamentary panel headed by Congress leader KV Thomas, in its report on public accounts, criticised the women and child development ministry. “It (the panel) is disappointed to find that even after a restructured and strengthened ICDS was launched in 2012 with an allocation of Rs 1,23,580 crore, the ministry is unlikely to achieve the target of covering 14 lakh habitations by anganwadi centres (AWCs) in foreseeable future.” It may be mentioned that the supreme court had in December 2006 directed the government to sanction and operationalise a minimum of 14 lakh AWCs by December 2008.

The ICDS is the largest programme in the world with a huge manpower and budgetary allocation at anganwadi (frontline) centres, yet about 30 percent of them are either locked or defunct. No wonder, India continues to carry the burden of hosting approximately one-third malnourished children of the world.

Even though long distances to service centres remain a major hindrance in fulfilling the supreme court directive to have one anganwadi centre for every 1,000 population, the number is coming down to 600 for tribal areas.

“I have been working on ground to see the functioning of these programmes and am pained to say that these programmes are certainly not working in the manner they should be for reasons like untrained staff, absence of capacity building, low quality standards of in-house formula feeds, besides many other things. The same applies to mid-day meals. The food at AWCs is not up to quality standards and lacks micronutrients. Children require special feeding programme so as not to get into the complicated SAM (severe acute malnutrition) category,” says Dr Bhandari.

Nearly 10 years ago, NRHM started nutritional rehabilitation centres in district hospitals meant especially for severely wasted children with a set protocol as given by WHO and UNICEF. “While the government may say that the programme for wasted children is functioning, there has been no external agency audit done on the government data,” says Dr Bhandari.

Led by noted agricultural scientist MS Swaminathan, the Coalition of Food and Nutritional Security had in 2010 prepared a consensus document titled – Sustainable Nutrition Security in India: A leadership Agenda for Action, outlining pathways for achieving a malnutrition-free India. The document has been lying with the government. “Updating documents will depend upon the data available. Unfortunately, the work of the nutritional monitoring bureau is probably coming to a stop. This will make it further difficult to have accurate data,” Swaminathan told Governance Now.

Dr Bhandari, however, ends on an optimistic note. “Though challenges remain we cannot say nothing is available. Wherever available in the country, services of these centres (AWCs) must be availed,” he says.



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