Consensus Statement of the Indian Academy of Pediatrics on Integrated Management of Severe Acute Malnutrition.

Justification: Severe acute malnutrition (SAM) is a major public health issue. It afflicts an estimated 8.1 million under-five children in India causing nearly 0.6 million deaths. The improved understanding of pathophysiology of SAM as well as new internationally accepted growth charts and newer modalities of integrated intervention have necessitated a relook at IAP recommendations. Process: A National Consultative Meeting on Integrated Management of Severe Acute Malnutrition was held in Mumbai on 16th and 17th October, 2010. It was attended by the invited experts in the field. Extensive discussions were held as per the program. The participants were then divided into six groups for detailed discussions. The groups deliberated on various issues pertaining to the task assigned and presented recommendations of the groups in a plenary session. The participants made a list of recommendations after extensive discussions. A Writing Committee was formed and was entrusted with the task of drawing a Consensus Statement on the basis of these Recommendations. After multiple deliberations, the following Consensus Statement was adopted. Objectives: To critically evaluate the current global evidence to formulate a consensus among stakeholders regarding diagnosis and management of SAM. Recommendations: An integrated management of malnutrition is likely to yield more dividends. Thus, management of SAM should constitute an important component of Integrated Management of Neonatal and Childhood Illnesses (IMNCI) program. Determination of SAM on the basis of Z-scores using WHO Growth charts is considered statistically more appropriate than cut-offs based on percentage weight deficit of the median. Considering the fact that many children with SAM can be successfully managed on outpatient basis and even in the community, it is no more considered necessary to advise admission of all children with SAM to a healthcare facility. Management of SAM should not be a stand-alone program. It should integrate with community management therapeutic programs and linkages with child treatment center, district hospitals and tertiary level centers offering inpatient management for SAM and include judicious use of ready-to-use-therapeutic Food (RUTF). All sections of healthcare providers need to be trained in the integrated management of SAM.

Community Management of Acute Malnutrition in the Developing World / 대한소아소화기영양학회지

Globally, acute malnutrition triggers more than 50% of childhood mortality in children under 5 years old, which implies that about 3.5 million children die of malnutrition each year. Prior to the advent of ready-to-use therapeutic food (RUTF), the management of acute malnutrition was limited to hospitals, resulting in low coverage rates with high mortality, as malnourished cases were indentified at later stages often plagued with complications. However, current availability of RUTF has enabled malnourished children to be treated at communities. Further, because RUTF is dehydrated and sealed, it has the added advantage of a lower risk of bacterial contamination, thereby prolonging its storage life at room temperature. Recent data indicate that Community Management of Acute Malnutrition (CMAM) is as cost effective as other high-impact public health measures such as oral rehydration therapy for acute diarrheal diseases, vitamin A supplementation, and antibiotic treatment for acute respiratory infections. Despite the high efficacy of CMAM programs, CMAM still draws insufficient attention for global implementation, suggesting that CMAM programs should be integrated into local or regional routine health systems. Knowledge gaps requiring further research include: the definition of practical screening criteria for malnourished children at communities, the need for systematic antibiotic therapy during malnutrition treatment, and the dietary management of severe malnutrition in children below 6 months of age.

Production and Distribution of a Therapeutic Nutritional Product for Severe Acute Malnutrition in India: Opportunities and Challenges.

Limited resources for hospitalized treatment of India’s nearly 8 million children with severe acute malnutrition (SAM) make community management of SAM a priority. Capability to produce sufficient quantities of Ready to Use Therapeutic Food (RUTF) is one component of preparedness for community management of SAM. Production of RUTF is a simple process that consists of grinding, mixing and packaging using widely available equipment. Nitrogen flush packaging increases shelf life to 2 years though it is the most expensive and slowest step of the production process. Being a therapeutic product, quality and safety must be ensured including aflatoxin measurement and estimation of micronutrient and macronutrient content consistently. RUTF can be made in India in several production models – (i) Dairy cooperatives and private manufacturers can produce large quantities to meet regional requirements, (ii) small and niche food manufacturers can produce smaller volumes but have a major presence in most parts of India; and (iii) “hand made” RUTF can be made by “village industries” for immediate local consumption. All the ingredients and equipment for RUTF are widely available in India – RUTF is already being produced in India for export. Concerns from various sections of society will need to be heard before community management of SAM using therapeutic, processed nutritional products can begin. Despite apprehensions about processed RUTFs or the sections of the public health community that press for its use, withholding alternative treatment for one of the largest killers of India’s children must not be the option. It is time public health/ medical communities and civil society come together to make effective community management of SAM an immediate reality.

Comparison of ready-to-use therapeutic food with cereal legume-based khichri among malnourished children.

Objective: To compare the acceptability and energy intake of Ready-to-Use Therapeutic Food (RUTF) with cereal legume based khichri among malnourished children. Design: An acceptability trial with cross-over design. Setting: Urban low to middle socioeconomic neighbor-hoods in Delhi. Subjects: 31 children aged ³6 to £36 months with malnutrition, defined as Weight for height (WHZ) <–2 to ³–3 SD, with no clinical signs of infection or edema. Intervention: Children were offered weighed amounts of RUTF and khichri in unlimited amounts for 2 days, one meal of each on both days. Water was fed on demand. Caregivers’ interviews and observations were conducted on the second day. Outcome Measures: Acceptability of RUTF compared to khichri based on direct observation and energy intake for test and control meals. Results: The proportion of children who accepted RUTF eagerly was 58% as against 77% for khichri. 42% children on RUTF and 23% on khichri accepted the meal but not eagerly. The median (IQR) energy intake over the two day period in children aged 6 to 36 months from RUTF was 305 (153, 534) kcal, and from khichri was 242 (150, 320) kcal (P=0.02). Conclusion: RUTF and khichri were both well accepted by study children. The energy intake from RUTF was higher due to its extra energy density.