Diagnosis, Treatment and Prevention of Nutritional Anemia in Children: Recommendations of the Joint Committee of Pediatric HematologyOncology Chapter and Pediatric and Adolescent Nutrition Society of the Indian Academy of Pediatrics

Justification: Anemia in children is a significant public health problem in our country. Comprehensive National Nutrition Survey 2016-18 provides evidence that more than 50% of childhood anemia is due to an underlying nutritional deficiency. The National Family Health Survey-5 has reported an increase in the prevalence of anemia in the under-five age group from 59% to 67.1% over the last 5 years. Clearly, the existing public health programs to decrease the prevalence of anemia have not shown the desired results. Hence, there is a need to develop nationally acceptable guidelines for the diagnosis, treatment and prevention of nutritional anemia. Objective: To review the available literature and collate evidence-based observations to formulate guidelines for diagnosis, treatment and prevention of nutritional anemia in children. Process: These guidelines have been developed by the experts from the Pediatric Hematology-Oncology Chapter and the Pediatric and Adolescent Nutrition (PAN) Society of the Indian Academy of Pediatrics (IAP). Key areas were identified as: epidemiology, nomenclature and definitions, etiology and diagnosis of iron deficiency anemia (IDA), treatment of IDA, etiology and diagnosis of vitamin B12 and/or folic acid deficiency, treatment of vitamin B12 and/or folic acid deficiency anemia and prevention of nutritional anemia. Each of these key areas were reviewed by at least 2 to 3 experts. Four virtual meetings were held in November, 2021 and all the key issues were deliberated upon. Based on review and inputs received during meetings, draft recommendations were prepared. After this, a writing group was constituted which prepared the draft guidelines. The draft was circulated and approved by all the expert group members. Recommendations: We recommend use of World Health Organization (WHO) cut-off hemoglobin levels to define anemia in children and adolescents. Most cases suspected to have IDA can be started on treatment based on a compatible history, physical examination and hemogram report. Serum ferritin assay is recommended for the confirmation of the diagnosis of IDA. Most cases of IDA can be managed with oral iron therapy using 2-3 mg/kg elemental iron daily. The presence of macro-ovalocytes and hypersegmented neutrophils, along with an elevated mean corpuscular volume (MCV), should raise the suspicion of underlying vitamin B12 (cobalamin) or folic acid deficiency. Estimation of serum vitamin B12 and folate level are advisable in children with macrocytic anemia prior to starting treatment. When serum vitamin B12 and folate levels are unavailable, patients should be treated using both drugs. Vitamin B12 should preferably be started 10-14 days ahead of oral folic acid to avoid precipitating neurological symptoms. Children with macrocytic anemia in whom a quick response to treatment is required, such as those with pancytopenia, severe anemia, developmental delay and infantile tremor syndrome, should be managed using parenteral vitamin B12. Children with vitamin B12 deficiency having mild or moderate anemia may be managed using oral vitamin B12 preparations. After completing therapy for nutritional anemia, all infants and children should be advised to continue prophylactic iron-folic acid (IFA) supplementation as prescribed under Anemia Mukt Bharat guidelines. For prevention of anemia, in addition to age-appropriate IFA prophylaxis, routine screening of infants for anemia at 9 months during immunization visit is recommended.

Indian Academy of Pediatrics Guidelines on the Fast and Junk Foods, Sugar Sweetened Beverages, Fruit Juices, and Energy Drinks

Justification: In view of easy availability and increasing trend of consumption of fast foods and sugar sweetened beverages (fruit juicesand drinks, carbonated drinks, energy drinks) in Indian children, and their association with increasing obesity and related non-communicable diseases, there is a need to develop guidelines related to consumption of foods and drinks that have the potential toincrease this problem in children and adolescents. Objectives: To review the evidence and formulate consensus statements related toterminology, magnitude of problem and possible ill effects of junk foods, fast foods, sugar-sweetened beverages and carbonated drinks;and to formulate recommendations for limiting consumption of these foods and beverages in Indian children and adolescents. Process:A National Consultative group constituted by the Nutrition Chapter of the Indian Academy of Pediatrics (IAP), consisting of variousstakeholders in private and public sector, reviewed the literature and existing guidelines and policy regulations. Detailed review ofliterature was circulated to the members, and the Group met on 11th March 2019 at New Delhi for a day-long deliberation on framing theguidelines. The consensus statements and recommendations formulated by the Group were circulated to the participants and aconsensus document was finalized. Conclusions: The Group suggests a new acronym ‘JUNCS’ foods, to cover a wide variety ofconcepts related to unhealthy foods (Junk foods, Ultra-processed foods, Nutritionally inappropriate foods, Caffeinated/colored/carbonated foods/beverages, and Sugar-sweetened beverages). The Group concludes that consumption of these foods and beveragesis associated with higher free sugar and energy intake; and is associated with higher body mass index (and possibly with adversecardiometabolic consequences) in children and adolescents. Intake of caffeinated drinks may be associated with cardiac and sleepdisturbances. The Group recommends avoiding consumption of the JUNCS by all children and adolescents as far as possible and limittheir consumption to not more than one serving per week. The Group recommends intake of regional and seasonal whole fruits over fruitjuices in children and adolescents, and advises no fruit juices/drinks to infants and young children (age <2 y), whereas for children aged 2-5 y and >5-18 y, their intake should be limited to 125 mL/day and 250 mL/day, respectively. The Group recommends that caffeinatedenergy drinks should not be consumed by children and adolescents. The Group supports recommendations of ban on sale of JUNCSfoods in school canteens and in near vicinity, and suggests efforts to ensure availability and affordability of healthy snacks and foods. TheGroup supports traffic light coding of food available in school canteens and recommends legal ban of screen/print/digital advertisementsof all the JUNCS foods for channels/magazines/websites/social media catering to children and adolescents. The Group further suggestscommunication, marketing and policy/taxation strategies to promote consumption of healthy foods, and limit availability and consumptionof the JUNCS foods

Prevention of Micronutrient Deficiencies in Young Children: Consensus Statement from Infant and Young Child Feeding Chapter of Indian Academy of Pediatrics

Justification: Micronutrient deficiencies have significant impact on the overall health and well-being of society and potential targets forsupplementations. It is important to formulate a consensus statement in view of current evidence, and put in place strategies to meettargets. Objectives: To formulate by endorsement or adoption and disseminate a consensus statement for prevention of micronutrientsdeficiencies in young children for office practices from an Indian perspective. Process: A National Consultative Meeting was convenedby Infant and Young Child Feeding Chapter (IYCF) of Indian Academy of Pediatrics (IAP) on 17 December, 2016 at Mumbai. IYCF chapter,IAP, United Nations Children Fund, National Institute of Nutrition and Government of India were the participating agencies; and participantsrepresenting different parts of India were included. Conclusions: Micronutrient deficiencies are widespread. For its prevention propermaternal and infant-young child feeding strategies need to be practiced. Encourage delayed cord clamping, dietary diversification,germinated foods, soaking and fermentation processes. Existing Iron, Vitamin A, Zinc supplementation and universal salt iodizationprograms need to be scaled up, especially in high risk groups. Universal vitamin D supplementation need to be in place; though, the doseneeds more research. Vitamin B12 deficiency screening and supplementation should be practiced only in high-risk groups. Availability ofappropriately fortified foods needs to be addressed urgently.

Crusade against Malnutrition: Nutrition Education Program.

A holistic approach in assessment and plan for intervention in childhood malnutrition is the need of the hour. This is in the context of nutrition education program (NEP), undertaken under the National IAP action plan, 2015. In the crusade against malnutrition, an ABCDEFQ assessment scale is recommended, with aspects covering anthropometric, biochemical, clinical, dietary, ecological/epidemiological, functional parameters and quality of life. In the dietary assessment, a scoring system based on the ten interventions related to infant and young child feeding (IYCF) practices recommended by UNICEF and the food frequency table score are incorporated. In the evaluation of quality of life and plan for intervention, a tool called IMPACT (IAP Malnutrition Proactive Assessment: A Comprehensive Tool) is proposed.