Community-based management of severe acute malnutrition in India: new evidence from Bihar

Abstract

Background: An estimated one-third of the world’s children who are wasted live in India. In Bihar state, of children <5 y old, 27.1% are wasted and 8.3% have severe acute malnutrition (SAM). In 2009, Médecins Sans Frontières (MSF) initiated a community-based management of acute malnutrition (CMAM) program for children aged 6–59 mo with SAM.Objective: In this report, we describe the characteristics and outcomes of 8274 children treated between February 2009 and September 2011.Design: Between February 2009 and June 2010, the program admitted children with a weight-for-height z score (WHZ) <−3 SD and/or midupper arm circumference (MUAC) <110 mm and discharged those who reached a WHZ >−2 SDs and MUAC >110 mm. These variables changed in July 2010 to admission on the basis of an MUAC <115 mm and discharge at an MUAC ≥120 mm. Uncomplicated SAM cases were treated as outpatients in the community by using a WHO-standard, ready-to-use, therapeutic lipid-based paste produced in India; complicated cases were treated as inpatients by using F75/F100 WHO-standard milk until they could complete treatment in the community.Results: A total of 8274 children were admitted including 5149 girls (62.2%), 6613 children aged 6–23 mo (79.9%), and 87.3% children who belonged to Scheduled Caste, Scheduled Tribe, or Other Backward Caste families or households. Of 3873 children admitted under the old criteria, 41 children (1.1%) died, 2069 children (53.4%) were discharged as cured, and 1485 children (38.3%) defaulted. Of 4401 children admitted under the new criteria, 36 children (0.8%) died, 2526 children (57.4%) were discharged as cured, and 1591 children (36.2%) defaulted. For children discharged as cured, the mean (±SD) weight gain and length of stay were 4.7 ± 3.1 and 5.1 ± 3.7 g · kg−1 · d−1 and 8.7 ± 6.1 and 7.3 ± 5.6 wk under the old and new criteria, respectively (P < 0.01). After adjustment, significant risk factors for default were as follows: no community referral for admission, more severe wasting on admission, younger age, and a long commute for treatment.Conclusions: To our knowledge, this is the first conventional CMAM program in India and has achieved low mortality and high cure rates in nondefaulting children. The new admission criteria lower the threshold for severity with the result that more children are included who are at lower risk of death and have a smaller WHZ deficit to correct than do children identified by the old criteria. This study was registered as a retrospective observational analysis of routine program data at http://www.isrctn.com as ISRCTN13980582.

Treatment outcome and associated factors of severe acute malnutrition among 6–59 months old children in Debre Markos and Finote Selam hospitals, Northwest Ethiopia: a retrospective cohort study

“…The present study also found that higher mortality rate than reports from Tigray [10], Southern region of Ethiopia [18] and India [15]. However, it is lower than reports from Uganda [12], Sudan [13], Jimma University Specialized Hospital [16], Woldiya General Hospital [17] and Rural Ethiopia [19].…”

“…Not only recovery and death rate but also the other outcome indicators in this study showed that there were in the minimum standard set of sphere project values/international standards [9]. The recovery rate in our study is higher than previous findings from Tigray [10], Kamba District [11], Uganda [12], Sudan [13], Tamale Teaching Hospital [14] and India [15]. But it is lower than findings from Jimma University Specialized Hospital [16], Woldiya General Hospital [17], Southern region of Ethiopia [18] and Rural Ethiopia [19].…”

Concerning public health situation of under-nutrition in children and anemia in women in Indian Sundarbans delta: a community based cross-sectional investigation

“…Children managed at specialized units located at health facilities also require follow up services at their households after discharge in order to maintain a continuum of care and support and to prevent relapse [19,20]. The eastern Indian state of Bihar has generated encouraging results through community based intervention in this regard [21]. The current investigation, by highlighting a severe state of under-nutrition in Sundarbans, thus underscores the need for establishing outreach activities paired with facility based intervention.…”

Foregrounding ‘Community’ in Community Management of Severe Acute Malnutrition

“…This has also been postulated more recently by academics theoretically, arguing that India suffers a kind of malnutrition that is somewhat peculiar, being 'acute-on-chronic' rather than purely 'acute' (9). Not only does this have implications for the understanding of its determinants, it also seems to have an effect on relative mortalities and morbidities, as seen in two rigorous studies of large-scale CMAM interventions in India of the primarily medical typology (1,10). While resulting in lower mortalities, it also makes recovery more difficult and far lower recovery rates are seen as compared to Africa with similar interventions (11).…”