Viewpoints from the National Consultation on Addressing Acute Malnutrition on Mainstreaming Community-Based Program for Management of Acute Malnutrition in India

Abstract

High burden of acute malnutrition among children less than 5 years is a major public health problem in India. A ”Two-days National Consultation on Addressing Acute Malnutrition” was organized to gather experiences and evidence from 13 states of India on prevention and management of acute malnutrition among children and documenting viewpoints from experts and government counterparts on the same. The consultation centered around five key themes of addressing acute malnutrition; 1) capacity building, 2) strengthening screening, 3) nutritional care of wasting, 4) tracking progress, and 5) scale-up. The paper highlights the experiences and key recommendations around the above key themes. It emerged that there is a need to further accelerate the efforts toward strengthening existing platforms and services to address acute malnutrition among children. Regular trainings of the frontline workers, increased convergence, regular monitoring, and continued service delivery during the pandemic should be undertaken for better outcomes.

INTRODUCTION

Undernutrition among children less than 5 years is one of the leading causes of childhood morbidity and mortality.^[1] In India, wasting and severe wasting affects 19.3% and 7.7% children under the age of 5 years, respectively,^[2] and we are still far from reaching the sustainable development goal of wasting reduction to less than 3% by 2030. Several national programmes and policies have been implemented to improve their nutritional status, including the Integrated Child Development Scheme (ICDS) and POSHAN Abhiyaan. For severe acute malnutrition (SAM), specialized prevention and treatment interventions through facility-based and community-based care have been implemented. However, the problem of wasting still largely remains unresolved because of gross under-utilization of services,^[3] poor infant and young child feeding (IYCF) practices,^[4] high prevalence of infections and diseases, a poor maternal nutritional status, and inadequate water, sanitation, and hygiene (WASH) practices.^[5] Additionally, coronavirus disease 2019 (COVID 19) waves led to disruption of regular nutritional and health services, leaving the vulnerable children with limited means to access these services.^[6,7] In this backdrop, the National Centre of Excellence on Management of SAM, Kalawati Saran Children’s Hospital, New Delhi, organized a “Two-days National Consultation on Addressing Acute Malnutrition” in October 2021, in collaboration with NITI Aayog, UNICEF India, ICMR-NIN, Centre of Excellence for SAM Network and Paediatric and Adolescent Nutrition Society, and Nutrition Chapter of the Indian Academy of Paediatrics. The objective of the consultation was to provide a common platform for cross-learning and experience sharing on the existing evidence and the best practices for strengthening CMAM in India around its five key themes and getting recommendations from experts [Figure 1]. The current paper summarizes the experiences and recommendations on these five themes to provide policy directions and to guide states for strengthening the CMAM program in India.

Figure 1: Themes of National Consultation on Addressing Acute Malnutrition

Theme 1: Capacity building on CMAM

Experiences from Telangana showed that cascading trainings requires preparation which includes developing training packages, creating a resource pool, and developing training plans and their execution. Coordination with the government to ensure resources and quality assessment of training programs can be useful to avert dilution of key messages during cascading trainings. To ensure quality of trainings, uniform training materials, role plays, practical exercises for anthropometric measurements, and determining the nutritional status correctly as per WFH SD score charts can be used. The process of cascading trainings is summarized in Figure 2.

Figure 2: Cascading capacity building for CMAM

Experiences from Chhattisgarh showed that because the execution of physical trainings became challenging because of COVID 19 pandemic, virtual/hybrid/blended trainings can be a solution to these problems. Blended trainings had several advantages; for example, it helped to reach out all district functionaries despite travel constraints and ensure participation even from hard-to-reach areas. However, these trainings did pose a few limitations such as having poor internet connectivity, unavailability of smart phones with frontline workers (FLWs), and most importantly the lack of practice and demonstration of anthropometric measurements. These limitations were overcome by organizing refresher trainings later in small batches and of shorter duration.

Theme 2: Strengthening screening

Currently, in India, all children less than 5 years are being screened for SAM at regular intervals at Anganwadi Centres (AWCs) by FLWs. However, experts highlighted several points to improve its coverage and ensure greater adherence to screening protocols by FLWs [Figure 3].

Figure 3: Strategies for strengthening screening for acute malnutrition

Ensuring availability of functional growth monitoring devices and enhancing the knowledge and skills of FLWs

States should ensure availability of growth monitoring devices (GMDs) at all the AWCs and also ensure their maintenance and if needed timely replacement. To improve coverage, states reported their experiences of preparing microplans for screening, sharing of GMDs within nearby AWCs, and using MUAC for identification of wasted/severely wasted children as an interim measure. For improving the skills and knowledge of FLWs, regular trainings and supportive supervision visits by supervisors were useful.

Intensified targeted screening

A more targeted approach can be adopted by states with increased focus on reaching out to underserved areas and the vulnerable population. Some states have also demonstrated increased screening coverage by using strategies such as designating a specific day of every month for SAM screening, increased involvement of family and community members [like involving Panchayati Raj Institutions (PRIs), self-help groups (SHGs), and community leaders], greater mobilization of identified SAM cases by FLWs to Village Health, Sanitation and Nutrition Day (VHSND) for further screening and management by ANM, and establishing stronger referral linkages between in-patient and out-patient facilities for SAM management. The state of Assam celebrates the intensive growth monitoring month to aid in increased coverage under CMAM program.

Theme 3: Nutritional care of wasting

In India, poor IYCF practices still remain one of the leading causes of high prevalence of acute malnutrition.^[8] Following recommendations were provided by experts to improve nutritional care of children with wasting.

Appropriate food for wasting management

Experts in India have raised concerns over the use of ready-to-eat-therapeutic food (RUTF) for treatment of children with SAM because of its high cost, possibility of commercial exploitation, risk of developing metabolic diseases, and adverse effects on traditional dietary practice. Uniform guidelines on CMAM and therapeutic food are also lacking in the country, as a result of which many states have adopted different alternative food items for their CMAM program. In order to improve dietary intake of nutritious foods for managing children with SAM, the following principles can be adopted: the use a combination of take-home ration and home food-based menus and taking it closer to WHO recommendations for nutritional rehabilitation of children with uncomplicated SAM in terms of total calories, proteins, and micronutrients.^[9] It was also agreed to encourage mothers to continue breastfeed, promote use of locally available and inexpensive ingredients (such as roasted groundnuts, soyabean, fruits, and green leafy vegetables), and improve dietary diversity. Menus prepared should be able to meet required micronutrients, especially iron, calcium, vitamin A, thiamine, riboflavin, niacin, free folic acid, vitamin C, and zinc, matching up to 50% of the RDA or the expected average requirement.

Use of Balamrutham Plus in Telangana

Balamrutham Plus was developed by ICMR-NIN as per the directives of Government of Telangana to meet the varied nutrient requirement of children with MAM and SAM under Supervised Supplementary Feeding Programme (SSFP). Balamrutham Plus was developed by modifying the existing THR. The gaps in the intakes of protein and energy for children with SAM and MAM were derived from National Nutrition Monitoring Bureau 2012 data using their average body weights based on the NFHS-4 database. This was followed by calculation of energy and protein requirements based on their body weights and adding additional ingredients to fulfill those gaps. They also assessed shelf life, acceptability, and sensory evaluation for consumption of Balamrutham Plus before using it in the program.

Theme 4: Tracking progress

For consistency and adequacy in reporting of CMAM program, many states have devised applications for data entry and automated computation of anthropometric z-scores for correct classification of child’s nutritional status. One such example for improving reporting mechanisms was shared from Madhya Pradesh. The state data of the CMAM program in Madhya Pradesh are maintained using Bal Poshan Pragati Patra (BPPP) and a newly devised android-based application – Sampark Application. The data entered in the application flow to the CMAM dashboard through which information regarding the grade change in nutritional status of SAM and MAM children, weekly follow-up, and death (if any) can be easily made available. Additionally, there is also a provision of data validation through application and dashboard for ensuring data quality. Another example for real-time tracking was shared from Telangana, which showcased the usefulness of setting up of nutrition surveillance systems for monitoring the activities of AWCs by creating QR codes for each AWC. These QR codes are being used to monitor each child’s growth at different levels using real-time data.

Theme 5: Scaling up

Acute Malnutrition Management and Action Program in Rajasthan

Acute Malnutrition Management and Action (AMMA) program, launched in 2018, as a pilot program, has now been scaled up to the entire state. Some of the challenges faced during scaling up of the program in the state included unavailability of guidelines for management of SAM in children at the community level, lack of convergence between different government departments, unavailability of GMDs, poor reporting mechanisms, unavailability of financial support, and disruption of services because of COVID pandemic. In order to deal with the issue of unavailability of CMAM guidelines, a joint guideline was released by Departments of Medical, Health and Family Welfare and Women and Child Development for management of children with SAM at the community level. To mitigate unavailability of GMDs, MUAC was used for screening and identification of children with SAM. Continuous monthly screenings were conducted for identification and treatment of children with SAM using home-based energy dense feeding and regular counseling sessions conducted by FLWs. Convergence between line departments and Civil Society Organisation partners was also ensured for capacity building of field functionaries, developing IEC materials, and improving reporting and supportive supervision. For strengthening reporting mechanisms, a booklet was developed (for use at the AWC level) to capture anthropometric and screening details of the children along with their nutritional status.

CMAM program in Assam

State-wide implementation of CMAM program in Assam was performed in September 2020, followed by state-level and district-level trainings of all field functionaries. Online refresher trainings were also conducted for FLWs on growth monitoring, screening for SAM, Maternal Infant Young Child Nutrition counseling, and CMAM services. However, during the pandemic, the AWCs were closed, and the state adopted the following alternative service delivery platforms to continue providing services to children with SAM: 1) Using alternative service delivery platforms such as home visits and VHSND and THR distribution points to deliver last mile service; 2) Launch of innovation centers across the state: The state invested their innovation funds on identification of evidence-based interventions for prevention and management of malnutrition; 3) Active participation during POSHAN Maah with increased focus on community interaction and intensified screening: The state distributed nutri-kits as a healthy food option along with the handouts elaborating information on optimal child feeding behavior in the community. Children with SAM were also adopted by departmental officials for house-to-house counseling of families. PRI members and SHGs were also engaged in awareness efforts; 4) Reaching the underserved: POSHAN On Wheels was another initiative where three custom-modified buses (with nutrition IEC materials, GMDs, and an LED monitor displaying short movies on nutritional interventions for different age groups) were used for spreading awareness on nutrition and ICDS services across the state. Ten custom-made mobile AWCs travelled in hard-to-reach areas, delivering all ICDS services right at the doorsteps of the tea garden communities to bridge the gap between community and health facility; 5) Strengthening monitoring and supervision and reporting mechanism: The Department of Social Welfare launched a telephonic sensitization and supportive supervision mechanism to reach out to CDPOs and supervisors, and a team of ‘Mentors for Nutrition’ was constituted. All the CDPOs, supervisors, and AWWs were sensitized on CMAM program, and their knowledge status and gaps are being monitored on a quarterly basis. To improve the reporting mechanism, a light reporting mechanism on CMAM and NRC referrals was introduced across the state.

KEY RECOMMENDATIONS AND CONCLUSION

SAM among children less than 5 years is a serious public health problem in the country. In order to intensify the efforts toward reducing wasting prevalence in the country, the national consultation brought together experiences from different states and experts’ recommendations. It highlighted that addressing acute malnutrition requires systems strengthening by adopting a multi-sectoral approach catering to several underlying causes of malnutrition. Stronger mechanisms for continuous supervision of the existing programs and policies should be in place. Accurate and real-time data capturing, continued trainings of field functionaries, and adequate supply of growth monitoring devices and food supplements should be ensured. Scaling-up of existing programs with improved quality and greater community involvement can help in effective management of acute malnutrition among children. Last, experience sharing between different implementing partners and government counterparts can further help in strengthening the existing programs and foster cross-learning [Figure 4].

Figure 4: Key recommendations from the National Consultation on Addressing Acute Malnutrition

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.