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Indian Pediatr 2014;51: 17-18 |
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Managing Children with Severe Acute
Malnutrition – What’s New?
A HEALTH POLICY PERSPECTIVE
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Mercedes de Onis and Zita Weise Prinzo
Department of Nutrition, World Health Organization.
Email: [email protected]
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S evere acute malnutrition (SAM), i.e. severe
wasting and/or mid-upper-arm circumference (MUAC) <115 mm and/or
bilateral pitting edema, remains a major killer of young children with
mortality rates in preschool-aged children with severe wasting
(weight-for-length/height z-score < –3SD from WHO standards median)
being nine times higher than in well-nourished populations [1].
Globally, 17.3 million children, or 2.6% of the pre-school aged
children, were severely wasted in 2012 [2]. With a national prevalence
of severe wasting of 6.8%, or approximately 8.4 million children [3],
India is home to about half the total. The response to SAM in India is
thus of utmost importance to large numbers of affected children. This
underscores the relevance in this issue of Indian Pediatrics of
the contribution of Singh and colleagues [4] who assess the
effectiveness of facility-based care for children with SAM in nutrition
rehabilitation centres (NRCs) in India’s most densely populated state,
Uttar Pradesh, which has an average of 1.2 million severely wasted
children at any given moment [4].
The program in Uttar Pradesh achieves good results in
terms of survival, and reaches the recommended average weight gain and
length of stay [4]. This is significant and those responsible for
running the NRCs should be commended. In contrast, the prevalence of
"defaulters" and "discharged, non-recovered" is very high. Two factors
likely underlie the poor performance of these two program outcomes. The
first relates to the discharge criterion, i.e., 15% weight gain, and the
second to the absence of a community component to complement
facility-based services.
For the sake of simplicity, the use of 15% weight
gain had been recommended until recently as a criterion for discharge
from treatment. However, since this recommendation was first made [5],
new evidence has shown that a 15% weight gain is not an appropriate
discharge criterion because it results in many children not so severely
affected being discharged labeled as "not recovered" as they were unable
to reach a 15% weight gain. In contrast, the more severely affected
children tend to have the shortest duration of treatment and be
discharged while still malnourished [6]. Thus, the updated WHO
guidelines on the management of SAM no longer recommend discharging
children from treatment on the basis of percentage weight gain but by
relying solely on anthropometric indicators, i.e. children with SAM
should be discharged from treatment only when their
weight-for-height/length is at least
³ –2 Z-score and they
have had no edema for at least 2 weeks, or mid-upper-arm circumference
is ³125 mm and
they have had no edema for at least 2 weeks [6].
Another noteworthy recommendation from the updated
WHO guidelines is that children with SAM who are discharged from
treatment programs should be periodically monitored to prevent relapse
[6]. This highlights the key role of a community-based component that
not only detects SAM cases in a timely manner and provides treatment for
those without medical complications, but also ensures appropriate
follow-up after discharge [7]. This component is currently lacking in
the approach taken in Uttar Pradesh, and its establishment could greatly
benefit the many program "defaulters". A detailed review of the
community-based management of severe malnutrition in children can be
found elsewhere [8]. Essential to this approach is the availability of
appropriate therapeutic foods that are ideally locally produced and
follow WHO specifications for Ready-to-use therapeutic foods [7].
The provision of appropriate doses of vitamins and
minerals is indispensable to the recovery of SAM children. In Uttar
Pradesh, the locally prepared therapeutic formula meant as a substitute
for F-75 and F-100 does not include an electrolyte-mineral solution [4].
The paper by Singh and colleagues mentions that children admitted to the
NRCs were administered micronutrients (namely, vitamin A, folic acid,
zinc, potassium and magnesium) in sufficient doses during their stay.
However, it is not clear how this was done, e.g., as drops or by other
means. Ideally, the vitamins and minerals should be part of the
therapeutic food [7].
The program in Uttar Pradesh covers children 6-59
months of age [4]. Infants less than 6 months are excluded as they are
thought to be protected from SAM by breastfeeding. However, since the
release of the WHO Child Growth Standards, SAM is now increasingly
recognized in young infants [9]. In addition to etiologies such as low
birth weight, persistent diarrhea and other underlying diseases or
disability, the development of SAM in this age group commonly reflects
suboptimal feeding practices. To achieve optimal nutrition and the
greatest protection against infections, infants below six months should
be exclusively breastfed. Yet, rates of exclusive breastfeeding
worldwide remain disappointingly low, with only an estimated 25–31% of
infants who are 2–5 months of age being exclusively breastfed [1].
Greater vulnerability among young infants results in SAM associated with
higher mortality in this age group than in older infants and children
[6]. The updated WHO guidelines [6] include recommendations for managing
infants with SAM below six months taking into consideration the
important physiological differences between them and older children.
Successes or failures occuring in the management of
SAM in India will drive progress in fighting severe malnutrition
worldwide. Not withstanding the importance of treating affected
children, long-lasting progress is contingent on investing in primary
prevention. Preventive interventions may include improving access to
high-quality foods and health care, improving nutrition and health
knowledge and practices, promoting exclusive breastfeeding for the first
six months of life and continued breastfeeding with improved
complementary feeding practices for children aged 6–24 months that focus
on ensuring access to locally available age-appropriate foods, and
improving water supply and sanitation systems and hygiene practices to
protect children against communicable diseases [7].
Because severe acute malnutrition occurs mainly in
families with limited access to nutrient-rich food and that are living
in unhygienic conditions, preventive programs are hugely important in
the context of poverty. Meanwhile, children who are already suffering
from SAM require treatment based on national protocols that follow
evidence-informed guidelines and have a strong community-based component
that complements facility-based services.
Disclaimer: MdO and ZWP are staff members of the
World Health Organization. They alone are responsible for the views
expressed in this commentary that do not necessarily represent the
decisions or policies of the World Health Organization.
Funding: None; Competing interest: None
stated.
References
1. Black RE, Victora CG, Walker SP, Bhutta ZA,
Christian P, de Onis M, et al. and the Maternal and Child
Nutrition Study Group. Maternal and child undernutrition and overweight
in low-income and middle-income countries. Lancet. 2013;382:427-51.
2. United Nations Children’s Fund, World Health
Organization, The World Bank. UNICEF-WHO-The World Bank: 2012 Joint
Child Malnutrition Estimates - Levels and Trends. UNICEF, New York; WHO,
Geneva; The World Bank, Washington, DC; 2013.
3. International Institute for Population Sciences
(IIPS) and Macro International. National Family Health Survey (NFHS-3),
2005-2006. International Institute for Population Sciences: Mumbai,
India, 2007.
4. Singh K, Badgaiyan N, Ranjan A, Dixit HO, Kaushik
A, Kushwaha KP, et al. Management of children with severe acute
malnutrition: Experience of nutrition rehabilitation centers in Uttar
Pradesh, India. Indian Pediatr. 2014; 51:21-5.
5. World Health Organization. WHO Child Growth
Standards and the Identification of Severe Acute Malnutrition in Infants
and Children. A Joint Statement by The World Health Organization and The
United Nations Children’s Fund. 2009. Available from:
http://www.who.int/nutrition/publications/severemalnutrition/9789241598163/en/index.html.
Accessed November 21, 2013.
6. World Health Organization. Updates on the
Management of Severe Acute Malnutrition in Infants and Children. World
Health Organization: Geneva, 2013.
7. World Health Organisation, World Food Programme,
United Nations Standing Committee on Nutrition, United Nations
Children’s Fund. Community-Based Management of Severe Acute
Malnutrition. 2007. Available from: http://www.who. int/nutrition/publications/severemalnutrition/97892806
41479/en/index.html. Accessed November 21, 2013.
8. Prudhon C, Briend A, Weise Prinzo Z, Bernadette
MEG, Mason JB. WHO, UNICEF, and SCN informal consultation on
community-based management of severe malnutrition in children. SCN
Nutrition Policy Paper No. 21. Food Nutr Bull. 2006;27:1-108.
9. de Onis M, Onyango AW, Borghi E, Garza C, Yang H;
the WHO Multicentre Growth Reference Study Group. Comparison of the WHO
Child Growth Standards and the NCHS/WHO international growth reference:
implications for child health programmes. Public Health Nutr.
2006;9:942-7.
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