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Indian Pediatr 2014;51:
21-25 |
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Management of Children with Severe Acute
Malnutrition: Experience of Nutrition Rehabilitation Centers in
Uttar Pradesh, India
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K Singh, N Badgaiyan, *A Ranjan,
#HO Dixit, $A
Kaushik, †KP Kushwaha and VM
Aguayo
From the Child Nutrition and Development Programme,
UNICEF, New Delhi; *Child Nutrition and Development Programme, UNICEF,
Uttar Pradesh; #National Rural Health Mission, Uttar Pradesh; $MLB
Medical College, Jhansi, Uttar Pradesh, and
†BRD Medical College, Gorakhpur, Uttar Pradesh; India.
Correspondence to: Dr. Karanveer Singh, UNICEF; 73,
Lodi Estate, New Delhi, 110003, India.
Email: [email protected]
Received: July 27, 2012;
Initial review: September 26, 2012;
Accepted: August 14, 2013.
Published online: September 05, 2013.
PII: S097475591200686
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Objective: To assess the effectiveness of facility-based care
for children with severe acute malnutrition (SAM) in Nutrition
Rehabilitation Centers (NRC).
Design: Review of data.
Setting: 12 NRCs in Uttar Pradesh, India.
Participants: Children admitted to NRCs (Jan 1,
2010 - Dec 31, 2011).
Intervention: Detection and treatment of SAM with
locally-adapted protocols.
Outcomes: Survival, default, discharge, and
recovery rates.
Results: 54.6% of the total 1,229 children
admitted were boys, 81.6% were in the age group 6-23 months old, 86%
belonged to scheduled tribes, scheduled castes, or other backward
castes, and 42% had edema or medical complications. Of the 1,181 program
exits, 14 (1.2%) children died, 657 (47.2%) children defaulted, and 610
(51.7%) children were discharged The average (SD) weight gain was 12.1
(7.3) g/kg body weight/day and the average (SD) length of stay was 13.2
(5.6) days. 206 (46.8%) children were discharged after recovery (weight
gain ³15%)
while 324 (53.2%) were discharged, non-recovered (weight gain <15%)
Conclusions: NRCs provide life-saving care for
children with SAM; however, the protocols and therapeutic foods
currently used need to be improved to ensure the full recovery of all
children admitted.
Keywords: Child, Management, Protein energy
malnutrition, Severe wasting.
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S evere acute malnutrition (SAM) remains a major
killer of children as mortality rates in children with severe wasting -
a widespread form of SAM - are nine times higher than those in
well-nourished children [1]. India’s third National Family Health Survey
(NFHS-3) indicates that the prevalence of severe wasting is 7.9% as per
WHO Child Growth Standards [4]. Therefore, at any point in time, an
average eight million Indian children under age five years are severely
wasted [5] and are dangerously undernourished to survive, grow and
develop to their full potential.
In the state of Uttar Pradesh – the most densely
populated state of India - NFHS-3 indicates that 14.9% of children 0-59
months old are wasted and 5.2% (an average 1.2 million children at any
point in time) are severely wasted [4]. The response to SAM in Uttar
Pradesh is led by the National Rural Health Mission (NRHM). Currently,
this response relies on a network of Nutrition Rehabilitation Centers
(NRCs), where children with SAM receive therapeutic care following
protocols based on the guidelines for the management of SAM by the World
Health Organization (WHO) [7] and the Indian Academy of Pediatrics (IAP)
[8].
The objective of the analysis presented here is to
assess the effectiveness of NRCs in providing therapeutic care for
children with SAM in Uttar Pradesh and to inform the future design and
implementation of programs for the provision of care for children with
SAM in Uttar Pradesh and in India.
Methods
For the purpose of this analysis, we retrieved the
data of all children with SAM admitted from 1 January, 2010 to 31
December, 2011 to the 12 functional NRCs of Uttar Pradesh.
The detection of children with SAM was ensured in the
villages by the community workers of the Integrated Child Development
Services (ICDS) program either as part of monthly growth monitoring and
promotion sessions at the ICDS center (passive case finding) or in the
context of community drives for the identification of children with SAM
(active case finding). During passive case finding sessions the weight
and mid-upper-arm circumference (MUAC) of children 6-59 months old were
measured, and the presence of bilateral pitting edema was assessed.
During active case finding sessions the MUAC of children 6-59 months old
was measured and the presence of bilateral pitting oedema was assessed.
All children with bilateral pitting edema, and/or MUAC <115 mm, and/or
weight-for-age z-score (WAZ) below -3 SD of WHO Child Growth Standards
[9] were referred to the NRC.
At the NRC, the age, weight, height/length, MUAC,
presence/absence of bilateral pitting edema and appetite were assessed
in all children. SAM was defined as per WHO recommendations by the
presence of bilateral pitting edema or the presence of severe wasting.
Severe wasting was defined as per WHO recommendations by a MUAC below
115 mm and/or a weight-for-height/length z-score (WHZ) below -3SD of WHO
Child Growth Standards [10]. All children 6-59 months with SAM were
admitted to the NRC.
At the NRC, a physician conducted a clinical
examination in children to detect the presence/absence of medical
complications (altered alertness, respiratory tract infections, diarrhea/severe
dehydration, high fever/malaria, tuberculosis, and/or severe anemia)
using the criteria for the Integrated Management of Neonatal and
Childhood Illnesses (IMNCI) [11]. Children with medical complications,
and/or bilateral pitting edema, and/or with poor appetite were fed a
locally-prepared therapeutic formula meant as a substitute for F-75
(herewith referred to as F75-proxy) to provide 100 kcal/kg/day (Web
Table I). These children were fed F75-proxy every two hours for
two days while their medical complications were treated and monitored by
a physician. After completion of the initial 48 hours in the NRC, these
children were fed a locally prepared therapeutic formula meant as a
substitute for F-100 (herewith referred to as F100-proxy) (Web
Table I) six times a day for 48 hours to initiate rapid weight
gain (rehabilitation phase). Children with normal appetite and free of
bilateral pitting edema and medical complications were fed F100-proxy
from the day of admission. After completing four days at the NRC,
children were fed F100-proxy alternated with a locally prepared
semi-solid food (Web Table II) until the child was
discharged from the NRC. All children admitted to the NRC were
administered micronutrients, namely vitamin A (one age-appropriate
preventive dose), folic acid, zinc, potassium and magnesium in
sufficient doses during the entire period of stay in the NRC as well as
broad spectrum antibiotics for 7-10 days.
Children were discharged from the NRC when they met
the following discharge criteria: (i) the child was active and
alert; (ii) the child had no signs of bilateral pitting edema,
fever, and/or infection; (iii) the child had completed all
age-appropriate immunizations; (iv) the child was being fed
120-130 kcal/kg weight/day; and (v) the primary caregiver knew
the care that the child needed to receive at home. Once discharged from
the NRC, children were to be followed up in the community by the ICDS or
NRHM workers to ensure that the child was enrolled in and benefited from
ICDS Supplementary Nutrition Program, and that the child returned for a
follow up visit to the NRC every 15 days during the six weeks following
discharge (i.e. three follow up visits).
Data management: Data recording was done in the
registers maintained at the NRCs. Data entry and data analysis preserve
children’s anonymity by using children’s unique identification number
only. Data management was done with support by NRHM, Government of Uttar
Pradesh. Data analyses were conducted using Stata Software 12.1 (Stata
Corp LP).
Results
A total of 1,264 children 6-59 months old were
referred to the NRCs; 35 children (2.8%) did not meet the admission
criteria (Table I). Of the 1,130 children with severe
wasting 1,013 children (89.7%) had a weight-for-height/length z-score
(WHZ) below -3 SD, 907 children (80.7%) had a MUAC <115 mm, and 799
children (70.7%) had both a weight-for-height/length z-score (WHZ) below
-3SD and a MUAC <115 mm.
TABLE I Characterstics of The Study Children
Category |
Number (%) |
Children referred to NRCs |
1,264 (100) |
Not admitted
|
35 (2.8) |
Children admitted to NRCs |
1,229 (100) |
Girls |
558 (45.4) |
Age |
|
6-11 mo |
489 (39.9) |
12-23 mo |
514 (41.8) |
24-35 mo |
147 (12.0) |
36-47 mo |
32 (2.6) |
48-59 mo |
47 (3.8) |
Caste |
|
Scheduled Tribe (ST) |
148 (12.0) |
Scheduled Caste (SC) |
420 (34.2) |
Other Backward Class (OBC) |
425 (34.6) |
Clinical findings |
|
Social identity not recorded |
70 (5.7) |
With bilateral pitting edema |
99 (8.1) |
With severe wasting |
1,130 (91.9) |
With medical complications |
417 (36.9) |
With complicated SAM* |
516 (42.0) |
*SAM with edema and/or medical complications. |
The program outcomes recorded are detailed in
Table II. 610 children (51.7% of the exists) were discharged
from the program when they met the discharge criteria; the average
weight gain of these children while in the NRC - determined as the total
individual weight gain (after loss of edema in the case of children who
had edema at admission) of all the discharged children divided by 610 -
was 12.1 ± 7.3 g/kg body weight/day and their average length of stay in
the NRC - determined as the sum of the number of days in the NRC of all
discharged children divided by 610 – was 13.2 ± 5.6 days (Web
Table III).
TABLE II Outcomes in study Children with Severe Acute Management (SAM) Admitted to Nutrition
Rehabilitation Centers Uttar Pradesh (Jan 1, 2010 to Dec 31, 2011), India
Outcomes |
Complicated SAM* |
Uncomplicated SAM# |
All children with SAM |
|
(N=516), n (%) |
(N=713), n (%) |
(N=1229), n (%) |
Admitted |
|
|
|
Exits |
483(93.6) |
698(97.9) |
1,181(96.1) |
Transfers |
33(6.4) |
15(2.1) |
48(3.9) |
Exits |
|
|
|
Deaths |
12(2.5) |
2(0.3) |
14(1.2) |
Defaulters |
237(49.1) |
320(45.8) |
557(47.2) |
Discharged |
234(48.4) |
376(53.9) |
610(51.7) |
Discharged |
|
|
|
Recovered |
86(36.8) |
200(53.2) |
286(46.8) |
Non-recovered |
148(63.2) |
176(46.8) |
324(53.2) |
*SAM with edema and/or medical complications; #SAM without edema
or medical complications.
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TABLE III Program Performance Indicators in Nutrition Rehabilitation Centers Uttar Pradesh (Jan 1, 2010 to Dec 31, 2011), India
Outcomes |
Complicated SAM* |
Uncomplicated SAM# |
All children with SAM |
|
n (%) |
n (%) |
n (%) |
Deaths |
12(2.5) |
2(0.3) |
14(1.2) |
Defaulters |
237(49.1) |
320(45.8) |
557(47.2) |
Discharged, recovered |
86(17.8) |
200(28.7) |
286(24.2) |
Discharged, non-recovered |
148(30.6) |
176(25.2) |
324(27.4) |
Total exits |
483(100.0) |
698(100.0) |
1,181(100.0) |
*SAM with edema and/or medical complications; #SAM
without edema or medical complications. |
Only 154 (25%) of the 610 discharged children, came
back for three follow up visits after discharge, 175 (29%) came back for
two follow up visits, 219 (36%) came back for one follow up visit and 62
(10%) did not come back for any follow up visit. Of the 62 discharged
children who did not come back for any follow up visit, 50 (80%) had
been discharged, recovered while 12 (20%) had been discharged,
non-recovered (data not presented). The program performance indicators
are shown in Web Table III. Of the 1,181 program exits
(deaths, defaulters and discharged), the proportion of children who died
was 1.2% and the proportion of children who defaulted was 47.2 %.
Discussion
The program achieved survival outcomes that compare
favorably with national and international standards of care (<10% child
deaths) [12,14]. This is important as the primary objective of NRCs is
to reduce fatality rates among children with SAM. More than half (58.2%)
of the children admitted to the NRCs had uncomplicated SAM (no edema
and/or medical complications). International guidelines recommend that
children with uncomplicated SAM be cared for through a community-based
program for the management of SAM [13] as these children are at a
significantly lower risk of death than children with complicated SAM and
can be cared for at home if an appropriate community-based therapeutic
feeding program is in place. The data presented here indicate that in
the NRCs in Uttar Pradesh, the death rate among children with
complicated SAM was six times higher than among children with
uncomplicated SAM.
The proportion of children who defaulted (45.3%) was
significantly above national and international standards of care (<15%)
[12,14]. High defaulter rates have been reported by other facility-based
interventions for children with SAM in India [15]. Undoubtedly, the high
defaulter rates observed raise a question about the quality and
relevance to families of the care provided at the NRCs. This merits
further investigation for corrective action.
Only 51.7% of the children admitted were discharged.
The average weight gain of these children while in the NRC compares
favorably with the nationally and internationally-agreed upon minimum
average weight gain ( ³8
g/kg body weight/day) for programs that treat children with SAM [12,14].
This average weight gain is significantly higher than that achieved by
therapeutic feeding programs in India using energy dense local foods in
hospital-based nutrition rehabilitation units (5g/kg body weight/day)
and so is the proportion of discharged children who achieved rapid catch
up growth i.e. >10g/kg/day (37.4% vs. 12%) [15]. However,
only 46.8% of the 610 children discharged gained at least 15% of their
initial weight, the minimum weight gain recommended by WHO and India’s
Ministry of Health to discharge children as recovered [12,14]. The
proportion of children discharged is below the national and
international standard of care (>75%) for programs that treat children
with SAM [12,14]. The average length of stay of children who were
discharged, recovered and children who were discharged, non-recovered
was not significantly different, indicating that the main difference
between these two groups was not the length of stay but the ability to
gain weight while in the NRC.
Thus, NRCs provide live-saving care for children with
SAM as demonstrated by the high survival rates of the program. However,
other than survival, program outcomes are below optimal. Two program
outcomes - the high defaulter rate and the low recovery rate are of
particularly concern. 53% of the discharged children did not fully
recover (weight gain <15%), primarily because their average daily weight
gain was sub-optimal. Therefore the protocols and therapeutic foods
currently used need to be improved and include the use of appropriate
therapeutic foods (F 75 and F 100) containing all nutrients in
appropriate concentration for the optimal recovery of children with SAM.
Community-based therapeutic care for children with
uncomplicated SAM needs to become a key component of the
continuum of care for children with SAM. 58% of the children admitted
could have been treated in their communities as they had uncomplicated
SAM. Global evidence shows that good quality ready-to-use therapeutic
foods are effective in supporting rapid catch-up growth in children with
SAM [16] and can be safely used in community-based programs [13]. There
is emerging consensus as to why and how they can be used in India
[17-19]. With an effective community-based program for early detection
and treatment, most children with SAM can be cared for by their mothers
and families at home while Nutrition Rehabilitation Centers (NRCs) are
reserved for children with SAM and medical complications.
Acknowledgements: We acknowledge the
medical officers and staff in the NRCs for their contribution to the
implementation of the program and thank Rajni Tomar, for coordinating
records management and data entry for the purpose of this analysis.
Contributors: KS, RA and VA contributed to
program design; RA, HOD and AK contributed to program implementation and
monitoring; KS, NB and VA led data analysis and interpretation and wrote
the manuscript. All the authors reviewed and approved the final
manuscript.
Funding: Government of Uttar Pradesh (NRHM) and
UNICEF; Competing interests: None stated.
Disclaimer: The views expressed in this paper are
those of the authors and do not necessarily reflect the official
position of the institutions they are affiliated with.
What is Already Known?
• In Uttar Pradesh, the response to SAM
relies on a network of Nutrition Rehabilitation Center (NRCs)
where children with SAM receive therapeutic care
What This Study Adds?
• NRCs provide live-saving care for children
with SAM as indicated by survival rates of over 98%; however,
default and recovery rates are below standards.
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