Severe acute malnutrition: Time for urgent action
Department of Pediatrics, TN Medical College and BYL Nair Hospital and Editor, Journal of Postgraduate Medicine, India
S B Bavdekar
Department of Pediatrics, TN Medical College and BYL Nair Hospital and Editor, Journal of Postgraduate Medicine
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Bavdekar S B. Severe acute malnutrition: Time for urgent action.J Postgrad Med 2010;56:61-62
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Bavdekar S B. Severe acute malnutrition: Time for urgent action. J Postgrad Med [serial online] 2010 [cited 2020 Apr 6 ];56:61-62
Available from: http://www.jpgmonline.com/text.asp?2010/56/2/61/65270
Children who have very low weight-for-height (over 3 z scores below the median) or have a mid-upper arm circumference (MUAC) of less than 115 mm or have nutritional edema are labeled as having severe acute malnutrition (SAM).  It is estimated that the world over, 26 million children suffer from SAM. In India, over 8 million children are afflicted by SAM. These children have mortality rates that are nine times higher than well-nourished children. SAM contributes to approximately 1 million child deaths annually. These statistics make it amply clear that SAM is a major health problem and should be a top priority for any country.
The good news is that most of the deaths due to SAM can be prevented. The WHO-UNICEF Joint statement provides a plan for the management of these children. It envisages two phases of management depending upon the child's condition: a facility-based management and a community-based management.  These two phases are complementary and not mutually exclusive. Children with SAM who have poor appetite or those who have an acute medical complication need to be managed in a facility; while those without these indications can be managed at the community level. Community-based or home-based management is a crucial component of management of children with SAM. Not all children with SAM require inpatient care and in any case no country has enough hospital beds to house every child with SAM. Community-based care ensures that the family is disturbed to only a minimal extent. This is of vital importance, as admission of the child to a healthcare facility exacerbates economic and social stresses in the poverty-stricken families. For restoration of nutritional status, F-75 and F-100 formulae are sequentially used during admission, if necessary through a nasogastric tube. After recovery, when the child shows weight gain of over 5 gm/kg/d, the child is discharged and followed up in the community-based phase. To ensure continued weight gain, WHO and UNICEF employ a peanut butter-based ready-to-use therapeutic food (RUTF) for feeding children.
Experience from studies has shown that it is possible to implement the WHO-UNICEF protocol in facilities and this has resulted in a decline in the mortality rates. , The community-based care has also been shown to be effective and sustainable in managing children with SAM. ,,,, India has a large number of children with SAM and they require urgent attention. Pilot studies have shown that it is feasible to implement the WHO-UNICEF protocol for treating children with SAM in healthcare facilities and that RUTF is acceptable to these children.  India also has a large healthcare sector with primary health centers and sub-centers catering to smaller communities even in remote areas and district hospitals and specialty hospitals situated in cities, towns and district places. It is possible to implement a large-scale program through this public health infrastructure utilizing the experience gained through other schemes such as Integrated Child Development Scheme (ICDS).
It is true that the healthcare infrastructure faces several challenges including shortage of dedicated personnel, need for training, and inaccessibility of certain healthcare posts; etc. These need to be tackled through various measures listed in [Table 1]. The need to identify the right RUTF for home management is a major issue. For the home-management phase, children with SAM require safe, palatable high-energy-density food which also contains adequate amounts of vitamins and minerals. This therapeutic food needs to be provided in a ready-to-use form, to avoid bacterial contamination and differences in composition that may occur, if they are prepared or cooked at home. WHO has approved a high-protein and high-energy peanut-based paste for use as a ready-to-use therapeutic food (RUTF). The spread is a mixture of milk powder, sugar, vegetable oil, peanut butter, vitamins and minerals. Several scientists and activists have expressed reservations regarding using an imported RUTF for the program.  They feel that relying on imported food rather than developing a comprehensive strategy for managing SAM could only be, at best, a short-term measure. They also feel that the potential of indigenous infant foods in treating SAM has not been completely explored and that the cost-effectiveness of using RUTF needs further evaluation. They also fear that using imported RUTF could provide a back-door entry for infant food manufacturers and would threaten the culture of providing 'home-made food' for infants. They suspect that huge commercial interests are acting as a driving force influencing scientists, doctors and governments across the world.  Considering the havoc played by the breast-milk substitutes and infant food industry in the past, these fears cannot be considered to be totally unfounded. At the same time, one cannot neglect the urgent need to have a therapeutic food for children with SAM. Ensuring that RUTF is distributed only through public health programs for the management of children with SAM would help assuage some of these fears. Simultaneously, there is a need for research aimed at developing indigenous infant foods that would provide equivalent weight gain and ensure early recovery from severe acute malnutrition. It is interesting to note that Maharashtra's child and mother nutrition program has achieved some success with indigenously developed infant foods.  This data needs to be analyzed further.
As always, prevention is better than cure! What we need is promotion of low-cost sustainable solutions like optimal infant and young child feeding so that SAM does not occur. This can be achieved through promotion of breastfeeding, education of mothers regarding proper infant feeding practices, transferring the skills in preparation of low-cost high-energy foodstuffs to mothers, training of doctors and healthcare workers in nutrition and dietetics and motivating them to provide appropriate nutritional advice at every health contact.
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