SevereAcuteMalnutrition:Time for action

Context

One in every twelve children under five in the world today is facing a struggle between life and

death due to a condition that is preventable. These children are at risk of dying because of Acute

Malnutrition. What is shocking is that India contributes to the maximum number of wasted 1children in the world . According to UNICEF, every year 1 million children under 5 die due to

malnutrition related causes in India. The statistics are alarming, and far above the emergency

thresholds for Acute malnutrition (as per WHO classification of the severity of malnutrition). 2Global Acute Malnutrition (GAM) or wasting has been detected in 20% of India's children . One in

3every two child deaths in India every year is due to malnutrition . These deaths are completely

preventable if early action is taken to educate, screen, detect, refer, treat and follow up children

found to be either severely or moderately malnourished.

In the state of Madhya Pradesh, according to NFHS 3, 40% children were stunted [NFHS 2 – 49%], 460% underweight [NFHS 2 – 54%] and 33% wasted [NFHS 2 – 20%] . The rise in these nutritional

indicators in the state is worrisome and it is essential that strategies for addressing this are

adopted on a war footing. According to NIN 2010, about 49% of rural children below five years of

age are stunted in Madhya Pradesh, 52% are underweight and 26 % of the state's children are 5wasted (Global Acute Malnutrition or GAM) .

ACF-India, a member of Action Against Hunger International (www.actionagainsthunger.org) has

been working in Burhanpur district in Madhya Pradesh since 2012 to address the issue of Global

Acute Malnutrition and specifically Severe Acute Malnutrition (SAM) amongst children under 5.

1UNICEF's Improving Child Nutrition Report 2013

2NFHS 3

3UNICEF India

4NFHS 3

5Global Acute Malnutrition or GAM (weight-for-height <-2 SD WHO 2006)

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Nutritional Situation in Burhanpur district in Madhya Pradesh

Burhanpur district is divided into two development blocks, Burhanpur and Khaknar, and three

tehsils, Nepanagar, Burhanpur and Khaknar.

6SMART or “Standardized Monitoring and Assessment of Reliefs and Transitions” is a nutrition survey providing information on

nutritional and mortality indicators

The prevalence of GAM in Burhanpur district is 34.7 % and the SAM prevalence at 4.7 % as per ACF 6last nutrition survey conducted in June 2014. A previous survey was conducted in November 2013

and an increase of 10 percentage points between both periods has been worryingly reported.

Indicator – WHO 2006 Nov. 2013 June 2014

GAM

(weight-for-height <-2 SD; MUAS < 125mm)

SAM

(weight-for-height <-3 SD; MUAC < 115mm)

24.6%

[20.4% - 29.3%]

3.4%

[1.9% - 6.1%]

34.7%

[30.6% - 38.8%]

4.7%

[3.3% - 6.0%]

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Based on these results, ACF will strengthen and scale up its nutrition activity in 149 villages of

Khaknar block and adjust its current program to better address the nutritional situation of the

district.

ACF's intervention in Khaknar Block

7In the last year of project , 77584 screenings were done in 80 villages, covering 91% of the total

number of children under 5 in the intervention area.

77584 Screenings

80 Villages

91% Children screened

9 988 Children screened monthly

629 Total SAM detected

ACF effectively referred 74% of the above children to the 3 Nutrition Rehabilitation centers of the

block, using MUAC criteria (Mid-Upper Arm Circumference < 115mm for SAM children and

<125mm for MAM children). ACF found a 22% increase in referrals from the project area based on

MUAC used by ACF community mobilisers to screen the children. MUAC is used at community level

while both MUAC and WFH are used at facility level.

Why MUAC as a measurement is important?

WHO/ UNICEF recommend the MUAC as an important measure for SAM as it is

- The best index to assess the risk of death: it is at least as good or even better to identify children with a high risk of death in need of treatment.

- Easy to use community level tool: the MUAC is an easy and cheap tool to use both in the community and in the health facility and easy for service providers and caretakers of children to understand.

7 From September 2013 to August 2014

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Activities done in Khaknar block

In the past year, ACF has conducted several activities to increase awareness on acute

malnutrition and improve understanding amongst caregivers of SAM children and their

communities. ACF also ensures the early detection of children with Severe and Moderate Acute

Malnutrition, along with the awareness of their caregivers on the life threatening condition of

their children. Effective referral to Nutrition Rehabilitation centers (NRCs) for SAM children and

Angawandi Centers (AWC) for MAM children are monitored by the field team.

The activities conducted for increasing awareness are mother's education and counseling

sessions, focus group discussions and home follow-up visits. Impacting the entire community, in

the past year 1076 awareness camps gathering 7167 people per month have been conducted in

the 80 villages where ACF is working. Currently an average of 4143 people of the community are

receiving educational sessions every month. The sessions also strive to increase community

awareness and participation so as to prevent risks of acute malnutrition amongst the

communities.

A typical Education Session would include:

Awareness of Good Nutrition Practices

Sensitization of Child Care Practices and Mother Child Bonding

IYCF practice promotion focused on the 1000 days of windows of opportunities, for

children aged under 2 years

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Challenges and limitations of the intervention

ACF's intervention in 80 villages in the past year has resulted in 74% children being effectively

referred to NRCs. However, data from the NRC shows that only 32% children have been discharged

as cured (based on WHO criteria of MUAC and WFH), 11% were discharged as defaulters and 56%

children were discharged as non-recovery. The cured rate is below the minimum SPHERE

standards (Cured rate should be >75% for a nutrition program targeting Acute malnutrition).

What is of concern is that although there are several admissions, the NRCs also face a lack of beds

available and 32% of the time, they reach the full capacity of service delivery. With the protocols

currently in use in NRCs, most SAM children are discharged still uncured, presenting an existing

risk of deterioration.

Education sessions

IYCF practicespromotion

Home follow-up visit

Child care practices during/after illness

11% defaulters56% discharged as non recovery

32% discharged as cured

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Some findings that are alarming and need consideration:

Findings Facts to consider

The 3 NRCs of Burhanpur have a total capacity of 45 beds.

The admissions from the project have been much larger (average 70 per month from April to August 2014). Therefore bed availability for children who need it is an absolute necessity but is not available.

32% of the time (yearly basis), these NRCsare fully occupied

A third of the year, if the NRCs are fully occupied, it means that even if more referrals happen, then admissions are not possible. That implies that for some children who need admission and treatment there may not be space in the NRC.

The protocol followed in these NRCs are aligned with the MP guidelines, not complying with WHO latest recommendations of 2013

The protocol needs to be aligned with WHO's latest recommendations for in- patient care at NRCs.

Discharge criteria are not based on MUAC or WFH but percentage of weight gain, leading to discharge of children that still have SAM

WHO's latest recommendations are that Children with severe acute malnutrition should only be discharged from treatment when their:

— weight-for-height/length is �–2 Z-score .and they have had no oedema, or

— mid-upper-arm circumference is �125 mm and they have had no oedema

Percentage weight gain should not be used as a discharge criterion

There is no continuum of care because the community does not have the means to take over the management of the SAM child to complete his/her treatment until complete recovery, neither the PHC/CHC nor the AWC through its Suposhan program.

After being discharged from the NRC, there needs to be a system of community based management of SAM children. This entails regular follow up with children, who have been discharged, adopted therapeutic food being provided to the family, care and support being extended to the child such that he/she recovers fully.

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Recommendations

Community action and involvement is necessary. Adopt the CMAM approach. Involve caregivers in planning processes for identification, treatment, and prevention of

malnutrition. Without this, there will be no change in the statistics.

The CMAM approach has 4 components:

1. Under-nutrition awareness and prevention to Community mobilization:

reinforce the community ownership, early detection and referral with subsequent

follow-up.

2. once SAM children are detected by the Outpatient Therapeutic Program (OTP):

community workers, they are referred to the nearest OTP. The OTP sites will open

once in a week following a regular rotation, and will admit SAM children without

medical complications and provide them appropriate follow-up and home-based

treatment. The location of these sites will be strategically determined based on

the current program catchment area. A clear therapeutic protocol would need to

be prior developed and validated based on MP guidelines and latest WHO

recommendations. An adapted ready-to-use treatment will allow home-based

recovery for SAM children, increase the coverage of the program and ease the

follow-up process when compared to the current facility-based response of 14-day

of MTC hospitalization.

3. These MAM children should be referred Supplementary Feeding Program (SFP):

to the Angawandi Centre (ICDS program) in absence of specific Ready-to-use

supplementary food.

4. This component mainly focuses on the facility-based treatment of Inpatient care:

SAM children with medical complications threatening his life and his recovery.

The CMAM approach helps creating long-term community-based therapeutic care program to

continue throughout the year and decentralizes malnutrition care and treatment, increasing the

coverage and making it more accessible to children residing in interior villages.

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Set up an Emergency response system for peak seasons. Given the seasonal nature of the problem, and the monsoons being 'a season of death', an

emergency response is essential to ensure all SAM children are detected and attended to

on an immediate basis.

Convergent action is necessary. Involving all government departments and NGOs that relate to malnourished children and

their families is essential so that relief efforts can be coordinated. Not only do Health and

WCD departments need to work together to ensure this., but other departments such as

Water-Sanitation, Education, Rural Development , Panchayati Raj, PDS and Agriculture

also need to converge as recommended in the Block Operational Plan document of the

Coalition of Food and Nutrition Security (www.nutritioncoalition.in).

Nutrition Training for Frontline workers: ANM, ASHA, AWWs and helpers Provide on the ground job training to all frontline workers on malnutrition identification,

treatment, and prevention.

Use criterion for detection, as recommended by WHO updated guidelines Use the MUAC tape for community screening and the MUAC and WFH criterion for

admission and discharge at the NRC. Make provisions for weighing machines, and MUAC

Tapes at all AWCs and with all ASHAs such that detection of SAM is early and easy.

Therapeutic Feeding programs Ensure all feeding programs – PDS, Anganwadis and State programs that address

malnutrition - (Suposhan) are well coordinated in order to ensure food and care reach the

most needy children.

Production and procurement of adapted therapeutic foods for acutely malnourished

children will ensure that SAM children without medical complications can be treated at

community level and SAM children with medical complications discharged from NRCs

after hospitalization will continue to receive proper therapy until their complete

recovery.

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Contact us:

ACF-India (Action Against Hunger)

Thomas GONNET, Executive Director Email: tgonnet@actioncontrelafaim.org

Dr. Rajiv Tandon, Deputy DirectorEmail: deputycd@in.missions-acf.org

Tram Le Minh , Head of Nutrition & Health DepartmentEmail: cmn@in.missions-acf.org

Action Against Hunger | ACF International is a humanitarian organization committed to ending world hunger.

Recognized as a leader in the fight against malnutrition, Action Against Hunger | ACF International saves the lives of malnourished children while providing communities with access to safe water and sustainable solutions to hunger. With 35 years of expertise in emergency situations of conflict, natural disaster, and chronic food insecurity, ACF intervenes in over 40 countries benefiting seven million people each year.

ACF's 5,000+ professionals worldwide carry out innovative, life-saving programs in nutrition, food security & livelihoods, health, water, sanitation and hygiene through direct assistance and capacity building programs, in collaboration with government ministries and other Civil Society Organizations. Committed to principled humanitarian action, ACF restores dignity, self-sufficiency and independence to vulnerable populations around the world.

For more information, visit us at: www.www.actioncontrelafaim.org/en

Address: D-14, 3rd Floor, Lajpat Nagar II, New Delhi 110 024India

We are thankful for the support from ECHO towards this Program report.