Adequate nutrition is required for physical, cognitive and overall growth of the child. India’s under-5 mortality rate is 39 per 1000 live births. This is worse than China (9 per 1000), Libya (12), Tunisia (13), Indonesia (25), Philippines (28), Bangladesh (32) and Nepal (33). Malnutrition is the major cause of India’s under 5 mortality numbers. It was the predominant risk factor of death in children under 5 years in India in 2017, accounting for 68.2% deaths, and the leading risk factor for health loss of all ages, responsible for 17.3% of the total disability adjusted life years (DALYs).[1]

There are various case fatality rates reported by different experts on SAM. While the WHO estimates mortality rates to be around 10-20%[2], some experts in India believe that it is much lower.  But, even at the lowest average case fatality suggested, at 3%, about 1.7 lakh children are at risk of death in India.

Treatment of SAM:

At present the only treatment protocol in India for SAM children is to admit the complicated cases for facility-based care. But there are only about 1200 Nutritional Rehabilitation Centers – and at around 7800 cases per center - these are not enough to treat so many sick children. Covid-19 has also disrupted health services across the country. It is also suitable during the pandemic that treatment facilities be avoided.

In any case, 90% of SAM cases need not go to facility based care and can be treated in the community through community-based management (CMAM) programs using Ready-to-use Therapeutic Food (RUTF)[3], which is the universally accepted treatment protocol recommended by UNICEF & WHO for uncomplicated SAM children.

CMAM is a treatment protocol wherein the caregivers of the child are trained in proper nutritional habits, hygiene and breastfeeding practices. The child is provided emergency nutritional supplement in the form of RUTF for 8-12 weeks and medicines to treat any illnesses like diarrhea and edema which are found in many SAM children.

Alternative feeding models using a combination of RUTF and home-based food are also being explored. The suitability of these alternative models must be studies in the Indian context.

CMAM programs using emergency RUTF have been successful in saving lives of SAM children in various countries in Africa and Asia and in independent pilot projects in various Indian states like Rajasthan, Gujarat, Bihar, Madhya Pradesh and Jharkhand. In Rajasthan, a recovery rate of 70.4% was recorded and mortality rate was brought down to 0.1% under the state POSHAN program using RUTF. However, the final guidelines on CMAM are still pending

[1] https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(19)30273-1/fulltext

[2] https://www.ncbi.nlm.nih.gov/pubmed/31613883

[3] RUTF are energy-dense, micronutrient enhanced pastes which typically have peanuts (or corn, chickpea etc.), oil, sugar, milk powder and citamin and mineral supplements

In India, Severe Acute Malnutrition (SAM) is amongst the top causes of deaths for children under five years of age. The current official treatment protocol for SAM in our country is facility-based approach or F-SAM, which in a lay men’s term is where SAM children with medical complications are treated at a facility. The number of SAM children with medical complications are close to 10-15% of the total SAM children, the question here is, how the rest of the 85-90% of SAM children without medical complication are treated?

The answer is they are left at the community level, to be taken care by angawadi’s and at home. Why is that a problem you ask? These 85-90% of children are 9 times more likely to die as compared to a healthy child. It is very important to provide treatment for uncomplicated severe acute malnutrition at the community level as well.

According to the WHO guidelines about best practices to deal with SAM, a synergised action at institutional and community level is essential to deal with SAM effectively. This integrated multi-sectoral synergised approach could comprise of in-facility treatment of children afflicted with illnesses, and out-patient management of children without medical complications in community settings using Ready-to-Use Therapeutic Food (RUTF).

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