Treating Malnutrition: An integrated approach required

A child suffering from Severe Acute Malnutrition, needs to undergo a treatment protocol, we must understand that the very reason for a child becoming severely malnourished is an outcome of socio-economic imbalance and chronic hunger

CJ: Sachin Kumar Jain

Thu, Jun 11, 2009 12:08:34 IST

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Health Care :

WE HAVE an army of 130 thousand anganwadi workers and Accredited Social Health Workers (ASHA) but even then we are not able to counter the serious problem of Sever Acute Malnutrition (SAM) that is causing the death of millions of children in their childhood and even after that age, because we are still lacking in an integrated strategic protocol for addressing SAM in Madhya Pradesh. Our present policy just considers one solution, double the ration for SAM children and forget other protection services! It is a matter of concern that till date, we could not come out with suggestive recipes that could be prepared and cooked at family level by using locally available ingredients. The National Institute of Nutrition (NIN), Hyderabad has been coming out with studies on such recipes many a times but those have not been incorporated in the system. So the services of NIN should be sought by the state government for help in finalising recipes and production processes for RUTF.

In very first stage of addressing the grave problem of malnutrition, we need to adopt proper strategies for the identification of malnutrition by using Mid Upper Arm Circumference (MUAC). SAM children with complications need to be provided proper institution (Nutritional Rehabilitation Centers and Primary Health Centers) based services, while the uncomplicated cases can be treated in the community with support from the ICDS.

Further, while once a child enters the category of SAM, he/she needs to undergo the treatment protocol; we must also understand that the very reason for a child becoming severely malnourished is an outcome of socio-economic imbalance and chronic hunger. Since we are not addressing this situation, after the treatment, the child will go back to the same conditions of access to food and is likely to become malnourished again. The other children in the family are also vulnerable. The group working on children’s right to food therefore feels that while working on the treatment protocols for SAM children, the affected families should be given protection through food and employment entitlement based schemes (like AAY, NREGS, Social Security Pension etc.). The various field analyses show that having a social security net is a fundamental requirement to address malnutrition. There has to be an immediate step by the state government to prepare a Comprehensive and Integrated Child Health and Nutrition Policy on priority.

Similarly, the treatment protocol for SAM must identify promotion of breastfeeding up to two years of age as one of the non-negotiable components. The linkages of malnutrition with low breastfeeding are quite visible. In Madhya Pradesh also, malnutrition rises once the cycle of breast feeding is broken. While support must be provided for exclusive breast feeding for the children under the age of 6 months, those in the age group between 6-36 months should be provided with locally made and culturally accepted nutrition in the form of take home rations. Children in the 3 to 6 years age group can be provided with hot cooked meals in the anganwadi centre.

A system of using milk based Formula 75 (75 calorie in 100 gram food mix)/ Formula 100 (100 calorie energy in 100 gram food mix) while at the Nutritional Rehabilitation Centres (NRCs) and decentralised ready mixes for community management can be developed. In efforts, Vellore Instititute of Health and Children In Need Initiative (CINI) Kolkata have already shown the ways of developing high calorie food within the families itself.

It should be honestly accepted that malnutrition is a complex problem and therefore demands complex solutions as well. The strategy for prevention and management of malnutrition must also address issues such as access to quality institutional services, capacities of personnel (like ANM, AWW, MPW, ASHA etc), quality of services, accountability, community participation, nutrition counseling and so on. The clinical treatment and nutritional care for SAM children will be a critical component of this larger framework and cannot be addressed in isolation.

The issues relating to convergence and responsibilities are also to be resolved. In this context, a system needs to be put in place at three levels -
1) Community – For early identification and referral to medical institution 2) Nutrition Rehabilitation Centers – Once children are identified and brought to the institution
3) ICDS or in the community again – For follow up of the treatment protocol.

The systems of co-ordination between the network of NRCs and ICDS centres need to be operationalised. It must be ensured the victims themselves are not blamed for failure in treatment, with arguments mothers of or parents of the child don’t want to get their child treated, They themselves go back to home, what government can do? Any treatment strategy must be sensitive to the limitations of the deprived families. In this context, community based treatment of severe malnutrition is the one and only strategy for adoption. Any government can not be in a position to bring 1.2 million SAM children with their parents in institutions and treat them. Capacity building of communities and families on local food mixes and care of children followed by regular-prompt service support through the local services like anganwadis and ANM will be the best strategy.

The Women and Child Development and the Health Department must co-ordinate in the treatment of SAM children. The health department has the responsibility of not only treating children with SAM in the institutions but their community outreach workers such as ANMs and ASHAs must be involved in the counseling and other processes taking place in the community. On the other hand the capacities of the ICDS needs to be built so that they can identify SAM children, ensure timely referral, counsel the families and are able to ensure the rehabilitation of children in the community after the treatment phase.

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