APPROACHES OF ICDS AND NRHM IN ADDRESSING SEVERE ACUTE MALNUTRITION - A NEED FOR COHERENCE

Malnutrition is the term which is seen in almost all the newspapers and it is our countries attention too. In order to address malnutrition issue, there are 2 primary agencies i.e. NRHM and ICDS. However the management of severe malnutrition has huge gaps in the public policy of our country.

There is an inconsistency between the approaches of ICDS & NRHM leading to lack of clarity on the criteria for screening and identification, treatment protocols and the role of difference agencies for rehabilitation and follow up. Focus of intervention under NRHM is primarily on treatment of severe acute malnutrition (SAM) through nutrition rehabilitation centers (NRCs).

World Health Organization (WHO) definition of SAM is

•          Very low weight for height (Below -3Z score of median WHO standards)
•          Visible severe wasting
•          Presence of nutrition edema

Statistics at glance

         SAM children have a mortality risk higher than normally nourished children. The under 5 morality rate for SAM ranges from 30% - 50%. National Family Health Survey (NFHS) – 3 reveales that 6.4% of Indian children Under 5 years have weight for height scores less than -3SD which means at given point of time we have 8 million children who are SAM.

Role of ICDS

           Anganwadi worker’s (AWWs) are responsible for the regular growth monitoring of children Under 6 years of age, they identify the children for malnourishment and provide follow up care including referrals. AWW are suppose to refer children who are severely underweight as per WHO standards of Weight for Age.

Management of Malnutrition at NRC

           Currently there are no central guidelines available for the management of SAM. Under NRHM different states have now set up NRCs and the broad programmatic interventions are more or less similar.

At NRC, the child is screened for SAM by

1.     Weight for height/length
2.    Mid upper arm circumference (MUAC)
3.   Presence of edema

What happens at NRC is the children who are referred to the NRC by the AWW based on the weight for age are screened for SAM. Children who fit the criteria are only admitted and rest all sent back.

Data set from NFHS and Integrated Nutrition Health Program (INHP) reveals that this approach has 2 errors

• It misses identifying a substantial proportion of SAM cases
•  The numbers of referred cases by AWW are not the actual SAM cases. By this approach the recent acute weight loss are not referred because they are not yet below the cut-off to actually qualify as severe underweight.

Simple relying on weight for age measure would leave around 36%-44% of SAM children because they fall under moderate or normal weight for age. Thus screening for severely underweight done at Anganwadi centre (AWC) is simply not a sensitive test for identifying SAM

And, among the referred children to NRC (58% - 75%) are not SAM to fit the entry criteria for NRC’s admission. Thus, the specificity of severe underweight cut-off scores test in identifying SAM cases is very poor.

Gap in the entry criteria

·                          There is lack of consistency between the referral criteria of AWW (weight for age) and the entry criteria of NRC. Many children are needlessly referred to and sent back. This could create a poor impression on the AWW at the village level demotivating her as well as parents of the children.

·         Entry criteria also does not include appetite test. Children who has appetite can be treated at community level.

Gap in exit criteria and follow up

·                        As per WHO and Indian Association of Pediatrics (IAP) guidelines, a child are discharged from NRC when weight for height/length is more than -1 SD. SAM is treated institutional based with therapeutic foods of F-100 formula.

·        Children who are admitted in NRC are kept for 14 days for nutritional rehabilitation, medical treatment and nutritional counseling unless physician extends the stay.

·         Approximately Rs.50/day is sent on the SAM child for food and drugs + Rs. 6/day worth food from AWC after discharge. 

·         Due to non availability of community based management (CBM) this whole exercise of treatment goes in Vain. International experiences say that NRC has limited role for this reason making it just a one side link of this ‘conveyor belt’ approach.

Stunting an issue to be addressed

·         Stunting is an indicator of long neglected inadequate growth. A focus of SAM has no direct impact on stunting but a focus on stunting will help in preventing SAM by reducing low birth weight.

·         Also instead of waiting for weight for age to reach the cut-off of NRC, it’s better to refer cases based on percentage of weight loss.

Conclusion and Recommendations

        Ready to use therapeutic drugs (RUTFs) can be used in the community as an effective SAM management. As it is estimated from international experiences that 80% SAM can be treated at community level, freeing the scare resources to treat for more intensive sick SAM children at the NRC.

• AWW to asses child on weight for height/length and train her to identify & screen children who are SAM affected for entry of NRC.
•  AWW to be trained on conducting appetite test for SAM for proper case referrals.
• CBM of SAM children can be effectively done by ICDS with their huge network of AWC. A strategy to manage them at community level would be to combine providing 
• ü  Therapeutic foods                                                    presently done at NRC 
  ü  Nutrition counseling                                                presently done at NRC 
  ü  Regular growth monitoring and                              presently done at AWC 
  ü  Community mobilization                                         presently done at AWC 
  ü  Facilitate intensive breast feeding practices            presently done at AWC

Thus there is an urgent need to bring the ICDS of malnutrition in coherence NRC of malnutrition.