Providing care for children with severe acute malnutrition in India: new evidence from Jharkhand.

OBJECTIVE: To assess the effectiveness of facility-based care for children with severe acute malnutrition (SAM) in malnutrition treatment centres (MTC). DESIGN: Early detection and treatment of SAM using locally adapted protocols; assessment of programme outcomes, including survival, default, discharge and recovery rates. SETTING: All forty-eight MTC in Jharkhand, India. SUBJECTS: Children (n 3595) with SAM admitted to MTC (1 July 2009-30 June 2011). RESULTS: Of children admitted, 55·0% were girls, 77·7% were 6-23 months old and 68·6% belonged to scheduled tribes or castes; 34·4% had oedema or medical complications. Of the 3418 programme exits, the proportion of children who died was 0·6% (n 20), the proportion of children who defaulted was 18·4% (n 628) and the proportion of children discharged was 81·0% (n 2770). Children's average weight gain was 9·6 (sd 8·4) g/kg body weight per d and their average length of stay was 16·0 (sd 5·7) d. Among the 2770 children who were discharged from the programme, 39·4% (n 1090) gained 15 % or more of their initial weight while 60·6% (n 1680) gained less than 15 % of their initial weight. CONCLUSIONS: MTC provide live-saving care for children with SAM as demonstrated by high survival rates. However, the protocols and therapeutic foods currently used need to improve to ensure the recovery of all discharged children. MTC should be reserved for children with complicated SAM; children with uncomplicated SAM should be admitted to a community-based programme for the management of SAM, at a lesser risk to children and a lesser cost to families and the health system.

Intensifying efforts to reduce child malnutrition in India: an evaluation of the Dular program in Jharkhand, India.

BACKGROUND: The Dular strategy is a unique nutrition initiative initiated by UNICEF India in collaboration with the states of Bihar and Jharkhand. Designed to complement the government's Integrated Child Development Services (ICDS) and build upon its infrastructure, one of the major goals of the Dular program is to capitalize and develop community resources at the grassroots level. The emphasis of the Dular program is on establishing a community-based tracking system of the health status of women and of children 0 to 36 months of age by neighborhood-based local resource persons (LRPs). The main objectives of the Dular program include increased prenatal attendance, improvement in breastfeeding and colostrum delivery, improved nutritional practices, and decreased malnutrition. OBJECTIVES AND METHOD: An impact evaluation of 744 women and children in Jharkhand examined antenatal and birthing practices, colostrum delivery, delivery of breastmilk as first food, reported use of iodized salt, measured iodized salt status, immunization and weight-for-age z-scores (WAZ) of children 0 to 36 months of age, controlling for various measures of socioeconomic status. RESULTS: Differences were found between Dular and non-Dular villages in all major outcomes. Particularly noteworthy is that young children in Dular areas had a 45% lower prevalence of severe malnutrition and were four times more likely to receive colostrum than those in non-Dular villages. CONCLUSIONS: Our evaluation results indicate that programmatic overlays to the ICDS program, which focus primary attention on children 0 to 36 months of age and on women, have the potential to transform into a cost-effective instrument for reducing child malnutrition in India, with implications for women and children in India.