Prevalence of Wasting and its Associated Factors among Children Under 5 Years of Age in India: Findings from the Comprehensive National Nutrition Survey.

BACKGROUND: The burden of wasting among under five children in India, has not reduced in the last decade. OBJECTIVES: We used child-level data from the latest nationally representative Comprehensive National Nutritional Survey (CNNS) to estimate the prevalence of wasting at the national and state level in India. METHODS: We explored the association of wasting with maternal, child and household factors using multivariable logistic regression for the age group of 0-5, 6-23 and 24-59 months. RESULTS: The overall prevalence of wasting was 17.3%, ranging from 5.8% to 29.1% across states, 23.3% in children 0-5 months, 19.6 % in children 6-23 months and 15.4 % in children 24-59 months of age. Higher birthweight i.e., every 100g increase (0-5 months aOR = 0.96, 6-23 months aOR = 0.94, 24-59 months aOR = 0.96), higher maternal BMI (0-5 months aOR = 0.51, 6-23 months aOR = 0.62, 24-59 months aOR = 0.67), increasing child age in months (0-5 months aOR = 0.84) and female sex of the child (24-59 months aOR = 0.82) was found to have significantly lower odds of wasting. The odds of wasting were significantly higher for poorest wealth quintile (0-5 months aOR = 1.99, 6-23 months aOR = 2.13), maternal unemployment (0-5 months aOR = 2.25), and lower levels of maternal education (6-23 months aOR = 1.74). CONCLUSIONS: Our analyses showed that burden of wasting continues to remain high in India. Preventive interventions must target reduction of low birthweight. Early identification and management of wasting should be done, especially during the first six months of life who are not part of current therapeutic feeding programme.

Viewpoints from the National Consultation on Addressing Acute Malnutrition on Mainstreaming Community-Based Program for Management of Acute Malnutrition in India.

High burden of acute malnutrition among children less than 5 years is a major public health problem in India. A "Two-days National Consultation on Addressing Acute Malnutrition" was organized to gather experiences and evidence from 13 states of India on prevention and management of acute malnutrition among children and documenting viewpoints from experts and government counterparts on the same. The consultation centered around five key themes of addressing acute malnutrition; 1) capacity building, 2) strengthening screening, 3) nutritional care of wasting, 4) tracking progress, and 5) scale-up. The paper highlights the experiences and key recommendations around the above key themes. It emerged that there is a need to further accelerate the efforts toward strengthening existing platforms and services to address acute malnutrition among children. Regular trainings of the frontline workers, increased convergence, regular monitoring, and continued service delivery during the pandemic should be undertaken for better outcomes.

A narrative review of efficacy of antibiotics in treatment of children with severe acute malnutrition in community based out-patient treatment.

The World Health Organisation (WHO) updated guidelines on the management of severe acute malnutrition in infants and children (2013) recommends antibiotic treatment of uncomplicated severe acute malnutrition (SAM) in the community setting. As community-based treatment is gaining ground, this evidence review looks at the emerging data to improve the decision-making process. The databases of Pubmed, Google Scholar, Cochrane Database of Systematic Review were searched for experimental and observational studies in the English literature for the period of 2011-2021. The search identified seven studies: two interventional and five observational. Six of these studies showed significant improvement in recovery rates using weight for height Z-score-2. Emerging evidence supports the continuation of antibiotic treatment for uncomplicated SAM in out-patient settings, as recommended in the WHO guideline of 2013.

Association between anthropometric criteria and body composition among children aged 6-59 months with severe acute malnutrition: a cross-sectional assessment from India.

A multicentric study is being conducted in which children with severe acute malnutrition (SAM) aged 6-59 months are identified with only weight-for-height z-score (WHZ) < - 3 criteria. The present study aimed to assess associations of anthropometric parameters and body composition parameters, to improve treatment of SAM. We conducted a cross-section assessment using the enrolment data of children who participated in a multi-centric longitudinal controlled study from five Indian states. Fat-free mass (FFM) and fat mass (FM) were determined by bio-electrical impedance analysis (BIA). Six hundred fifty-nine children were enrolled in the study using WHZ < -3 criteria. Available data shows that WHZ, WAZ and BMIZ were significantly associated with FFMI while MUACZ was significantly associated with both FMI and FFMI. Children with both severe wasting and severe stunting had significantly lower FFMI compared to those who were only severely wasted. All forms of anthropometric deficits appear to adversely impact FFM and FM.Trial registrationThe study is registered with Clinical Trial Registration of India (Registration No.: CTRI/2020/09/028013 dated 24/09/2020).

Effectiveness of community-based treatment programs for treatment of uncomplicated severe acute malnourished children aged 6-59 months using locally produced nutrient dense foods: protocol for a multicentric longitudinal quasi-experimental study.

BACKGROUND: Severe acute malnutrition (SAM) is a major underlying cause of mortality among children. Around one third of the world's acutely malnourished children live in India. The WHO recommends community-based management of acute malnutrition (CMAM) for managing children with SAM. In India, different states are implementing community-based SAM treatment programme, hereinafter called CSAM, using varieties of locally produced nutrient dense food items with different nutrient compositions. The study will assess the effectiveness of these state specific CSAM interventions. METHODS: The longitudinal quasi-experimental study will be undertaken in two purposively selected blocks of one district each in the four intervention states and one comparison state. From each state, 200 SAM children identified using weight-for-length/height z-score (WHZ) < - 3 criteria will be enrolled in the study. Their anthropometric data and skinfold thickness will be taken on admission, at sixth week and at discharge by trained field investigators. Other child details, incidence of morbidity and socio-economic details will be collected on admission. To assess food consumption pattern including consumption of locally produced nutrient dense food supplements, dietary assessment, using 24-h dietary recall will be conducted on admission, at sixth week and at discharge. In addition, body composition parameters will be assessed for a sub-set of children using bio-electrical impedance analysis on admission and at discharge to analyse changes in total body water, fat-free mass, and fat mass. Post discharge, all study participants will be followed up monthly until 6 months. Atleast 10% of the sample will be checked for quality assessment. The study's primary outcome is cure rate defined as children attaining WHZ ≥ -2. Secondary outcomes include mean weight gain, mean length of stay, body composition parameters, relapse and mortality rates. Additionally, process evaluation and cost effectiveness analysis will be conducted. DISCUSSION: There is a shortage of robust evidence regarding the effectiveness of locally produced nutrient dense food supplements provided as part of the CSAM intervention in India. This study will contribute to evidence on effective strategies to manage children with uncomplicated SAM in India. The study protocol has all necessary ethical approvals. Written informed consent will be obtained from caregivers of the children. TRIAL REGISTRATION: The study is registered with Clinical Trial Registration of India (Registration No.: CTRI/2020/09/028013 ) Date of registration 24/09/2020.

Strengthening Psychosocial Stimulation in the Management of Children With Severe Acute Malnutrition: Experience From a Nutrition Rehabilitation Center.

Severe acute malnutrition (SAM) not only increases risk of mortality, but it also increases the risk of impaired motor, cognitive, and psychosocial development. Across the globe, 43% of all children younger than five years of age are at risk of not achieving their developmental potential. The World Health Organization management guidelines for SAM has included the integration of early childhood development (ECD) directed sensory and psychosocial stimulation and structured play therapy in the medico-nutritional care process. Despite this, management still largely focuses on nutrition rehabilitation, while these interventions take a backseat. Most countries are moving towards home-based management of uncomplicated SAM children. Hence, it is equally important to have a strong ECD component in the community-based management programs. Strengthening the support of sensory and psychosocial stimulation and structured play support in both facility and community-based care of SAM children will not only help them to survive, but also thrive and transform. With this background, we briefly describe the experiences of a pilot study aiming at strengthening of these interventions support in 10 nutritional rehabilitation centers across India.

Perfil socioprofissional dos médicos atuantes em serviços hospitalares / Social and professional profile of physicians working in hospitals

Objetivo: Determinar o perfil socioprofissional dos médicos que atuam em serviços hospitalares de urgência e emergência. Métodos: Realizou-se uma pesquisa descritiva com delineamento transversal. Foram avaliadas as informações de 60 médicos que atuavam em três hospitais com serviços de urgência e emergência do município de Imperatriz (MA), no período de janeiro a março de 2018. Para coleta de dados, utilizou-se um questionário autoaplicável contendo 18 questões. Resultados: Dos 60 participantes, 70% eram do sexo masculino, e 53,3% não ingressaram em programas de Residência Médica. A média de idade dos profissionais foi de 37 anos, enquanto a média do tempo de atuação no setor de urgência e emergência foi de 11 anos. Dos participantes, 85% referiram ter realizado cursos complementares voltados para a área da emergência. Os cursos mais citados foram o Advanced Cardiac Life Support (39,3%) e o Advanced Trauma Life Support (38,1%). Conclusão: Os perfis dos médicos foram de jovens, com predominância do sexo masculino e com pouco tempo de experiência profissional em atuação no setor de urgência e emergência. Identificou-se grande adesão aos cursos complementares na área de emergência e de educação continuada. Entretanto, apenas uma minoria dos participantes possuía especialidade e pós-graduação stricto e lato sensu.

Objective: To establish the social and professional profile of physicians working in emergency hospital services. Methods: A descriptive study with cross-sectional design was carried out. The information of 60 physicians working in hospitals with emergency services in the municipality of Imperatriz, MA, from January to March 2018 was assessed. A self-administered questionnaire with 18 questions was applied for data collection. Results: Of the 60 participants, 70% were men and 53.3% did not enroll in Medical Residency Programs. The physicians' mean age was 37 years, while the mean time of work in the emergency department was 11 years. Of the participants, 85% declared taking complementary courses on the emergency area. The most cited courses were Advanced Cardiac Life Support (39.3%) and Advanced Trauma Life Support (38.1%). Conclusion: The physicians' profiles were being young, a predominance of men, and little experience in on the emergency area. There was high adhesion to complementary courses in the area of emergency and of Continuing Education. However only a minority of participants had a graduate certificate or a graduate degree.

Growth faltering in early infancy: highlights from a two-day scientific consultation.

Faltering of growth in early life has been recognized as a public health challenge among Indian babies. A two-day consultation on growth faltering in early infancy was organized to examine the data and evidence on identification and management of early growth failure and to identify knowledge gaps and future areas of research. The consultation was supported by the Biotechnology Industry Research Assistance Council (BIRAC), the Indian Academy of Pediatrics (Nutrition Chapter), Vardhman Mahavir Medical College and Safdarjung Hospital, and the Society for Applied Studies. It brought together researchers, clinicians, policy makers and program managers.

Effect of Differences in Month and Location of Measurement in Estimating Prevalence and Trend of Wasting and Stunting in India in 2005-2006 and 2015-2016.

BACKGROUND: Child undernutrition in India remains widespread. Data from the National Family Health Survey 3 and 4 (NFHS-3 and NFHS-4) suggest that wasting prevalence has increased while stunting prevalence has declined. OBJECTIVE: The objectives of this study were to do the following: 1) describe wasting and stunting by month of measurement in India in children <5 y of age in NFHS-3 and NFHS-4 surveys, and 2) test whether differences in the timing of anthropometric data collection and in states between survey years introduced bias in the comparison of estimates of wasting and stunting between NFHS-3 and NFHS-4. METHODS: Data on wasting and stunting for 42,608 and 232,744 children aged >5 y in the NFHS-3 and NFHS-4 survey rounds were analyzed. Differences in the prevalence of wasting and stunting by month of year and by state of residence were examined descriptively. Regression analyses were conducted to test the sensitivity of the estimate of differences in wasting and stunting prevalence across survey years to both state differences and seasonality. RESULTS: Examination of the patterns of wasting and stunting by month of measurement and by state across survey years reveal marked variability. When both state and month were adjusted, regardless of the method used to account for sample size, there was a small negative difference from 2005-2006 to 2015-2016 in the prevalence of wasting (-0.8 ± 0.6 percentage points; P = 0.2) and a negative difference in stunting prevalence (-8.3 ± 0.7 percentage points; P < 0.001), indicating a small bias for wasting but not for stunting in unadjusted analyses. CONCLUSIONS: State and seasonal differences may have introduced bias to the estimated difference in prevalence of wasting between the survey years but did not do so for stunting. Future data collection should be designed to maximize consistency in coverage of both time and place.

Outcomes of Hospitalized Infants Aged One to Six Months in Relation to Different Anthropometric Indices - An Observational Cohort Study.

OBJECTIVES: Malnutrition in infants less than six months is increasingly recognized. However, the WHO criteria for identifying malnutrition have not been fully evaluated against the risk of in-patient mortality. The observational study was conducted to evaluate the predictability of in-patient mortality of different anthropometric criteria and combination of criteria in order to understand which diagnostic criteria or combination of criteria most accurately predict in-patient mortality. METHODS: Data from a cohort of infants aged one to six months, admitted to Kalawati Saran Children's Hospital, New Delhi between February and December 2018 was analyzed. The discriminatory ability of different anthropometric indexes [weight-for-age Z score (WAZ), weight-for-length Z score (WLZ) and mid-upper arm circumference (MUAC)] and their combinations to predict in-patient mortality was assessed using Receiver operating characteristic (ROC) curves. RESULTS: A total of 1813 infants aged one to six months were admitted during the 11 mo period, of which 107 (5.9%) died in the hospital. Of all admissions, 39.9%, 26% and 23.4% were severely underweight, severely wasted and severely stunted, respectively. WAZ < -3 was the most sensitive predictor of mortality [sensitivity: 74.8%; specificity: 62.3%; area under the curve (AUC): 0.69, 95% CI: 0.64-0.74]. CONCLUSIONS: WAZ < -3 was the most sensitive predictor out of all individual and combined parameters/indexes in identifying infants less than six months at high risk of mortality which suggests that, it should be used to identify at-risk infants between one to six months on admission to in-patient care. Children identified as falling into this category should be properly evaluated and treated during their in-patient stay.

Integrated multisectoral strategy to improve girls' and women's nutrition before conception, during pregnancy and after birth in India (Swabhimaan): protocol for a prospective, non-randomised controlled evaluation.

INTRODUCTION: Swabhimaan is a community-based programme to improve adolescent girls' and women's nutrition in the rural areas of three Indian states-Bihar, Chhattisgarh and Odisha with high prevalence of undernutrition. METHODS AND ANALYSIS: Swabhimaan has a nested prospective, non-randomised controlled evaluation. Since 2017, five intervention sites receive community-led interventions through national government's livelihood mission supported women's self-help group federations and five control sites will initiate these activities 36 months later, in 2020. Community-led activities aim to improve coverage of 18 interventions including adequacy of food consumed, prevention of micronutrient deficiencies, access to basic health services and special care of nutritionally 'at risk' girls and women, improving hygiene and access to water and sanitation services and access to family planning services. The evaluation includes baseline (2016-2017), midline (2018-2019) and endline (2020-2021) surveys covering 6638 adolescent girls, 2992 pregnant women and 8755 mothers of children under 2. The final impact analysis will be by intention to treat, comparing primary and secondary outcomes in five intervention areas and five control areas. The primary outcomes are: (1) a 15% reduction in the proportion of adolescent girls with a body mass index (BMI) <18.5 kg/m2; (2) a 15% reduction in the proportion of mothers of children under two with a BMI <18.5 kg/m2 and (3) and a 0.4 cm improvement in mean mid-upper arm circumference among pregnant women. ETHICS AND DISSEMINATION: All procedures involving human subjects were approved by the Institutional Ethics Committee of the All India Institute of Medical Sciences, Bihar, Chhattisgarh and Odisha and in compliance with guidelines laid down in the Declaration of Helsinki. Evidence will inform maternal and preconception nutrition policy at national and state level. TRIAL REGISTRATION NUMBER: 58261b2f46876 and CTRI/2016/11/007482; Pre-results.

WASH practices and its association with nutritional status of adolescent girls in poverty pockets of eastern India.

BACKGROUND: Water, Sanitation, and Hygiene (WASH) practices may affect the growth and nutritional status among adolescents. Therefore, this paper assesses WASH practices and its association with nutritional status among adolescent girls. METHODS: As a part of an intervention programme, this study is based on baseline cross-sectional data. It was conducted between May 2016-April 2017 in three Indian states (Bihar, Odisha, and Chhattisgarh). From a sample of 6352 adolescent girls, information on WASH practices, accessibility to health services and anthropometric measurements (height, weight and mid upper arm circumference (MUAC)) was collected. Descriptive statistics were used to examine WASH practices, and nutritional status among adolescent girls. Determinants of open defecation and menstrual hygiene were assessed using logistic regression. Association between WASH and nutritional status of adolescent girls was determined using linear regression. RESULTS: Findings showed 82% of the adolescent girls were practicing open defecation and 76% were not using sanitary napkins. Significant predictors of open defecation and non use of sanitary napkin during menstruation were non Hindu households, households with poorer wealth, non availability of water within household premise, non visit to Anganwadi Centre, and non attendance in Kishori group meetings. One-third of adolescent girls were stunted, 17% were thin and 20% had MUAC < 19 cm. Poor WASH practices like water facility outside the household premise, unimproved sanitation facility, non use of soap after defecation had significant association with poor nutritional status of adolescent girls. CONCLUSIONS: Concerted convergent actions focusing on the provision of clean water within the household premise, measures to stop open defecation, promotion of hand washing, accessibility of sanitary napkins, poverty alleviation and behavior change are needed. Health, nutrition and livelihood programmes must be interspersed, and adolescents must be encouraged to take part in these programmes.

Context for layering women's nutrition interventions on a large scale poverty alleviation program: Evidence from three eastern Indian states.

Over 70 million women of reproductive age are undernourished in India. Most poverty alleviation programs have not been systematically evaluated to assess impact on women's empowerment and nutrition outcomes. National Rural Livelihoods Mission's poverty alleviation and livelihoods generation initiative is an opportune platform to layer women's nutrition interventions being tapped by project Swabhimaan in three eastern Indian states-Bihar, Chhattisgarh and Odisha. A cross-sectional baseline survey covering 8755 mothers of children under-two years of age, one of the three primary target groups of program are presented. Standardized questionnaire was administered and anthropometric measurements were undertaken from October 2016 to January 2017. 21 indicators on women's empowerment, Body Mass Index and Mid-upper Arm Circumference for nutrition status, food insecurity indicators as per the Food Insecurity Experience Scale and selected indicators for assessing women's access to basic health services were included. National Rural Livelihoods Mission operates in contexts with stark social and gender inequalities. Self-help group members exhibited better control on financial resources and participation in community activities than non-members. Using Body Mass Index, at least 45% mothers were undernourished irrespective of their enrolment in self-help groups. Higher proportion of self-help group members (77%-87%) belonged to food insecure households than non-members (66%-83%). Proportion of mothers reporting receipt of various components of antenatal care service package varied from over 90% for tetanus toxoid vaccination to less than 10% for height measurement. Current use of family planning methods was excruciatingly low (8.2%-32.4%) in all states but positively skewed towards self-help group members. Participation in monthly fixed day health camps was a concern in Bihar. Layering women's nutrition interventions as stipulated under Swabhimaan may yield better results for women's empowerment and nutrition status under National Rural Livelihoods Mission. While this opportunity exists in all three states, Bihar with a higher proportion of matured self-help groups offers more readiness for Swabhimaan implementation.

Comparison between Weight-for-Height Z-Score and Mid Upper Arm Circumference to Diagnose Children with Acute Malnutrition in five Districts in India.

BACKGROUND: The World Health Organization recommends weight-for-height Z-score (WHZ) or mid-upper arm circumference (MUAC) and bilateral pitting edema to diagnose acute malnutrition among children aged 6-59 months. WHZ and MUAC identify different sets of children with acute malnutrition, and overlap between their prevalence varies greatly among countries. OBJECTIVE: The objective of the study was to determine the degree of overlap and agreement between WHZ and MUAC to diagnose children with acute malnutrition in India. METHODS: Five nutrition surveys using Standardized Monitoring and Assessment of Relief and Transitions methodology were conducted in four Indian states. A total of 2127 children aged 6-59 months were analyzed. All anthropometric indices were calculated using emergency nutrition assessment software and analyzed in Epi-Info 3.5.4. RESULTS: Of total global acute malnutrition (GAM) cases, 96% and 28.4% cases were diagnosed with WHZ and MUAC, respectively. Similarly, of total severe acute malnutrition (SAM) cases, 95.1% were identified using WHZ and 30% using MUAC. The proportion of overlap between the two criteria for GAM and SAM cases was 24.5% and 25.2%, respectively. The analysis showed that MUAC was comparatively more sensitive to identify acute malnutrition among 6-23-month aged children and females. CONCLUSION: One-fourth of GAM and SAM cases were identified with both criteria. MUAC identified approximately 30% of the total SAM cases which was lower than other countries. MUAC identified more number of females and younger children, who may have higher mortality risk and would result significantly smaller caseload (68% smaller) that requires intervention compared to when using WHZ.

Partnering with women collectives for delivering essential women's nutrition interventions in tribal areas of eastern India: a scoping study.

BACKGROUND: We examined the feasibility of engaging women collectives in delivering a package of women's nutrition messages/services as a funded stakeholder in three tribal-dominated districts of Odisha, Jharkhand and Chhattisgarh States, in eastern India. These districts have high prevalence of child stunting and poor government service outreach. METHODS: Conducted between July 2014 and March 2015, an exploratory mix-methods design was adopted (review of coverage data and government reports, field interviews and focus group discussion with multiple stakeholders and intended communities) to assess coverage of women's nutrition services. A capacity assessment tool was developed to map all types of community collectives and assess their awareness, institutional and programme capacity as a funded stakeholder for delivering women's nutrition services/behaviour promotion. RESULTS: Limited targeting of pre-pregnancy period, delays in first trimester registration of pregnant women, and low micronutrient supplementation supply and awareness issues emerged as key bottlenecks in improving women's nutrition in these districts. Amongst the 18 different types of community collectives mapped, Self Help Groups (SHGs) and their federations (tier 2 and tier 3), with total membership of over 650,000, emerged as the most promising community collective due to their vast network, governance structure, bank linkage, and regular interface. Nearly 400,000 (or 20% of women) in these districts can be reached through the mapped 31,919 SHGs. SHGs with organisational readiness for receiving and managing grants for income generation and community development activities varied from 41 to 94% across study districts. Stakeholders perceived that SHGs federations managing grants from government and be engaged for nutrition promotion and service delivery and SHG weekly meetings can serve as community interface for discussing/resolving local issues impeding access to services. CONCLUSIONS: Women SHGs (with tier 2 and tier 3) can become direct grantees for strengthening coverage of women's nutrition interventions in these tribal districts/pockets, provided they are capacitated, supervised and given safe guards against exploitation and violence.