Integrated Program for Children With Severe Acute Malnutrition in Madhya Pradesh, India
Condition: Severe Malnutrition
MeSH terms: Malnutrition; Severe Acute Malnutrition
Study type: Observational

Summary: 
      The purpose of this study is to assesses the effectiveness of an integrated model for the
      management of severe acute malnutrition (IM-SAM) in India comprising facility- and
      community-based care and using locally-adapted protocols
    

Detailed description: 
      Madhya Pradesh's program for the provision of care to children with severe acute malnutrition
      (SAM) was initiated in the district of Shivpuri in January 2006. By January 1, 2010, Madhya
      Pradesh National Rural Health Mission (NRHM) had established 199 Nutrition Rehabilitation
      Centers (NRCs) where children were receiving therapeutic care following protocols based on
      the guidelines for the management of SAM by the World Health Organization (WHO)and the Indian
      Academy of Pediatrics.

      The detection of children with SAM was ensured in the communities by frontline workers in the
      context of monthly growth monitoring and promotion sessions. Once at the NRC the age, weight,
      height, mid-upper arm circumference (MUAC) and presence of bilateral pitting edema were
      determined for each child. SAM was defined as per WHO recommendations by the presence of
      bilateral pitting edema or the presence of severe wasting. Severe wasting was defined by a
      MUAC below 115 mm and/or a weight-for-height z-score (WHZ) < - 3 of the median WHZ in WHO
      Child Growth Standards. All children 6-59 months with bilateral pitting edema, and/or WHZ < -
      3 and/or MUAC < 115 mm were admitted to the NRC.

      Once children were admitted to the NRC, a medical doctor conducted a clinical examination on
      them to detect the presence of medical complications (lethargy, pneumonia, dehydration,
      fever, tuberculosis, and/or severe anemia) using the criteria for the Integrated Management
      of Neonatal and Childhood Illnesses (IMNCI).

      As per protocol, children with edema, and/or medical complications, and/or poor appetite were
      fed locally-prepared F-75 therapeutic milk every two hours for 48 hours (stabilization phase)
      while their medical complications were treated. After completion of the initial 48 hours,
      children were fed alternatively F-75 and locally-prepared F-100 therapeutic milk six times a
      day for about 48 hours (transition phase). After the transition phase, children were fed
      F-100 and locally-produced lipid-based therapeutic food (TF) with the aims of initiating
      rapid weight gain (rehabilitation phase). Children with normal appetite and free of medical
      complications entered the rehabilitation phase from the day of admission. All children
      received a course of broad spectrum antibiotic.

      Upon the completion of a prescribed 14-day stay in the NRC, children were transitioned to the
      community phase of the program where they were followed up by community-based frontline
      workers. Frontline workers were to ensure that the child benefited a Supplementary Nutrition
      Program (SNP) and returned for a follow up visit at the NRC every 15 days during the 60 days
      following discharge. At the four follow up visits, children's weight gain was assessed and
      mothers were counseled on child feeding and care.

      From January 1 to December 31, 2010 a total of 44,017 children 6-59 months old were admitted
      to the IM-SAM program. This study evaluates the effectiveness of the program by analyzing
      program outcomes in sample of children (n=2,740) randomly selected among the 44,017 children
      admitted.
    

Intervention name(s): Therapeutic feeding for children with SAM
Intervention type(s): Other
Intervention description(s): Comparison of outcomes between children with complicated SAM and children with uncomplicated SAM as well as comparisn of outcomes against national and internationally agreed upon standards of care
Observational model: Cohort
Time perspective: Retrospective
Sampling method: Probability Sample
Study population: 
        The detection of children with severe acute malnutrition was ensured in the communities by
        frontline workers in the context of monthly growth monitoring and promotion sessions.
      
Keywords: severe acute malnutrition; severe wasting; facility-based care; community-based care; Madhya Pradesh; India