Severe Acute Malnutrition: Spiked Rate Of Childhood Wasting And SAM In India

 

Across the globe, too many children are still in the grip of severe acute malnutrition. It is projected that nearly 14 million children under the age of five are expected to suffer from acute malnutrition from June 2022 – May 2023. This figure includes 367,000 cases of Severe Acute Malnutrition (SAM) - an increase of 16% compared to last year’s estimate. That's one child every 60 seconds in 15 crisis-hit countries.

Severe Acute Malnutrition is both a medical and social disorder. Lack of exclusive breast feeding, late introduction of complementary feeds, feeding diluted feeds containing less amount of nutrients, repeated enteric and respiratory tract infections, ignorance, and poverty are some of the factors responsible for Severe Acute Malnutrition (SAM); which can cause muscle wasting, blurred vision and organ damage.

As UNICEF stated-"Children who are severely wasted succumb to those diseases because their bodies provide virtually no protection against the bacteria, virus or fungi that infect them. They die because their digestive systems can no longer absorb nutrients. A severely wasted child is reduced to the most basic bodily functions. It takes all their energy just to keep breathing."

Extreme starvation causes malnutrition among children, it would not be wrong to say that it is one of the biggest killers of young children in the world today. Strong scientific evidence exists on synergism between undernutrition and child mortality due to common childhood morbidities including diarrhea, acute respiratory infections, malaria and measles. In SAM, the case fatality rates related to these morbidities are excessively high.

WHAT IS SEVERE ACUTE MALNUTRITION?,

Severe acute malnutrition (SAM) is caused by a significant imbalance between nutritional intake and individual needs. It is most often caused by both quantitative (number of kilocalories/day) and qualitative (vitamins and minerals, etc.) deficiencies.

Severe Acute Malnutrition is defined by a very low weight for height (below -3 z scores of the median WHO growth standards), by having a a mid-upper arm circumference (MUAC) <115 mm, by visible severe wasting or by the presence of nutritional oedema. Decreasing child mortality and improving maternal health depends heavily on reducing malnutrition which is responsible for major deaths among children under 5 years of age.

There are 4 broad sub-forms of undernutrition: wasting, stunting, underweight, and deficiencies in vitamins and minerals.

According to WHO report- globally in 2020, 149 million children under 5 were estimated to be stunted (too short for age), 45 million were estimated to be wasted (too thin for height), and 38.9 million were overweight or obese.

SAM increases dramatically with chronic poverty, lack of education among mothers, inadequate and low-nutrient diet, and lack of clean water and sanitation.

It can be a direct or indirect cause of child death by increasing the case fatality rate in children suffering from such common illnesses as diarrhoea, acute respiratory infections, malaria and measles.

SEVERE ACUTE MALNUTRITION IN INDIA,

Severe Acute Malnutrition is a major public health issue. It afflicts an estimated 8.1 million under-five children in India. Nearly 0.6 million deaths and 24.6 million DALYs (disability adjusted life years) are attributed to this condition. Diarrhea and pneumonia account for approximately half the under-five deaths in India, and malnutrition is believed to contribute to 61% of diarrheal deaths and 53% pneumonia deaths.

India is on the policy radar for nutrition-related interventions as more than half (29.6 million) of the global 51.7 million wasted children live in this region. Around 13 states and UTs out of the 22 surveyed recorded a rise in percentage of children under five years who are stunted in comparison to 2015-16; 12 states and UTs recorded a rise in percentage of children under five years who are wasted; 16 states and UTs recorded a rise in the percentage of children under five years who are severely wasted and underweight in 2019-20.

Acute malnutrition in preschool children increased in 341 out of 707 districts across 36 states and UTs between 2016 and 2021. Approximately 10 billion children (below 60 months of age) in India suffer from SAM. Meaning that the case fatality rate of 3.4%–35% would translate into 340 000 to 3.5 million deaths among under-five children in India.

It has increased from 6.6% in 2005–2006 as per the National Family Health Survey-3 (NFHS-3) to 7.5% in NFHS-4 in 2015–2016. As per the most recent NFHS-5 survey (2019–2021) covering 36 states and union territories (UTs), the prevalence continues to be an alarming 7.7%. Whereas, a rapid assessment of data from NFHS-5 for some of the Indian districts shows an alarming increase in SAM in several malnutrition hotspot districts.

According to the Women and Child Development Ministry, more than 9.2 lakh children (from six months to six years) in India were ‘severely acute malnourished’ till November, 2020. While it underlines the concern that the COVID-19 pandemic has exacerbated the health and nutrition crisis among the poorest of the poor.

These states have the most SAM children- Uttar Pradesh (3,98,359) followed by Bihar (2,79,427). Uttar Pradesh and Bihar are also home to the highest number of children in the country.

Maharashtra (70,665) > Gujarat (45,749) > Chhattisgarh (37,249) > Odisha (15,595) > Tamil Nadu (12,489) > Jharkhand (12,059) > Andhra Pradesh (11,201) > Telangana (9,045) > Assam (7,218) > Karnataka (6,899) > Kerala (6,188) > Rajasthan (5,732).

Ladakh, Lakshadweep, Nagaland, Manipur and Madhya Pradesh reported no severely malnourished children are the states with No Severely Malnourished Children.

Figures said - 57% of the children are not fed properly in the first 2 years of their life, as required. Children from even well-to-do families are not getting adequate nutrition in those formative years; and only 36% of children between 6-24 months are fed at least 3 times a day. Worse, only just over 9% of children get adequate food with nutrients to support the growth of their bodies and brain in those early critical months where the damage can be irreversible.

The global body called the situation an ‘overlooked child survival emergency’ in its May 2022 child alert.

STEPS TAKEN BY GOVERNMENT,

In order to bring holistic development of a child, the Government of India has taken some markable steps -

POSHAN Abhiyaan: The government of India has launched the National Nutrition Mission (NNM) or POSHAN Abhiyaan to ensure a “Malnutrition Free India” by 2022.

Anemia Mukt Bharat Abhiyan: Launched in 2018, the mission aims at accelerating the annual rate of decline of anaemia from one to three percentage points.

Mid-day Meal (MDM) scheme: It aims to improve nutritional levels among school children which also has a direct and positive impact on enrolment, retention and attendance in schools.

The National Food Security Act (NFSA), 2013: It aims to ensure food and nutrition security for the most vulnerables through its associated schemes and programmes, making access to food a legal right.

Pradhan Mantri Matru Vandana Yojana (PMMVY): Rs.6,000 is transferred directly to the bank accounts of pregnant women for availing better facilities for their delivery.

Integrated Child Development Services (ICDS) Scheme: It was launched in 1975 and the scheme aims at providing food, preschool education, primary healthcare, immunization, health check-up and referral services to children under 6 years of age and their mothers.

Although, ICDS (Integrated Child Development Services) and NRHM (National Rural Health Mission) have an emphasis on nutritional intake but implementation and effectiveness of these programmes haven’t yielded major gains. Policies and programmes are also hurdled by implementation scope and strategic design.

LACK OF SAM DETECTION AND TREATMENT IN INDIA,

The systemic gap in identifying SAM children and their treatment is still a major issue for the current nutritional programme in India. Lack of trained local frontline and Anganwadi workers(AWW) and errors in data collection due to lack of understanding of the standard cut offs on the measuring scales often results in misinterpretation of a child’s nutritional status.

Studies conducted in several parts of the country reported such under-reporting of SAM due to inadequate capacity-building of AWWs and the supply of growth monitoring devices. Adding to this, administrative pressure from higher authorities forces AWWs to under-report the prevalence of SAM, fearing retribution due to reputational harm to the district rather than support for dealing with SAM children.

In addition to the geographical clustering of SAM, an unfair clustering of SAM prevalence occurs among the socially marginalised communities. While an estimated 800 000 children with SAM needed treatment in Nutrition Rehabilitation Centres (NRCs). However, the recent data suggests that only 20% of children could be covered, possibly due to poor functioning of facility-based NRCs and high drop-out rate.

Even as the government is pushing for Poorna Ahaar there is a category of children we must never lose sight of. Only 43% of children are introduced to complementary foods in time. Despite some improvements, our stunting, wasting, undernutrition, anaemia figures for children are as high as they were in previous years. 2 out of 5 children are stunted, 1 out of 5 wasted, and 3 out of 5 are anaemic.

This is a group of children, often talked about, but whose numbers remain unaltered: the SAM (severe acute malnutrition) kids. These children are so vulnerable that a mere bout of diarrhoea or pneumonia can be fatal for them.

Early detection of children with SAM can ensure that these children can be identified before they develop medical complications. This could mean management of many of them before their prognosis worsens and it could also reduce the need for hospitalized care .

MUAC is a simple measure for the detection of SAM. Screening of children in the community for SAM can be done using MUAC tape. Good quality, non-stretchable, long lasting MUAC tapes should be available at every healthcare facility.

COST OF SEVERE ACUTE MALNUTRITION AND CHILDHOOD WASTING IN INDIA,

Recently, a study conducted by 'The Coalition for Food and Nutrition Security (CFNS)', a non-profit organization working in the field of children's food and nutrition, has published a report titled 'The Severity of Wasting and Severe Wasting'.

The study estimated that an average of Rs. 60 million was lost every day from 2006 to 2018 due to untreated childhood wasting in India. Wasting is defined as low weight in proportion to height.

In addition, childhood wasting accounts for an annual economic loss of about 4.7 percent of gross domestic product (GDP).

A study by the World Bank in 2010 estimated 13 key interventions for treating malnutrition in India and pegged resource requirements of about INR 43 thousand crores per year (USD 6.6 billion) along with complementary efforts towards health system strengthening. There are also positive externalities to investing in health as it creates a better work force with increased productivity.

In India high prevalence of SAM has a strong link with poverty, food insecurity, poor health care and low awareness about complementary feeding practices.

A recent report by the Centre for Science and Environment and Down to Earth magazine showed that 71% of Indians cannot afford a nutritious meal and more than 17 lakh people die annually because of diseases attributable to poor diet.

Given the rising prevalence, India is deviating far from the global targets set by the World Health Assembly (WHA) of reducing and managing wasting to below 5% or the Sustainable Development Goals (SDGs) for the elimination of malnutrition. In fact, it will be an uphill task to achieve the SDG target of elimination of wasting by 2025. (Source: IFPRI Project Paper)