A study of facility and community phase management of children with Severe Acute Malnutrition at NRC in Central Gujarat

Background: The burden of Severe Acute Malnutrition, Severe underweight, and stunting is -29.4%, 15.1% and 15%. The India National Family Health Survey (NFHS 3, 2006) states that 20% of children under five in India are wasted, contributing to half of the global burden of malnutrition. SAMis responsible directly or indirectly for 35% of deaths among children under five years. Objective: The objective of this study was to assess the demographic and clinical profiles of patients with SAM, assess effectiveness of NRC with relation to short term outcome and to assess compliance with the program and weight gainat the end of 2 months. Methods: A retrospective study was conductedin children with SAM aged less than 5 years in the NRC at GMERS Medical College Vadodara. The study assessed all children for recovery and mortality at end of inpatient stay and at end of program at 60 days. The short-term outcomes were compared to the SPHERE standards 2011. Period of study was from January 2017 to December 2017. Variables assessed were gender, age at presentation, socioeconomic criteria, co-morbidities, anthropometric criteria, mean weight gain and compliance with follow up. Inclusion criteria used were anthropometric and clinical criteria used for classification of SAM. Results: 143 patients between age of 2 months to five years were admitted with SAM. The gender distribution for male to female patients was 1.1:1. Majority of children were aged less than 2 years (78.3). 89.5% childrenwere coming from families below poverty line and 38.5% were fully immunized for age. 72.7% patients satisfied both anthropometric criteria. Commonest comorbidity associated with SAM was diarrhea 22.4%, followed by lower respiratory tract infections 20.3%. Severe anemia was observed in 9.1% of patients. Outcomes were successful discharge in 93.7%, mortality in 2.1%, and default in 4.2%. 76.2% children showed weight gain at least 15% from baseline weight. Complete follow up (3 visits) was achieved in 57.3% patients. Conclusion: Majority of patients presenting with SAM were belonging to below poverty line families which suggests that improving the socio economic conditions will have a positive impact on reduction on the incidence of severe malnutrition. Complete follow up visits were achieved in only half of the patients. Education of parents regarding the implications of malnutrition on long term quality of life and positive reinforcement for follow up can ensure that successfully discharged children do not default.


Introduction
Severe Acute Malnutrition (SAM) is defined as a weight-for-height measurement of <-3SD, presence of bilateral pitting edema of nutritional origin, ormidupper-arm circumference of less than 115 mm in children age 1-5 years [1]. It is alife threatening condition requiring urgent treatment. SAM is responsible directly or indirectly for one-third of deaths among children under five years. The global burden of Severe Acute Malnutrition, Severe underweight, and stunting is-29.4%, 15.1% and 15.1% [2]. Malnutrition in children is highly prevalent in India. Emphasis is laid on management of children with SAM due to 9 times higher risk of mortality in these children with mortality being higher in children co infected with HIV. Decreasing child mortality and improving maternal health depends heavily on reducing malnutrition. Initially, focus wasto refer these children to the NRC to receive therapeutic diets along with medical care. The introduction of ready to use therapeutic foods (RUTF) allows management of SAM without complications and passing the appetite test, in the community [3]. The Pediatric Review: International Journal of Pediatric Research Available online at: www.pediatricreview.in 469|P a g e India National Family Health Survey (NFHS 3, 2006) states that 20% of children under five in India are wasted, contributing to half of the global burden of malnutrition. The objective of this retrospective study was to assess the demographic and clinical profiles of patients with SAM, assess effectiveness of NRC with relation to short term outcome and to assess compliance with the program and weight gainat the end of 2 months.
In India, the inpatient model for treatment of severe acute malnutrition (SAM) as well as community-based management of acute malnutrition (CMAM) was adopted under Mission Balam Sukham in year 2012 [4].
NRCs and CMTCs are inpatient facilities to treat SAM childrenin tertiary care hospitals and community respectively. Children fulfilling criteria for SAM according to WHO criteria are admitted in NRC with counseling of mothers for proper feeding, medical management, and discharged after completion of required NRC stay and requisite weight gain.
Management is done based on WHO and IAP guidelines for malnutrition. 3 follow up visits are done post discharge. The SPHERE project sets minimum standards in management of children with severe acute malnutrition, i.e. proportion of those who have recovered should be >75%, death should be <10% and defaulted is <15% [5]. Recent study that is a compilation of information from five different studies on the efficacy of inpatient management of acute malnutrition in India reveals that the recovery rates of SAM children attending the inpatient facilities are still low and the defaulter rate is high when compared to the acceptable minimum standard.
The recovery rate varies widely in India from state to state and can be as low as 37%. In all the studies, the recovery rate was well below the 75% standard set by SPHERE for intervention in children with SAM. All patients with SAM admitted in NRC are treated with therapeutic food, F-75and F-100 followed by energy dense foods and adequate wt gain is expected. The outcomes for facility based management are good but the child falters in the community based phase as it returns to the same environment where optimal care is compromised.
Therefore the program provides for support till 60 days in form of 3 reimbursed follow up visits, micronutrients and RUTF (in some states), butlittle is known about the long-term sustainability of the nutritional and health benefits of treatment after rehabilitation.

Objectives
1. To assess the demographic and clinical profile of patients with SAM.
2. To assess the short term outcomes in form of successful discharge, mortality effective weight gain and to assess compliance with the program and weight gainat the end of 2 months.

Materials and Methods
Study Design-Retrospective cohort study, hospital based.

Study Center-NRC at GMERS Medical College and
General Hospital, Gotri, Vadodara, Gujarat.
Study Period-January 2017 to December 2017 (one year).

Study Population-Children aged under 5 years with SAM
Inclusion Criteria-The criteria for admission for inpatient treatment in NRC were as per WHO reference [3].
Infants less than 6 months: Infant is too weak or feeble to suckle effectively (independently of his/her weight-for-length) or WFL (weight-for-length) < -3SD (in infants >45 cm) or Visible severe wasting in infants. Children 6-59 months classified as SAM on basis of anthropometric and clinical criteria We have 15 bedded NRC with separate kitchen and Toy room. Consultant pediatricians along with medical officers attend to medical complications andguide the nutritionist regarding nutritional rehabilitation. All children were managed according to the 10 point program with early stabilization followed by catch up growth and preparation for discharge.
Therapeutic nutrition was administered, F-75 and F-100. Daily weight gain was monitored. Micronutrients were provided and appetite was assessed. Monetary assistance was provided to family as wage loss, Rs 200/day. Outcome in form of successful discharge, default and death was recorded. Weight at the time of admission and discharge was recorded and average weight gain was calculated. Children were considered successfully discharged from the NRC when 1) The child had no signs of bilateral pitting edema, fever, and/or infection.
2) The child had completed all age appropriate immunizations.
3) The child was being fed 120-130 kcal/kg weight/day 4) Adequate weight gaini. e 15% of weight gain at presentation in a non -edematous child 5) The primary caregiver is confident to care for child at home [3,5].
All patients were discharged after 14 days and called for 3 visits at 15 day intervals at 1 month, 1.5 month and 2 months respectively. Monetary compensation and micronutrients wereprovided at each visit.

Statistical Analysis-The data was entered into
Microsoft excel spread sheet and descriptive statistical analyses was done by SPSS Software.  Commonest co morbid condition observed was acute gastroenteritis (22.4 %), followed by pneumonia (20.3%). Severe anemia and Urinary tract infections were observed in 09.1% and 08.4% children. One -third of children with SAM suffer from Pneumonia and one-third of children suffer from urinary tract infection. Therefore Chest X -ray and urine examination are mandatory for all children with SAM.

Discussion
143 patients were admitted in our NRC. Total NRC admissions contributed to 2.1% of all pediatric admissions. Prevalence of SAM is reported to vary in different studies in India from 3.6% in Puducherryto national prevalence being 6.4% [6].
There was no statistical difference in sex distribution of admitted patients in our study. Some studies suggest a difference in sex distribution in children with SAM with a slight female predominance due to socio cultural factors. Other studies in Africa as well as India do not suggest a statistical difference [6][7][8].
In our study SAM was predominant in children less than 2 months to1 year and 1-2 years, (46.1%) and (32.2%) respectively. 80% children with SAM in study by Mathur et all were under 24 months [9]. 92.5% of SAM children were under 24 months in study in Nigeria. This is a reflection of poor feeding practices observed in the lower socio economic strata like poor exclusive breast feeding rates, improper complementary feeding practices and recurrent diarrhea and respiratory tract infections.
The median age of presentation was 14 months. The mean age of presentation is similar to other studies in India and Africaa [8][9][10]. Mean age was reported to be 22.3 months in Sudan and 14 .8 months in Enugu, Nigeria [8].
89.5% of patients with SAM were from families living below poverty line. Lesser association was observed in African studies (35.4%) and in Bangladesh (64.9%) [10]. Poor economic conditions have adirect impact on nutrition in form of reduced and poor quality of nutrients and limited access to health care. Partial immunization was also reported to be a risk factor for SAM in study in central India. Immunization is an indicator of health care and has role in prevention of malnutrition. The risk of malnutrition increases in incompletely immunized children due to increased risk of infections and late identification of growth faltering.

Conclusion
Hence, we can conclude that Severe Acute Malnutrition is a problem that needs to be tackled aggressively. NRCs are well supported by the government. Strengthening of the rural health sector for immunization, active screening for common childhood illnesses as per IMNCI program can lead to early detection, arrest and correction of growth deceleration in our children.
Community management of SAM and introduction of RUTF is the next step that will reduce the prevalence of SAM in long run.

Recommendation-
The outcomes of children with SAM admitted at the center were favourable as per the SPHERE standards. Continuous evaluation and strengthening of the NRCs with adequate human resources and infrastructure along with motivation of parents can sustain these outcomes.
The follow up rates of these children are poor. Parents need guidance and motivation by the local health workers to improve the follow up. Therefore a robust system of liasioning between the tertiarycare centres and peripheral health sector needs to be developed.

Contribution
 Dr Kedar Mehta :for statistical analysis and final drafting.