1. ICDS/IAP growth charts overlook Severe Acute Malnutrition in Under-five children Investigators: Dr Abhijit P. Pakhare (PG student) Dr R. R. Shinde (Professor & Head) Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

2. Severe Acute Malnutrition Very low weight for height (below -3 Z scores of the median WHO growth standards) OR Visible severe wasting OR Presence of nutritional edema Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

3. SAM-Problem Statement Globally – 20 million U-5 children India – 7.5 million U-5 children Case fatality 20 to 30% Malnutrition is contributing factor in over 50% of child deaths Reduction in child mortality and morbidity (i.e. DALY loss averted) if malnutrition was eliminated would be at least one third Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

4. Until recently……… Developing and applying better community based management methods was almost non- existing instead indoor hospital based management was the only option practiced This was because until recently there was no clearly effective community based management strategy to prevent deaths from severe malnutrition Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

5. Community Based Management of Severe Acute Malnutrition Present paper is inspired by the following observations endorsed by WHO & UNICEF Uncomplicated forms of severe acute malnutrition can be treated in the community With modern management regimens and improved access to treatment, case-fatality rates can be as low as 5 per cent, both in the community and in health-care facilities. Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

6. Conceptual Framework of Study Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

7. Research Question Do IAP growth charts used in ICDS program detect optimal Sever Acute Malnutrition under Grade III, Grade IV malnutrition category? Research Hypothesis The IAP Weight for Age Percentage of Median (Wt/A) growth charts underestimate cases of Severe Acute Malnutrition thus influencing assessment of the magnitude of problem of SAM. Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

8. Objectives To assess the level of Severe Acute Malnutrition (SAM) (Wt/H) detected in Grade III, Grade IV malnutrition as per IAP classification (Wt/A) & WHO classification To determine the extent of difference in prevalence of severe underweight children in comparison with the two classifications (by Wt/Age Z score (WHO) and Wt/Age percentage of median (IAP) ) Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

9. Methodology Design: Cross-sectional comparative study (Secondary data analysis of NFHS-3 data) Setting: It is a nationally representative data Participants: 51155 under five children Study tool: Anthropometry as per standard protocol, WHO Growth standards (2006). Statistical Analysis : SPSS & ANTHRO software Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

10. Statistical Analysis NFHS-3 data sets obtained from Measure DHS NFHS-3 computed malnutrition prevalence based on WHO 2006 Growth standards Percentage of Median Weight of WHO 2006 Growth Standards were calculated Malnutrition prevalence as per IAP classification was calculated Cross tabulations of IAP classification & WHO classification Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

11. Wt/A Percentage of Median (IAP) Wt/Ht (WHO) (Total %) Severe Wasting Moderate Wasting Normal Above 2 SD Total Grade IV0.10.0 0.1 Grade III1.20.90.80.02.9 Grade II2.54.47.30.014.2 Grade I1.75.523.60.130.9 Normal1.02.846.71.451.9 Total6.513.578.41.5100.0 Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

12. Wt/A Percentage of Median (IAP) Wt/Ht (WHO) (Column %) Severe Wasting Moderate Wasting Normal Above 2 SD Total Grade IV 1.50.20.0 0.1 Grade III 19.26.41.00.02.9 Grade II 38.032.99.30.814.2 Grade I 26.440.330.15.830.9 Normal 14.820.359.593.451.9 Total 100.0 Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

13. Wt/A (WHO) Wt/Ht (WHO) (Total %) Severe Wasting Moderate Wasting Normal Above 2 SD Total Severe Underwieght 3.85.07.00.015.8 Moderate Underwieght 1.65.219.80.126.7 Normal1.13.251.61.357.1 Above 2 SD0.0 0.2 0.4 Total6.413.478.61.6100.0 Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

14. Wt/A (WHO) Wt/Ht (WHO) (Column %) Severe Wasting Moderate Wasting Normal Above 2 SD Total Severe Underwieght 58.537.68.90.315.8 Moderate Underwieght 24.638.825.25.026.7 Normal 16.823.665.781.557.1 Above 2 SD 0.0 0.213.20.4 Total 100.0 Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

15. Wt/A Percentage of Median (IAP) Wt/A (WHO) (Under-weight) (Total %) SevereModerateNormal Above 2 SD Total Grade IV0.10.0 0.1 Grade III2.90.0 2.9 Grade II12.02.20.10.014.2 Grade I0.924.06.00.030.9 Normal0.00.551.00.451.9 Total15.826.757.10.4100.0 Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

16. Wt/A Percentage of Median Wt/A (WHO) (Under-wieght) (Column %) SevereModerateNormal Above 2 SD Total Grade IV 0.80.0 0.1 Grade III 18.20.0 2.9 Grade II 75.58.20.10.014.2 Grade I 5.689.910.60.030.9 Normal 0.01.989.3100.051.9 Total 100.0 Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

17. Wt/A Percentage of Median Wt/A (WHO) (Under-wieght) SevereModerateNormal Above 2 SD Total Grade IV 100.00.0 100.0 Grade III 99.70.2 0.0100.0 Grade II 84.215.40.40.0100.0 Grade I 2.977.619.60.0100.0 Normal 0.01.098.30.7100.0 Total 15.826.757.10.4100.0 Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

21. Discussion Primary Prevention first…….. …but treatment is urgently needed for those who are severely malnourished Growth monitoring tools used in Anganwadi/SC/PHC/Hospitals (Universalisation & Training) Anthropometry to be done by AWW or ASHA Reliability, Precision issues Rajmata Jijau Mission and CDC centres Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

22. Conclusions IAP charts missed 80% of SAM cases Thus, ICDS/IAP growth charts underestimate prevalence of Severe Acute Malnutrition WHO child growth charts (Z-score) is highly sensitive tool to detect SAM Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

23. Recommendations Only WHO charts should be considered as indispensable tools for community based management of malnutrition Long term implications in planning national health programmes WHO Wt/A and Wt/Ht growth charts (Z-score) should be used universally epecially with reference to NRHM & NUHM Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai

24. Appropriate training methodolgies to be utilized to impart training in interpretations of growth charts to all categories of health care providers Further evidence based research studies be promoted to develop matching indigenous community based tools Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Recommendations

25. International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005–06: India: Volume I. Mumbai: IIPS. WHO (2006). WHO Child Growth Standards Methods and development. 2006 WHO (1999) Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva: WHO, 1999. V.V. Khadilkar, A.V. Khadilkar, Panna Choudhury, K.N. Agarwal, Deepak Ugra, Nitin K. Shah.IAP Growth Monitoring Guidelines for Children from Birth to 18 Years INDIAN PEDIATRICS VOLUME 44,187-197, 2007. Steve Collins, Nicky Dent, Paul Binns, Paluku Bahwere, Kate Sadler, Alistair Hallam Management of Severe acute malnutrition in children Lancet 2006; 368: 1992–2000 Published Online September 26, 2006 DOI:10.1016/S0140- 6736(06)69443-9 Mercedes de Onis,*, Adelheid W Onyango, Elaine Borghi, Cutberto Garza and Hong Yang.Comparison of the World Health Organization (WHO) Child Growth Standards and the National Center for Health Statistics/WHO international growth reference: implications for child health programmes Public Health Nutrition: 9(7), 942–947DOI: 10.1017/PHN20062005 Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai References

26. Mark Myatt, Tanya Khara, and Steve Collins A review of methods to detect cases of severely malnourished children in the community for their admission into community- based therapeutic care programs Food and Nutrition Bulletin, vol. 27, no. 3 (supplement) © 2006, The United Nations University COMMUNITY-BASED MANAGEMENT OF SEVERE ACUTE MALNUTRITION A Joint Statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children’s Fund. André Briend, Claudine Prudhon, Zita Weise Prinzo, Bernadette Daelmans, John Mason Putting back the management of severe malnutrition on the international health agenda World Health Organization, Department of Child and Adolescent Health and Development, Geneva, Switzerland. Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai References

27. Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai Department of Preventive & Social Medicine Seth G.S. Medical College & K.E.M. Hospital, Mumbai