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Community Based Management of

Acute Malnutrition (CMAM)

Dr Suparna Ghosh-Jerath
Associate Professor
Indian Institute of Public Health Delhi

Burden of malnutrition

6.4% of children
have SAM

2 (NFHS 3)
Burden of SAM
An estimated 8 million children with SAM
Addressing problem through facility based approach alone:
Perhaps not Feasible.!!
Evidence exists: Children with SAM without medical complications
(85–90% of all) can be treated in the communities
Also, children managed at specialised units need to be followed up at
communities after being discharged for continued care and support
Thus community based programme, need to complement and link
with facility based interventions
Effective management of SAM :
• Principle of “Continuum of Care”
• Home community health center/health facility
• Considering the fact that many children with SAM can be
successfully managed on outpatient basis and even in the
community, it is no more considered necessary to advice
admission of all children with SAM to a healthcare facility
• Management of SAM should not be a stand alone program
• It should integrate with community management therapeutic
programs and linkages with child treatment centres, district
hospitals and tertiary level centers offering inpatient
management of SAM and include judicious use of RUTF
• All sections of health care providers need to be trained in the
integrated management of SAM

Community Based Management of SAM
Large proportion of children with SAM can be treated in their

• Maximum access and coverage
• Timeliness
• Appropriate medical and nutrition care
• Care for as long as needed

Community based management of SAM
• Most children with SAM without medical complications can
be treated as outpatients at accessible, decentralised sites
using Ready to Use Therapeutic Foods (RUTF) and simple
medical protocols
• Community outreach for
community involvement
and early detection
and referral of cases
of SAM

Simple outpatient protocols
• Initial
Measurement, Medical check and appetite test (referral if required)
Vitamin A, Routine Antibiotic, De-worming, Measles vaccination, Anti
200Kcal/kg/d RUTF
Orientation for carer on giving RUTF, antibiotic, basic hygiene &
provision of other clinic services
• Weekly visits to clinic
Medical check & appetite test
Weight monitoring
200Kcal/kg/day RUTF

Ready-to-use therapeutic foods
Children with SAM need foods that are
• safe
• palatable
• high energy content and
• adequate amounts of vitamins and minerals
 RUTF are soft or crushable foods that can be consumed easily by
children from the age of six months without adding water
Characteristics of RUTF
• Similar nutrient composition to F100 (calorie density is higher
and RUTF has iron)
• Not water-based
• Can be used safely at home without refrigeration even in sub
optimal hygiene conditions

• The specific composition of the RUTF has been tested and
proved effective in functional recovery of SAM children ,
primarily in African setting
• Controlled trials and experience with RUTF in India is limited
• “To Evaluate the Impact of Three Feeding Regimens on the Recovery of
Children From Uncomplicated Severe Acute Malnutrition (SAM) in India and to
Use the Evidence to Inform National Policy” Bhandari et al (2012-2015)
• No robust comparative data documenting benefits of this
formulation over locally produced analogous Medical
Nutrition Therapy or augmented home foods
• Experiences have been reported from Maharashtra, West
Bengal and Gujarat from locally developed products
Dubey et al, Consensus statement of the Indian Academy of Pediatrics on Integrated Management of Severe Acute Malnutrition.
11 Indian Pediatric 2013;50:399-404
• A rough guide about the amount of RUTF to be consumed

Dubey et al, Consensus statement of the Indian Academy of Pediatrics on Integrated Management of Severe Acute Malnutrition.
12 Indian Pediatric 2013;50:399-404
• Breast feeding should be continued while the child is on
therapeutic food
• Other foods may be given if child has good appetite and has
no diarrhea
• The amount is to be given in 2-3 hourly feeds along with
plenty of water

Dubey et al, Consensus statement of the Indian Academy of Pediatrics on Integrated Management of Severe Acute Malnutrition.
13 Indian Pediatric 2013;50:399-404
• It must be emphasized to the families and to the society at
large , that the therapeutic food is to be used only in children
with SAM as a part of therapy
• It is not meant to be supplementary food for other children
or part of regular diet
• To ensure availability and reach to target population ,
appropriate notification for use and its procurement through
institutional mechanisms and its distribution through
appropriate channels like NRC, AWC would be ideal and
• To ensure that it is not misused , the Govt may consider
implementing appropriate restrictions on availability only
under the program
14 Dubey et al, Consensus statement of the Indian Academy of Pediatrics on Integrated Management of Severe Acute Malnutrition.
Indian Pediatric 2013;50:399-404
Dubey et al, Consensus statement of the Indian Academy of Pediatrics on Integrated Management of Severe Acute Malnutrition.
15 Indian Pediatric 2013;50:399-404
Key factors in determining impact of community
based program for treating SAM

1. People must be able to access the service with socio-

economic costs that are acceptable;
2. Efforts and resources must be put into engaging and
mobilising the population
3. The local primary health care system must have sufficient
resources, organisation and supervision to deliver simple
outpatient therapeutic protocols with consistently quality

Cost effectiveness of CMAM

• Puett C , Sadler K, Alderman H, Coates J, Fiedler JL, Myatt M.Cost-effectiveness of

the community-based management of severe acute malnutrition by community
health workers in southern Bangladesh. Health Policy Plan. 2013 Jul;28(4):386-99.
doi: 10.1093/heapol/czs070

• Wilford R,1 Golden K, Walker DG . Cost-effectiveness of community-based

management of acute malnutrition in Malawi Health Policy and Planning 2011;1–
11 doi:10.1093/heapol/czr017

Case studies

Case study 1
• MSF’s approach to manage CMAM in Darbhanga district of

CMAM in Bihar (MSF)
• Biraul block in February 2009
• Population of 286,000
• The inpatient Stabilization Centre (SC)was established within
the Biraul PHC
• Over the next 3 y, 5 ambulatory treatment centres [called
Ambulatory Therapeutic Feeding Centres (ATFCs) were
• Human resources: Government general nurse midwives
(GNMs), ANMS and ASHAs were trained to use MUAC tapes

Admission criteria
• Treat all children 6 to 59 months of age who presented with
WHZ <-3SD and or MUAC < 110mm later revised to 115 mm
and /or bilateral pedal edema

Discharge criteria
• Old: WHZ >-2 SD, MUAC > 110 with no edema for 1 week and
in good clinical condition and good appetite
• New: MUAC maintaining above 120 mm with no edema for 1
week and in good clinical condition and good appetite

CMAM in Bihar (MSF Foundation)

• ATFC were open on an average of 1 d/wk
• Newly diagnosed case of SAM,
• details were entered into a register,
• Health education was provided to the caregiver
• while an ANM or GNM repeated anthropometric
measurements, took the child’s vital signs,
• performed a basic triage
• a standardized appetite test
If it was a complicated case of SAM or failed appetite test
then referred for inpatient care in SC

Treatment at ATFC
The initial treatment comprised
• Albendazole
• Amoxicillin
• vitamin A (given once edema resolved in affected children)
• folic acid
• measles vaccination
• and screening for malaria

Treatment on ATFC
• Caregivers counselled regarding the program
• Given a 1-wk supply of WHO-standard (16), prepackaged F100-equivalent
(per kcal), lipid-based, ready-to-use therapeutic paste produced in India

Protocol at the stabilization centre

Case Study 2

Rajmata Jijau Mother –Child Health and

Health & FW

Nutrition (RJMCHN) Mission,


Operational Facets (Maharashtra)
• Independent and autonomous Mission Structure
• Neither Society nor Trust, steering by CM
• Headed by a very senior IAS Officer of PS/Secretary level on full time basis
as Director-General of the Mission
• Committed Officers (3 to 4) identified and posted in the Mission to assist
the Director -General
• Champions (people willing to contribute) identified in all Depts
• Nodal Department is DWCD
• Funding from multiple sources like DWCD, NRHM, TSP, SCSP, District
Planning Boards, etc

Levels of Intervention (Maharashtra)
Three tier approach adopted in Maharashtra:
1. Village Child Development Centres / Camps (VCDC) at
AWCs- 30 days camp
2. Child Treatment Centres / Camps (CTC) – at PHC/ Sub-
district/ district hospitals- 21 days camp on residential basis
3. Nutrition Rehabilitation Centres (NRC)- Medical College /
super specialty hospitals- as per need

Village Child Development Camps /Centre

• Both SAM and MAM children

• At Village level, at Anganwadi Centres managed by AWW and Helper
• Nutritional Supplements as per protocols
• Incentive to AWW and AWH
• Stay is for full 30 days
• Daily visit by a Dr and an ANM
• An expenditure of Rs 32/- per child/day: Rs 16 for diet (Dynamic as per
region) , Rs 8/- for Medicines and Rs.8/- for Incentives
• As per revised norms Rs. 53 pdpc.
• Done in a camp approach

Admission criteria of malnourished children at 3 levels
• In VCTCs improved in CDC
• SAM/MAM with NO illness (85-90%)

• In CTC
• SAM/MAM with illness
• SAM/MAM not improved in VCDC

• In NRC
• SAM/MAM not improved in CTCs
• SAM/MAM with critical illness requiring paediatric services

Salient Features….
• Admission procedure:
a) Primary screening by AWW of SAM/ MAM without
b) Medical Check up by MO is recommended
• Discharge criteria: After 30 days (after adopting new protocols
after 21 days) irrespective of weight gain.
• If no/poor weight gain then child is to be referred to CTC/NRC
• No need for parents to stay with the child with some
• Low cost intervention
VCDC model includes…
1. Health Protocol

2. Nutrition Protocol

3. Training Protocol

4. Monitoring protocol

Health Protocol
• Health Checkup by MO
• Identification and management of ill child
• De-worming & Vitamin-A Administration
• Correction of Micro Nutrient Deficiency
• Treatment of Infections
• Referral as per need
• Medicines dose calculations – Chart preparation

Nutrition Protocol
Sr. Time Calories Protein Nutrition for each child
No (kcal) (gms)
Halwa/Upma/Daliya made out
1 8:00 AM 420 8 of amylase rich flour
2 10:00 AM Anganwadi food+ 5ml oil
3 12 Noon Anganwadi food+ 5ml oil
4 2:00 PM Home Diet
1 boiled Potato/1 Banana/1
5 4:00 PM 100 4 Boiled egg
Halwa/Upma/Daliya made out
6 6:00 PM 420 8 of amylase rich flour
7 8:00 PM Home Diet
Total 940 20
What is amylase flour?

Wheat & Green Gram

Sprouted Dried Roasted Floured
In 3:1 Proportion
Recipe of Upma
Sr. Ingredient Amount Calories Proteins
No (gms) (Kcal) (gms)
1. Milk 25 33.3 1.8
2. Sugar 5 20.0 00
3. Amylase flour (Wheat) 20 68 2.56
4. Amylase flour (Green gram) 10 34.8 2.45

5. Groundnut 10 56.8 2.52

6. Oil 20 180 00
7. Gingelly Seed (Til) 5 28.15 0.92
8. Spices and condiments for taste
Total 95 421.05 10.25
Cost of recipe is Rs. 4.25
Amylase flour based recipes
prepared by Mother at home
Revised Nutrition protocols (proposed)

SF Composition (100 gms)

Ingredients (gms) Energy (kcal) Proteins (gms) Fats (gms) Cost (rs.)
Milk Powder 30 107.1 11.4 6
Peanut 20 113.4 5.1 8.0 1.6
Sugar 28 112 0.98
Vegetable oil 20 180 20 1.8
Powder 1.6
Total 512.5 16.5 28.0 10.38
Training Protocol – Health and ICDS
• Anthropometric measurements- How to take weight, height,

• Categorizing of children for admission using Wasting table

(SAM/MAM) also using MUAC and bilateral pitting oedema
(swelling on feet).

• Pre-VCDC preparations: procurement of medicines, raw food

materials, utensils, toys, preparation of amylase flour, child food
corner etc.
Training Protocol- Mothers
Empowerment of mothers on following things:

1. Growth spurt during childhood

2. Brain development
3. Feeding frequency (minimum 6 times)
4. Quality nutrition
5. Proper consistency of diet (No liquids)
6. Child food corner
7. Filling pockets with food items/snacks
8. Personal hygiene (Hand Washing)

Child Food
Corner For

Case Study 3

“Keno Parbo Na”

Positive Deviance Approach

A community based strategy for reduction of

undernutrition in young children
Why Positive Deviance?
• Malnutrition in young children is more due to incorrect
feeding and caring practices rather than only lack of
availability of food
• Preventing Malnutrition as early as possible and Promoting
Early Child Development is crucial and there needs to be a
focus on under-three children
• Lancet says that a single change in behavior can bring down
the IMR by 13% and that behavior is Exclusive Breast Feeding
Who is a Positive Deviant?
• A positive deviant child is a healthy and developed child in a
poor, disadvantaged and distressed family
• A positive deviant family is one which has PD children
• The special practices of a PD family which enables a child to
grow and develop well inspite of poor socioeconomic
conditions are called PD practices
• The attempt is to find out these practices in the community
and formulate strategies and activities which motivate all
families with children to adopt these best practices through
participatory learning
How Positive Deviance Works
• Making Malnutrition Visible to the families and community
through weighing of children and using colour-coded charts,
maps and other tools

• Finding out prevalent child care and feeding practices in the

area – both good and bad and identifying young children who
have good or bad (Grade 2,3,4) nutritional status as a result of
these practices

• Bringing the moderate to severe malnourished young children

(0-3 years) and their care-givers regularly to the AWCs
(Nutrition Counseling and Child Care Session-NCCS). AWWs
along with community, positive deviant mothers & SHGs and
teach them the correct feeding and care practices through
hands-on demonstration and urge them to follow the same
care practices at home

• Close monitoring and follow up

Steps of Positive Deviance
• Sensitisation workshop at the district and block level
• Training – Joint Training on Community Mobilization & PD approach for
AWWs, ANMs, PRI members, SHGs
• Community Mobilization at the village level to make malnutrition
• Identifying prevalent common practices – Focus Group Discussion (FGD)
• Identifying PD Child / Families – PD Inquiry
• Sharing findings with Community by VHC/ SHGs/ ICDS
• Setting up Nutrition Counseling & Childcare Session (NCCS)-12 days
monthly session at AWCs, followed by 18 days home-based practice on
child feeding and care
• Monitoring and follow-up
• For implementation, AWWs and supervisors take lead role, assisted by
PRI members, ANMs, SHG members, community and care-givers in the
Areas where Positive Deviance is
Operational in West Bengal
PD Operational with
UNICEF support in
Murshidabad (10 blocks)
U DINAJPUR Dakshin Dinajpur,
Purulia, South 24 PGs (4
blocks) & with State
support (RCH) in Uttar
Dinajpur & Birbhum.
PD will be Operational in 2
new districts Bankura and
Paschim Medinipur with
State support (SW) in 2007.
Discussions on with Jalpaiguri to
start in selected blocks with RCH
Is PD making any change?
• National Institute of Nutrition conducted an independent
evaluation in 2006

• Survey done in about 1000 children in 40 AWCs implementing

PD for atleast one year and compared with equal no.s in
matched non PD control areas

• Positive impact found in:

• Young child care and feeding practices
• Utilization of health & nutrition services, quality improvement of ICDS
• Improved community participation in PD areas

• Relatively better nutrition status of children in PD areas:

• Better mean heights and weights of <3 yr children,
• Lower prevalence of stunting and underweight in 12-17 months

Statistically significant difference among 12-17
months children
• IAP Classification: Undernutrition
• PD area-55%
• non-PD area- 64%
• SD Classification:
• Undernutrition:
• PD area- 45.6%
• Non-PD area- 63.2%
• Stunting:
• PD area- 25.2%
• Non-PD area- 37.4%
In conclusion
• Positive Deviance has been accepted as a best
practice in ICDS in the state
• It is now being replicated in different districts using
funds from the state
• The challenges are
• To maintain the quality of intervention with up-scaling
• To mainstream the PD strategy for improving quality of
ICDS, especially focusing on care and feeding practices of
under-three children and involving the community in
monitoring and combating malnutrition
Excerpts from 12th Five year plan


Thank you