What are the Indian national guidelines for screening, assessing, and treating malnutrition in adults and children?

Malnutrition According to Indian Guidelines

Screening and Diagnosis

Indian guidelines recommend screening all children under 5 years for severe acute malnutrition (SAM) using WHO Growth Standards with Z-scores, where SAM is defined as weight-for-height Z-score less than -3 or presence of bilateral pitting edema. 1

Diagnostic Criteria for Children

• Severe Acute Malnutrition (SAM): Weight-for-height Z-score <-3 using WHO Growth Standards, or mid-upper arm circumference (MUAC) <115 mm in children 6-59 months, or presence of bilateral pitting edema 1
• Moderate Acute Malnutrition: Weight-for-height Z-score between -2 and -3 2
• Z-score methodology is statistically more appropriate than percentage weight deficit calculations 1

The Indian Academy of Pediatrics consensus emphasizes that Z-scores based on WHO Growth Charts should replace older percentage-based classifications, as this approach aligns with international standards and provides more accurate statistical assessment 1.

Screening Frequency and Tools

• Screen all children at every contact with healthcare system, particularly those 6-59 months of age 1, 3
• Use validated tools including MUAC tape measurements for community-level screening 3
• Conduct regular nutrition surveys in high-risk populations, targeting at least 80% enrollment in feeding programs 2

Classification by Severity and Complications

Complicated vs Uncomplicated SAM

Children with SAM should be classified as complicated (requiring facility-based care) or uncomplicated (eligible for community-based management). 1, 4

Complicated SAM indicators requiring facility admission:

• Bilateral pitting edema 1
• Medical complications (severe pneumonia, severe dehydration, severe anemia, high fever) 1, 4
• Failure to pass appetite test 1
• Age less than 6 months 1

Uncomplicated SAM eligible for community management:

• Weight-for-height Z-score <-3 without edema or medical complications 1, 4
• Passes appetite test 1
• Alert and clinically stable 4

Treatment Approach

Facility-Based Management (Malnutrition Treatment Centers)

Children with complicated SAM require admission to Malnutrition Treatment Centers (MTC) for stabilization and initial treatment. 4

MTC protocols include:

• Initial stabilization phase addressing hypoglycemia, hypothermia, dehydration, and electrolyte imbalances 1, 4
• Therapeutic feeding with locally adapted protocols 4
• Average length of stay: 16 days 4
• Target weight gain: 9.6 g/kg body weight per day 4
• Discharge criteria: Clinical stability and weight gain of 15% or more of initial weight 4

Indian data from Jharkhand demonstrates that facility-based care achieves 0.6% mortality, 81% discharge rate, and 18.4% default rate, indicating effective life-saving care for complicated cases 4.

Community-Based Management

Uncomplicated SAM should be managed through community-based therapeutic programs using Ready-to-Use Therapeutic Food (RUTF), reserving facility beds for complicated cases. 1, 4

• Integrate with Integrated Management of Neonatal and Childhood Illnesses (IMNCI) program 1
• Weekly follow-up visits for weight monitoring and RUTF distribution 1
• Immediate referral to MTC if complications develop 1, 3

Supplementary Feeding Programs

Implement Supplementary Feeding Programs (SFP) when acute malnutrition prevalence exceeds 10-20% or general rations provide less than 1,900 kcal/person/day. 2

SFP inclusion criteria:

• Children <5 years with weight-for-height Z-score <-2 (moderate acute malnutrition) 2
• Pregnant and lactating women 2
• Elderly and chronically ill individuals 2

SFP requirements:

• Provide minimum 500 kcal and 15 g protein/day in one to two feedings 2
• If general ration <1,900 kcal/day, provide 700-1,000 kcal/day in supplementary rations 2
• Discharge children after maintaining >85% median weight-for-height (Z-score >-1.5) for 1 month 2

Micronutrient Supplementation

Vitamin A Protocol

All children with SAM require full treatment schedule of vitamin A: 200,000 IU on day 1, day 2, and 1-4 weeks later (half doses for infants <12 months). 2

Preventive supplementation schedule:

• Children 12 months to 5 years: 200,000 IU every 3 months 2
• Infants <12 months: 100,000 IU every 3 months for 1 year 2
• Lactating mothers: 200,000 IU within 2 months postpartum 2

Iron and Folic Acid

• Provide routine iron/folate supplements to all pregnant and lactating women through antenatal and postnatal clinics 2
• Screen for anemia using portable hemoglobin photometer (HemoCue system) 2
• Anemia definitions: Children <15 years Hb <11.0 g/dL, pregnant women Hb <11.0 g/dL, non-pregnant women Hb <12 g/dL 2

Monitoring and Follow-Up

Program Performance Indicators

Track enrollment rates, default rates, mortality, and recovery rates to ensure program quality. 2, 3

• Target minimum 80% enrollment and 80% daily attendance in feeding programs 2
• Monitor weight gain weekly in community programs 3
• Conduct active case-finding in communities through health workers 2, 3

Capacity Building Requirements

All healthcare providers require training in integrated management of SAM, including frontline workers, facility staff, and community health workers. 1, 3

• Regular refresher trainings for frontline workers 3
• Strengthen convergence between health, nutrition, and social welfare sectors 3
• Maintain service delivery continuity during emergencies and pandemics 3

Critical Pitfalls to Avoid

• Never delay admission for complicated SAM: Children with edema, medical complications, or failed appetite test require immediate facility-based care, not community management 1, 4
• Do not use percentage weight deficit: Z-scores using WHO Growth Standards are statistically superior and internationally accepted 1
• Avoid standalone programs: SAM management must integrate with IMNCI and link community programs with facility-based care 1, 3
• Do not reserve all facility beds for SAM: Community-based management for uncomplicated cases reduces facility burden and family costs while maintaining safety 1, 4
• Never skip vitamin A treatment: All SAM cases require full 3-dose vitamin A treatment schedule regardless of serum levels 2

Current Burden and Targets

India faces an estimated 8.1 million children under 5 with SAM, causing approximately 600,000 deaths annually 1. National data shows 39.3% stunting prevalence, 15.7% wasting prevalence, and 32.7% underweight prevalence as of 2017 5. The National Nutrition Mission 2022 targets require substantially higher rates of improvement than current trends, with projected gaps of 9.6% excess stunting, 10.4% excess wasting, and 4.8% excess underweight relative to targets 5. State-level variation is substantial, with malnutrition DALY rates varying 6.8-fold between states, highest in Uttar Pradesh, Bihar, Assam, and Rajasthan 5.