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Stunting is the devastating result of poor nutrition in-utero and early childhood. Children suffering from stunting may never attain their full possible height and their brains may never develop to their full cognitive potential. Children with stunting begin their lives at a marked disadvantage: they face learning difficulties in school, earn less as adults, and face barriers to participation in their communities.

CMAM is an evidenced-based model, to address acute malnutrition, both in development and humanitarian contexts. It is currently implemented in more than 70 countries worldwide, and is the globally endorsed standard for management of acute malnutrition. The key objective of a CMAM programme is to reduce mortality and morbidity from acute malnutrition by providing timely diagnosis and effective treatment of acute malnutrition, and through building local capacity (health system and community) in the identification and management of acute malnutrition.

F-SAM is short for facility-based management of SAM. This includes admitting a child to a nutrition centre of a hospital and providing in-patient treatment. The child can only be admitted if they fulfil a certain criteria. Usually, only children with critical cases of malnutrition are admitted in such facilities.

Children suffering from wasting have weakened immunity, are susceptible to long term developmental delays, and face an increased risk of death, particularly when wasting is severe. These children require urgent feeding, treatment and care to survive.

The World Health Organization (WHO) classifies wasting as severe or moderate, according to the WHO growth reference for weight-for-height3. Acute malnutrition in children aged 6 to 59 months can be either moderate or severe. Severe acute malnutrition is defined as severe wasting and ⁄or mid-upper arm circumference (MUAC) > 115 mm and ⁄or bilateral pitting oedema. Moderate acute malnutrition is defined as moderate wasting and ⁄or MUAC ≥ 115 mm and < 125 mm.

Nutrition Rehabilitation Center (NRC) is a unit in a health facility that admits and manages children with conditions of nutrition deficiency such as severe acute malnutrition, stunting and deficiencies of micronutrients. Children are admitted as per the defined admission criteria and provided with medical and nutritional therapeutic care.

NRCs are meant to help a child after they have been treated at a hospital for a life-threatening problem. At the NRC, a child is meant to undergo intensive feeding to recover lost weight, development of emotional and physical stimulation, capacity building of the primary caregivers of the child with acute malnutrition through sustained counselling and continuous behavioural change activities. Thus an NRC is intended to function as a bridge between hospital and home care. Hence, NRC is meant to be a short stay home for children with acute malnutrition along with the primary care givers.

Ready-to-use therapeutic food (RUTF) are energy- dense, micronutrient enhanced pastes used in therapeutic feeding. These soft foods are a homogenous mix of lipid rich foods, with a nutritional profile similar to the World Health Organization-recommended therapeutic milk formula used for inpatient therapeutic feeding programmes.

For several reasons, RUTF is essential for the community-based management of children who are suffering from uncomplicated severe acute malnutrition and who retain an appetite. First, it provides all the nutrients required for recovery. Second, it has a good shelf life, and does not spoil easily even after opening. Third, since RUTF is not water based, the risk of bacterial growth is very limited, and consequently it is safe to use without refrigeration at household level. Fourth, it is liked by children, safe and easy to use without close medical supervision. Finally, it can be used in combination with breastfeeding and other best practices for infant and young child feeding.

Frontline Health Workers (FLWs), also known as Community Health Workers, are those who take health services directly to communities, where access is often limited.

In India, FLWs are often women who come from the communities that they are serving; they act as an essential link to health facilities by bringing services to people’s doorsteps.

In the Indian public system, there are three categories of frontline health workers: anganwadi workers, ASHA (Accredited Social Health Activist) and ANM (Auxiliary Nurse Midwife).

The Integrated Child Development Service (ICDS) Scheme was launched in 1975 and has been a popular flagship programme of the government provides. This scheme provides supplementary nutrition, immunization and pre-school education to children. It is one of the world’s largest programmes providing for an integrated package of services for the holistic development of the child. ICDS is sponsored centrally and implemented by state governments and union territories. The scheme is universal and covers all districts in the country. It is also known as the anganwadi scheme.

Since 2018, the month of September has been celebrated as Poshan Maah i.e. nutrition month. It is an initiative under the POSHAN Abhiyaan, and includes a month-long activities focussed on antenatal care, optimal breastfeeding, anaemia, growth monitoring, girls education, diet, right age of marriage, hygiene and sanitation and eating healthy (food fortification).

It is India’s flagship program to improve nutritional outcomes, focusing on children, adolescents, pregnant women and Key elements of the POSHAN Abhiyaan include the focus on convergent approaches, a people’s movement to influence behaviour change, and the use of technology for real-time monitoring.

The mid-upper arm circumference (MUAC) measure is a quick way of identifying children at risk. The MUAC measure is a long strip with a series of colour bands. When measured properly against a bare upper arm, the gauge provides a number and indicates the colour range. This range indicates the nutritional status of a child.

UNICEF is of the opinion that RUTF is proven in saving children’s lives, even in chronic settings of SAM. On an average the recovery rate of CMAM programs using RUTF is more than 75%. In Rajasthan 70.4% SAM children who had been enlisted in the programme recovered. And only 0.1% died.1 Other smaller studies in India have shown that mortality rates under CMAM programmes were only 0.4%2 and 1.1%3. In Bihar, CMAM was successful in curing 88.4% of children who completed the treatment.

CMAM programs encourage home prepared meals being offered to children. RUTF is to be administered only for 8-12 weeks and does not create long term taste preferences.

A holistic approach ensuring access to healthy diets, behavioral change of families, empowerment of women and removal of inequalities is required to prevent all forms of malnutrition, including SAM. But when prevention fails, treatment protocols under CMAM using RUTF need to kick in. Treatment protocols are meant to complement the prevention efforts and to save lives of children and must be undertaken together

CMAM programs include behavior change programs for caregivers, so that once the child is discharged from the program, the child is under proper care at home. Such behavior change programs will ensure that the gains made from CMAM programs using RUTF are sustained by the families at home. The fact that there are many relapses at present point to the fact that caregiver orientation and access to healthy diets are not available for most families. This is the problem sought to be addressed by CMAM programs using RUTF.

An independent validation of POSHAN-I program in Rajasthan revealed that after 4 months of follow-up 95% children retained their weight gain and only 5% children slipped back into severe acute malnutrition.

Adequate nutrition is required for physical, cognitive and overall growth of the child. India’s under-5 mortality rate is 39 per 1000 live births. This is worse than China (9 per 1000), Libya (12), Tunisia (13), Indonesia (25), Philippines (28), Bangladesh (32) and Nepal (33). Malnutrition is the major cause of India’s under 5 mortality numbers. It was the predominant risk factor of death in children under 5 years in India in 2017, accounting for 68.2% deaths, and the leading risk factor for health loss of all ages, responsible for 17.3% of the total disability adjusted life years (DALYs)

There are various case fatality rates reported by different experts on SAM. While the WHO estimates mortality rates to be around 10-20%7, some experts in India believe that it is much lower. But, even at the lowest average case fatality suggested, at 3%, about 1.7 lakh children are at risk of death in India.

Relapses are caused due to lack of nutrition in the home prepared food. If the child received the same food as she used to prior to the CMAM program, then she could relapse into SAM. But CMAM programs ensure that caregivers are oriented on preparing nutritious food, ensuring sanitation and giving medicines when required. This will ensure that once the child is discharged from the CMAM program after recovering, the child would not relapse into SAM as the caregivers will ensure that the child received nutritious food in sanitized conditions. Further cognitive and overall growth till age 5 is critical.

An independent validation of POSHAN-I program in Rajasthan revealed that after 4 months of follow-up 95% children retained their weight gain and only 5% children slipped back into severe acute malnutrition.

The Indian government launched the POSHAN program for sustained improvement in nutrition levels in the country and to ensure eradication of malnutrition.

The feeding of malnourished children is budgeted through the Supplementary Nutrition Program (SNP) under the ICDS. As per the SNP, the budget for a feeding a SAM child is Rs 12 per day. A child is to receive hot cooked meals costing Rs 12 for 300 days. This means that the cost for feeding the child comes up to Rs 3600.

Instead if the child is provided RUTF (@ 150 packets per child costing Rs 25 per packet over 2-3 months) the total cost of feeding the child would be Rs 3500 – Rs 3750. It will also reduce administrative cost as the RUTF is fed at home for 2-3 months whereas hot cooked meals will have to be given in Anganwadi centers or delivered to home for 300 days.

In any case, RUTF is a medical treatment like ORS which is essential to prevent mortality. RUTF is also the cheapest option available as it prevents need for facility-based treatment of SAM children which would be more expensive.

Whereas, in an NRC, the cost of treatment of a child is about Rs 4500 for 2 weeks. This cost does not include capital costs, costs of medicines and human resources and cost of stay beyond 14 days. In most cases the child will be required to stay for longer than 2 weeks.

About 10% of SAM children develop complications and need NRC treatment. That means out of 60 lakhs, about 6 lakh children need to be treated in NRCs. Every 10 bedded NRC can admit 20 children in a month if the children do not stay for longer than 2 months. And there are about 1200 NRCs in the country. As per this, at present, the country has the capacity to only treat about 2.9 lakh children. That means there is also a need to double the number of NRCs in the country.

RUTF formulations are as per nutrition guidelines mentioned by WHO and UNICEF after much deliberation. They include multiple vitamins and minerals besides core therapeutic food. RUTF is only to be administered for 8-12 weeks and does not contain any substance which would be harmful to the child in the long term

RUTF is not meant to given to children who have peanut allergies.

Food augmentation is required in children beyond 6 months along with breastmilk. CMAM programs encourage children below 2 years of age to be offered breastmilk before they are offered the RUTF feed. Each packet of RUTF contains this information.

As per pilot studies in India and the ground situation in Africa and Asia, the default rates in CMAM programs are very low. Counselling and training of caregivers will bring down the rates further.

The greatest advantage of CMAM programs using RUTF is that the child and caregivers are required to go to the local facility only once a week unlike in facility-based treatments where they have to be admitted for weeks leading to loss of wage for caregivers, which in turn leads to high default rates.

It is suggested that the aversion to RUTF creates leads to high default rates. But these claims are unfounded. In Rajasthan POSHAN-I program the default rates were found to be lower than 2.5%.9 A research studying the acceptability of RUTF among children revealed that 93% children accepted RUTF eagerly whereas cooked food was accepted by only 68%.

RUTF is like ORS – it is a specially prepared treatment, which cannot be prepared in community kitchens or by small SHGs. They require technical factory-based manufacturing to ensure that quality standards are met.