Maharashtra to implement a new malnutrition screening method

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    Indx TechStyle Perfaarmance Naarmal Senior Member

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    Maharashtra to implement a new malnutrition screening method
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    Adds a tried-and-tested process to get rid of current ambiguities
    Struggling to address the fluctuating malnutrition figures in Maharashtra, and to make the identification process of severely malnourished children robust, the State government will now roll out a simple but effective screening tool to add to the process already in place. The new tool is measuring the mid-upper arm circumference (MUAC) of a child with a flexible tape.

    According to World Health Organisation’s guidelines states, including Maharashtra, measure stunting (low height for the age) and wasting (low weight for a height). Now, the government has amended its last resolution dated September 17, 2010, to include MUAC as a standard tool to measure malnourishment at anganwadis, prathamik arogya kendras, and district hospitals.

    The government resolution states: “The mid-upper arm circumference (MUAC) method must now be stressed upon as a parameter and be given more emphasis. Accordingly, Severe Acute Malnourishment and Moderately Acute Malnourishment are to be identified along with the use of height-weight ratio.”

    Already implemented in Odisha, officials said that MUAC numbers can be a strong indicator of chronic malnutrition. The reason for introducing MUAC is rooted in the ambiguity in prevailing methods. At the primary screening of children for severe and moderately acute malnourishment, in anganwadis, weight as per age is measured, but in gram bal vikas kendras, the height-weight ratio is preferred. With the amendment, the measurement processes for preliminary and secondary screenings will ‘give preference’ to MUAC.

    An official said: “A new analysis of the WHO growth standards have confirmed the importance of the first two years of life as a window of opportunity for growth promotion. It is in this phase, we thought, it was important to be systematic in our screening process, [and therefore] the introduction of this new measurement standard.”



    The challenge and the change

    Malnutrition has for long been one of the biggest challenges faced by Maharashtra’s health machinery; the government’s own data says there were 1.17 lakh deaths due to malnutrition between 2008 and 2012.

    The Rapid Survey of Children, 2014, said that of the 93 lakh-odd children in the under-five age group in Maharashtra, stunting was recorded in 35.4 per cent, and wasting in about 18 per cent. State officials said nutrition-related factors contribute to about 45 per cent of child deaths under the age of 5.

    Maharashtra had a three-tier system to treat severely acute malnourished (SAM) and moderately acute malnourished (MAM) children starting with screening by anganwadi workers using the ‘weight-to-height’ criteria. Those identified as SAM or MAM, with no medical complications, are admitted to village child development centres (VCDCs) for 30 days. Officials say about 70 per cent children show improvement at this stage itself, given the special nutrition protocol designed for the VCDCs. Children with medical complications who do not show improvement in VCDCs are referred to child treatment centres at district hospitals for 21 days. After the treatment, children are sent back home. However, those with severe complications are referred to nutrition treatment centres at the district hospital for 14 days. The only difference in the new process will be the MUAC measurement at the anganwadi itself.

    Road map

    A new set of guidelines, based on the Odisha model, has been issued by the Maharashtra Health Department, laying down the new rules on mapping malnourishment.

    Senior officials told The Hindu that there had been a heavy reliance on just the supplementary diet and health services to tackle malnutrition cases. But now, with better clarity in the screening process, and an added tier, a coordinated effort could be mounted.

    The screening processes, according to the new guidelines, will be carried out during the pre-monsoon months of April-June, and post-monsoon between October and December, 2016. The new procedure laid out in the resolution makes MUAC mandatory in the preliminary screening of children in the six months to six years age group. The required flexible measuring tapes will be purchased by the State Health Department and supplied to anganwadis and arogya kendras.

    Children with MUAC less than 11.5 cm will be classified as severely acute malnourished, and those with 15 cm will fall under moderately acute malnourished category. Those not under any of these will not need further screening. For the secondary screening, the MAM children will also be measured on the height-weight ratio.

    The new resolution lays out standard operating procedures for dietary requirements, admission and discharge of SAM, MAM and normal category children. For example, a child admitted to the VCDC having an MUAC of 11.5 cm, will be discharged only on reaching 12.5 cm circumference.

    ‘Low-cost method, good for mass screenings’

    Public health expert and activist Dr Abhay Bang said the MUAC method is well-known, and has been in use for the past 30 to 40 years the world over. He said, the method was not only cheap, there was also no maintenance concern involved. And unlike carrying a weighing machine, the health workers just have to carry a tape. “It’s a handy and an easy method,” Dr Bang said. But the method is not without its limitations, Dr Bang admitted; for instance, small improvements or deteriorations cannot be measured: “It is not a good for monitoring an individual child’s improvement, but it is good for mass screenings.”

    Clearly, the MUAC method cannot replace the prevailing screening system. Dr Bang said, “Chronic malnutrition is best represented by stunting, but MUAC cannot detect it. Those identified as malnourished using the MUAC method will have to be measured for their weight and height correlated with age.”

    The Odisha Experience

    In 2011, the Odisha government overhauled its approach to malnutrition and made major changes in the ICDS. “We introduced MUAC not as a replacement for weighing, but as an addon,” Arti Ahuja, principal secretary (health) with the Odisha government, told The Hindu.

    The State designed its intervention strategies based on the malnutrition data that emerged from the MUAC measuring process.

    The result? “A larger number of children started getting attention. In our current system, we were unable to identify severely acute malnourished children,” Ms Ahuja said. She said MUAC was tried out as a pilot in Kandhamal district, which had higher under-5 mortality rate. “It was a community management of acute malnutrition.

    Every child was weighed and MUAC used,” she said, adding the results were positive with all children identified with SAM treated.

    Keywords: malnutrition, mid-upper arm circumference, MUAC, stunting, height-weight ratio
     
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