title: Community-based management of severe acute malnutrition in India: new evidence from Bihar.
abstract: BACKGROUND
  An estimated one-third of the world's children who are wasted live in India. In Bihar state, of children <5 y old, 27.1% are wasted and 8.3% have severe acute malnutrition (SAM). In 2009, Médecins Sans Frontières (MSF) initiated a community-based management of acute malnutrition (CMAM) program for children aged 6-59 mo with SAM.
  
  
  OBJECTIVE
  In this report, we describe the characteristics and outcomes of 8274 children treated between February 2009 and September 2011.
  
  
  METHODS
  Between February 2009 and June 2010, the program admitted children with a weight-for-height z score (WHZ) <-3 SD and/or midupper arm circumference (MUAC) <110 mm and discharged those who reached a WHZ >-2 SDs and MUAC >110 mm. These variables changed in July 2010 to admission on the basis of an MUAC <115 mm and discharge at an MUAC ≥120 mm. Uncomplicated SAM cases were treated as outpatients in the community by using a WHO-standard, ready-to-use, therapeutic lipid-based paste produced in India; complicated cases were treated as inpatients by using F75/F100 WHO-standard milk until they could complete treatment in the community.
  
  
  RESULTS
  A total of 8274 children were admitted including 5149 girls (62.2%), 6613 children aged 6-23 mo (79.9%), and 87.3% children who belonged to Scheduled Caste, Scheduled Tribe, or Other Backward Caste families or households. Of 3873 children admitted under the old criteria, 41 children (1.1%) died, 2069 children (53.4%) were discharged as cured, and 1485 children (38.3%) defaulted. Of 4401 children admitted under the new criteria, 36 children (0.8%) died, 2526 children (57.4%) were discharged as cured, and 1591 children (36.2%) defaulted. For children discharged as cured, the mean (±SD) weight gain and length of stay were 4.7 ± 3.1 and 5.1 ± 3.7 g · kg(-1) · d(-1) and 8.7 ± 6.1 and 7.3 ± 5.6 wk under the old and new criteria, respectively (P < 0.01). After adjustment, significant risk factors for default were as follows: no community referral for admission, more severe wasting on admission, younger age, and a long commute for treatment.
  
  
  CONCLUSIONS
  To our knowledge, this is the first conventional CMAM program in India and has achieved low mortality and high cure rates in nondefaulting children. The new admission criteria lower the threshold for severity with the result that more children are included who are at lower risk of death and have a smaller WHZ deficit to correct than do children identified by the old criteria. This study was registered as a retrospective observational analysis of routine program data at http://www.isrctn.com as ISRCTN13980582.
authors.affiliation: From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM).
authors.forename: Sakib
authors.initials: S
authors.lastname: Burza
authors.affiliation: From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM).
authors.forename: Raman
authors.initials: R
authors.lastname: Mahajan
authors.affiliation: From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM).
authors.forename: Elisa
authors.initials: E
authors.lastname: Marino
authors.affiliation: From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM).
authors.forename: Temmy
authors.initials: T
authors.lastname: Sunyoto
authors.affiliation: From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM).
authors.forename: Chandra
authors.initials: C
authors.lastname: Shandilya
authors.affiliation: From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM).
authors.forename: Mohammad
authors.initials: M
authors.lastname: Tabrez
authors.affiliation: From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM).
authors.forename: Kabita
authors.initials: K
authors.lastname: Kumari
authors.affiliation: From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM).
authors.forename: Prince
authors.initials: P
authors.lastname: Mathew
authors.affiliation: From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM).
authors.forename: Amar
authors.initials: A
authors.lastname: Jha
authors.affiliation: From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM).
authors.forename: Nuria
authors.initials: N
authors.lastname: Salse
authors.affiliation: From Médecins Sans Frontières (MSF), New Delhi, India (SB, RM, EM, TS, CS, MT, KK, PM, and AJ); MSF, Barcelona, Spain (NS); and the Department of Pediatrics, Darbhangha Medical College Hospital, Darbhangha, India (KNM).
authors.forename: Kripa Nath
authors.initials: KN
authors.lastname: Mishra
mesh_terms: D001827:Body Height; D002675:Child, Preschool; D003153:Community Health Services; D019468:Disease Management; D005260:Female; D006760:Hospitalization; D006801:Humans; D007194:India / Q000453:epidemiology; D007223:Infant; D008297:Male; D011502:Protein-Energy Malnutrition / Q000453:epidemiology* / Q000628:therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D015430:Weight Gain
keywords: India; community-based management of acute malnutrition; mean upper arm circumference; severe acute malnutrition; severe wasting
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