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1Transforming Child Nutrition
TRANSFORMING
CHILD NUTRITION
STATE-LEVEL APPROACHES AND PRACTICES FOR
COMMUNITY-BASED COMPREHENSIVE CARE AND
MANAGEMENT OF ACUTE MALNUTRITION Transforming Child Nutrition: State-Level Approaches and Practices
for Community-Based Comprehensive Care and Management of
Acute Malnutrition
Publisher:
NITI Aayog
Government of India, Sansad Marg, New Delhi–110001, India
Year of Publication: 2023
Language: English
ISBN: 978-81-956821-7-1
Authors:
NITI Aayog
Rajib Kumar Sen, Senior Advisor
Hemant Kumar Meena, Deputy Secretary
Dr. Rinky Thakur, Research Officer
UNICEF
Dr. Sameer Pawar, Nutrition Specialist
Dr. Abner Daniel, Nutrition Specialist
Farida Sultana Shaik, Nutrition Officer
Disclaimer:
The document titled “Transforming Child Nutrition: State-Level Approaches and
Practices for Community-Based Comprehensive Care and Management of Acute
Malnutrition” relies on secondary sources and information obtained from the
Department of Women and Child Development of various States. NITI Aayog
wishes to emphasize that while every effort has been made to present accurate and
up-to-date data, NITI Aayog does not guarantee the accuracy of the information
and does not accept responsibility for the consequences of using this data.
NITI Aayog disclaims any legal liability for the accuracy or inferences drawn from
the material contained in the document or for any consequences arising from the
use of this material. Reproducing any part of this report, whether electronic or
mechanical, is strictly prohibited without prior permission or intimation to NITI
Aayog. Users are encouraged to seek permission for reproduction through official
channels to avoid any legal implications. TRANSFORMING
CHILD NUTRITION STATELEVEL APPROACHES AND PRACTICES FOR
COMMUNITYBASED COMPREHENSIVE CARE AND
MANAGEMENT OF ACUTE MALNUTRITION Nutrition has a profound impact on a country’s human capital as it directly influences both
physical and cognitive development. Optimum nutrition is linked to better learning outcomes,
higher productivity and economic growth. Improving nutritional outcomes among children
under five years of age is especially critical for harnessing India’s demographic dividend and
laying a solid foundation for Viksit Bharat @ 2047.
While considerable progress has been made, reducing the prevalence of wasting in children
across states, together with action on other health and nutrition indicators, remains a key
policy priority. It is imperative to take strong steps for preventing and reducing the burden
of malnutrition through sustainable, community-based interventions.
Recently, the Ministry of Women and Child Development has launched the Protocol for
Management of Malnutrition in Children. Many states have successfully implemented
community-based programs for managing acute malnutrition by developing their own
guidelines. States that have initiated their own programs focus on strengthening last-mile
delivery of key services. The emphasis of such guidelines and programs is on improving
adherence to standard operating protocols, augmenting the skills of frontline workers,
ensuring adequate supplies, enhancing data quality, and enforcing regular monitoring
mechanisms.
The collaboration between NITI Aayog and UNICEF has yielded this comprehensive report
that compiles good practices on community-based management of acute malnutrition from
across the country.
I hope that this document will aid States/UTs in refining their community-based programs
for management of acute malnutrition. The tried-and-tested solutions documented in this
report provide an opportunity for cross-learning and addressing shared challenges, across
varying local contexts. By implementing these practices at scale, India can take significant
strides towards ensuring a healthier and more prosperous future for its children.
FOREWORD
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Government of India
NATIONAL INSTITUTION FOR TRANSFORMING INDIA
NITI Aayog, Parliament Street,
New Delhi - 110 001
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mik/;{k
SUMAN K. BERY
VICE CHAIRMAN
Phones : 23096677, 23096688
Fax : 23096699
E-mail : vch-niti@gov.in
Suman Bery
iiiTransforming Child Nutrition Malnutrition is one of the significant public health concerns affecting the population across
the country. Undernutrition among children under 5 years of age is associated with cognitive
impairment, impaired physical growth, and increased risk of infections and morbidity.
Community-based management of acute malnutrition has proven to be highly effective in
addressing the issue of acute malnutrition. Evidence shows that about 80 percent of children
with severe acute malnutrition can be treated at home. Therefore, providing these children with
prompt care and treatment is essential.
Community-based management of acute malnutrition uses key strategies such as community
mobilization and awareness, regular screening and identification of children, use of nutrient-
dense food, medical management, health, and nutritional counselling, regular follow-ups of
children, regular monitoring and reporting, engagement of multiple stakeholders, timely capacity
building of health workers with special focus on low-birth-weight babies. Intensification of the
above-mentioned strategies and building strong linkages among different stakeholders are
crucial to ensure that beneficiaries receive a comprehensive package of services essential for the
prevention and management of malnutrition.
The report "Transforming Child Nutrition: State-Level Approaches and Practices for Community-
Based Comprehensive Care and Management of Acute Malnutrition" provides valuable insights
drawn from different States for enhancing program coverage and achieving better outcomes by
State governments.
FOREWORD
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uhfr vk;ksx
llan ekxZ] ubZ fnYyh & 110 001
Government of India
NATIONAL INSTITUTION FOR TRANSFORMING INDIA
NITI Aayog
Sansad Marg, New Delhi - 110 001
Tele.: 23096809, 23096820, Fax : 23096810
E-mail: vinodk.paul@gov.in
Vinod Paul
vTransforming Child Nutrition
MkW- fouksn dqekj ikWy
lnL;
Dr. Vinod K. Paul
MEMBER Good nutrition is paramount for enhancing social capital and economic productivity of a
country. Children who suffer from malnutrition face obstacles in their physical and cognitive
development, hindering their ability to learn and thrive. An action-oriented approach is
imperative to establish a comprehensive care continuum that tackles malnutrition, especially
at the community level.
In alignment with our unwavering commitment to provide nutrition, the government has
introduced Poshan 2.0 guidelines, emphasizing the management of moderate and severe
malnutrition. States are encouraged to adopt community-based strategies for the successful
execution of these guidelines. Many states have developed their own community-based
management of acute malnutrition guidelines and Ministry of Women and Child Development
has also developed the protocol for the management of malnutrition in children at the
community level.
To enhance program effectiveness, it is crucial to comprehend the insights, best practices, and
challenges derived from state experiences. This comprehensive report delves into key thematic
areas crucial for the community-based management of acute malnutrition. It commences
with community mobilization and awareness, emphasizing the importance of timely growth
monitoring and intervention. Quality services, including nutritional, medical management,
and education, are underscored, with frontline worker skills and product supply identified as
integral components. The report also meticulously outlines the establishment of recording,
reporting, and monitoring mechanisms and the need for continuous capacity building.
I am confident that this report will serve as an important guidebook for policymakers and
administrators of States and Union Territories. By adopting the practices outlined in the
thematic areas, they can strengthen their efforts in combating malnutrition within their
jurisdictions. It is my sincere hope that the insights, state practices, and challenges presented
in this report will contribute significantly to our collective mission of building a malnutrition-
free and healthier Bharat.
MESSAGE
B.V.R. Subrahmanyam
eq[; dk;Zdkjh vf/kdkjh
Chief Executive Officer
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Government of India
National Institution for Transforming India
NITI Aayog, Parliament Street,
New Delhi - 110 001
Tel.: 23096576, 23096574
E-mail: ceo-niti@gov.in
[B.V.R. Subrahmanyam]
viiTransforming Child Nutrition
ch- oh- vkj- lqczã.;e ixTransforming Child Nutrition
Optimum nutrition and adequate care during early childhood is critical to ensure good health, growth,
and development of children. To achieve nutrition and development outcomes, it is critical to strengthen
coverage, continuity, intensity, and quality of evidence based high impact Health, Nutrition and WASH
interventions via health, ICDS, Food and other systems and, across the continuum of care (from facility
to community) during the most critical life stage (1000-days window of opportunity – from conception to
the age of 2 years old).
As the growth and development potential in childhood is tremendous, any deficit in care and nutrition
during this period can adversely affect the immunity of the child making them prone to diseases that
ultimately leads to increased risk of mortality and morbidity. Severe acute malnutrition (SAM) among
children is a life-threatening form of malnutrition resulting from inadequate feeding and / or repeated
illnesses. Government of India is committed to address prevent and manage SAM. Recently released
guidelines from Ministry of WCD states that Poshan 2.0 shall focus on Maternal Nutrition, Infant and
Young Child Feeding Norms, Treatment of MAM/SAM, and Wellness through AYUSH. It encourages states
to implement community-based approaches for prevention, identification, and care of acute malnutrition.
Many state governments have developed guidelines and initiated implementation of integrated services for
children with SAM linking growth monitoring and promotion to identify children with MAM and SAM and
linking them with facility and community-based care through the functionaries of Department of Women
and Child Development (DWCD) in collaboration with the Department of Health and Family Welfare
(DHFW). The states are providing an integrated package of prevention, identification and care services
for children with SAM, which includes screening of children for wasting and medical complications; care
for children with MAM and prevention of SAM among them; referral to facility-based care if any medical
complications; for uncomplicated children with SAM - provision of antibiotic, de-worming, multivitamin,
IFA at community level; and locally available nutrient dense food; discharge on achieving target weight
and referral if the child develops any complication.
Since 2020, the world has been dealing with the COVID-19 pandemic, with an unprecedented public
health crisis that affected the health and nutrition care service delivery across the country. Despite this,
states have innovated and modified the components of the program to maintain continuity and in several
cases even expansion of the health and nutrition services to the most nutrition vulnerable children.
In order to further strengthen the programs, it is important to understand the learnings, best practices
and challenges from the state experiences. NITI Aayog led the process of documenting the experiences
through this thematic compendium on identification, prevention, and community-based care of children
with acute malnutrition, with support of UNICEF and National Centre of Excellence on care of children
with SAM (C-SAM) - Kalawati Saran Children’s Hospital and state level centers of excellence. This
document summarizes key learning from several states of India on thematic areas of the program and
serves to inspire and guide other states to adopt the experiences. As the number of children with SAM
United Nations Children’s Fund I India Country Office
UNICEF House, 73 Lodi Estate, New Delhi — 110 003
Telephone: (+91) 11 24690401 I Facsimile: (+91) 11-24627521 I
newdelhi@unicef.org I www.unicetin
ixTransforming Child Nutrition
MESSAGE
Arjan de Wagt
Chief, Nutrition | UNICEF India xTransforming Child Nutrition xiTransforming Child Nutrition
ACKNOWLEDGEMENT
We extend our heartfelt gratitude to the Ministry of Women and Child Development and
the Ministry of Health and Family Welfare for their valuable contributions in enriching
this document through their insightful comments and inputs. Their expertise has been
instrumental in shaping the content and enhancing its impact.
We would also like to express our sincere appreciation to the State Government officials of
the Women and Child Development departments who generously shared their innovative
practices. Their contributions have been invaluable in showcasing effective strategies for
managing acute malnutrition at the community level.
Our gratitude also goes to the UNICEF state teams for their unwavering support in facilitating
responses from the states and providing essential insights throughout the process.
The National Center of Excellence for Management of Severe Acute Malnutrition (NCoESAM),
Kalawati Saran Children’s Hospital, New Delhi, has played a significant role in enhancing this
document. We are immensely thankful to Dr. Praveen Kumar, Dr. Rajesh Sinha, Ms. Shristi
Arora and Ms. Shikha Sayal from the National Centre of Excellence for their valuable inputs.
Special thanks are extended to Dr. Rakesh Sarwal, former Additional Secretary, NITI Aayog,
for his invaluable comments and feedback during the preparation of this document. His
guidance has been crucial in ensuring the document’s comprehensiveness and relevance.
We also acknowledge the efforts of Ms. Sumana Arora, Senior Consultant, Ms. Urvashi Prasad,
Director, and Dr. Aakriti Gupta, Associate, NITI Aayog, for editorial assistance, which has
greatly contributed to the document’s clarity and coherence. xiiTransforming Child Nutrition
ACRONYMS
AD – Additional Director
AIIMS – All India Institute of Medical Sciences
AMMA – Acute Malnutrition Management Action
ANM – Auxiliary Nurse Midwife
ASHA – Accredited Social Health Worker
AWC – Anganwadi Centre
AWT – Anganwadi Teacher
AWW – Anganwadi Worker
VO – Village Organization
BCM – Block Child Manager
BD – Twice a day
BPPP – Baal Poshan Pragati Patrak
CAS – Common Application Software
CBEs – Community Based Events
CDPO – Child Development Project Officer
CGHA – Community Gender & Health Activists
CHC – Community Health Center
CMAM – Community-Based Management of Acute
Malnutrition
CC-SAM – Community based Management of Children
with Severe Acute Malnutrition
CMHO – Chief Medical & Health Officer
CSO – Civil Society Organization
DD – Deputy Director
DEIC – District Early Identification Center
DM - District Magistrate
DoHFW – Department of Health and Family Welfare
DPO – District Project Officer
DSWO – District Social Welfare Office
DWCD – Department of Women and Child Development
DRPCAU – Dr. Rajendra Prasad Central Agricultural
University
ECCE – Early Childhood Care and Education
ECD – Early Childhood Development
FLWs – Field Level Workers
GMD – Growth Monitoring Devices
GMP – Growth Monitoring and Promotion
GOM – Government of Maharashtra
GMSH – Government Multi Specialty Hospital
GMERS – Gujarat Medical Education and Research
Society
GMSCL – Gujarat Medical Services Corporation
GPDP – Gram Panchayat Development Plan
HBYC – Home-Based Care for Young Child Programme
HBNC – Home Based New Born Care
ICDS – Integrated Child Development Scheme
ICMR NIN – Indian Council of Medical Research –
National Institute of Nutrition
IEC – Information Education Communications
IFA – Iron Folic Acid
ILA – Incremental Learning Approach
IMAM – Integrated Management of Acute Malnutrition
IMSAM – Integrated Management of Severe Acute
Malnutrition
IVR – Interactive Voice Response
IYCF – Infant and Young Child Feeding
JD – Joint Director
JFMC – Joint Forest Management Committee xiiiTransforming Child Nutrition
JSLPS – Jharkhand State livelihood Promotion Society
KSCH – Kalawati Saran Children’s Hospital
LHV – Lady Health Visitor
LS – Lady Supervisor
LBW – Low Birth Weight
MoWCD – Ministry of Women and Child Development
MAA – Mother’s Absolute Affection
MAM – Moderate Acute Malnutrition
MCHN – Maternal Child Health and Nutrition
MIS – Management Information System
MO – Medical Officer
MPR – Monthly Progress Report
MSSSKA - Mukhya Mantri Sustho Shaishob Sustho
Kaishore Abhiyaan
MTC – Malnutrition Treatment Centre
MUAC – Mid-Upper Arm Circumference
NCoE-SAM – National Centre of Excellence for
Management of Severe Acute Malnutrition
NFHS – National Health and Family Survey
NHE – Nutrition and Health Education
NHM – National Health Mission
NIPCCD – National Institute of Public Cooperation and
Child Development
NNM – National Nutrition Mission
NNMB – National Nutrition Monitoring Bureau
NIN – National Institute of Nutrition
NRC – Nutrition Rehabilitation Centre
NRLM – National Rural Livelihood Mission
OD – Once Daily
ORS – Oral Rehydration Solution
PESA – Panchayat (Extension to Scheduled Areas)
PHC – Primary Health Center
PHD – Public Health Department
PMCC – The Performance Monitoring and Control Centre
PR – Public Relations
PRI – Panchayati Raj Institution
PSM – Preventive and Social Medicine
RBSK – Rashtriya Bal Swasthya Karyakram
RCH – Reproductive and Child Health
RCoENRRT – Regional Centre of Excellence for
Nutritional Rehabilitation Resource & Training
RIMS – Rajendra Institute of Medical Sciences
RTE – Ready to Eat
SAAMAR – Strategic Action for Alleviation of Malnutrition
and Anaemia Reduction
SAM – Severe Acute Malnutrition
SBCC – Social Behavior Change Communication
SCoE – State Centre of Excellence
SDM – Sub-Divisional Magistrate
SHGs – Self-Help Groups
SIHFW – State Institute of Health & Family Welfare
SNP – Supplementary Nutrition Programme
SNCU – Special Newborn Care Unit
SSFP – Supervised Supplementary Feeding Programme
SUW – Severe Underweight
THR – Take-Home Ration
TOT – Training of Trainers
UNICEF – United Nations Children’s Fund
U6M – Under 6 Months
VCDC – Village Child Development Center
VHSNC – Village Health Sanitation and Nutrition
Committee
VHSND – Village Health, Sanitation and Nutrition Day
WASH – Water, Sanitation and Hygiene
WCD – Women and Child Development
WHO – World Health Organization xvTransforming Child Nutrition
Foreword, Vice chairman, NITI Aayogiii
Foreword, Member, Health, NITI Aayog v
Message, CEO, NITI Aayogvii
Message, UNICEFix
Acknowledgementxi
Acronymsxii
Executive Summary1
1.Backgrounds5
1.1 Approaches for Management of Children with Acute Malnutrition8
1.2 Principles for Management of Acute Malnutrition at Community
Level
8
2.Thematic Areas for Community-Based Management of Acute
Malnutrition
13
3.Methodology for Development of the Compendium 15
4.Status of CMAM Implementation in India17
5.Thematic Areas on CMAM across India21
5.1 Community Mobilization for Strengthening CMAM 21
5.2 Screening and Identification 27
5.3 Appetite Test31
5.4 Medical Management38
5.5 Nutritional Management 41
5.6 Follow-Up 45
5.7 Nutrition and Health Education50
5.8 Technology Enabled Recording and Reporting System 54
5.9 Monitoring and Supervision57
5.10 Multisectoral Convergence61
5.11 Capacity Building 64
5.12 Scalability, Replicability and Sustainability 69
6Community-Based Management of Infants (Under 6 months)
with Severe Acute Malnutrition
73
7Challenges Faced during Implementation75
8The Way Forward81
Annexures 82
References85
CONTENTS xviTransforming Child Nutrition 1Transforming Child Nutrition
For successful programme implementation and its scale-up, the key thematic
components are - community mobilization, screening/identification,
appetite test, medical management, nutritional management,
nutritional and health education, recording and reporting,
monitoring, multisectoral engagement and capacity building.
Executive Summary
Malnutrition is a major public health concern in the country. To address the issue of acute malnutrition among
children under 5 years of age, integrated prevention and treatment approaches are critical to be implemented
through community- and facility-based management systems. Facility-based management programme is
already in place through functional Nutrition Rehabilitation Centers (NRCs) as per the national guidelines
issued by the Ministry of Health and Family Welfare, Government of India. A protocol for management of
malnutrition in children has been released by the Ministry of Women and Child Development.
The community-based programme for management of acute malnutrition is being implemented in several
states following the development of state-specific guidelines. There is a need to strengthen the services
delivered to children with Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM) by
increasing coverage, standardizing protocols and improving adherence, enhancing the knowledge and
skills of frontline functionaries, ensuring adequate supplies, boosting data quality and enforcing regular
monitoring mechanisms.
For successful programme implementation and its scale-up, the key thematic components are - community
mobilization, screening/identification, appetite test, medical management, nutritional management,
nutritional and health education, recording and reporting, monitoring, multisectoral engagement and
capacity building.
The practices under community mobilization cover a range of Information Education Communications (IEC)
activities such as community meetings, media engagement, social audits, rallies, wall paintings and food-
related games, among others. These activities help Anganwadi Workers (AWWs), Accredited Social Health
Workers (ASHAs), Auxiliary Nurse Midwives (ANMs) and Anganwadi Services Supervisors to interact with the
community and families, thereby building a relationship with them and encouraging their participation in
the programme.
Early screening and identification of malnutrition among infants and young children are instrumental to the
programme. Various states have adopted innovative methods to screen children under the CMAM programme
through multiple screening modes, including monthly door-to-door screening, the constitution of a special
team for screening and enrollment and fixed days for routine growth monitoring and identification. 2Transforming Child Nutrition
SAM and MAM children without medical complications can be treated at the community level using
medicines and supplements as per Integrated Management of Neonatal and Childhood Illness (IMNCI)
protocols. In most states, health team comprising of ANMs or doctors conduct a medical assessment of
children identified with SAM.
The nutritional needs of SAM and MAM children differ from those of normally nourished children in terms
of energy density, quantity, and feeding frequency. SAM and MAM children can take only a small amount of
food at a time. Therefore, the food must be easily digestible, rich in energy and contain appropriate amount
of proteins. Some states are focusing on strengthening targeted counselling to enhance home prepared
food using locally available and culturally-appropriate food ingredients, while others have enhanced the
routine THR, also tried to make provision as per the age and weight of the child. States have also tried
energy-dense recipes where the recipe is provided only after approval of the recipe committee of districts,
special provision of funds is made for the nutritional management of SAM and MAM children, and flexibility
is given to AWWs for preparing recipes using locally available foods.
Children under the CMAM programme are frequently followed-up, and different activities are undertaken
during follow-up visits. Most states have fixed duration of the follow-up visits at regular fixed intervals
by frontline workers while the child is in the programme - and even after they are discharged from the
programme - to prevent relapse and take timely action.
The strategies for nutrition and health education include interpersonal counselling during follow up as well
as home visits using audio-visual aids and other printed IEC materials, or cooking demonstration at AWC.
The recording and reporting system allows for assessing the progress of CMAM programme. The states have
developed tracking tools such as a management information system (MIS), an android-based application,
for real-time data entry of enrolled children and for tracking all the parameters of children with SAM and
MAM. 3Transforming Child Nutrition
Monitoring and supervision are conducted to observe and check the
Details of logistics
including
equipment, THR
and medicine
supplies
Recording
and reporting
formats and
quality of data
recorded
Knowledge and
skills of frontline
functionaries or field-
level workers (FLWs)
on identification
and classification of
nutritional status
Services provided
to enrolled
children in CMAM
programme
Outcome of the
programme
Regular monitoring of CMAM activities and review of data can also help in early identification of gaps.
The multisectoral involvement and capacity building is enabled by the active participation of Health and
Family Welfare Department, with the lead role taken by the Department of Women and Child Development
(in most states), to streamline CMAM implementation and avoid duplication of efforts.
At the time of COVID-19 restrictions, innovative strategies were adopted to ensure the continuity of service
delivery while minimising the spread of infection. These included the organisation of virtual trainings of
health functionaries in place of physical trainings to keep up the momentum, delivery of services (including
food) at the doorsteps of beneficiaries when the Anganwadi centres were closed, and the use of Mid-Upper
Arm Circumference (MUAC) in case of unavailability of growth monitoring devices.
State-specific practices documented here will serve as examples to help other states overcome the
challenges and improve CMAM implementation at scale. This documentation will also support in planning
and implementation of interventions for the management of under 6-months infants with early-growth
faltering, at the community level, by ensuring home visits of Low-birth Weights (LBWs) under the Home-
Based Care for Young Child Programme (HBYC) and Home Based New Born Care (HBNC) programmes and by
providing special care to these infants and their mothers. Community participation fostered by awareness
generation among key community members like families, PRIs, SHGs and village leaders through individual
and group counselling sessions using IEC tools, growth charts, videos and counselling flipbooks, has been
highlighted. Tools and practices for real-time data monitoring and tracking for improved screening outcomes
have also been shared. Efforts towards decreasing undernutrition prevalence are sustained by focusing on
preventive approaches such as by promoting better infant and young child feeding practices and WASH
conditions to reduce childhood infections.
The practices and learning outlined in this document can be taken up by state governments to leverage
and strengthen the existing services. It will also provide an opportunity for cross-learning and help state
governments mitigate potential challenges by implementing tried-and-tested solutions from other states.
The purpose of this document is to strengthen implementation of community based integrated approach
for prevention and management of childhood wasting, increase the coverage, ensure better outcomes, and
hence reduce the prevalence of undernutrition in the country. 4Transforming Child Nutrition 5Transforming Child Nutrition
Backgrounds
Malnutrition results from inadequate consumption of food, inappropriate feeding practices,
illnesses like diarrhoea, pneumonia etc., and poor sanitation, and inadequate hygiene
ĥA low-birth-weight infant is at high risk of undernutrition.
ĥIf adequate quantity of food containing appropriate amount of nutrients is not consumed for
an extended period, the child will become undernourished gradually.
ĥIllnesses like diarrhoea can cause excessive loss of nutrients from a child’s body, which might
lead to making the child malnourished.
ĥAcute Respiratory Infection also badly impacts the nutritional status of a child.
Types of undernutrition: Generally, the three indicators, namely weight-for-age, height/length-
for-age, and weight-for-height/length are used to identify three undernutrition conditions viz.
underweight, stunting and wasting respectively (Figure 1).
Figure 1: Types of undernutrition
Underweight condition can result from either chronic or acute malnutrition, or both. An underweight child has a weight-for-age Z score of (-2SD) below the median for the World Health Organization (WHO) Child Growth Standards. According to WHO standard, a child is considered moderately underweight when its weight-for-age Z-score falls between -2 and -3 SD, and severely underweight when weight-for-age Z-score falls less than -3 SD.
Underweight
Failure to achieve expected height/length as compared to a healthy, well-nourished child of the same age is a sign of stunting. Stunting is an indicator of linear growth retardation and chronic growth failure. It is associated with a number of long-term factors including chronic insufficient nutrient intake, frequent infection, inappropriate feeding practices and poverty. A stunted child has a height-for-age Z score that is at least two standard deviations (-2SD) below the median for the WHO Child Growth Standards.
Stunting
It is acute malnutrition resulting from either failure to gain weight or from actual weight loss. Wasting in individual child and population groups can change rapidly and show marked seasonal patterns, since it is very sensitive to changes in food availability or disease prevalence. A wasted child has a weight-for-height/length Z score at least two standard deviations (-2 SD) below the median for the WHO Child Growth Standards.
Wasting 6Transforming Child Nutrition
As per the National Family Health Survey (NFHS-5) 2019-21, the prevalence of stunting (35.5%), underweight
(32.1%), wasting (19.3%), and severe wasting (7.7%) remains very high among children under 5 years (U5)
of age (Figure 2). Although a decline in undernutrition from NFHS-2, 3, 4 to NFHS-5 has been witnessed, the
progress seems to be very slow.
In 2006, WHO released new growth standards for children aged 0-5 years, which inform all WHO definitions
and estimates of malnutrition. Accordingly, acute malnutrition can be classified into two categories viz.
Moderate Acute Malnutrition (MAM) and Severe Acute Malnutrition (SAM).
Moderate Acute Malnutrition (MAM) (WHO, 2013) is defined by moderate wasting, i.e., weight-for-height/
length (WFH) between ‐2 and ‐3 Z score (SD) or mid-upper-arm circumference (MUAC) between 11.5 cm to
12.5 cm for children 0‐59 months. It makes up the greatest portion of malnourished children. It is, therefore,
vital to intervene in children with moderate malnutrition at the community level before they slip into severe
malnutrition and develop complications.
Severe Acute Malnutrition (SAM) (WHO, 2013) is when a child suffers severe wasting that may or may not
be accompanied by swelling of the body due to fluid retention. It occurs when infants and children do
not have adequate energy, proteins and micronutrients in their diet, combined with other health problems
such as recurrent infections. For children 0-6 months, it is defined by weight-for-length (WFL) Z score below
three standard deviations (‐3SD) of the median WHO child growth standards and/or presence of bilateral
pitting oedema (build-up of fluid in the body which causes the affected tissue to become swollen, could
be generalized but commonly seen in the lower extremities first). For children 6-59 months, it is defined by
weight-for-height/length (WFH) Z score below three standard deviations (‐3SD) of the median WHO child
growth standards and/or presence of bilateral pitting oedema and/or MUAC<11.5 cm.
Children with SAM are at an increased risk of mortality due to common childhood illnesses since they have
reduced immunity and a deranged metabolic system. Global evidence suggests that severely malnourished
children contribute significantly to deaths in children under the age of five years.
Figure 2: Trends in prevalence of different forms of child undernutrition in India
Underweight Stunting Wasting
47
42.5
35.7
32.7
Severe wasting
2.2
6.4
7.57.7
15.5
19.819.3
21
45.4
38.4
35.5
48
0
10
20
30
40
50 7Transforming Child Nutrition
Children with SAM require thorough assessment and clinical examination for identifying complications
(Figure 3) like oedema, loss of appetite, severe anaemia, pneumonia, diarrhoea, dehydration, cerebral palsy,
tuberculosis, HIV, and heart disease, and any other danger signs (according to IMNCI algorithm). If any of
these are present, it is classified as SAM with medical complication, and the child is referred for inpatient
management. If the child with SAM has no associated medical complication, it can be managed in the
outpatient/community setting with care at home. Evidence shows that about 85-90% children with severe
acute malnutrition do not have medical complications when they are identified early through active case-
finding, or through sensitizing and mobilizing communities to access decentralized services themselves,
and can be treated at home.
It is important to recognise that malnutrition is preventable and treatable, and therefore, there is an urgent
need to have mechanisms in place for early detection of growth faltering and for taking corrective measures
before the child progresses to severe grades of malnutrition. Children who have already developed SAM
require immediate curative care closer to their homes in the community settings to prevent further
complications. However, children with SAM who have also developed medical complications need to be
treated at the health facilities/NRCs.
Figure 3: Assessment and clinical examination for identifying complications
ANY OTHER
DANGER SIGNGS
(ACCORDING
TO IMNCI
ALGORITHM)
HEART DISEASE
HIV
CEREBRAL
PALSY
DIARRHOEA
DEHYDRATION
TuberculosisPNEUMONIA
SEVERE
ANAEMIA
LOSS OF
APPETITE
OEDEMA
Children with SAM
require thorough
assessment and
clinical examination
for identifying
complications like 8Transforming Child Nutrition
1.1 Approaches for Management of Children with Acute Malnutrition
There are two approaches for management of children with acute malnutrition (Figures 4 and 5).
Inpatient or Facility-Based Management of Acute Malnutrition: Only
about 10-15% children with SAM suffer from medical complications and require
inpatient care. Inpatient management at NRCs is effective in reducing case fatality
rates. NRCs have already been established in many states to provide specialised
care, while other states are in the process of setting them up or integrating the
protocols in the existing paediatrics care.
Community-Based Management of Acute Malnutrition (CMAM): The
majority of severely malnourished children who do not have medical complications
can be managed in the community setting. In addition, children discharged from
the NRC can also continue to be cared for in the community setting after initial
phase of stabilisation and onset of recovery phase. Community-based management
is also important from another perspective. Under the best of circumstances, the
NRCs will not be able to provide care to the entire case load of children with SAM in
each district or state, as NRCs are meant for facility-based management of the SAM
children with medical complications only. Inability of the caregivers to stay in the
NRC for a considerable period till the child is on the way to recovery is also a reason
for incomplete treatment/recovery of admitted children in NRCs. There is, thus, a
need to establish continuum of care at the community level. Community-based
care will complement the services delivered through NRCs. This will create scope
for most children with SAM to be provided with care in the community setting
itself, thus reducing the load on resources and health facilities.
1
2
Figure 4: Two approaches for management of children with acute malnutrition 9Transforming Child Nutrition
Screening with weight-for-height
/ length (all under-five children)
NormalSAM
Medical Assessment with
support from ANM: Check for
bilateral pitting oedema, visible
medical complications, and
other medical complications
Appreciate and encourage
positive behaviors
Counseling on Maternal, Infant
and Young Child Feeding
practices. Continue micronutrient
supplementation as per routine
programme guidelines
MAM
Care Provision for 12/16 weeks (6
services) and Follow-up after 4 weeks
1. Antibiotics and de-worming
2. Energy & nutrient dense food/
Double THR
3. Weekly home visits & interpersonal
counselling
4. Micronutrient supplementation
5. Weekly/Fortnightly weight for
height by AWW and health check up
by ANM
6. Follow-up
SAM with medical
complications
Refer and
Treatment
at NRC
SAM without medical
complications
Children who don’t
respond under
CMAM or in
case any medical
complications arise
Figure 5: Approaches for management of children with acute malnutrition
1.2 Principles for Management of Children with
Acute Malnutrition at Community Level
Community-based management is founded on the understanding that if children with MAM/SAM are
identified in the early stages, then treatment can be provided at community level, thereby averting medical
complications in these children. Community-based management, therefore, focuses on the timely detection
and addressing of acute malnutrition in early stages, before the metabolic and immunological aspects
become severe enough to warrant inpatient treatment.
The community-based care programme builds on the existing local capacity and resources of the Health
and Anganwadi Services systems, providing easy access to services and making appropriate care available
within the community setting as long as needed.
Community-based care is linked with facility-based care through referrals; children developing medical
complications can be referred to a nearby health facility, for example, a Primary Health Center (PHC) or
Community Health Center (CHC) with the availability of medical officers for further outpatient/inpatient
care, and even NRCs, wherever available. Those discharged from NRCs are enrolled into the community-
based programme for continuation of care and nutritional rehabilitation. 10Transforming Child Nutrition
Community-Based Management of Acute Malnutrition (CMAM) is based on the principle that children should
receive timely and appropriate care and assistance, especially if they are facing health risks (Figures 6 and 7).
The core operating principles of CMAM are as follows.
Maximum coverage
and access
To achieve the greatest
possible coverage
by making services
accessible to the
maximum possible
proportion of children
in need.
Timeliness
To begin case-finding
and treatment before
additional medical
complications occur
and the prevalence
or complexity of SAM
escalates.
Sectoral integration
To be integrated with other
programmes especially prevention
interventions, including health
and nutrition education;
protection, promotion and
support of optimal breastfeeding;
complementary feeding and
hygiene and sanitation practices.
Capacity building
To build existing
structures through
collaboration,
training and ongoing
support rather than
establishing parallel
systems
Appropriate care
To provide simple,
effective outpatient care
for children who can be
treated at home while
identifying children
who need clinical care
(inpatient treatment).
Care for as long as needed
To ensure that children stay in
the programme or are linked with
existing services until they have
recovered or get timely referral,
as and when needed. By building
local capacity and integrating the
programme with existing health
and anganwadi service system,
CMAM also aims to ensure that
effective treatment remains
available for as long as malnutrition
is a public health concern in the
population.
Figure 6: Core operating principles of Community-Based Management of Acute Malnutrition Figure 7: Comprehensive integrated package of services under community-
based programme for children with severe wasting/growth faltering
Nutrient-dense
food/ Take home
ration (THR)
Interpersonal
counselling
Referral for medical
complication
Assessment of medical
complication
Monthly growth
monitoring & promotion
(GMP) and screening
Regular monitoring
for progress or
deterioration (weekly/
fortnightly)
Medicines, antibiotics,
deworming, iron &
folic acid (IFA) and
vitamin A 12Transforming Child Nutrition 13Transforming Child Nutrition
Thematic Areas for Community-Based
Management of Acute Malnutrition2
Thematic areas under Community-Based Management of Acute Malnutrition (CMAM) are
categorised as follows (Figure 8)
Figure 8: Key thematic areas under CMAM Programme
Key Components for
CMAM Programme
Community
Mobilization/
Awareness
Medical
Management
Nutritional
Management
Nutrition and
Health Education
Recording
and Reporting
Multisectoral
Engagement
Capacity Building
Monitoring
Appetite Test
Screening
Scalability,
Replicablity and
Sustainability 14Transforming Child Nutrition 15Transforming Child Nutrition
Methodology for Development of
the Compendium
3
To understand the programme implementation approaches adopted by states, NITI Aayog
reached out to state governments. A Google form was developed to capture different aspects of
CMAM programme implemented by states, such as capacity building, screening and identification,
community mobilization, nutritional care and management, medical management, nutrition
and health education and scaling of the programme (Figure 9). Information on challenges
faced, strategies to mitigate those challenges, and practices under each state’s respective CMAM
programme were also captured through the Google form. The form was shared with nodal
department of all the state governments within India, in December 2021. Information received
from different states of India on the practices of CMAM has been collated in this document. The
Google form used to capture the information is appended in Annexure 1.
Figure 9: CMAM programme implementation approaches
Capacity
Building
Scaling
of the
programme
Screening and
identification
Nutritional
care and
management
Nutrition
and health
education
Community
mobilization
Medical
management 16Transforming Child Nutrition 17Transforming Child Nutrition
Status of CMAM Implementation
in India4
As per the information received from the states, CMAM programme is operational in different
states by different names, varying with regards to its scale of implementation and salient features.
State-wide implementation of the CMAM programme has been reported by Assam, Bihar,
Chandigarh, Chhattisgarh, Gujarat, Haryana, Maharashtra, Jharkhand, Madhya Pradesh, Odisha,
Rajasthan, Telangana, Uttar Pradesh and Meghalaya. In other states, it has been implemented on
a smaller scale catering to few districts (Figure 10). Details of CMAM implementation in several
states of India is summarized in Table 1.
Figure 10: Status of implementation of CMAM programme across India
Andaman &
Nicobar Islands
Chandigarh
Jammu
and Kashmir
Ladakh
Haryana
Himachal
Pradesh
Uttarakhand
Punjab
Jharkhand
West
Bengal
Sikkim
Yanam
(Puducherry)
Karaikal
(Puducherry)
Mahe (Puducherry)
Kerala
Telangana
Karnataka
Lakshadweep
Rajasthan Uttar Pradesh
Delhi
Bihar
Andhra
Pradesh
Tamil
Nadu
Odisha
Goa
Mizoram
Tripura
Chhattisgarh
Madhya Pradesh
Arunachal
Pradesh
Nagaland
Meghalaya
Manipur
Assam
Maharashtra
Gujarat
Dadra,
Nagar Haveli,
Daman and Diu 18Transforming Child Nutrition
S.
No.
State State-wide
implementation
Scale of
implementation of
CMAM programme
Name of the district(s)Title of the CMAM
programme in the state
1Assam Yes State-wide All districts Community Based
Program for Children
with Severe Acute
Malnutrition (CP-SAM)
2Bihar No 6 districts Purnea, Araria, Begusarai,
Katihar, Sheikhpura,
Sitamarhi
Samvardhan:
Comprehensive
Health and Nutrition
Interventions for
Community Care of
SAM
3Chandigarh No 4 high risk areasBapu dham colony (East),
Hallomajra (West), Dhanas
(North), Maloya (South)
Chatur Dishai Poshan
on Wheels
4ChhattisgarhYes State-wide in
phased manner
17 districts in first phase:
Durg, Mohla-Manpur-
Ambagadh Chowki,
Mahasamund, Kanker,
Kondagaon, Bastar, Bijapur,
Dantewada, Narayanpur,
Korba, Bilaspur, Raigarh,
Surguja, Jashpur, Koriya,
Kawardha (Kabirdham),
Balrampur
Community Based
Management for
Children with Severe
Acute Malnutrition (CC-
SAM)
5Gujarat Yes State-wide All districts and 8
Corporations
Kuposhan Mukt
Gujarat Maha
Abhiyaan – Integrated
management of Severe
Acute Malnutrition
6Haryana Yes State-wide All districts Strategy for
Identification &
tracking of SAM & MAM
Children
7Jharkhand Yes State-wide in
phased manner
6 districts in first phase:
West Singhbhum, Godda,
Sahibganj, Simdega,
Chatra, Latehar
Known as:
»Johar Poshan in
West Singhbhum
district (launched on
31
st
March 2021)
»SAAMAR
programme
(launched on 29
th
December 2021
)
Table 1: Status of Implementation of CMAM Programme in India 19Transforming Child Nutrition
S.
No.
State State-wide
implementation
Scale of
implementation of
CMAM programme
Name of the district(s)Title of the CMAM
programme in the state
8Madhya
Pradesh
Yes State-wide All districts Mukhya Mantri Baal
Aarogya Samvarshan
Karyakram (IMAM
- Integrated
Management of Acute
Malnutrition)
9MaharashtraYes State-wide All districts Village Child
Development Center
(VCDCs)
10Odisha Yes State-wide All districts Community-Based
Management of Acute
Malnutrition (CMAM)
11Rajasthan Yes State-wide in
phased manner
Accelerated action in 20
priority districts: Udaipur,
Dungarpur,Chittorgarh,
Pratapgarh, Banswara,
Rajasmand, Jodhpur,
Jaisalmer, Jalore, Barmer,
Pali, Sirohi, Jaipur, Tonk,
Bundi, Baran, Karauli,
Dholpur, Alwar, Bharatpur
Acute Malnutrition
Management Action
(AMMA) Programme
12Telangana Yes State-wide All districts Supervised
Supplementary
Feeding Programme
(SSFP)
13Uttar PradeshYes State-wide All districts SAMBHAV
14Meghalaya Yes State wise All districts Collaborative Actions
to improve nutrition
status of SAM and MAM
children in Meghalaya 20Transforming Child Nutrition 21Transforming Child Nutrition
Thematic Areas on CMAM
across India5
5.1. Community mobilization for
strengthening CMAM
For a successful CMAM programme, coverage is key. It is important to reach each and every child
under five years of age. To ensure the best possible coverage, understanding of the community is
crucial, as people have diverse educational and economic backgrounds. Laying the groundwork
for CMAM requires a range of activities designed to help implementers interact with the
community, especially families of SAM and MAM children.
It is crucial that the community is aware of the signs of malnutrition, the preventive and curative
services available, and the process and the benefits of the services for children. Families of at-
risk children should be encouraged to seek and continue appropriate care. A range of activities
designed to help AWWs, ASHAs, ANMs and Anganwadi Services Supervisors interact with the
community and families help build a relationship with them and foster their participation in the
programme. The mobilisation process covers three activities: community sensitisation, follow-up
and on-going sensitisation (Figure 11).
Figure 11: Stages in community mobilization process
Community
sensitisation
Community
Follow up
On-going
sensitisation
based on feedback 22Transforming Child Nutrition
Some of the creative and innovative community mobilization processes followed across different states of
India are discussed in the section below:
5.1.1 Community mobilization through media and showcasing videos
(Jharkhand)
5.1.2 Mobilization through utilizing community platforms (Jharkhand,
Maharashtra, Meghalaya)
i. In Jharkhand, the Information and Public Relations Department (IPRD) is involved in
disseminating IEC messages.
i. In Jharkhand, platforms like the Village Health, Sanitation and Nutrition Day (VHSND) at the
Anganwadi Centre (AWC), Ratri Chaupals (community meetings held at night), Gram Sabhas,
and SHG meetings are being utilised by frontline workers to inform community members about
the CMAM programme. Let’s look at these closely:
ĥRatri Chaupal meetings are organized in the evening for community awareness on nutrition
issues including anaemia, dietary diversity and WASH practices, during which IEC materials,
videos and LED vans are used. District-level officers also participate in these awareness
meetings.
ĥAt the AWC level, cooking demonstrations are organized by AWWs in groups of 10-15
women, focusing on enhancing dietary diversity using locally-available ingredients.
ĥCommunity-related issues are discussed by 20–25-gram sangathan women in SHG meetings
held twice in a month. They use flip-books to share information about malnutrition with
the community members. Under the Poshan Abhiyaan, regular sensitization activities are
conducted. These include seminars and workshops undertaken during Poshan Pakwada
and Poshan Maah, during the months of March and September respectively, for community
mobilization.
ĥThe Johar Poshan Van, with an LED
screen, is leased by the district for
90 days @ Rs. 8000/day to showcase
videos and spread awareness about
malnutrition, breastfeeding and
anaemia in the weekly haat bazaar,
bus stand and public gathering
areas. The district has a structured
weekly route plan for LED vans to
ensure all the areas are covered.
The following films are being
displayed through the LED van:
Anemia Mukt Bharat (AMB) video,
Mother’s Absolute Affection (MAA)
video, breastfeeding and nutrition
videos, COVID precaution-related videos, Poshan Abhiyaan animation video and CMAM video,
Zindagi fir muskurayegi (Figure 12).
Figure 12: Use of LED Van in Jharkhand for
showcasing videos for spreading awareness 23Transforming Child Nutrition
The initiatives have led to increased awareness, ownership, and participation among community
members and greater utilization of available services and platforms by the family for children.
ii. In Maharashtra, frontline functionaries and officers of Department of Women and Child
Development (DWCD) and the Public Health Department (PHD) organize and participate in the following:
ĥCommunity-based events (CBEs), home visits and Growth Monitoring and Promotion (GMP) sessions.
ĥOther initiatives being undertaken in the state for community awareness include Mata Baithak (Mother’s meeting), Bal Kopra (designated food corner at AWCs or at home), promotion of Paras Bagh (nutri-gardens to improve dietary diversity), and the Muth Bhar Dhanya (contribution of a fistful of grain) campaign.
iii. Meghalaya took the collaborative approach of involving the Self-Help Groups (SHGs) and Village Organisations (VOs) of the National Rural Livelihood Mission (NRLM) for community mobilisation.
ĥSHG members were mainly involved in the mobilization of women with children below 6 years of age, whereby such women are advised to take their children to the Anganwadi Centres for physical check-ups.
ĥSome of the SHGs and VOs were also trained by the Social Welfare Department (Women and Child Development) on the identification of SAM and MAM children. They were able to identify SAM and MAM children with the support of the ASHA, AWW and ANM.
ĥBased on the recommendation, the SHGs also took responsibility of transferring cases to the PHCs or CHCs. Apart from this, SHGs were also involved in awareness programmes, rallies, and other programmes during the Poshan Maah celebrations.
Furthermore, during visits, community-based events and VHSNDs, the SHGs/VOs push malnutrition as a special agenda to be discussed during the meeting. The SHGs/VOs and AWWs were instrumental in mobilizing parents, especially mothers, to encourage weighing and monitoring their children’s health status on a regular basis.
ĥDissemination media used include radio, TV, miking (subtitled) and hoardings. Coordination with the representatives of district- and block-level public relations department is being done for larger-scale dissemination and awareness generation (Figure 13).
Figure 13: Ratri chaupal: Community awareness
through discussion on health and nutrition 24Transforming Child Nutrition
5.1.3 Community mobilization through participatory learning
approach, involvement of local bodies and use of IEC tools
(Madhya Pradesh)
i. In Madhya Pradesh, mobilization is strengthened by the convergence between concerned
departments at the village level through different initiatives:
ĥSanjhi Sehat: Participatory Learning and Action (PLA) to empower women’s groups to
improve feeding practices. The PLA approach encourages community to identify and
take ownership of their children’s health concerns. This is executed in a series of meetings
conducted by trained frontline workers who encourage community members to participate,
interact and learn by utilizing visual tools and interactive games.
ĥPoshan Sarkar: Participation and leadership of local bodies/gram panchayats and urban
bodies in the nutrition campaign innovations.
ĥPoshan Matka: Community members contribute nutritious, locally available grains/
vegetables/fruits for malnourished children in their community.
ĥPoshan Mitra: Local people/officers of different departments take responsibility for
improving the nutritional status of the children.
ii. Community-based Information Education Communications (IEC) tools like community growth
chart (wasting-based) are used effectively on village immunization days to create awareness
among community members. It was used to show the nutritional status of SAM/MAM children
to their mother/caretaker and to demonstrate in the individual and group counselling sessions.
iii. A convergent action plan for every village was prepared for the orientation of the members of
VHSNC, Joint Forest Management Committee (JFMCs), Sahyognin Matra Samiti (SMS) and other
local committees on the prevalence of malnutrition, its underlying and immediate causes, and
community responsibility and ownership to address it.
iv. Orientation of VHSNCs, Panchayati Raj Institution (PRI) and local committee members was also
done to build their capacity, thereby increasing their engagement in local nutrition governance.
The initiatives of convergence of different departments have led to greater mobilization, improved participation, and more empowerment among women’s groups to identify SAM and MAM children.
5.1.4 Community mobilization through innovative activities (Bihar)
The AWWs, ASHA and ANM organized community outreach meetings, supported by village leaders, Panchayati Raj Institution (PRI) members and other village resource persons to share information and experience with the village leaders and the community members about CMAM programme prior to its launch. The purpose of the meetings was community sensitization; to create understanding, to communicate importance of their participation and to own the programme. Subsequent meetings were held once a month on the occasion of VHSND or other contact points to reinforce the importance of CMAM. 25Transforming Child Nutrition
These initiatives in Bihar resulted in improved participation of community members in programme
activities like screening and nutrition-education sessions. This also improved the understanding of
community members about dietary diversity, age-appropriate feeding of children, care practices,
including micronutrient supplementation and hygiene, food safety and home augmentation of food
Under the Samvardhan programme in Bihar, social behavior change regarding nutritional practices
is at the core of all efforts. Nutritional treatment under Samvardhan programme is based on the
augmentation of the diet available at home as well as improving the understanding of caregivers
on the frequency, diversity and adequacy of the food to be given to children. Therefore, following
community mobilization activities are planned to provide information about a child’s diet and care
practices to improve community awareness:
ĥCommunity Meetings – On the day of annprashan, community meetings are organized
and male members from the families are also invited to attend the meeting- to enhance
their understanding on nutrition and care practices. These meetings are organized at AWC by
AWWs and ASHA to demonstrate the low-cost food recipes and to display food groups to the
caregivers and other community leaders of PRIs.
ĥFood basket game – A food basket game is organized at AWCs by AWWs, ASHA and Lady
Supervisors (LSs) under the leadership of resource persons from Dr. Rajendra Prasad Central
Agricultural University (DRPCAU), Pusa. AWWs and ASHA invite family members (both male
and female) of acutely malnourished children. During this game, there are two kinds of
baskets placed in front of caregivers, one with nutritious food items like leafy vegetables, eggs,
peanuts, seasonal fruits and sattu powder (protein-rich flour made from powdered chana or
other cereals and pulses) and the other basket with junk food items like chips, chocolates,
or puffs. Parents are then asked to choose the food basket for their children to assess their
nutritional knowledge. They choose the food items and are asked the reason behind the
selection. Choosing nutritious food items leads to positive reinforcement by the AWWs,
whereas the selection of junk food signifies the need for guidance. In this manner, this game
opens up a discussion about the nutritive value of food items given to children (Figure 14).
Figure 14: Glimpses from the food basket game played with the
caregivers of children with MAM/SAM to create awareness in Bihar
ĥPoshan Prahari Award– A Poshan Prahari is identified at the community level. They can be
a mother, field functionary, lady supervisor, PRI or JEEViKA didi. They are awarded for their
significant work done in the identification of nutritional status, improvement of the acutely
malnourished children, and community mobilization. 26Transforming Child Nutrition
5.1.5 Creation of ICDS mascot (Uttar Pradesh)
In the state of Uttar Pradesh, under the
SAMBHAV programme, the community
mobilization and awareness components
have been led by the AWWs, and in 2022,
the Integrated Child Development Scheme
(ICDS) mascot “Aanchal” was created for
taking forward the communication around
the wasting agenda.
The SAMBHAV campaign focuses on a
different determinant of wasting each
month – like maternal nutrition in July, infant
and young child feeding in August and
importance of care during first 1000 days –
from conception to two years of child’s life
(hand washing, kitchen gardens, diarrhoea
and care during illness) in September.
The ICDS mascot Aanchal has a) enabled the targeted population to better understand the programme, and b) increased awareness and transfer of relevant information about nutrition across the population. 27Transforming Child Nutrition
5.2. Screening and Identification
Regular and optimal screening at the community level is imperative for timely diagnosis and management
of malnutrition. If not identified timely, severe wasting in children may lead to an increased risk of morbidity
and mortality. Currently, in India, all children aged 0-59 months are being screened at regular intervals in
the community settings at AWCs by frontline health workers (AWWs, ASHA and ANMs). Children are usually
screened based on weight-for-height Z score and the presence of bilateral pitting oedema. The use of MUAC
for screening of children with SAM is not endorsed by the Ministry of Women and Child Development
(MoWCD). The use of MUAC as a rapid screening tool to detect wasting in children can be restricted to only
emergency situations, like the COVID-19 pandemic or natural disasters.
During Village Health, Sanitation, and Nutrition Day (VHSND) SAM and MAM children are checked for medical
complications and those with medical complications or poor appetite are referred to NRCs or Malnutrition
Treatment Centre (MTC). In contrast, children without medical complications are enrolled in the CMAM
programme. Screening efforts need to be strengthened to enhance coverage. In this section, we describe
the strategies adopted by different states for improved screening of children in communities under the
CMAM programme.
5.2.1 Multiple modes of screening (Gujarat)
i. In Gujarat, screening for children with SAM is undertaken in the following ways (Figure 15).
The comprehensive efforts for screening took the limelight, where all the field-level functionaries were engaged in the identification process. The strategy helped identify, refer and treat children with SAM in mission mode at the community as well as facility level.
Screening for
children with
SAM undertaken
Screening by Rashtriya Bal
Swasthya Karyakram (RBSK)
teams
Initial screening and identification of
children is done by the Rashtriya Bal
Swasthya Karyakram (RBSK) teams/
medical officers and ANM. ANM also
performs screening of the children
(U5) for identification of SAM based
on weight-for-height Z scores and
bilateral pitting oedema.
Passive screening in OPDs
Passive screening is done in all
Outpatient Department (OPD) facilities
at the Primary Health Center (PHC)/
Community Health Center (CHC)/ Sub-
Divisional/Sub-District Hospital (SDH)
and District Hospital (DH), including
the paediatric ward for identification of
cases.
Active screening in community
ASHAs and AWWs conduct active
screening each month, and prepare
a line list of children. ASHA and ANM
maintain the records of the identified
children. This line list is provided to ANM
for further screening and identification
of children with MAM and SAM. Through
this initiative, ANMs have to screen only
the children line listed by
ASHAs and AWWs during VHSND.
Screening in
campaign mode
Campaign mode (conducting a
screening drive across state at a notified
time) is also a part of the CMAM strategy
in Gujarat, through which all the children
under five years are screened for SAM.
Figure 15: Screening for children with SAM 28Transforming Child Nutrition
5.2.2 Joint screening drive by Department of Women and Child
Development and the Public Health Department (Maharashtra)
5.2.3 Fixed screening days (Madhya Pradesh, Haryana)
i. In Maharashtra, routine growth monitoring has been strengthened for screening of children
and the nutritional status of children is tracked as per standard charts, using formula-based Excel
sheets or the Poshan Tracker. If a child is categorized as SAM by AWWs, he/she is reassessed by
health functionaries (Medical Officer or ANM).
Joint screening drive is also undertaken in the state to intensify screening for SAM during the
monsoon season, between 15 June to 30 August. The DoWCD and PHD work in close coordination
at all levels to ensure an effective screening drive. The newly-identified children are admitted to
Village Child Development Centre (VCDCs) or Nutrition Rehabilitation Centers (NRCs) followed
by efforts for improving their nutritional status. This initiative has scaled up the identification
of children with SAM by more than two-fold. Considering the effectiveness of the convergence
between DWCD and PHD, the joint screening drive has been promoted in the upcoming period,
and it has been supplemented with the execution of treatment protocol and tracking, using end-
to-end SAM management software.
In Madhya Pradesh, the weight and length/height of all children are measured between day 11 to
20 of every month under regular growth monitoring service through the ICDS. Name-wise details
of children with MAM and SAM are recorded in the registers and in a dedicated android application
(called Sampark IMAM Module. Following efforts are made to strengthen the identification of SAM
children in Madhya Pradesh (Figure 16).
In Haryana, children are screened for MAM and SAM using weight and height measurements by
AWWs and ASHAs on VHSND and every saturday of the week. The compiled reports of SAM/MAM
children are shared with Rashtriya Bal Swasthya Karyakram (RBSK) team by lady supervisor of ICDS.
Children with SAM having complications are admitted to NRCs/District Early Identification Centres
(DEIC) at district hospitals/private hospitals.
This initiative led to the identification of 8000 SAM children in June and 19000 August 2021.
These efforts led to name-wise tracking and identification of children with SAM under IMAM programme. Despite COVID-19, about 1 lakh children with SAM and more than 4 lakh children with MAM were identified and treated under IMAM (during 2020-21).
Use of community
growth chart (wasting)
and demonstrating
nutritional status of
SAM/MAM children to
their mothers.
Involving the
community in
vazan melas
Provision of
simplified WHO
Z score wasting
table in the
Hindi language
Repeated
training of
FLWs on the
identification
of SAM
Figure 16: Steps to strengthen the identification of SAM children 29Transforming Child Nutrition
5.2.4 Bimonthly screening on Village Health, Sanitation & Nutrition
Days (VHSND) (Telangana)
5.2.5 Intensive screening by special team (Chandigarh)
In Telangana, two Village Health,
Sanitation & Nutrition Days (VHSND) are
organized every month at AWCs.
The first VHSND is dedicated to growth
monitoring, organized collectively by
ASHA and AWW, during which height,
weight and MUAC measurements of all
children aged 0-59 months are obtained.
Due to COVID-19 lockdown in March 2020,
the routine growth monitoring under
ICDS had halted and the identification of
children with wasting at village-level got
disrupted.
MUAC tapes were introduced as a
screening tool across the state keeping the
minimal risk of corona virus transmission.
Children below 6 months who are identified as SAM are referred to NRC by the Anganwadi
worker through ANMs and children aged 7-59 months undergo Appetite Test at AWC on the day
of screening (Figure 17).
The second VHSND is organized as per National Health Mission (NHM) micro-plan by ANM for
ante-natal care and immunization activities.
An innovative pilot project was launched on 20 September 2021, for providing care to malnourished
children including the following:
ĥOutreach camps were conducted on Wednesdays on a weekly basis, as a multi-convergence
approach wherein peripheral doctors and field functionaries of the Health Department and
Social Welfare Department as well as a team of doctors (paediatrics and dieticians) from
Dietetics Department, Government Multispeciality Hospital (GMSH) sector-16 Chandigarh,
are present. Children are screened for severity of malnutrition, and those who require
inpatient care are proposed to be admitted to NRC at Department of Paediatrics, GMSH-16
Chandigarh. Dietary counselling was given to the mothers and caregivers on-the-spot by
dieticians. Each child was measured and provided care at their doorstep. Take-away food
(ration) was provided to beneficiaries by functionaries of the Social Welfare Department and
their intake and compliance was monitored by field workers.
As a result of this special multi-convergence approach to treatment, there has been upswing in
detection by intensive screening and convenient domiciliary treatment of SAM/MAM children.
Figure 17: Screening and identification of children
with SAM in Jharkhand 30Transforming Child Nutrition
5.2.6 Formation of core village health team for identification of
MAM/SAM children (Meghalaya)
The ASHA, AWW and ANM, SHGs/VOs and the ICDS Supervisor form the core village health team.
They work together for the identification and management of SAM children. 480 VOs were trained
by the Social Welfare Department on identification of SAM & MAM children. These SHGs & VOs
play a vital role in mobilizing women to bring their children for screening. The core team members
coordinate effectively, keeping each other informed about their activities and the local health
status and assist each other with various tasks, such as organizing village health sanitation days
and encouraging visits to the Anganwadi centres and sub-centres for regular monitoring of a child’s
health status.
During September 2020, 358,056 (85%) children between 0 to 5 years were weighed. As a result of
this exercise, the number of SAM and MAM children identified in September 2020 was 1,788 and 16,327 respectively.
Such concerted efforts resulted in the identification of 1.2 lakh and 91,000 SAM cases in June and September 2021 rounds respectively under SAMBHAV campaign.
5.2.7 SAMBHAV-Three month long intensive campaign (Uttar Pradesh)
In Uttar Pradesh, “Vazan Divas” is organized on the first tuesday of every month, dedicated to
growth monitoring and identification of children with undernutrition inclusive of SAM/MAM. Keeping in mind the Government of India priority on wasting, the Department of ICDS, Uttar Pradesh introduced a novel initiative by the name of “SAMBHAV”, which is a three-month-long
intensive campaign (July-September) focusing on the identification, health check-up, referral and community-based care of SAM/MAM children. The implementation phase is preceded by a weighing/screening campaign in the month of June.
ĥIn 2021, the Department of ICDS successfully managed to provide essential anthropometry equipment for identifying SAM/MAM cases. Screening of all eligible under-five children present in the community for SAM/MAM was done using weight for height/length criteria and through the Poshan Tracker. In 2021, two special screening drives were conducted: one in June and another in September during Poshan Maah.
To strengthen the screening process, rigorous capacity building of field supervisory staff on the correct use of Anthropometric Devices was undertaken through local videos demonstrating the use of Growth Monitoring Devices (GMDs) and reference charts as ready reckoners for identification of wasting grade. AWWs were trained to use the Poshan Tracker application as a tool for reporting the SAM/MAM cases, for an external assessment of the quality of growth monitoring session, and to feed the learnings into the departmental reviews.
Overall, the states have adopted innovative practices with respect to the screening and identification
of children with SAM at the community level. There has been involvement from both Health and
WCD/ICDS departments for screening of children and identification of SAM. Additionally, in a few
states, RBSK team has also been involved in improving the quality of screening. These provide
compelling case studies and playbooks which can be adopted by other states as well.
5.2.7 Sambhav-Three month long intensive campaign (Uttar Pradesh) 31Transforming Child Nutrition
5.3. Appetite Test
Usually, SAM children with medical complications or infection have a loss of appetite due to physiological
changes. Appetite test helps in identifying children with SAM with underlying medical complications.
Appetite test is carried out to decide the future course of treatment. Child is offered recipes made from Take-
Home Ration (THR)/locally-available food items like Khichdi/any hot cooked meal or milk for the appetite
test. If the child is able to eat/drink the offered food with eagerness, the child is considered to have passed
the appetite test. On passing the appetite test, the child is enrolled in the community-based programme,
otherwise, referred to NRC for further treatment. 32Transforming Child Nutrition
Different states have adopted slightly different method of testing, as mentioned in Table 2.
State Who
conducts
it?
Where? What
food
used?Steps followed Amount
offered
Deciding
criteria
for
passing
the test
Bihar
AWW At CMAM clinic
during VHSND
Locally-
prepared
energy-
dense food
or locally
available
food items
like khichdi/
any hot
cooked meal
or milk.
1. The test is to be
conducted in a
separate quiet area.
2. Explain to the mother/
caregiver the purpose
of the appetite test and
how it is carried out.
3. Ask the mother/
caregiver to wash her/
his hands.
4. The mother/
caregiver needs to sit
comfortably with the
child in her/his lap.
5. The child should not
have taken any food for
last two hours.
6. The test usually takes a
short time but may last
up to one hour.
7. Offer small amount
of locally prepared
energy-dense food or
food items like khichdi/
any hot cooked meal
or milk to the child,
encouraging the child
all the time.
8. If the child refuses, then
the mother/caregiver
should continue to
quietly encourage the
child.
9. The child must not be
forced to eat during
the test.
10. The child should have
free access to safe
drinking water while
he/she is eating the
offered food.
Not
specified
If the child
is able to
eat/drink
the offered
food with
eagerness
Table 2: Method adopted for conducting appetite test by the states 33Transforming Child Nutrition
State Who
conducts
it?
Where? What
food
used?Steps followed Amount
offered
Deciding
criteria
for
passing
the test
Chhattisgarh
AWW At CMAM clinic
during VHSND
EDF (Energy-
Dense Food)
prepared
with THR
or locally
available
food items
like Khichdi/
any hot
cooked meal
or milk.
1. The test should
be conducted in a
separate quiet area.
2. Explain to the mother/
caregiver the purpose
of the appetite test
and how it will be
carried out.
3. Ask mother/caregiver
to wash her/his hands.
4. The mother/caregiver
should sit comfortably
with the child on her/
his lap.
5. The child should not
have taken any food for
last two hours.
6. The test usually takes
a short time but may
take up to one hour.
7. Offer a small amount of
energy-dense food or
locally available food
items like Khichdi/
any hot cooked meal
or milk to the child,
encouraging the child
all the time.
8. If the child refuses,
then the mother/
caregiver should
continue to quietly
encourage the child.
9. The child must not be
forced to take the EDF
(Energy Dense Food)
or any other diets
being used for the test.
10. The child should have
free access to safe
drinking water while
he/she is taking
the EDF.
Not
specified
If the child
is able to
eat/drink
the offered
food with
eagerness 34Transforming Child Nutrition
State Who
conducts
it?
Where? What
food
used?Steps followed Amount
offered
Deciding
criteria
for
passing
the test
Jharkhand
AWW During VHSNDTHR/Hot
cooked meal
e.g., halwa
1. The child should not
have eaten any food for
last two hours.
2. The test should
be conducted in a
separate quiet area.
3. Explain to the mother/
caregiver the purpose
of the appetite test and
how it will be carried
out.
4. Ask mother/caregiver
to wash her/his hands.
5. The mother/caregiver
should sit comfortably
with the child in her/
his lap.
6. The test usually takes
a short time but may
take up to one hour.
7. The child should be
offered a small amount
of food prepared with
THR, with constant
encouragement.
8. If the child refuses,
then the mother/
caregiver should
continue to quietly
encourage the child.
9. The child must not be
forced to take the food
being used for the
appetite test.
10. The child should have
free access to safe
drinking water while
he/she is taking the
food for appetite test.
Not
specified
If the child
eats the
offered
food with
eagerness. 35Transforming Child Nutrition
State Who
conducts
it?
Where? What
food
used?Steps followed Amount
offered
Deciding
criteria
for
passing
the test
Madhya
Pradesh
AWW At CSAM clinic
during
VHSND
Available
THR such
as halwa,
balahaar and
khichdi
1. The child should not
have taken any food for
last two hours.
2. The test should
be conducted in a
separate quiet area.
3. Explain to the mother/
caregiver the purpose
of the appetite test
and how it will be
carried out.
4. Ask mother/caregiver
to wash her/his hands.
5. The mother/caregiver
should sit comfortably
with the child on her/
his lap.
6. The test usually takes
a short time but may
take up to one hour.
Also, should offered
small amount of food
prepared with THR to
the child, encouraging
the child all the time
during the appetite
test.
7. If the child refuses,
then the mother/
caregiver should
continue to quietly
encourage the child.
8. The child must not be
forced to take the food
being used for the
appetite test.
9. The child should have
free access to safe
drinking water while
he/she is taking the
food for appetite test.
Not
specified
If the child
is able to
eat the
offered
food with
eagerness. 36Transforming Child Nutrition
State Who
conducts
it?
Where? What
food
used?Steps followed Amount
offered
Deciding
criteria
for
passing
the test
Odisha
AWW At CMAM clinic
during VHSND
Food
prepared
with
Augmented
THR/locally
available
food items
like khichdi/
any hot
cooked meal
or milk.
1. The test should
be conducted in a
separate quiet area.
2. Explain to the mother/
caregiver the purpose
of the appetite test and
how it will be carried
out.
3. Ask mother/caregiver
to wash her/his hands.
4. The mother/caregiver
should sit comfortably
with the child on her/
his lap.
5. The child should not
have taken any food
for last two hours, else
wait for some time.
6. The test usually takes
a short time but may
take up to one hour.
7. Offer a small amount
of food prepared with
augmented THR or
locally available food
items like Khichdi/
any hot cooked meal
or milk to the child,
encouraging the child
all the time during the
appetite test.
8. If the child refuses,
then the mother/
caregiver should
continue to quietly
encourage the child.
9. The child must not be
forced to take the food
being used for the
appetite test.
10. The child should have
free access to safe
drinking water while
he/she is taking the
food for appetite test.
Age band
7-18
months:
at least
15 grams
19-36
months:
at least
30 grams
37-59
months:
at least
50 grams
If the child
is able to
eat/drink
the offered
food with
eagerness 37Transforming Child Nutrition
State Who
conducts
it?
Where? What
food
used?Steps followed Amount
offered
Deciding
criteria
for
passing
the test
Telangana
Anganwadi
Teacher
(AWT)
At Supervised
Supplementary
Feeding
Program (SSFP)
session during
VHSND
Balamrutham
plus
1. The test should
be conducted in a
separate quiet area.
2. Explain to the mother/
caregiver the purpose
of the appetite test
and how it will be
carried out.
3. Ask mother/caregiver
to wash her/his hands.
4. The mother/caregiver
should sit comfortably
with the child on her/
his lap.
5. The child should not
have taken any food for
last two hours.
6. The test usually takes
a short time but may
take up to one hour.
7. Offer a small amount
of balamrutham plus
to the child based on
the age of the child,
encouraging the child
all the time.
8. If the child refuses,
then the mother/
caregiver should
continue to quietly
encourage the child.
9. The child must not
be forced to take the
balamrutham plus.
10. The child should have
free access to safe/
portable drinking
water while he/she
is taking the food for
appetite test.
Children
(7-18
months):
at least
15 grams
Children
(19-36
months):
30 grams
Children
(37-59
months):
50 grams
The child
should eat
the offered
amount
based on
the age
within one
hour. 38Transforming Child Nutrition
5.4. Medical Management
Few children with SAM may have medical
complications which may or may not be
apparent. If not diagnosed and managed
timely, they may lead to increased risk of
mortality. Timely medical assessment and
management is, therefore, crucial.
Usually, under CMAM programme, medical
assessment of the identified cases is done
by ANM. Children having any medical
complication or any danger signs are referred to
NRC/MTC/health facility for further treatment.
Those without any medical complications
are managed at the level of community by
frontline workers (Figure 18).
In Assam, Bihar, Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh, Rajasthan and Odisha, children identified
as SAM are examined for the presence of medical complications by ANM at “CMAM Clinic” on VHSND. ANM
assesses the child for any danger/emergency signs and refers the child to NRC if any of the signs are present.
If child doesn’t require immediate referral, ANM undertakes further medical examination. The medical
examination includes assessment of oedema, appetite, vomiting, temperature, respiratory rate, anaemia,
superficial infections, alertness, and hydration status. ANM observes and asks the mother/caregiver about
complaints like cough, fever, diarrhoea, lethargy, convulsions, skin infections, or eye complaints.
Figure 18: Medical assessment of a child with SAM
being done in Jharkhand 39Transforming Child Nutrition
If a child with SAM shows no medical complications, he/she is treated as per the protocol at the community
level, and medicines are provided as per the IMNCI protocol. Through other national programmes and
schemes, children are provided with vitamin-A syrup, multivitamin syrup, and iron syrup, if required.
Complete medicine package given under CMAM programme in states is summarized in Table 3.
Medicine
Bihar
Chhattisgarh
Jharkhand
Assam
Gujarat
Maharashtra
Madhya
Pradesh
Odisha
Rajasthan
Telangana
Uttar Pradesh
Amoxycillin
Albendazole
Folic acid
Iron Folic acid syrup
Multivitamin syrup
Vitamin A
Zinc
Paracetamol*
ORS*
Table 3: Medicines given CMAM programme across different states of India
Table 4: Details of dosage of medicines
DrugWhenWeight or age of the childDose
Amoxycillin Syrup
(125 mg / 5 ml)
First dose on
enrollment (to be
prescribed by ANM)
and then for home (two
times daily for five days)
3 – 4.9 kg2.5 ml twice a day
5 – 6.9 kg5 ml twice a day
7 – 9.9 kg7.5 ml twice a day
10 – 12.9 kg10 ml twice a day
13 – 15.9 kg12.5 ml twice a day
16 – 18.9 kg15 ml twice a day
Details of dosage of medicines are explained in detail in Table 4 below. 40Transforming Child Nutrition
DrugWhenWeight or age of the childDose
Albendazole (400
mg / 10 ml)
Once on enrollmentLess than 1 year Not to be given
1-2 years5 ml / 200 mg once
2-5 years10 ml / 400 mg once
Iron Folic Acid
(1 ml of Iron and
Folic Acid Syrup
containing 20 mg
elemental iron and
100 mcg Folic Acid)
Biweekly 6 months to 5 years 1 ml Iron and Folic
Acid syrup
Vitamin A (100000
IU/ 1 ml)
One dose on admission
if not given during last
1 month
6-12 months100000 IU/ 1 ml
Above 12 months200000 IU/ 1 ml
Multivitamin syrupDaily for 90 days 6 months to 5 years 5 ml
*Paracetamol and ORS are not routinely given. Paracetamol and ORS will be given as per the complications
of fever and diarrhoea if required. They are to be used only if needed as per standard dosage prescribed
under IMNCI. ORS dose: 5 ml/kg body weight in every 30 minutes for the first 2 hours. 41Transforming Child Nutrition
5.5. Nutritional Management
Nutritional management is a critical component for SAM and MAM children for improved recovery at the
community level. These children have additional nutritional needs in terms of calories and proteins to regain
the loss. For successful rehabilitation, food provided should achieve intakes (compliance for consumption)
that will promote catch-up growth and improve immune function.
Different states in India have adopted different food options to be given to SAM and MAM children aged 6-59
months without medical complications under their CMAM programme. Largely, the food given to children
with SAM includes THR, dry ration or ready-to-eat supplement packets, which are distributed by frontline
workers in AWCs in specific amounts at regular intervals.
Nutrition protocols followed under CMAM programme for the nutritional management of children is
discussed in this section.
5.5.1 Under Samvardhan Programme- Amylase-rich food and
standardized energy-dense recipes (Bihar)
5.5.2 Age-specific energy-dense Take Home Ration (Chhattisgarh)
In Bihar, under the Samvardhan Programme, dry ration (rice, dal and soyabean) is provided under
the SNP of ICDS to children younger than 6 years. Mothers of children with SAM are counselled to
prepare amylase-rich food by soaking, germination, roasting and grinding of wheat and whole
green gram and to be used for making products called as balahar, sattu laddu and paushtik laddu.
These are the products demonstrated by AWW to mothers at AWCs during SAM sessions (organized
15 days after SAM Clinic).
Additionally, sesame seeds/peanuts and jaggery are also provided to children. Roasted flax seed
powder, which can be added to khichdi, rice or dal or sprinkled on the roti, is promoted as a protein
supplement. Dr. Rajendra Prasad Central Agricultural University (DRPCAU), Pusa have standardized
some energy-dense recipes for demonstration including semolina kheer and halwa, vegetable
khichdi, vegetable parantha, spinach parantha, besan cheela, meetha cheela, rice kheer, pua, thekua,
sweet and namkeen daliya, and upma. During the home visits done by AWW, there is focus on finding
out the dietary practices of children and consumption of any home-made energy-dense nutritious
product, promotion of optimum dietary practices and counselling on appropriate feeding practices.
In Chhattisgarh, all children are given state-prescribed energy-dense THR as per the child’s age at
AWCs during VHSND.
A packet of THR weighing 1200g is given every week to all children (~170g/day), while children with
SAM enrolled in CC-SAM aged 6 months-3 years are given 200g of THR per day and children aged 3
to 5 years are given 75g THR per day along with hot cooked meal of 430 calories and 11g of protein.
100g of energy-dense THR comprises of wheat (30g), soyabean (10g), bengal gram (20g), sugar
(27g), soyabean oil fortified (5g), peanuts (5g), ragi (3g), providing 12.7g protein and 410 calories. 42Transforming Child Nutrition
5.5.3 Provision of Ready to Eat (RTE) food supplement and Third meal
along with regular THR (Madhya Pradesh)
In Madhya Pradesh, there is provision of regular THR (khichdi premix), Ready-to-Eat (RTE) food
supplements and Third meal (which is enriched with locally available nutritious grains, vegetables,
and ghee/oil).
ĥRTE food supplement packets are given to children with SAM aged 6-36 months include
halwa premix (made from wheat, soya, sugar, sorghum, green gram, finger millet and edible
oil; @ 125 g/beneficiary, i.e. 625 g for a week), baal aahar premix (made from wheat, soya,
edible oil, finger millet, rice, bengal gram flour and sugar; @ 125 g/beneficiary i.e. 625 g for a
week) and Khichdi Premix (made from rice, soya, green gram, pearl millet, edible oil & spices
@125 g /beneficiary i.e. 625 g for a week).
ĥThird meal includes premixes like dalia mix (made from wheat, moong daal, jaggery), paushtik
sattu (made from wheat flour, jau, groundnuts, soya, chana dal, rice, sugar and khadya daal)
and gudh patti/chikki (made from roasted gram, peanuts and jaggery). Nutritious eatables
such as grains and fruits collected in poshan matka are also distributed. Community and
poshan mitra also provide protein-rich foods.
5.5.4 Augmented THR (Odisha)
5.5.5 Balamrutham Plus formulated by ICMR-NIN (Telangana)
In the state of Odisha, each child with SAM is provided with 100 – 250 gm per day of augmented
THR as per body weight, once every fortnight and seven eggs every week (1 per day) by the
AWW. Ingredients used in the preparation of the augmented THR (per 100g) include wheat (30g),
groundnut (10g), bengal gram (10g), sugar (15g), vegetable oil (15g), milk powder (20g). 100g of THR
provides 462.0 calories, 16.0g protein and 20.1g fat. The augmented ICDS THR is ready to consume.
For young children, 100g of THR powder can be mixed with 60ml of lukewarm water or milk to
make semi-solid consistency porridge. Routine recommended for consumption of augmented THR,
egg and home cooked food is as follows: morning 8 AM augmented THR (1/2 of recommended
amount), 10 am boiled egg, 12 PM freshly prepared home food/food at AWC, afternoon 2 PM
augmented THR, evening 4 PM homemade snacks / fruits, 6 PM augmented THR and night 8 PM
freshly prepared home food. Follow-ups are conducted on a weekly basis through home visits by
AWWs to assess their feeding and growth status.
In Telangana, under the Supervised Supplementary Feeding Programme (SSFP), children with SAM
and MAM are given balamrutham plus 4 times per day along with home available foods, under
the supervised supplementary feeding programme. The standard consumption for children with
severe acute malnutrition is 125 kcal/kg body weight. 43Transforming Child Nutrition
Findings from the sensory evaluation study
revealed that balamrutham plus had better
acceptability in terms of appearance, colour,
texture, flavor, taste, and palatability. Shelf-life
study of the product also showed absence of
harmful microorganisms, with total bacterial
count within the reference range (Table 5).
Balamrutham plus is formulated by ICMR-NIN specifically for children with SAM and MAM, using
wheat, groundnut, bengal gram, skim milk powder, sugar, oil and rice flakes with an energy
content of 703 kcal/150g and 15.6g of protein. It is fortified with vitamin B-1, B-2, B-12, calcium,
vitamin-A, folic acid, iron, niacin and zinc.
Anganwadi teachers calculate the number of packets a child needs per month according to
the current weight of the child. She also instructs the caregivers about the number of spoons,
consistency, and frequency of feed. During the first week of admission in the SSFP programme,
the Anganwadi teacher asks the caretaker/mother to feed the child at AWC during daytime so
that they can observe how the mother is feeding and provide guidance to them.
Balamrutham plus was developed looking at the increased prevalence of SAM in the state
from 5% in NFHS-4 to 8.5% in NFHS-5. Balamrutham plus was developed using the following
parameters:
ĥThe average body weight of SAM and MAM children based on NFHS-4 database
ĥCalculation of energy and protein requirements based on the body weight
ĥDeriving gaps in the intakes of protein and energy from National Nutrition Monitoring
Bureau (NNMB) 2012 data
ĥModifying the existing THR of balamrutham to balamrutham plus to address the gaps in
energy and protein requirements
ĥConducting shelf-life analysis, acceptability and sensory evaluation of consumption of
required portion of balamrutham plus (Figure 19).
Balamrutham plus is given to
SAM children at a frequency
of 4 times per day along
with home available foods.
The standard consumption
for children with severe acute
malnutrition is 125 kcal/kg
body weight.
Balamrutham plus is given
to MAM children at a
frequency of 2 times
per day along with home
available foods. The
standard consumption
for children with moderate
acute malnutrition is 75
kcal/kg body weight.
Children without MAM
and SAM are given
routine balamrutham
under the ICDS
programme.
Figure 19: Door-step supply of balamrutham plus
during COVID-19 44Transforming Child Nutrition
State Nutritional Supplement Quantity / dose
Bihar Amylase rich food, dry ration (rice, dal and
soyabean) + balaahar, sattu laddu and
paushtik laddu
Existing quantity of dry ration /
THR along with counselling for
enhancement / recipes
Chhattisgarh Energy dense THR: 100g of THR comprise-
wheat (30g), soyabean (10g), bengal gram
(20g), sugar (27g), soyabean oil fortified
(5g), peanuts (5g) and ragi (3g)
Additional THR: 200 gram per
day for 6-to-36-month child and
75 gram per day (along with hot
cooked meal) for 3-to-6-year child
Madhya Pradesh Provision of regular THR, RTE and a third
meal (enriched with locally available
nutritious grains, vegetables, and ghee/
oil). For children aged 6-36 months: RTE
food supplement packets of halwa premix,
baal aahar premix and khichdi premix
are given. Third meal includes dalia mix,
paushtik sattu and gudh patti/chikki.
Additional THR as per the body
weight
Telangana THR-balamrutham plus (wheat,
groundnut, bengal gram, skim milk
powder, sugar, oil rice flakes with energy
content of 703 kcal/150 grams and 15.6
grams of protein)
For SAM: 30 to 90g (as per weight
of the child) 4 times a day
For MAM: 30 to 75g (as per weight
of the child) 2 times a day
Odisha Augmented THR and egg. 100g packet
include- wheat (30g), groundnut (10g),
bengal gram (10g), sugar (15g), vegetable
oil (15g) and milk powder (20g)
THR as per the body weight (100
to 250gper day) and one egg daily
(including Saturday and Sunday).
Table 5: Nutritional supplement provided to children with SAM in different states of India under
CMAM programme. 45Transforming Child Nutrition
5.6. Follow-up
Under the CMAM programme, regular follow-ups are done for children with SAM/MAM by frontline workers.
Follow-ups take place while the children with SAM/MAM are still in the programme, and even after they are
discharged from the programme, to monitor their progress, prevent relapse and take timely action. Follow-up
visits are used to monitor the child’s weight gain, ensure intake of food supplements and medicines, assess
development of medical complications, ensure timely referral (if needed) and conduct counselling sessions
with the caregivers of children on important aspects of nutritional management. The protocol of follow-up
under CMAM varies slightly across different states. Some of the practices are summarized in Table 8.
In addition to the practices of the states mentioned in Table 8, in Chandigarh, monitoring is done by a team
of doctors every Wednesday. Weekly weight record is maintained and the children are also monitored by field
workers under the supervision of their supervisors/senior officials.
In Haryana, timeline has been given to the AWWs for regular follow-ups. They also fill the details of children in
Poshan monitoring card.
5.6.1 Regular follow-up of children on a monthly basis for two years
after discharge (Gujarat)
ĥFollow-up in CMAM programme is done on a weekly basis during the programme to monitor the
progress of enrolled children. Common monitoring indicators measured in CMAM programme
are weight, bilateral pitting oedema, feeding pattern, weekly counselling, weight-for-height
SD score and monthly check-up for any medical complications/oedema.
ĥIf any child has lost weight or develops any medical complication during weekly follow-up,
further medical assessment of the SAM child is done for medical complications. These children
are then referred to facility NRC for further management.
ĥIndicators like cured, not cured, defaulter, death and medical transfer are measured as output
indicators after 8 weeks of treatment in CMAM programme. SAM Children are discharged on
the same criteria as they are admitted/enrolled in CMAM programme (Figure 20).
Figure 20: Regular follow-up of children on a monthly basis after discharge
After maximum
duration of treatment
(8 weeks) children with
SAM are discharged if
WHZ score >-2SD (If admitted by WHZ <- 3SD)
1
2
3
Child is clinically well
No oedema for last two weeks 46Transforming Child Nutrition
5.6.3 Weekly follow-up for 12 weeks (Madhya Pradesh)
5.6.4 Weekly home visits by AWW to Follow up SAM Children
(Uttar Pradesh)
Weekly follow-up is done in Madhya Pradesh for up to 12 weeks during the programme to monitor
the progress of enrolled children. Common monitoring indicators measured in CMAM programme
include anthropometric measurements, compliance to nutritional supplements, medicines and
health counseling. After being discharged from the programme, monthly follow-ups are done
during VHSND for three months.
In Uttar Pradesh, when the child is enrolled in the programme, weekly home visit is done by AWW
for demonstration of food, assessing progress, interpersonal counselling, and dietary assessment
of SAM children.
Fortnightly visits for monitoring the progress of enrolled children are conducted for up to 12
weeks. After getting discharged, monthly follow-up visits by AWW take place for 3 months, wherein
monthly VHSND/sub-centre-based follow-up by ANM is done to assess the overall progress and
medical condition (Table 6).
5.6.2 Follow-up for 16 weeks for SAM and 8 weeks for MAM
(Telangana)
Child-wise progress is monitored regularly by Anganwadi workers at AWC and recorded in SSFP
mobile application along with SAM/MAM card until the beneficiaries are discharged from the
programme.
ĥFor SAM children, routine visit to AWC is done weekly in the first month and then fortnightly,
while for MAM children it is fortnightly.
ĥThe maximum duration of stay in SSFP is 16 weeks for SAM and 8 weeks for MAM child.
ĥPost-discharge follow-up is scheduled for children who reach above -2 SD (WHZ).
The children can be enrolled in the Supplementary Nutrition Programme of ICDS (i.e THR
balamrutham plus for children aged <24 months and Hot Cooked Meal at AWC for >24 months) and
their growth can be monitored every month during the first 6 months after discharge.
ĥIf SAM child does not recover from the CMAM programme after 8 weeks, the child is discharged
and classified as non-responder and is further referred to a higher health facility for detailed
investigations.
After 8 weeks of CMAM programme, children are regularly followed up on a monthly basis for two
years after discharge from the programme. Children discharged from the CMAM programme are
enrolled in the Supplementary Nutrition Programme (SNP) of the ICDS and their growth monitoring
is done on a monthly basis during VHSND. 47Transforming Child Nutrition
Table 6: Protocol of follow-up under CMAM programme across different states of India
State While the child is in
CMAM
After discharge from
CMAM
Activities undertaken
during follow-up visits
Duration of
follow-up
Frequency of
follow-up
Duration of
follow-up
Frequency
of follow-up
Gujarat 8 weeks Weekly
monitoring
of weight,
bilateral pitting
oedema,
feeding
pattern and
counseling.
Monthly
monitoring
of weight for
height SD
score and
checking for
any medical
complications/
oedema.
2 years Monthly 1. If a child has lost weight
or develops any medical
complication during weekly
follow-up, further medical
assessment of the SAM
child for danger signs,
medical complications is
done. These children are
then referred at facility
NRC/CMTC for further
management.
2. Children discharged from
the CMAM programme
are enrolled in the
Supplementary Nutrition
Programme (SNP) of the
ICDS and their growth
monitoring is done on
a monthly basis during
VHSND.
Telangana 16 weeks
for SAM
&
8 weeks for
MAM
Weekly
follow-up
at AWC by
Anganwadi
teacher for
SAM children
in the first
month
and then
fortnightly
visits.
Fortnightly
visits for
children.
First
6months
after
discharge
Monthly 1. Distribution of food
supplements
2. Growth monitoring
3. Recording in SSFP mobile
application along with
SAM/MAM card.
4. Health and nutrition
education
5. Evaluation of balamrutham
plus consumption each
week 48Transforming Child Nutrition
State While the child is in
CMAM
After discharge from
CMAM
Activities undertaken
during follow-up visits
Duration of
follow-up
Frequency of
follow-up
Duration of
follow-up
Frequency
of follow-up
Madhya
Pradesh
12 weeksWeekly 3 monthsMonthly
follow-ups
during
VHSND
1. Anthropometric
measurements
2. Assessing compliance to
nutritional supplements,
and medicines
3. Nutrition and health
counseling
Uttar
Pradesh
12 weeksWeekly
home visits
by AWW for
demonstration
of food to
be given to
children
&
Fortnightly
visits for
monitoring
the progress
of enrolled
children
3 monthsMonthly by
AWW
Two levels of follow up are
proposed as part of SAMBHAV
strategy:
1. Weekly follow-up as home
visits by AWWs – focused
on assessing progress,
dietary assessment, and
interpersonal counselling.
2. Monthly VHSND/sub-
centre-based follow-up by
ANM – to assess the overall
progress and medical
condition.
Bihar 16 weeksFortnightly6 monthsMonthly by
AWW
Weighing at AWC, assessment
for bilateral pitting oedema
and other illness, feeding
demonstration and individual
counselling of caregiver
Assam 12 weeksWeekly 1 month Weekly by
AWW
Anthropometric
measurements, appetite
test, micronutrient
supplementation, counselling
Chhattisgarh16 weeksWeekly 6 monthsMonthly by
AWW
Anthropometric
measurements, check for
oedema, history of illness and
loss of appetite, micronutrient
supplementation, counselling
on health and nutrition issues
including use of THR 49Transforming Child Nutrition
State While the child is in
CMAM
After discharge from
CMAM
Activities undertaken
during follow-up visits
Duration of
follow-up
Frequency of
follow-up
Duration of
follow-up
Frequency
of follow-up
Jharkhand 16 weeksFortnightly4 monthsMonthly by
AWW
Anthropometric
measurements, history of
illness, counselling
Maharashtra12 weeksWeeklyMonthly by
AWW
Anthropometric
measurements, history of
illness, provision of energy
dense nutritious food,
counselling
Odisha 16 weeksWeekly 6 monthsMonthly by
AWW
Anthropometric
measurements, check for
oedema, history of illness and
loss of appetite, counselling
on health and nutrition issues
including use of THR
Rajasthan 16 weeks Weekly 4 months Fortnightly
by ASHA
and
monthly by
ANM
Anthropometric
measurements, check for
oedema, history of illness and
loss of appetite, counselling
on health and nutrition issues 50Transforming Child Nutrition
Some of the innovative strategies for health and nutrition education being followed in different states are
as follows:
5.7.1 Counselling and Nutrition toolkit for dietary recommendation
(Bihar)
Under the Samvardhan programme of Bihar, NHE has two activities: Individual counselling of the
caregiver and education sessions for the caregivers. Education sessions for caregivers are organized
using audio-visual aids on a fortnightly-basis in AWCs and during monthly VHSND.
ĥPrinted IEC materials and cooking demonstrations are organized at AWC during the monthly
VHSND.
ĥNutrition toolkit has also been developed for counselling sessions, used by AWWs during
CMAM sessions/clinics. The nutritional toolkit has details about dietary recommendations for
normal children as well as ways to improve diets for the children with SAM/MAM using locally
available food items. The kit also contains recipes demonstrated by AWWs in SAM sessions as
well as during home visits of the children.
5.7. Nutrition and Health Education (NHE)
Nutrition and Health Education-cum-counselling is an important component of CMAM programme.
Caregivers of children with MAM/SAM are provided structured, individual as well as group counselling on
key topics of health and nutrition. This takes place at the time of follow-ups done by AWW or ANM during
home visits, CMAM clinics, VHSND and poshan panchayats. The aim of counselling sessions is to equip
children’s caregivers with adequate knowledge for adherence to the protocol for management of children
with MAM/SAM at home, to prevent undernutrition among other children in the family and to maintain
a sustainable change in the household-level feeding and care practices. Frontline workers use existing
counselling materials such as flipbooks, IEC videos and counselling cards during the counselling sessions.
The AWW and ASHA, supported by the ANM, explain the caregivers about the following aspects of the
community care programme in Table 7.
Table 7: Health and Nutrition Education
Nutrition and health education at the time of admission
Nutrition and health education during follow-up visits
Information about food, basic hygiene and antibiotics treatment at home
How to enrich/augment home foods
Use of local ingredients suitable for the child
Continued feeding during illness and importance of
frequent feeding 51Transforming Child Nutrition
5.7.2 Counselling by AAA to improve the maternal and child health
(Gujarat)
In Gujarat, social behavior change communication and counselling is done by AAA at the community
level to improve the maternal and child health components.
ĥDuring the weekly follow-up visits of children with SAM, ASHA workers counsel the mothers/
caregivers about consumption of balshakti fortified THR, homemade food to be given after
SAM child completes the recommended dose, handwashing and hygiene practices, medicine
protocol, and the importance of continued breastfeeding during illness, and age-appropriate
complementary feeding practices.
ĥThey also provide counselling on referral if needed, GMP and on practices to prevent relapse
and reoccurrence of malnutrition
Key topics
covered
Causes of SAM and why children need diversified locally-
available food with the right quality and frequency
How to prepare home-based nutrient-enriched food for
children
How to give iron folic acid syrup at home, and
The importance of vaccination and maintaining hygiene
Figure 21: Key topics covered under sessions by AAA
West Singhbhum district in Jharkhand is a tribal district with many hard-to-reach areas. Under
the Johar Poshan Programme, this district was specifically targeted for creating awareness in the
community to improve nutrition and health behavior with focus on breastfeeding, complementary
feeding, anaemia, maternal nutrition, hygiene and sanitation and immunization. With support from
UNICEF and State Center of Excellence (SCOE-SAM), Rajendra Institute of Medical Sciences (RIMS)
has compiled a package of communication material and a structured plan to create awareness
through individual/group counseling and through mass- and mid-media activities.
To improve acceptance and reach of the nutrition messaging, videos and documents are translated
into local tribal language. Following comprise the package of communication material is enumerated
in Figure 22 further.
5.7.3 Sessions by AAA using tools and flip books (Jharkhand)
In Jharkhand, NHE sessions are conducted by AWW, ASHA and ANM using essential nutrition flip-
book, ILA counselling tool and MAA flip-book. Information given to the caregivers of children with SAM is recorded by AWW in the follow-up and treatment register (Figure 21). 52Transforming Child Nutrition
Figure 23: Glimpse from a Nutrition and Health
Education session conducted in Maharashtra
5.7.4 Digital platform-based outreach strategy-“Tarang Suposhit
Maharashtracha” (Maharashtra)
In Maharashtra, AWWs, ASHAs, and ANMs are proactively working at the village level for providing
NHE during home visits, CBEs, and other SBCC activities. The DoWCD has initiated the special CBEs
focused on children with SAM in high-burden blocks. The focus is not just on curative aspects but also
on ensuring the further development of a child and avoiding relapse.
Due to COVID-19 and associated measures in the state, the DoWCD, Government of Maharashtra
(GOM), adopted a digital platform-based outreach strategy through the initiative of “Tarang Suposhit
Maharashtracha”. It is a digital platform for continuing interface with potential programme participants
for nutritional and early childhood development counselling even during the ongoing COVID-19
pandemic.
Jindagi Phir Muskuraigi video
that explains a comprehensive
approach to address
malnutrition in the district
MAA video focusing
on breastfeeding and
complementary feeding
Anemia Mukt Bharat communication
package adapted to the local language
Poshan Abhiyaan
animation video series
Johar Poshan video
that explains key
steps involved in the
CMAM programme
Nutrition during
COVID-19 videos
developed in local
language
Complementary feeding
booklet for individual and
group counselling
Essential nutrition practices flip-book for
individual and group counselling
Package of
communication
materials
1
2
3
4
5
6
7
8
Figure 22: Package of communication material 53Transforming Child Nutrition
5.7.5 Use of digital counseling toolkit (Telangana)
In Telangana, caregivers are sensitized about nutrition care, feeding techniques, diet quality,
complementary feeding and WASH practices. Digital counselling toolkit is a part of SSFP, used by
the AWT during follow-up visits of children with SAM. Posters with key messages are also displayed
at AWCs and AWT that delivers the messages to the caregivers during every point of contact. During
every fortnightly SSFP visit, AWT conducts the feeding demonstration and extends handholding
support for mothers to improve the responsive feeding.
Details of NHE innovative sessions conducted in different states of India are summarized in Table 8.
S.
No.
State By Whom WhereTools used
i. Bihar AWW AWC and home visit
ĥAudio-visual aids
ĥPrinted IEC materials
ĥCooking demonstration
ĥNutrition toolkit
ii.Gujarat AWW & ANM AWCCounseling on breastfeeding,
hygiene, cooking methods, intake of
medicine and THR daily dose
ASHA During weekly follow-
up visits
iii.MaharashtraAWWs, ASHAs,
& ANMs
During home visits,
CBEs, and other SBCC
activities
Digital platform-
ĥInteractive Voice Response (IVR)
helpline
ĥAuto-generated broadcast calls/
SMS, and
ĥWhatsApp Chatbot
iv.Jharkhand AWW, ASHA &
ANM
AWC, public
gatherings
ĥEssential nutrition flipbook
ĥILA counselling tool and
ĥMAA flip-book
v. Telangana AWT AWC (follow-up visits)
ĥDigital counselling tool kit
ĥPoster (with key messages)
ĥFeeding demonstration
Table 8: Nutrition and Health Education implementation in different states of India
It encompasses the Interactive Voice Response (IVR) helpline, auto-generated broadcast calls/ SMS,
and a Whatsapp Chatbot. The platform is leveraged for counselling, social auditing, and as a tool to
empower parents to assess the nutritional condition of their children. The platform is also being used
to ensure system-generated follow-up with parents with respect to increasing demand for growth
monitoring sessions at AWCs and their counselling. It is also utilized to capture feedback from parents
regarding the interventions such as inter alia, the consumption of energy-dense nutritious packets,
and counselling (Figure 23). 54Transforming Child Nutrition
5.8.1 SAMPARK application for data management and reporting
system (Madhya Pradesh)
In Madhya Pradesh, details of enrolled SAM children are recorded in Bal Poshan Pragati Patra (BPPP).
Further, the state has developed an android-based application (called Sampark) for the efficient
collation and monitoring of data. The data of SAM and MAM children related to enrollment, weekly
and monthly follow-ups, socio-demographic details and family details are recorded in the application.
Data validation and deletion of duplicate entries is undertaken by Child Development Project Offices
(CDPOs) and Lady Supervisors. The dashboard is available on the WCD website for which login details
are provided to the state officials, district collectors, DPOs, CDPOs, and supervisors. It was developed
by RCoENRRT, All India Institute of Medical Sciences (AIIMS) Bhopal, DWCD MP, NHM MP with support
from UNICEF. The application is being maintained by a dedicated team of android and web developers
at DWCD. The application can be downloaded and installed from the department’s MIS page
(Figure 24).
The information regarding the grade change (in nutritional status) of SAM and MAM children, weekly follow-up, and death (if any), along with NRC referral, is available on the dashboard of the Sampark application. All children added in the application are classified as SAM, MAM or normal as per WHO WFH Z score criteria under the ‘Child’s Detail’ tab. A few registration details of the children like date of registration, anthropometric measurements, result of appetite test, the assessment of oedema, and medical examination done by ANM are also entered. Through the application, it is easy to flag the children discharged from NRC so that AWW can immediately act to provide services to those children (Figure 25).
Figure 24: Android based Sampark Application
5.8. Technology-Enabled Recording and
Reporting System
Recording and reporting serve an important function of assessing the progress of programme, to track the
progress of individual cases, assess the larger outcomes, and provide feedback to relevant stakeholders to
fill the gaps in service delivery and programme implementation. Different reporting formats and techniques
are being used in different states to capture and analyse data.
The flow of reporting usually starts from field-level workers to supervisors, followed by block-level, district-
level and state-level assimilation of reports. Usually, the reporting formats are used to capture the following
information about children enrolled in the CMAM programme: Child’s socio-demographic information (such
as child’s name, age, gender, religion, name and age of parents, occupation of parents, birth history, family
income, family history and other household information), child’s anthropometric details like weight and
height / length, details on feeding regimen, immunization history and medical examination. 55Transforming Child Nutrition
5.8.2 Use of management information system (Rajasthan)
In Rajasthan, adoption
of MIS was warranted
due to the modality of
current reporting which
was bottom-heavy, relying
completely on competence
of AWW and lady
supervisors. The reporting
was delayed because the
data moved in hard copies
in Rapid Reporting System
(RRS) and Monthly Progress
Reports (MPRs), and AWWs
and lady supervisors would
compile all reports in sector
meetings, which generally
take place in the first
week of the next month.
As a result, reporting was
delayed (Figure 26).
The dashboard of the
Sampark application
is hosted at the WCD
website and login
details are provided
to the state officials,
district collectors,
DPOs, CDPOs and
supervisors for cleaning
of duplication and
real-time monitoring.
The information
related to
grade change
(nutritional
status), weekly
follow-up, and
deaths (if any)
are reflected on
the application
dashboard.
More than
80,000 SAM
children and
4,00,000
MAM children
were enrolled
in the IMAM
programme
during 2020-21.
Figure 25: Dashboard details of Sampark Application
Components
adopted for
Management
Information
System
Two reporting
formats; one for
line-listing and
other for summary
reporting on KPIs
1
Digitization is
done in Google
Sheets
3
The digitization
is done at the
block level
2
Hierarchical access
of Google Sheets
where the District
Coordinator of
NNM gave edit
rights to the Block
Coordinator
4
Figure 26: Components of MIS 56Transforming Child Nutrition
The reporting formats for field functionaries were carefully and comprehensively drafted; after several
rounds of iterations these were finalized for printing and hard copies were provided at all AWCs in the
20 districts.
The flow from field level was fast-forwarded by allowing AWWs and lady supervisors to share legible
photos through common messenger applications like WhatsApp in their dedicated sector-wise
groups, substantially reducing delays in reporting. At the block level, the information is digitized by
dedicated Data Entry Operators of NNM at block/sector office.
For capacity building on MIS, 6 rounds of orientation, reorientation, refreshers of the AMMA programme
and reporting framework are conducted. The final product consists of 35 Google Sheets for line listing
and 20 district-wise Google Sheets for summary reporting (Figure 27).
As of 2021, more than 20,000 children were being tracked in line listing sheets. As per summary reports, 80% of screening was done in these 20 districts, of which 1,49,641 children were identified as having MAM and 9,195 children as having SAM.
5.8.3 Real-time data entry and monitoring system through SSFP
Application (Telangana)
In Telangana, a real-time data entry and monitoring system through SSFP application is established
to collect data directly from AWCs. Cure rate, mortality rate, defaulter rate and average weight gain (g/
kg/day) are outcome indicators of the programme. The periodic data on specific outcome indicators
are collected using SSFP-MIS and analyzed monthly.
Figure 27: Reporting format used in Rajasthan 57Transforming Child Nutrition
5.9. Monitoring and Supervision
This chapter highlights the monitoring process being followed in different states to track progress and quality
of service delivery under CMAM programme. Monitoring visits are conducted as per the microplan, and a
structured tool is designed to observe and record the details of logistics including equipment, recording
and reporting formats, THR and medicine supplies, knowledge and skills of frontline functionaries (FLWs)
on identification and classification of nutritional status, services provided to enrolled children in CMAM
programme and outcome of the programme.
Then FLWs are provided with hands-on training on the identified gaps, and the block and district level
officials are offered recommended actions on improving service delivery. The data is used during the
structured reviews at the district and state level for corrective actions. Regular field visits are conducted by
District Programme Officers (DPOs)/District Social Welfare Office (DSWO), CDPOs and Supervisors to monitor
progress of CMAM programme. Roles and responsibilities at different levels in the state for monitoring and
supervision are provided in Table 9. Details of the monitoring process being followed are discussed and
summarized in Table 10.
Role of State Coordination Group (Committee from DWCD, DoHFW, CoE, PRI, Tribal, Water and sanitation departments)
Role at District level (DPO/ DSWO to monitor the implementation of the programme)CDPO to be
designated as
the focal point
Role of Lady
Health Visitor
(LSVs) and the
Anganwadi
Supervisors
Establishing
technology-
driven monitoring
system
ĥProvide technical
support for
planning and
implementation.
ĥFacilitate
convergence
between various
departments for
training, referrals
and linkages,
recording and
reporting,
supportive
supervision.
ĥFacilitate any
procurement e.g.,
procurement of
equipment, food.
ĥReview progress of
implementation.
ĥPlanning of
services in
discussion.
ĥFund flow and
positioning
of manpower,
trainings.
ĥInfrastructure
strengthening.
ĥQuarterly
review of the
programme
performance.
ĥFacilitate
training
of health
workers and
AWWs.
ĥEnsure
linkages
between the
SAMTUs and
the CMAM
programme.
ĥMonitor data
from the
blocks and
report to
the district/
state on a
periodic basis
and share
with PHC in-
charge/BMO.
ĥEnsure the
quality of
services and
facilitate the
supply and
logistics by
coordinating
with the
authorities at
the Block and
District level.
ĥResponsible
for finalisation
of the monthly
reports from
the AWCs.
ĥEnsure and
monitor
community
mobilisation
activities.
ĥApplication and
management
information
system is
crucial for
reaching the
unreached,
improving
service delivery
as well as
supervision,
monitoring and
counselling
actions with
impact on
accelerating
improvement
in child
nutrition
situation.
Table 9: Role and responsibilities at different levels in state 58Transforming Child Nutrition
5.9.1 In-person monitoring by sector, block, district officials and
by CSOs (Rajasthan)
In Rajasthan, in-person monitoring is done by sector, block and district officials and by Civil Society
Organizations (CSOs). Platforms for monitoring include Maternal Child Health and Nutrition (MCHN)
sessions and sector level meeting (Figure 28).
Implementing Partners (5 CSO
partners) are monitoring MCHN
sessions and sector meetings in their
respective areas, and the feedback is
shared with the DD ICDS office.
Figure 28: Platforms for monitoring sessions and sector level meeting
Sector-level officials
(LS) monitor the
work of AAAs on
monthly basis and
on selected
MCHN day.
Block-level officials
(CDPOs and Poshan
Abhiyaan staff)
monitor the AMMA
activities at AWCs
on MCHN day
District-level officials
(Deputy Director
- DD and Poshan
Abhiyaan staff)
monitor the AMMA
activities at AWCs on
MCHN Day. 59Transforming Child Nutrition
5.9.3 Field visits and telemonitoring to monitor the progress of the
programme (Telangana, Haryana)
5.9.2 Weekly granular monitoring by Principal Secretary, Social
Welfare, Community & Rural Development & Health Department
(Meghalaya)
i. In Telangana, field visits and telemonitoring are done by National Institute of Nutrition (NIN)
team to monitor the progress of the programme. The sector supervisors (CDPO) also visit AWCs for
supportive supervision and streamline the supply of balamrutham plus. Women Development and
Child Welfare Department conducts quarterly review meetings on the implementation of SSFP. The
review is chaired by the Commissioner WCD along with District Collectors, District Welfare Officers,
CDPOs, ICDS supervisors, state-level officers, NIN and UNICEF. The field findings of the programme
are shared for corrective actions.
ii. In Haryana, for reporting and recording, four different formats have been developed which are
given to AWWs. Name-wise monthly and weekly reports of SAM children are collected from AWWs.
Telemonitoring of the parents of SAM children is also being done by DPOs.
The weekly granular monitoring of SAM and MAM children at the state level is done by the Principal
Secretary, Social Welfare, Community & Rural Development, and Health Department, often chaired
by the Chief Minister. This exercise is unprecedented at the State level and at this frequency. These
weekly review meetings witnessed the attendance of representatives of three departments involved
in the process of management of SAM and MAM children, namely, Social Welfare Department
(Women and Child Development) through the ICDS Officials, Community and Rural Development
Department through the NRLM programme staff and the Health Department officials. These reviews
have inculcated a sense of responsiveness and urgency. The officials also took more ownership of
the problem and developed local solutions. A culture of synergy and collaboration is being created
between the three departments.
The block-level teams collected data from AWWs, and supervisors regularly reviewed registers during
their interactions in the field or in monthly sector meetings, communicating the importance of home
visits and maintenance of records. Reports were then shared with district ICDS teams and the state
team for documentation and analysis.
5.9.4 Dual monitoring system (Uttar Pradesh)
In Uttar Pradesh, two modes of monitoring are undertaken: first, departmental monitoring by ICDS
supervisory staff and second, external monitoring with the support of development partners.
5.9.5 Monitoring using Kobo Toolbox platform (Bihar)
In Bihar, monitoring and supportive supervision are periodically undertaken by SCoE, UNICEF as well
as district and state officials. The monitoring findings are recorded using Kobo Tool box application and data findings are disseminated in meetings of Health and WCD Department. Findings are also shared with District Magistrate (DM) and Sub-Divisional Magistrate (SDM) (Table 10). 60Transforming Child Nutrition
S.
No.
State Monitoring
format
By whomFrequency
i.Bihar Kobo Tool box
/ Kobo Collect
application
Government officials (LS,
CDPOs) and 3 technical
resource persons from DRPCAU
and PUSA.
Every AWC is visited quarterly
by a technical resource person.
Lady supervisors and CDPOs visit
AWCs as per their own plans of
monitoring.
ii.MeghalayaGranular
monitoring
Principal Secretary, Social
Welfare, C&RD & Health
Department chaired by Chief
Minister
Weekly
iii.JharkhandStandard
supportive
supervision
checklist
SCoE-SAM, RIMS and UNICEF
team
District Social Welfare Officer
and Civil Surgeon
Visit to minimum 5 admitted
children
CDPO and Medical OfficerVisit to minimum 8 admitted
children in the block
Lady Supervisors Visit to minimum 10 admitted
children in the sector
Development partners and
other
Visit to minimum 10 admitted
children in the sector
iv.RajasthanKobo collect
application
Sector-Level Officials Monthly
Block-Level officials MCHN Day
District-Level officialsMCHN Day
5 CSO partners MCHN Day & sector meetings
v.TelanganaTelemonitoring NIN TeamQuarterly
vi. HaryanaTelemonitoring DPOsMonthly
Table 10: Summary of process of monitoring of CMAM activities adopted in different states of India 61Transforming Child Nutrition
5.10. Multisectoral Convergence
Success of CMAM requires active participation of multiple stakeholders from different government
departments. In different states, CMAM is being implemented with the active participation of Health &
Family Welfare Department, with the lead taken by the Department of Women and Child Development.
Feeding of augmented THR, logistics costs, and counselling are looked after by the Department of WCD.
Treatment and medicine portion is managed by the Department of Health. Active support is also provided
by the Panchayati Raj Department in community mobilization process, while the development partners are
engaged in monitoring and data validation.
5.10.1 Multisectoral engagement between the Social Welfare and
Health Department (Assam, Rajasthan)
i. In Assam, there is multisectoral engagement between the Social Welfare Department (for registering
children under CMAM programme, conduct weight-for-height screening, giving counselling to
beneficiaries and paying home visits to children registered under CMAM programme) and Health
Department (involved in micronutrient and antibiotics supply and administration to children
registered under CMAM programme; ANMs are responsible for the medical assessment of all
children with SAM identified by AWW). Coordination between both departments is vital to ensure
children receive health and nutrition-related services. A draft statement of purpose (SOP) for the
identification of SAM, referral to NRC and CMAM programme has also been developed.
ii. In Rajasthan, convergence with Department of Health played a pivotal role in the success of AMMA
programme. It not only ensured regular supervision from ANMs but also helped in troubleshooting
the problem of lack of GMDs in the state. It also proved useful for streamlining and integrating
monitoring by AMMA programme officers at the block and district level on MCHN –day within
the regular monitoring system. District Nutrition Convergence Planning Committee, under the
chairmanship of District Collector and Deputy Director ICDS as member-secretary, reviews all
nutrition-related programmes and schemes with all line departments at the end of every quarter.
5.10.1 Multisectoral engagement between the Social Welfare and
Health Department (Assam, Rajasthan) 62Transforming Child Nutrition
5.10.2 Convergence in Department of Health and Family Welfare and
Department of ICDS in Samvardhan Programme (Bihar) and SAMBHAV
programme (Uttar Pradesh)
i. In Bihar, Samvardhan Programme in Purnea was led by the Department of Health, in close association
with Department of ICDS. The focal point of services was AWC and majority of the services were
to be delivered through AWWs and ANMs. SAM Clinic was organized on VHNDs in the presence of
AWW/ASHA. In these clinics, ANMs verified children with SAM, referred them to NRC (if needed)
or enrolled them in CMAM programme based on the medical condition and appetite of the child.
Along with these two departments, JEEVIKA (JEEVIKA didi) was involved in the programme
implementation with prime responsibility of community mobilization and imparting health and
nutrition education regarding Infant and Young Child Feeding (IYCF) and care of SAM children.
Block-level convergence meetings were planned on a quarterly basis, under the chairmanship of
BDO. In these meetings, block- and sector-level officials of the Department of Health and ICDS,
JEEVIKA and PRIs discussed programme challenges and mitigation efforts. Similarly, in district-
level review meetings, the programme review was conducted under the leadership of the district
magistrate with all concerned departments and key programme outcome indicators and processes
were discussed.
ii. In Uttar Pradesh, the Health and ICDS departments work in close coordination for CMAM
implementation. Health department is undertaking the medical management part of the
intervention both at the community and facility levels. There are separate departmental guidelines
for Health and ICDS departments, that describe the actions, roles, and responsibilities of both
departments. Joint Health and ICDS department meetings are organized for sensitizing the district
officials and reviewing programme progress.
The integration between two departments is critical for the success of the interventions such as
screening, identification, mobilization and nutrition management, and medical management. The
first phase of SAMBHAV served as a good learning experience. The future strategy involving several
other line departments is under development.
5.10.3 Involvement of Department of Women and Child Development
(DWCD), Public Health Department, Rural & Tribal Department, PRI
members in implementation of programme (Maharashtra, Meghalaya)
i. In Maharashtra, the following departments are involved in the implementation of the Village
Child Development Centre (VCDC) programme: DWCD (for screening, provision of food, follow
up, counselling, home visits), PHD (for supporting medical check-ups, certification of children with
SAM, providing medical treatment and referral services for children with medical complications,
and counselling services), Rural Development Department (for mobilizing the local funds and
logistics to ensure timely and uninterrupted supply of medicines), PRI members (for community
mobilization for growth monitoring sessions and follow-up processes), and Tribal Development
Department [for financial support in tribal districts through Panchayat Extension to Scheduled
Areas (PESA) funds and other local funds]. 63Transforming Child Nutrition
5.10.1 Multisectoral engagement between the Social Welfare and
Health Department (Assam, Rajasthan)
ĥIn Assam, there is multisectoral engagement between the Social Welfare Department (for
registering children under CMAM programme, conduct weight-for-height screening, giving
counselling to beneficiaries and paying home visits to children registered under CMAM
programme) and Health Department (involved in micronutrient and antibiotics supply and
administration to children registered under CMAM programme; ANMs are responsible for
the medical assessment of all children with SAM identified by AWW). Coordination between
both departments is vital to ensure children receive health and nutrition-related services. A
draft statement of purpose (SOP) for the identification of SAM, referral to NRC and CMAM
programme has also been developed.
ĥIn Rajasthan, convergence with Department of Health played a pivotal role in the success of
AMMA programme. It not only ensured regular supervision from ANMs but also helped in
5.10.4 Engagement of concerned departments and development
partners (Gujarat)
In Gujarat, UNICEF supported the Department of Health and Family Welfare (DoHFW) technically
throughout the programme planning and through developing strategy, implementation plan,
training package and guidelines, capacity development, monitoring and supportive supervision, MIS
development and joint review for the overall strengthening of CMAM programme across the State.
Faculty of Preventive and Social Medicine (PSM) Department of GMERS Medical College were involved
in capacity building at the district level and for supportive supervision and monitoring CMAM
programme implementation at district level across Gujarat.
State Institute of Health and Family Welfare (SIHFW), District Training Team (DTT) and District Training
Centers (DTC) teams collaborated to strengthen capacity building at state, district and block level
trainings. National Centre of Excellence for Integrated Management of Severe Acute Malnutrition
(IMSAM) technically supported state government, UNICEF and State Center of Excellence in developing
new THR-based recipes as nutritional therapy for treating SAM children without any complication at
the community level.
State Centre of Excellence (SCoE) was established jointly in collaboration with UNICEF and DoHFW
for supporting the IMSAM programme implementation, monitoring and supportive supervision and
joint review at the state level. DoHFW in convergence with DWCD helped in the field implementation
for CMAM programme for community mobilization, anthropometric assessments, screening children
with SAM, home visits, counselling, joint review, and supply of THR.
Additionally, government officials from various departments have been involved in a few districts
for the adoption of SAM children. It has helped in child-wise monitoring ensuring desired
weight gain and support to the families. As part of community participation, Muth Bhar Dhanya
(Contribution of a fistful of grain) has been promoted to ensure community ownership towards
the children.
ii. In Meghalaya, sectoral meeting, involving CDPO, MO, BDO, LS, ANM, AWWs ASHAs, Block
Programme Managers (NRLM), Village Heads, VO Leaders, is held on a monthly basis. The sectoral
meeting is intended to facilitate teamwork between the Health Department, Community & Rural
Department, Social Welfare Department and communities. Block Development Officers, CDPOs
and Block Medical Officers are specifically requested to attend the meetings of priority facilities.
Deputy Commissioners oversee and give approval for the sectoral meeting schedule of each block
within their district, ensuring that there is a set day and time for these meetings each month. 64Transforming Child Nutrition
ĥIn Assam, there is multisectoral engagement between the Social Welfare Department (for
registering children under CMAM programme, conduct weight-for-height screening, giving
counselling to beneficiaries and paying home visits to children registered under CMAM
programme) and Health Department (involved in micronutrient and antibiotics supply and
administration to children registered under CMAM programme; ANMs are responsible for
the medical assessment of all children with SAM identified by AWW). Coordination between
both departments is vital to ensure children receive health and nutrition-related services. A
draft statement of purpose (SOP) for the identification of SAM, referral to NRC and CMAM
programme has also been developed.
ĥIn Rajasthan, convergence with Department of Health played a pivotal role in the success of
AMMA programme. It not only ensured regular supervision from ANMs but also helped in
5.11.1 Training in small batches and hybrid mode (Odisha, Chhattisgarh)
During the COVID-19 pandemic, the training of field functionaries faced a setback due to COVID-19 related restrictions. This led to delays in the implementation and scale-up of CMAM in states like Chhattisgarh and Odisha. In order to continue the momentum of CMAM training even at the time of COVID-19, the states of Chhattisgarh and Odisha conducted training in virtual or hybrid mode to equip frontline workers with the right knowledge and skills for identifying and providing treatment to SAM children. The practices on training and capacity building adopted by both the states at the time of COVID-19 restrictions are highlighted in this section.
i. In Odisha, CMAM pilot project was implemented in Nabarangpur & Koraput districts.
5.11. Capacity Building
Continued communication and routine information exchange, coupled with technical guidance, should be
ensured for stronger capacities and effective implementation of CMAM programme in India. The practices
on capacity building followed in different states of India are as follows:
One-day
orientation training
programme on
the effectiveness
of community-
based treatment
programmes to
treat children aged
6-59 months with
uncomplicated
SAM using
alternative energy-
dense foods.
Three-day
district-level
orientation
training on the
implementation
of comprehensive
CMAM
programme.
Two-day
orientation
training
of SHG
members on
preparation
of augmented
THR.
Virtual training of
Medical Officers,
District Programme
Manager (DPM)
NHM, Reproductive
and Child Health
(RCH) team, RBSK
manager and
team and block
programme
manager from
NHM on CMAM
protocol.
One-day block-
level training
of frontline
workers on the
implementation
of CMAM
programme by
district trainers.
Training guides were prepared in English and translated into the local language for circulation
among grassroot-level workers. After the hybrid training, knowledge of master trainers (LHV,
CDPOs and LS) was assessed using a pre-training and post-training test, which showed an
improvement in the knowledge from 48.2% to 83.7% in Nawarangpur and from 53.7% and 89.5%
in Koraput. In all sector meetings, CMAM is an agenda point for discussion and doubt-clearing
sessions are also held.
ii. In Chhattisgarh, due to COVID-19 restrictions, trainings were initially limited as per instructions
from the DoWCD. During the launch of the programme in January 2021, special permission was
taken by Director, WCD to allow training of frontline workers on CCSAM programme in small
batches with the precautions to contain spread of COVID-19 infection. Hence, precautions for
respiratory hygiene like mask-wearing and use of sanitizer were simultaneously ensured along
with monitoring of training through district and state officials.
Decentralization of trainings was done by conducting trainings at sector level to ensure maximum
participation. Further, a staggered approach was adopted for screening of children for SAM
identification and help was taken from the AIIMS team to ensure high coverage, timely detection
and enrollment of children in CSAM programme. 65Transforming Child Nutrition
5.11.2 Bi-annual district level training (Assam)
5.11.3 Multiple rounds of training and training based on challenges
faced in field (Rajasthan)
5.11.4 Cascade-mode training (Bihar, Gujarat, Maharashtra, and
Jharkhand)
In Assam, with support from UNCIEF, in 2021, two rounds of training were conducted for all districts
and state-level officials (including DSWOs, CDPOs, Supervisors and Poshan Abhiyan coordinators)
under the innovation head of POSHAN Abhiyaan for 15 districts. Further, in the division-wise
Training of Trainers (ToT) programme at the state level, one resource person from each project has
been trained on CMAM for conducting further training at the project/district level. Trainings was
also organised for sector supervisors and other ICDS staff. Trainings is conducted every 6 months.
In Rajasthan, six rounds of orientation, reorientation and refreshers of the AMMA programme and
reporting framework have been conducted. An MIS framework was introduced and discussed with
all Deputy Directors (DDs) of 20 districts in an in-person orientation.
This was followed up by a phased zoom-video conference of ToTs in which a total of 1344 participants
from 20 districts were trained. This included 28 DC/DPA, 81 CDPO, 632 LS, 292 NTT and 66 monitors
from CSO partners. There were also continuous refresher training sessions held online to troubleshoot
challenges that are emerging in the field.
i. In Jharkhand, a cascade training approach was followed at the district level. A pool of district-level
master trainers was created with support from SCoE-SAM, Rajendra Institute of Medical Sciences
(RIMS) and UNICEF. The master trainers and resource person from RIMS and UNICEF supported
during block-level training. State-level monitors from UNICEF and RIMS monitor training at block
level to ensure quality. Two-day face-to-face trainings were conducted at the district level to
build capacity of ICDS and Health functionaries. Refresher training and orientation are conducted
at 6-months interval or on need basis (Figures 29 to 31).
ĥPreparation: A training package consisting of training module, formats, registers, and
presentations in local language, counselling book and Essential Nutrition Practices during
COVID-19 flipbook has been developed.
ĥResource person: Internal and external personnel & officials from medical college empaneled
at SCoE-SAM provide technical support at State/District training.
Micro-Plans of training have been developed after reviewing the number of participants, details
of the venue, finalization of batches with names of resource persons. Agenda was developed in
consultation with the districts. 66Transforming Child Nutrition
SCoE –SAM, RIMS with
support from UNICEF,
collaborated with
Government, NCoE, other
State Medical Colleges,
Birsa Agriculture University
(Nutrition Dept), Empaneled
external retired paediatricians
as resource person Created
a pool of 86 Resource Persons
for supporting CMAM
trainings
National
Centre of
Excellence
for SAM
Management,
New Delhi
Birsa
Agricultural
University,
Jharkhand
RIMS (Dept of
PSM, Paediatrics
& Obs & Gynae)
External resource
person
All other
5 Medical
Colleges of
Jharkhand
Resource
Pool
Figure 29: Resource Pool for capacity building
Figure 30: Tool used in CMAM trainings in West Singhbhum District, Jharkhand 67Transforming Child Nutrition
ii. In Bihar, trainings were conducted in cascade mode where first master-level trainings were
organised by the Department of Health in coordination with ICDS Department. National Centre of
Excellence for Management of Severe Acute Malnutrition (NCoE-SAM), Kalawati Saran Children’s
Hospital (KSCH), New Delhi was the technical agency for developing the training module and
imparting training through skilled trainers. Thereafter, separate batches for frontline workers
were formed.
Each of the cadres received training from Master Trainers with one representative from
KSCH, New Delhi who was present as observer to oversee the quality of training delivery.
One-day orientation of the programme was also conducted for the community mobiliser
of JEEVIKA and NRC staff as per their roles in the programme.
Training on management of malnutrition under 6 months of infants were also organized. Training
for frontline workers is organised every six months. During the COVID-19 period, trainings were
organised through the virtual mode, reverting to offline training soon after services opened up.
iii. In Gujarat, training is an integral part of the CMAM roll-out plan. Master trainers and training
packages were created for the CMAM programme. Cascade trainings were planned and executed
at the State, District, Block and PHC level. Satellite Communication (SATCOM) sessions were also
planned on a regular basis to reiterate the key messages on the identification of children with
SAM, monthly screening, CMAM programme implementation, Medicine and Nutrition Therapy,
monitoring, supervision, review, follow up and strengthening MIS for CMAM programme across
Gujarat.
iv. In Maharashtra, a separate training module was developed for VCDCs. The cascading model
of training was followed. At the state level, selected ICDS supervisors, CDPOs, THOs, and MOs
were trained as master trainers. These master trainers conducted training at the block level. The
frontline functionaries i.e., AWWs, ANMs were trained at the ICDS beat or PHC level. After the
initial intensive training programme, based upon the district-specific need, the refresher training
programmes were conducted.
Figure 31: Capacity building in Jharkhand 68Transforming Child Nutrition
5.11.5 Hands-on training (Telangana)
In Telangana, AWTs, Sector Supervisors, ANMs and MOs were trained on implementing the SSFP.
Hands-on training was also given to workers in the selected districts on screening and identification
of SAM & MAM, use of weight-for-height growth chart, conducting appetite test, assessment of
oedema, conducting counselling sessions with caregivers, referral, monitoring and discharge.
Three-day training programme was organized for AWTs and Sector Supervisors in every ICDS project
area. Refresher training is also given to all the frontline functionaries through T-SAT (Telangana State
Network) programme.
5.11.6 Collaboration with the National Institute of Public Cooperation
and Child Development (NIPCCD) for capacity building (Meghalaya)
In Meghalaya, capacity building of functionaries on identification and management of SAM/MAM
children was conducted in collaboration with the National Institute of Public Cooperation and Child
Development (NIPCCD).
Capacity building was conducted for the state-level functionaries and through them the field-level
functionaries were trained. Through this training programme 5896 AWWs of the State were taught
about SAM and MAM children identification and management through module 8 and 13 of the
Incremental Learning Approach (ILA).
Handholding support was provided to the field functionaries whereby the District Project Officers
(DPOs), CDPOs, and supervisors were physically present with selected AWWs (those who still needed
guidance) during the weighing and measuring process so that the measurements were correctly
undertaken. 69Transforming Child Nutrition
5.12.2 Madhya Pradesh
5.12.3 Odisha
In Madhya Pradesh, the IMSAM programme was initiated with 9 districts and scaled up across the
entire state (52 districts).
In Odisha, the CMAM programme has been scaled-up across 30 districts. The augmented THR or
therapeutic food is being prepared by the Women SHGs of the respective the district, indicating the
sustainable nature of the feeding component of the programme
5.12.4 Maharashtra
In Maharashtra, VCDC is already scaled-up throughout the State. The team is now focusing on quality
monitoring through building data systems such as dedicated software for end-to-end management of children with SAM.
5.12.5 Telangana
In Telangana, the programme was initiated in 2 districts and scaled-up across 7 districts in the state
by WDCW Department.
5.12. Scalability, Replicability and Sustainability
5.12.1 Gujarat
In Gujarat, between April to June 2016, CMAM programme was piloted in 4 districts. SAM children
enrolled in CMAM programme were managed at community level. Out of 798 SAM children who completed 8 weeks treatment in CMAM programme, 433 (54.87%) children were cured. This successful CMAM pilot was then immediately scaled up across select blocks of 13 tribal districts and then across all talukas of 13 tribal districts in a phased manner. The CMAM programme was then scaled up across Gujarat covering 33 districts and 8 corporations in second phase.
Between April to June 2016 CMAM programme
was piloted in
4 districts
798 SAM
children
completed 8 weeks
treatment
433
children
were cured
54.87% 70Transforming Child Nutrition
5.12.6 Jharkhand
In Jharkhand, Johar Poshan programme is being
scaled up in all AWCs of the West Singhbhum district.
Similar model has been adopted in Godda district and
community-based programme Suposhit Godda was
launched in October 2021 using district funds.
Johar Poshan programme relies on the existing ICDS and
Health department structure without any programme-
specific additional human resources. The medicines,
micronutrients, and food are also already available in the
existing government structure; therefore, it does not put
additional financial burden. Currently the programme is
district-funded.
SAAMAR (Strategic Action for Alleviation of Malnutrition
and Anaemia Reduction) programme has been
launched in the state in a phased manner, with phase
I focusing on 5 districts. It will be scaled up across the
state strategically (Figure 32).
Figure 32: CMAM programme being
scale-up in the entire states in phased
manner as SAAMAR programme
5.12.7 Rajasthan
Following points make the programme more scalable, sustainable and replicable based on the
experiences from Rajasthan (Figure 33).
Figure 33: Points included in Programme to be more scalable, sustainable and replicable
No new platform was developed
separately for this programme. This
was integrated in the existing MCHN
structure itself. This saves a lot of
functionaries’ time, helps skip many
operational challenges and serves
as a good example of unified policy
actions.
The AMMA programme activities on
MCHN day are carefully aligned and
integrated with regular activities of
ANM, AWW and ASHA workers. Doing
so only broadened their existing job
mandate instead of introducing new
workload.
The MIS developed is based on
Google Sheets which can be easily
integrated with any of the existing
or newly-developed reporting tools,
ensuring scalability and replicability
of the programme in the reporting
and monitoring systems.
Treatment of children is based on
locally-available, home-based,
energy-dense feeding and not
external supplements, thereby
increasing the programme’s
sustainability. 71Transforming Child Nutrition
5.12.8 Uttar Pradesh
In Uttar Pradesh, the SAMBHAV programme is already a state-wide initiative implemented across all
75 districts. The future strategy for SAMBHAV proposed two biannual campaigns; first, a three-month
long campaign between July-September, and second, a one-month campaign in December, with an
assessment between two rounds. The focus will be on all categories of malnourished children which
include LBW, SAM, SUW under 5 years. The SAMBHAV strategy is conceptualized in a way to utilize
existing programme opportunities with greater focus on the intersectoral engagement, improved
capacities, and a 360-degree communication approach to mobilize and engage the community.
Journey of different Indian states for CMAM programme scale is illustrated in Figure 34.
2016
2020
2018
2019
20212022
2022
2022
2019
2020
2020
2017
2018-19
20202021
Rajashthan
Uttar
Pradesh
CMAM piloted
in 5 districts
CMAM Piloted
in 4 districts
Scaled up across
select blocks of
13 districts
Scaled up to 9
districts
Plan for scale-
up covering 22
districts
Plan for scale-up
in 7 more districts
Replicated in
West Singhbhum
EDNF based
programme
C-SAM piloted
districts
2 districts
SSFP piloted
in 2 districts
CMAM piloted in
khutpani district
IMAM
programme
Implemented
in 20 districts
State wide
Implementation
(33 districts)
State wide
Implementation
(33 districts and
8 corporations)
State wide
Implementation
(52 districts)
State wide
Implementation
Plan to scale-up
in entire state in
Phased manner
(Phase 1 with
districts)
State wide
Implementation of
AMMA programme
(33 districts)
State wide
implementation
Replicated in
Godda districts
Assam
Odisha
Gujarat
Maharashtra
Madhya
pradesh
Telangana
Jharkhand
Figure 34: CMAM programme scale-up across the states 72Transforming Child Nutrition 73Transforming Child Nutrition
Community-Based Management of
Infants (Under 6 months) with Severe
Acute Malnutrition
6
Evidence from India suggests that a large proportion of the nutrition-risk observed in children
6-59 months, can be predicted by the nutrition-risk seen in the first six months of life. Cohort data
from India shows that two-third of children with wasting at 12 and 24 months have had wasting
at one or more points during the first six months of life. Evidence also suggests that interventions
delivered during child’s early life are more likely to succeed faster, with better and sustainable
outcomes. Both facility-based and community-based interventions are required to manage the
children who are at risk. Additionally, children who are discharged from facilities such as Special
Newborn Care Units (SNCUs), or those born with low birth weight or preterm are at risk and need
quality care during follow-up and at community level.
Several states like Maharashtra, Chhattisgarh, Madhya Pradesh and Bihar have prioritised care for
infants (under six months) who are at nutrition-risk and initiated efforts to improve the care and
services. Low birth-weight babies who do not fall under the criteria of admission in facility-based
care, require support regarding breastfeeding counselling and follow-up.
Samvardhan, a programme for Community-Based Management of Acute Malnutritionin
U6M infants, was initiated in Bihar because parents were not keen on inpatient treatment.
Development of guidelines and recording formats based on current national and international
resources were prepared. Capacity building and training of the frontline workers (ANMs, ASHA
and ASHA facilitators and AWWs ) were undertaken as per National HBNC & IYCF guidelines. Other
steps included hand-holding support to AWWs during supportive supervision visits, baseline
assessment and provision of care to children by counseling their mothers by FLWs (Figure 35).
Enrolling severely underweight
(SUW)/SAM and moderately
malnourished children having
difficulty in feeding
Monthly screening and
identification of severe and
moderate malnutrition in
children
Monitoring nutritional and health
status of children every 15 days
Home visits by ASHA as per
HBNC programme
Discharge from the
programme
Figure 35: Key activities for management of U6M infants under Samvardhan programme 74Transforming Child Nutrition 75Transforming Child Nutrition
Challenges Faced during
Implementation7
There are several challenges with respect to the implementation of community-based programme
for the management of children with SAM and MAM. Some of the key challenges, along with
the innovative strategies used by the states to overcome those challenges, are discussed in this
section.
i. Community engagement and participation
In Madhya Pradesh, Maharashtra, Odisha, and Bihar, lack of awareness among community
members and less participation from community members have been reported as a challenge.
In Madhya Pradesh, strengthening of community involvement is being done using Poshan
Sarkar approach (local nutrition governance). The Chief Minister appealed to all gram panchayats
to participate in Poshan Sarkar and also released an annual report of IMAM programme for
dissemination and effective engagement of more stakeholders.
In Odisha, poor community participation has been observed due to compulsive engagement of
mother/caregivers in cultivation or other household engagement and due to cultural taboos. To
overcome this, in Odisha, community meetings are held at the village level for mass awareness to
ensure uptake and utilization of the available CMAM services.
In Assam, due to COVID-19, group meetings and community-based events have not been held in
the community, due to which it’s not easy to do group counselling. To overcome this, strategies
like priority home visits, telephonic calls, WhatsApp messages were adopted.
ii. Lack of knowledge and skills in frontline workers on essentials of CMAM
Another challenge in effective implementation of CMAM pertains to poor knowledge and skills
of frontline workers in obtaining accurate anthropometric measurements (reported from Odisha
and Madhya Pradesh) and lack of availability of GMDs. To overcome this challenge, in Odisha, a
video in Odia was prepared on growth monitoring modules with support from UNICEF.
Field functionaries across the state are now being trained on growth monitoring, identification
and management of SAM and improving IYCF. Virtual zoom meetings are also held from time-to-
time to orient and clear doubts of field functionaries.
In Madhya Pradesh too, measures were taken for overcoming gaps with respect to skills and
capacity of FLWs in obtaining correct anthropometric measurements. They have also ensured
100% availability of medicines and supplements with support of the Health Department.
iii. Training, mindset and resource-related constraints
In Gujarat, there were initial challenges in the state with respect to the use of balamrutam.
There were additional challenges in adapting to the changes in modalities of the programme
and the introduction of new processes,for instance, the shift in MIS from E-mamta to TECHO+
(Technology Enabled Community Health Operations – Gujrat Government application).
Monitoring of CMAM in field and engagement of health officials and functionaries in COVID-19
related activities further created limitations. 76Transforming Child Nutrition
These challenges were overcome using the following strategies:
ĥConducting trainings in cascade mode for all the FLFs on CMAM programme.
ĥUpdating and revising guidelines under CMAM programme along with orientation/sensitization
sessions planning through use of SATCOM platform.
ĥIntegration of CMAM module in TECHO software.
ĥDevelopment of joint MIS for tracking SAM children in entire state in convergence with DWCD and
having joint convergence planning and review of CMAM programme across all levels.
In Haryana, there were challenges faced with respect to capacity building/trainings and refresher trainings
due to lack of funds. Parents of children with SAM were also not willing to bring their child for check-up/
admission to District Hospitals/Private Hospitals/NRCs. To overcome this, government vehicles were used for
bringing children for health check-up to facilities.
A similar challenge of lack of willingness of parents was also reported in Jammu and Kashmir due to
prevalent social taboos and practices, such as consulting local charlatans. Measures were taken by the state
government to create awareness among masses through radio, television and hoardings (prepared in local
languages). Health department was involved in the process by nominating CDPOs as nodal officers for ruling
out malnourished cases.
In Jharkhand, COVID-19 related restriction delayed the process of scale-up of CMAM programme in the
state due to poor involvement and less availability of ANMs, inability to conduct face-to-face trainings,
closure of AWCs, interrupted THR supply and cessation of GMP activities. To overcome these challenges,
following measures were taken:
iv. Integration challenges for multisectoral engagement and linkages (Figure 36).
In Chhattisgarh, engagement of frontline workers in COVID-19 vaccine duties led to disruption of CCSAM
services. Additionally, limited ownership of Health Department and convergence for CCSAM programme
and reluctance of workers due to new protocols defined under the programme also posed numerous
challenges in the implementation of CCSAM programme in the state. The proposed solution is conducting
regular intersectoral meetings, with the involvement of higher district officials like DM and SDM in TLs to
ensure convergence and overcoming of reported challenges.
Conducting online training with the
support from SCoE-RIMS and UNICEF.
Following COVID-19 appropriate
behavior during enrollment of a child.
Ensuring availability of masks, gloves,
and sanitizers for frontline workers.
Doorstep delivery of THR, nutrition counselling
during home visit, assess improvement in child
during home visit.
1
2
3
4
Figure 36: Multisectoral engagement and linkages 77Transforming Child Nutrition
In Maharashtra, the following challenges were observed: lack of convergence between health and ICDS
functionaries at all levels for ensuring accurate identification of children with SAM, lack of continuous
support from health functionaries at all levels in terms of certification and timely delivery of medicines, lack
of additional financial support from Gram Panchayat Development Plan (GPDP), PESA and DPDC for delivery
of medicines and other logistics, and inadequate data systems for end-to-end management of children with
SAM and understanding child-wise progress.
These affect the overall process of review, monitoring, and programme improvement. Need-based counselling
of caregivers concerning the management of children with SAM and the requirement of flexibility in CBEs
and SBCC campaign are also needed.
Lastly, strong linkages with NRCs through referral system for children with medical complications and those
who have not recovered through VCDCs need to be established. Following measures have been actioned in
the state to overcome these challenges (Figure 37).
In Rajasthan, challenges were faced while conducting offline training sessions due to COVID-19 pandemic
and GMP activities due to lack of GMDs and increased reliance on MUAC. There was a need for integrating
Joint Monitoring plans of Health and ICDS in existing system for speeding up data collection.
Continuous implementation of joint screening: The Department of WCD and the Department
of PHD work in close coordination at all levels to ensure the effectiveness of the screening
drive. It will help in the proper identification and certification of children with SAM. The crux of
the strategy was reshuffling of health and ICDS supervisory personnel, to bring transparency
and quality in the screening, and thereby fetch volume.
Continuous official communication through letters and government
resolutions to leverage local funds towards children with SAM.
Supplementing the treatment protocol and tracking with strong data systems of dedicated
software for end-to-end management of children with SAM management.
Initiation of the special CBEs focused on children with SAM in high-burden blocks. The
focus is not just on the curative aspects but also on ensuring the further development
of a child and avoiding relapse.
Care beyond NRC: The department ran a pilot project where the paediatric ward at the
hospital was supported to function as a facility to treat SAM children along with its ongoing
services. This was achieved by rationalizing the human resources, providing Standard F75 and
F100 WHO Medical Nutrition Therapy in the paediatric ward, and using an open-source digital
data collection, storage and reporting system.
Figure 37: Challenges observed in Maharashtra 78Transforming Child Nutrition
To overcome these challenges, refresher training of FLWs on COVID-19-appropriate behavior was conducted.
Frequency of online trainings was increased to compensate for the lack of offline trainings due to COVID-19.
Mapping of inventory and convergence with other departments and civil society organizations for action on
lack of GMDs were also undertaken. Continuous troubleshooting through social media messaging channels
and regular refresher and review meetings with block and district officials were also held.
v. Challenges related to the system, field functionaries and community
In Bihar, the following challenges came up in GMP activities: lack of functional GMDs, lack of knowledge
regarding the usage of machines and care of equipment, no system for calibration of equipment in ICDS,
lack of fair policy for annual maintenance of equipment, issues regarding identification and follow-up of
children with SAM. Regarding medicine supplies, distribution system is weak with respect to availability of
medicines at block level and ANM at field level.
Some medicines which are not a part of the essential drug list or which don’t have a regular supply chain
mechanism (like vitamin A, folic acid and multivitamin syrup) cannot be procured to be distributed to
children. There is also limited knowledge and capacity of field functionaries which affects the quality of
services delivered in the field.
There are issues in reporting, as preparing reports based on the recorded information and compilation from
AWC level to District level is cumbersome. There is no demand at the community level regarding nutrition
services like growth monitoring, nutrition counselling and annaprashan.
All these challenges can be divided in three categories i.e., system-level, field functionaries-level and
community-level (Figure 38).
For the system-
level challenges,
the system needs
to be strengthened
through fair policy
for equipment,
medicine supplies
and convergence
with other
departments.
A web-based MIS
can be a solution for
problems related to
reporting. Monitoring
of children with SAM
should be aligned
with the poshan
tracker and report
should be generated
on the basis of data
entered.
For field functionaries-
level issues, straining
need should be
assessed and
training should be
imparted as per the
knowledge level of
the functionaries, the
same methods and
duration of training
cannot be used for
different knowledge-
level functionaries.
Figure 38: Challenges categorised at various levels in Bihar 79Transforming Child Nutrition
Further investigation for better understanding of these challenges is warranted to develop solutions to
strengthen the programmes and improve the outcomes.
In Uttar Pradesh, the community-based programme for SAM was scaled up across the state through the
SAMBHAV campaign. At-scale implementation of the programme faced the following challenges: Closure of
AWCs due to COVID-19, engagement of districts in COVID-19 management and vaccination, impact on the
screening quality due to the late roll-out of GMDs, difficulty in ensuring capacities of 1.8 lacs AWWs across
the state, Additionally, the transition of paper-based reporting to technology-driven reporting using the
poshan tracker for AWWs is a challenging and time-consuming process, requiring considerable support and
handholding.
Necessary programmatic adjustments are being made considering the challenges in the first phase
of implementation of SAMBHAV programme. The next phase will continue to focus on strengthening
the capacities of the FLWs on GMDs, the use of poshan tracker and quality of home visits to improve
screening, service delivery and reporting; dedicated communication strategy to influence the demand
and mobilization (Figure 39).
Ensuring compliance to the protocol at the family
level especially for feeding, which also depends on
uninterrupted and efficient supply chain of foods and
medicines, besides focused counselling
Slower and lower recovery among these children, which could
be due to some physiological peculiarities of Indian children,
weaker compliance to the protocol, as well as nutrient
composition of the foods used for nutritional rehabilitation.
Common
challenges
1
2
Figure 39: Common challenges faced during implementation of SAMBHAV programme 80Transforming Child Nutrition 81Transforming Child Nutrition
The Way Forward8
Community-Based Management of Acute Malnutrition (CMAM) is an effective tool for combating
malnutrition. Several states have taken proactive steps in this direction by developing guidelines. Since
malnutrition is prevalent across the country, it is imperative to develop national guidelines on Community-
Based Management of Acute Malnutrition. In order to strengthen the existing CMAM programme in an
effective manner, the states can take the following actions (Figure 40).
Enhancing the capacity of
community health workers to
effectively screen and identify cases
of acute malnutrition by providing
regular training, ensuring the
availability of standardized tools,
and promoting the use of validated
measurement techniques.
Ensuring access to
prompt and effective
management by
developing CMAM
programme/
guidelines in all states
and union territories.
Special focus should
be accessibility of
programme in hard-
to-reach areas through
creative methods like
mobile clinics and
community outreach
programmes.
Recent research and recommendations
advocate for updating and improving
treatment protocols for acute malnutrition;
optimize dosage and duration of medicine and
food; monitor treatment response; manage
complications/comorbidities; incorporate herbal
bio-enhancers into food products to enhance
bioavailability and bioefficacy of nutrients in food.
Establishing robust supply
chain systems to ensure the
uninterrupted availability of
Take-Home Ration, medicines, and
other essential supplies. Improved
forecasting, procurement, storage,
and distribution mechanisms will
prevent stockouts and wastage.
Enhancing data collection
and monitoring systems
to track program
performance, treatment
outcomes, and coverage.
Regularly analyses of
data for identifying
bottlenecks, monitor
progress, and inform
evidence-based decision-
making. Invest in
robust monitoring and
evaluation mechanisms
to generate high-
quality data for program
improvement.
Fostering collaboration
among various stakeholders,
including government
agencies, non-governmental
organizations, development
partners, and community-based
organizations.
1
2
34
5
6
Proactive
Steps for
CMAM
Figure 40: Actions followed-up for proactive steps in various states under CMAM programme 82Transforming Child Nutrition
ANNEXURES
Annexure 1: Google form used to capture information from different states of India on CMAM
Community Based Management of children with Severe Acute Malnutrition(C-MAM) - Practices in India
* Required
Email *
Background Information
1. Name of the State
2. Geography of implementation *
State-wide
»Select districts
»Select blocks
If implemented in districts or blocks, mention the name of the districts
3. Title of the CMAM programme in the State (e.g., in Rajasthan it is called Acute Malnutrition Management Action
AMMA programme) *
4. Background (Geographical information, Health and Nutritional status of U5Y children)
5. Baseline Situation (Situation before the introduction of the practice) *
Steps of Management of children with MAM and SAM in community
6. Describe community awareness/sensitization/mobilization process
7. Screening Process- Anthropometric parameters (Method adopted and Process involved)
8. Special effort/Practice for finding the SAM cases
9. Result of special efforts for finding the SAM cases
10. Medical Assessment process
11. Appetite test
12. Details of Nutritional Treatment
13. Place of nutritional treatment
14. Selected Anganwadi centers in an ICDS project are designated as VCDCs.
15. Nutritional Product Name (Ingredients, quantity, Nutritive value, frequency of distribution, dose, packets weight
and packets distributed)
16. Mention the nutritional products details given to SAM children
17. Mention the nutritional products details given to MAM children
18. Medical treatment. Mention the condition that require medical management at community level, dose and
duration 83Transforming Child Nutrition
19. Follow-up while in CMAM programme (frequency and lasts how long, follow-up after discharge (where /who
conducts)
20. Health and Nutrition education. (By whom, frequency of counselling, mode of counselling)
Capacity building
21. Capacity building process
22. Mention the frequency of training
Sectoral Integration
23. Involvement of multisectors, any integration happened /who are involved /Process and benefits of that
integration
Monitoring and Reporting
24. Recording and reporting details
25. Mention if any methods of monitoring (telemedicine/helplines/ call center)
26. Please provide the details of monitoring (By whom, frequency, feedback and follow-up)
Practices
27. Describe practices on any of the components of community management and result of practice (400 words)
28. Scalability, replicability and sustainability plan
29. Challenges faced
30. Plans to overcome the challenge
31. Share hyperlinks/references to get more details, tools, background documents
32. Share appropriate Pictures – high resolution photographs as images
33. Share contact details of person for more information, details, guidance 84Transforming Child Nutrition
Annexure 2: Nutrient composition of Balamrutham Plus used for children with SAM under
CMAM programme in Telangana
Under the Supervised Supplementary Feeding Program (SSFP) protocol, 200 ml milk and one egg per
day are also provided to MAM/SAM children along with the balamrutham plus ration, which meets
the protein requirements. Balamrutham plus is a powder prepared by dissolving in equal amount of
lukewarm water to form a paste.
IngredientGrams / 100 gram
Skimmed milk powder13.3
Groundnut3.3
Oil20
Sugar20
Roasted wheat26.7
Bengal gram3.3
Rice flakes13.3
NutrientPer 100 gm
Energy (Kcal)460
Protein (g)11
Calcium (mg)419
Iron (mg)9.1
Zinc (mg)6.3
Vitamin A (mg)0.2
Vitamin B1 (mg)0.5
Vitamin B2 (mg)0.6
Vitamin C (mg)15.7
Vitamin B12 (mcg)0.7
Folic acid (mcg)36.1
Niacin (mg)5.5 85Transforming Child Nutrition
REFERENCES
1. UNICEF-WHO-The World Bank: Joint child malnutrition estimates – levels and trends – 2021 edition - UNICEF DATA
[Internet]. [cited 2022 Feb 3]. Available from: https://data.unicef.org/resources/jme-report-2021/
2. World Health Organization (WHO 2021). 2021 Global Nutrition Report: The state of global nutrition [Internet]. 2021
[cited 2022 Jan 13]. Available from: https://globalnutritionreport.org/reports/2021-global-nutrition-report/
3. National Family Health Survey (NFHS-5) [Internet]. [cited 2022 Jan 13]. Available from: http://rchiips.org/nfhs/
factsheet_NFHS-5.shtml
4. Comprehensive National Nutrition Survey. 2016;
5. Rana R, Vaze G, Christian P, Gupta P. Determinants of Acute Malnutrition among Under Five Children in Aravalli
District of Gujarat, India: A Community-Based Case-Control Study. Int J Heal Sci Res [Internet]. 2019 [cited 2022 Jan
13];9(6):1. Available from: www.ijhsr.org
6. Paul L, Chellan R, Sahoo H. Unmet Need of Integrated Child Development Services (ICDS) among Economically
Weaker Sections in Indian Society. Soc Sci Spectr [Internet]. 2018 Mar 8 [cited 2022 Jan 13];3(3):141–53. Available
from: http://www.socialspectrum.in/index.php/sp/article/view/105
7. World Health Organization. Guideline: updates on the management of severe acute malnutrition in infants and
children, Geneva: World Health Organization; 2013. Guidel Updat Manag Sev acute malnutrition infants Child
Geneva World Heal Organ 2013. 2013;(August 2013):111.
8. Child wasting and concurrent stunting in low- and middle-income countries - Andrew Mertens et al. med Rxiv
preprint doi: https://doi.org/10.1101/2020.06.09.20126979 June 2020’
9. Causes and consequences of child growth failure in low- and middle-income countries - Andrew Mertens et al.
medRxiv preprint doi: https://doi.org/10.1101/2020.06.09.20127100 June 2020
10. https://mailchi.mp/4d7b3aacf64e/new-evidence-on-prevalence-of-wasting-among-under-5-children-in-india
11. Early childhood linear growth failure in low- and middle-income countries - Jade Benjamin-Chung et al. medRxiv
preprint doi: https://doi.org/10.1101/2020.06.09.20127001 June 2020
12. https://www.ennonline.net/fex/67/indiawastingsummaryreport - Analysis of wasting & severe wasting and its
associated risk factors among under-5 children in India 90Transforming Child Nutrition
TRANSFORMING
CHILD NUTRITION
STATE-LEVEL APPROACHES AND PRACTICES FOR
COMMUNITY-BASED COMPREHENSIVE CARE AND
MANAGEMENT OF ACUTE MALNUTRITION Transforming Child Nutrition: State-Level Approaches and Practices
for Community-Based Comprehensive Care and Management of
Acute Malnutrition
Publisher:
NITI Aayog
Government of India, Sansad Marg, New Delhi–110001, India
Year of Publication: 2023
Language: English
ISBN: 978-81-956821-7-1
Authors:
NITI Aayog
Rajib Kumar Sen, Senior Advisor
Hemant Kumar Meena, Deputy Secretary
Dr. Rinky Thakur, Research Officer
UNICEF
Dr. Sameer Pawar, Nutrition Specialist
Dr. Abner Daniel, Nutrition Specialist
Farida Sultana Shaik, Nutrition Officer
Disclaimer:
The document titled “Transforming Child Nutrition: State-Level Approaches and
Practices for Community-Based Comprehensive Care and Management of Acute
Malnutrition” relies on secondary sources and information obtained from the
Department of Women and Child Development of various States. NITI Aayog
wishes to emphasize that while every effort has been made to present accurate and
up-to-date data, NITI Aayog does not guarantee the accuracy of the information
and does not accept responsibility for the consequences of using this data.
NITI Aayog disclaims any legal liability for the accuracy or inferences drawn from
the material contained in the document or for any consequences arising from the
use of this material. Reproducing any part of this report, whether electronic or
mechanical, is strictly prohibited without prior permission or intimation to NITI
Aayog. Users are encouraged to seek permission for reproduction through official
channels to avoid any legal implications. TRANSFORMING
CHILD NUTRITION STATELEVEL APPROACHES AND PRACTICES FOR
COMMUNITYBASED COMPREHENSIVE CARE AND
MANAGEMENT OF ACUTE MALNUTRITION Nutrition has a profound impact on a country’s human capital as it directly influences both
physical and cognitive development. Optimum nutrition is linked to better learning outcomes,
higher productivity and economic growth. Improving nutritional outcomes among children
under five years of age is especially critical for harnessing India’s demographic dividend and
laying a solid foundation for Viksit Bharat @ 2047.
While considerable progress has been made, reducing the prevalence of wasting in children
across states, together with action on other health and nutrition indicators, remains a key
policy priority. It is imperative to take strong steps for preventing and reducing the burden
of malnutrition through sustainable, community-based interventions.
Recently, the Ministry of Women and Child Development has launched the Protocol for
Management of Malnutrition in Children. Many states have successfully implemented
community-based programs for managing acute malnutrition by developing their own
guidelines. States that have initiated their own programs focus on strengthening last-mile
delivery of key services. The emphasis of such guidelines and programs is on improving
adherence to standard operating protocols, augmenting the skills of frontline workers,
ensuring adequate supplies, enhancing data quality, and enforcing regular monitoring
mechanisms.
The collaboration between NITI Aayog and UNICEF has yielded this comprehensive report
that compiles good practices on community-based management of acute malnutrition from
across the country.
I hope that this document will aid States/UTs in refining their community-based programs
for management of acute malnutrition. The tried-and-tested solutions documented in this
report provide an opportunity for cross-learning and addressing shared challenges, across
varying local contexts. By implementing these practices at scale, India can take significant
strides towards ensuring a healthier and more prosperous future for its children.
FOREWORD
Hkkjr ljdkj
uhfr vk;ksx] llan ekxZ
ubZ fnYyh & 110 001
Government of India
NATIONAL INSTITUTION FOR TRANSFORMING INDIA
NITI Aayog, Parliament Street,
New Delhi - 110 001
lqeu ds- csjh
mik/;{k
SUMAN K. BERY
VICE CHAIRMAN
Phones : 23096677, 23096688
Fax : 23096699
E-mail : vch-niti@gov.in
Suman Bery
iiiTransforming Child Nutrition Malnutrition is one of the significant public health concerns affecting the population across
the country. Undernutrition among children under 5 years of age is associated with cognitive
impairment, impaired physical growth, and increased risk of infections and morbidity.
Community-based management of acute malnutrition has proven to be highly effective in
addressing the issue of acute malnutrition. Evidence shows that about 80 percent of children
with severe acute malnutrition can be treated at home. Therefore, providing these children with
prompt care and treatment is essential.
Community-based management of acute malnutrition uses key strategies such as community
mobilization and awareness, regular screening and identification of children, use of nutrient-
dense food, medical management, health, and nutritional counselling, regular follow-ups of
children, regular monitoring and reporting, engagement of multiple stakeholders, timely capacity
building of health workers with special focus on low-birth-weight babies. Intensification of the
above-mentioned strategies and building strong linkages among different stakeholders are
crucial to ensure that beneficiaries receive a comprehensive package of services essential for the
prevention and management of malnutrition.
The report "Transforming Child Nutrition: State-Level Approaches and Practices for Community-
Based Comprehensive Care and Management of Acute Malnutrition" provides valuable insights
drawn from different States for enhancing program coverage and achieving better outcomes by
State governments.
FOREWORD
Hkkjr ljdkj
uhfr vk;ksx
llan ekxZ] ubZ fnYyh & 110 001
Government of India
NATIONAL INSTITUTION FOR TRANSFORMING INDIA
NITI Aayog
Sansad Marg, New Delhi - 110 001
Tele.: 23096809, 23096820, Fax : 23096810
E-mail: vinodk.paul@gov.in
Vinod Paul
vTransforming Child Nutrition
MkW- fouksn dqekj ikWy
lnL;
Dr. Vinod K. Paul
MEMBER Good nutrition is paramount for enhancing social capital and economic productivity of a
country. Children who suffer from malnutrition face obstacles in their physical and cognitive
development, hindering their ability to learn and thrive. An action-oriented approach is
imperative to establish a comprehensive care continuum that tackles malnutrition, especially
at the community level.
In alignment with our unwavering commitment to provide nutrition, the government has
introduced Poshan 2.0 guidelines, emphasizing the management of moderate and severe
malnutrition. States are encouraged to adopt community-based strategies for the successful
execution of these guidelines. Many states have developed their own community-based
management of acute malnutrition guidelines and Ministry of Women and Child Development
has also developed the protocol for the management of malnutrition in children at the
community level.
To enhance program effectiveness, it is crucial to comprehend the insights, best practices, and
challenges derived from state experiences. This comprehensive report delves into key thematic
areas crucial for the community-based management of acute malnutrition. It commences
with community mobilization and awareness, emphasizing the importance of timely growth
monitoring and intervention. Quality services, including nutritional, medical management,
and education, are underscored, with frontline worker skills and product supply identified as
integral components. The report also meticulously outlines the establishment of recording,
reporting, and monitoring mechanisms and the need for continuous capacity building.
I am confident that this report will serve as an important guidebook for policymakers and
administrators of States and Union Territories. By adopting the practices outlined in the
thematic areas, they can strengthen their efforts in combating malnutrition within their
jurisdictions. It is my sincere hope that the insights, state practices, and challenges presented
in this report will contribute significantly to our collective mission of building a malnutrition-
free and healthier Bharat.
MESSAGE
B.V.R. Subrahmanyam
eq[; dk;Zdkjh vf/kdkjh
Chief Executive Officer
Hkkjr ljdkj
uhfr vk;ksx] llan ekxZ
ubZ fnYyh & 110 001
Government of India
National Institution for Transforming India
NITI Aayog, Parliament Street,
New Delhi - 110 001
Tel.: 23096576, 23096574
E-mail: ceo-niti@gov.in
[B.V.R. Subrahmanyam]
viiTransforming Child Nutrition
ch- oh- vkj- lqczã.;e ixTransforming Child Nutrition
Optimum nutrition and adequate care during early childhood is critical to ensure good health, growth,
and development of children. To achieve nutrition and development outcomes, it is critical to strengthen
coverage, continuity, intensity, and quality of evidence based high impact Health, Nutrition and WASH
interventions via health, ICDS, Food and other systems and, across the continuum of care (from facility
to community) during the most critical life stage (1000-days window of opportunity – from conception to
the age of 2 years old).
As the growth and development potential in childhood is tremendous, any deficit in care and nutrition
during this period can adversely affect the immunity of the child making them prone to diseases that
ultimately leads to increased risk of mortality and morbidity. Severe acute malnutrition (SAM) among
children is a life-threatening form of malnutrition resulting from inadequate feeding and / or repeated
illnesses. Government of India is committed to address prevent and manage SAM. Recently released
guidelines from Ministry of WCD states that Poshan 2.0 shall focus on Maternal Nutrition, Infant and
Young Child Feeding Norms, Treatment of MAM/SAM, and Wellness through AYUSH. It encourages states
to implement community-based approaches for prevention, identification, and care of acute malnutrition.
Many state governments have developed guidelines and initiated implementation of integrated services for
children with SAM linking growth monitoring and promotion to identify children with MAM and SAM and
linking them with facility and community-based care through the functionaries of Department of Women
and Child Development (DWCD) in collaboration with the Department of Health and Family Welfare
(DHFW). The states are providing an integrated package of prevention, identification and care services
for children with SAM, which includes screening of children for wasting and medical complications; care
for children with MAM and prevention of SAM among them; referral to facility-based care if any medical
complications; for uncomplicated children with SAM - provision of antibiotic, de-worming, multivitamin,
IFA at community level; and locally available nutrient dense food; discharge on achieving target weight
and referral if the child develops any complication.
Since 2020, the world has been dealing with the COVID-19 pandemic, with an unprecedented public
health crisis that affected the health and nutrition care service delivery across the country. Despite this,
states have innovated and modified the components of the program to maintain continuity and in several
cases even expansion of the health and nutrition services to the most nutrition vulnerable children.
In order to further strengthen the programs, it is important to understand the learnings, best practices
and challenges from the state experiences. NITI Aayog led the process of documenting the experiences
through this thematic compendium on identification, prevention, and community-based care of children
with acute malnutrition, with support of UNICEF and National Centre of Excellence on care of children
with SAM (C-SAM) - Kalawati Saran Children’s Hospital and state level centers of excellence. This
document summarizes key learning from several states of India on thematic areas of the program and
serves to inspire and guide other states to adopt the experiences. As the number of children with SAM
United Nations Children’s Fund I India Country Office
UNICEF House, 73 Lodi Estate, New Delhi — 110 003
Telephone: (+91) 11 24690401 I Facsimile: (+91) 11-24627521 I
newdelhi@unicef.org I www.unicetin
ixTransforming Child Nutrition
MESSAGE
Arjan de Wagt
Chief, Nutrition | UNICEF India xTransforming Child Nutrition xiTransforming Child Nutrition
ACKNOWLEDGEMENT
We extend our heartfelt gratitude to the Ministry of Women and Child Development and
the Ministry of Health and Family Welfare for their valuable contributions in enriching
this document through their insightful comments and inputs. Their expertise has been
instrumental in shaping the content and enhancing its impact.
We would also like to express our sincere appreciation to the State Government officials of
the Women and Child Development departments who generously shared their innovative
practices. Their contributions have been invaluable in showcasing effective strategies for
managing acute malnutrition at the community level.
Our gratitude also goes to the UNICEF state teams for their unwavering support in facilitating
responses from the states and providing essential insights throughout the process.
The National Center of Excellence for Management of Severe Acute Malnutrition (NCoESAM),
Kalawati Saran Children’s Hospital, New Delhi, has played a significant role in enhancing this
document. We are immensely thankful to Dr. Praveen Kumar, Dr. Rajesh Sinha, Ms. Shristi
Arora and Ms. Shikha Sayal from the National Centre of Excellence for their valuable inputs.
Special thanks are extended to Dr. Rakesh Sarwal, former Additional Secretary, NITI Aayog,
for his invaluable comments and feedback during the preparation of this document. His
guidance has been crucial in ensuring the document’s comprehensiveness and relevance.
We also acknowledge the efforts of Ms. Sumana Arora, Senior Consultant, Ms. Urvashi Prasad,
Director, and Dr. Aakriti Gupta, Associate, NITI Aayog, for editorial assistance, which has
greatly contributed to the document’s clarity and coherence. xiiTransforming Child Nutrition
ACRONYMS
AD – Additional Director
AIIMS – All India Institute of Medical Sciences
AMMA – Acute Malnutrition Management Action
ANM – Auxiliary Nurse Midwife
ASHA – Accredited Social Health Worker
AWC – Anganwadi Centre
AWT – Anganwadi Teacher
AWW – Anganwadi Worker
VO – Village Organization
BCM – Block Child Manager
BD – Twice a day
BPPP – Baal Poshan Pragati Patrak
CAS – Common Application Software
CBEs – Community Based Events
CDPO – Child Development Project Officer
CGHA – Community Gender & Health Activists
CHC – Community Health Center
CMAM – Community-Based Management of Acute
Malnutrition
CC-SAM – Community based Management of Children
with Severe Acute Malnutrition
CMHO – Chief Medical & Health Officer
CSO – Civil Society Organization
DD – Deputy Director
DEIC – District Early Identification Center
DM - District Magistrate
DoHFW – Department of Health and Family Welfare
DPO – District Project Officer
DSWO – District Social Welfare Office
DWCD – Department of Women and Child Development
DRPCAU – Dr. Rajendra Prasad Central Agricultural
University
ECCE – Early Childhood Care and Education
ECD – Early Childhood Development
FLWs – Field Level Workers
GMD – Growth Monitoring Devices
GMP – Growth Monitoring and Promotion
GOM – Government of Maharashtra
GMSH – Government Multi Specialty Hospital
GMERS – Gujarat Medical Education and Research
Society
GMSCL – Gujarat Medical Services Corporation
GPDP – Gram Panchayat Development Plan
HBYC – Home-Based Care for Young Child Programme
HBNC – Home Based New Born Care
ICDS – Integrated Child Development Scheme
ICMR NIN – Indian Council of Medical Research –
National Institute of Nutrition
IEC – Information Education Communications
IFA – Iron Folic Acid
ILA – Incremental Learning Approach
IMAM – Integrated Management of Acute Malnutrition
IMSAM – Integrated Management of Severe Acute
Malnutrition
IVR – Interactive Voice Response
IYCF – Infant and Young Child Feeding
JD – Joint Director
JFMC – Joint Forest Management Committee xiiiTransforming Child Nutrition
JSLPS – Jharkhand State livelihood Promotion Society
KSCH – Kalawati Saran Children’s Hospital
LHV – Lady Health Visitor
LS – Lady Supervisor
LBW – Low Birth Weight
MoWCD – Ministry of Women and Child Development
MAA – Mother’s Absolute Affection
MAM – Moderate Acute Malnutrition
MCHN – Maternal Child Health and Nutrition
MIS – Management Information System
MO – Medical Officer
MPR – Monthly Progress Report
MSSSKA - Mukhya Mantri Sustho Shaishob Sustho
Kaishore Abhiyaan
MTC – Malnutrition Treatment Centre
MUAC – Mid-Upper Arm Circumference
NCoE-SAM – National Centre of Excellence for
Management of Severe Acute Malnutrition
NFHS – National Health and Family Survey
NHE – Nutrition and Health Education
NHM – National Health Mission
NIPCCD – National Institute of Public Cooperation and
Child Development
NNM – National Nutrition Mission
NNMB – National Nutrition Monitoring Bureau
NIN – National Institute of Nutrition
NRC – Nutrition Rehabilitation Centre
NRLM – National Rural Livelihood Mission
OD – Once Daily
ORS – Oral Rehydration Solution
PESA – Panchayat (Extension to Scheduled Areas)
PHC – Primary Health Center
PHD – Public Health Department
PMCC – The Performance Monitoring and Control Centre
PR – Public Relations
PRI – Panchayati Raj Institution
PSM – Preventive and Social Medicine
RBSK – Rashtriya Bal Swasthya Karyakram
RCH – Reproductive and Child Health
RCoENRRT – Regional Centre of Excellence for
Nutritional Rehabilitation Resource & Training
RIMS – Rajendra Institute of Medical Sciences
RTE – Ready to Eat
SAAMAR – Strategic Action for Alleviation of Malnutrition
and Anaemia Reduction
SAM – Severe Acute Malnutrition
SBCC – Social Behavior Change Communication
SCoE – State Centre of Excellence
SDM – Sub-Divisional Magistrate
SHGs – Self-Help Groups
SIHFW – State Institute of Health & Family Welfare
SNP – Supplementary Nutrition Programme
SNCU – Special Newborn Care Unit
SSFP – Supervised Supplementary Feeding Programme
SUW – Severe Underweight
THR – Take-Home Ration
TOT – Training of Trainers
UNICEF – United Nations Children’s Fund
U6M – Under 6 Months
VCDC – Village Child Development Center
VHSNC – Village Health Sanitation and Nutrition
Committee
VHSND – Village Health, Sanitation and Nutrition Day
WASH – Water, Sanitation and Hygiene
WCD – Women and Child Development
WHO – World Health Organization xvTransforming Child Nutrition
Foreword, Vice chairman, NITI Aayogiii
Foreword, Member, Health, NITI Aayog v
Message, CEO, NITI Aayogvii
Message, UNICEFix
Acknowledgementxi
Acronymsxii
Executive Summary1
1.Backgrounds5
1.1 Approaches for Management of Children with Acute Malnutrition8
1.2 Principles for Management of Acute Malnutrition at Community
Level
8
2.Thematic Areas for Community-Based Management of Acute
Malnutrition
13
3.Methodology for Development of the Compendium 15
4.Status of CMAM Implementation in India17
5.Thematic Areas on CMAM across India21
5.1 Community Mobilization for Strengthening CMAM 21
5.2 Screening and Identification 27
5.3 Appetite Test31
5.4 Medical Management38
5.5 Nutritional Management 41
5.6 Follow-Up 45
5.7 Nutrition and Health Education50
5.8 Technology Enabled Recording and Reporting System 54
5.9 Monitoring and Supervision57
5.10 Multisectoral Convergence61
5.11 Capacity Building 64
5.12 Scalability, Replicability and Sustainability 69
6Community-Based Management of Infants (Under 6 months)
with Severe Acute Malnutrition
73
7Challenges Faced during Implementation75
8The Way Forward81
Annexures 82
References85
CONTENTS xviTransforming Child Nutrition 1Transforming Child Nutrition
For successful programme implementation and its scale-up, the key thematic
components are - community mobilization, screening/identification,
appetite test, medical management, nutritional management,
nutritional and health education, recording and reporting,
monitoring, multisectoral engagement and capacity building.
Executive Summary
Malnutrition is a major public health concern in the country. To address the issue of acute malnutrition among
children under 5 years of age, integrated prevention and treatment approaches are critical to be implemented
through community- and facility-based management systems. Facility-based management programme is
already in place through functional Nutrition Rehabilitation Centers (NRCs) as per the national guidelines
issued by the Ministry of Health and Family Welfare, Government of India. A protocol for management of
malnutrition in children has been released by the Ministry of Women and Child Development.
The community-based programme for management of acute malnutrition is being implemented in several
states following the development of state-specific guidelines. There is a need to strengthen the services
delivered to children with Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM) by
increasing coverage, standardizing protocols and improving adherence, enhancing the knowledge and
skills of frontline functionaries, ensuring adequate supplies, boosting data quality and enforcing regular
monitoring mechanisms.
For successful programme implementation and its scale-up, the key thematic components are - community
mobilization, screening/identification, appetite test, medical management, nutritional management,
nutritional and health education, recording and reporting, monitoring, multisectoral engagement and
capacity building.
The practices under community mobilization cover a range of Information Education Communications (IEC)
activities such as community meetings, media engagement, social audits, rallies, wall paintings and food-
related games, among others. These activities help Anganwadi Workers (AWWs), Accredited Social Health
Workers (ASHAs), Auxiliary Nurse Midwives (ANMs) and Anganwadi Services Supervisors to interact with the
community and families, thereby building a relationship with them and encouraging their participation in
the programme.
Early screening and identification of malnutrition among infants and young children are instrumental to the
programme. Various states have adopted innovative methods to screen children under the CMAM programme
through multiple screening modes, including monthly door-to-door screening, the constitution of a special
team for screening and enrollment and fixed days for routine growth monitoring and identification. 2Transforming Child Nutrition
SAM and MAM children without medical complications can be treated at the community level using
medicines and supplements as per Integrated Management of Neonatal and Childhood Illness (IMNCI)
protocols. In most states, health team comprising of ANMs or doctors conduct a medical assessment of
children identified with SAM.
The nutritional needs of SAM and MAM children differ from those of normally nourished children in terms
of energy density, quantity, and feeding frequency. SAM and MAM children can take only a small amount of
food at a time. Therefore, the food must be easily digestible, rich in energy and contain appropriate amount
of proteins. Some states are focusing on strengthening targeted counselling to enhance home prepared
food using locally available and culturally-appropriate food ingredients, while others have enhanced the
routine THR, also tried to make provision as per the age and weight of the child. States have also tried
energy-dense recipes where the recipe is provided only after approval of the recipe committee of districts,
special provision of funds is made for the nutritional management of SAM and MAM children, and flexibility
is given to AWWs for preparing recipes using locally available foods.
Children under the CMAM programme are frequently followed-up, and different activities are undertaken
during follow-up visits. Most states have fixed duration of the follow-up visits at regular fixed intervals
by frontline workers while the child is in the programme - and even after they are discharged from the
programme - to prevent relapse and take timely action.
The strategies for nutrition and health education include interpersonal counselling during follow up as well
as home visits using audio-visual aids and other printed IEC materials, or cooking demonstration at AWC.
The recording and reporting system allows for assessing the progress of CMAM programme. The states have
developed tracking tools such as a management information system (MIS), an android-based application,
for real-time data entry of enrolled children and for tracking all the parameters of children with SAM and
MAM. 3Transforming Child Nutrition
Monitoring and supervision are conducted to observe and check the
Details of logistics
including
equipment, THR
and medicine
supplies
Recording
and reporting
formats and
quality of data
recorded
Knowledge and
skills of frontline
functionaries or field-
level workers (FLWs)
on identification
and classification of
nutritional status
Services provided
to enrolled
children in CMAM
programme
Outcome of the
programme
Regular monitoring of CMAM activities and review of data can also help in early identification of gaps.
The multisectoral involvement and capacity building is enabled by the active participation of Health and
Family Welfare Department, with the lead role taken by the Department of Women and Child Development
(in most states), to streamline CMAM implementation and avoid duplication of efforts.
At the time of COVID-19 restrictions, innovative strategies were adopted to ensure the continuity of service
delivery while minimising the spread of infection. These included the organisation of virtual trainings of
health functionaries in place of physical trainings to keep up the momentum, delivery of services (including
food) at the doorsteps of beneficiaries when the Anganwadi centres were closed, and the use of Mid-Upper
Arm Circumference (MUAC) in case of unavailability of growth monitoring devices.
State-specific practices documented here will serve as examples to help other states overcome the
challenges and improve CMAM implementation at scale. This documentation will also support in planning
and implementation of interventions for the management of under 6-months infants with early-growth
faltering, at the community level, by ensuring home visits of Low-birth Weights (LBWs) under the Home-
Based Care for Young Child Programme (HBYC) and Home Based New Born Care (HBNC) programmes and by
providing special care to these infants and their mothers. Community participation fostered by awareness
generation among key community members like families, PRIs, SHGs and village leaders through individual
and group counselling sessions using IEC tools, growth charts, videos and counselling flipbooks, has been
highlighted. Tools and practices for real-time data monitoring and tracking for improved screening outcomes
have also been shared. Efforts towards decreasing undernutrition prevalence are sustained by focusing on
preventive approaches such as by promoting better infant and young child feeding practices and WASH
conditions to reduce childhood infections.
The practices and learning outlined in this document can be taken up by state governments to leverage
and strengthen the existing services. It will also provide an opportunity for cross-learning and help state
governments mitigate potential challenges by implementing tried-and-tested solutions from other states.
The purpose of this document is to strengthen implementation of community based integrated approach
for prevention and management of childhood wasting, increase the coverage, ensure better outcomes, and
hence reduce the prevalence of undernutrition in the country. 4Transforming Child Nutrition 5Transforming Child Nutrition
Backgrounds
Malnutrition results from inadequate consumption of food, inappropriate feeding practices,
illnesses like diarrhoea, pneumonia etc., and poor sanitation, and inadequate hygiene
ĥA low-birth-weight infant is at high risk of undernutrition.
ĥIf adequate quantity of food containing appropriate amount of nutrients is not consumed for
an extended period, the child will become undernourished gradually.
ĥIllnesses like diarrhoea can cause excessive loss of nutrients from a child’s body, which might
lead to making the child malnourished.
ĥAcute Respiratory Infection also badly impacts the nutritional status of a child.
Types of undernutrition: Generally, the three indicators, namely weight-for-age, height/length-
for-age, and weight-for-height/length are used to identify three undernutrition conditions viz.
underweight, stunting and wasting respectively (Figure 1).
Figure 1: Types of undernutrition
Underweight condition can result from either chronic or acute malnutrition, or both. An underweight child has a weight-for-age Z score of (-2SD) below the median for the World Health Organization (WHO) Child Growth Standards. According to WHO standard, a child is considered moderately underweight when its weight-for-age Z-score falls between -2 and -3 SD, and severely underweight when weight-for-age Z-score falls less than -3 SD.
Underweight
Failure to achieve expected height/length as compared to a healthy, well-nourished child of the same age is a sign of stunting. Stunting is an indicator of linear growth retardation and chronic growth failure. It is associated with a number of long-term factors including chronic insufficient nutrient intake, frequent infection, inappropriate feeding practices and poverty. A stunted child has a height-for-age Z score that is at least two standard deviations (-2SD) below the median for the WHO Child Growth Standards.
Stunting
It is acute malnutrition resulting from either failure to gain weight or from actual weight loss. Wasting in individual child and population groups can change rapidly and show marked seasonal patterns, since it is very sensitive to changes in food availability or disease prevalence. A wasted child has a weight-for-height/length Z score at least two standard deviations (-2 SD) below the median for the WHO Child Growth Standards.
Wasting 6Transforming Child Nutrition
As per the National Family Health Survey (NFHS-5) 2019-21, the prevalence of stunting (35.5%), underweight
(32.1%), wasting (19.3%), and severe wasting (7.7%) remains very high among children under 5 years (U5)
of age (Figure 2). Although a decline in undernutrition from NFHS-2, 3, 4 to NFHS-5 has been witnessed, the
progress seems to be very slow.
In 2006, WHO released new growth standards for children aged 0-5 years, which inform all WHO definitions
and estimates of malnutrition. Accordingly, acute malnutrition can be classified into two categories viz.
Moderate Acute Malnutrition (MAM) and Severe Acute Malnutrition (SAM).
Moderate Acute Malnutrition (MAM) (WHO, 2013) is defined by moderate wasting, i.e., weight-for-height/
length (WFH) between ‐2 and ‐3 Z score (SD) or mid-upper-arm circumference (MUAC) between 11.5 cm to
12.5 cm for children 0‐59 months. It makes up the greatest portion of malnourished children. It is, therefore,
vital to intervene in children with moderate malnutrition at the community level before they slip into severe
malnutrition and develop complications.
Severe Acute Malnutrition (SAM) (WHO, 2013) is when a child suffers severe wasting that may or may not
be accompanied by swelling of the body due to fluid retention. It occurs when infants and children do
not have adequate energy, proteins and micronutrients in their diet, combined with other health problems
such as recurrent infections. For children 0-6 months, it is defined by weight-for-length (WFL) Z score below
three standard deviations (‐3SD) of the median WHO child growth standards and/or presence of bilateral
pitting oedema (build-up of fluid in the body which causes the affected tissue to become swollen, could
be generalized but commonly seen in the lower extremities first). For children 6-59 months, it is defined by
weight-for-height/length (WFH) Z score below three standard deviations (‐3SD) of the median WHO child
growth standards and/or presence of bilateral pitting oedema and/or MUAC<11.5 cm.
Children with SAM are at an increased risk of mortality due to common childhood illnesses since they have
reduced immunity and a deranged metabolic system. Global evidence suggests that severely malnourished
children contribute significantly to deaths in children under the age of five years.
Figure 2: Trends in prevalence of different forms of child undernutrition in India
Underweight Stunting Wasting
47
42.5
35.7
32.7
Severe wasting
2.2
6.4
7.57.7
15.5
19.819.3
21
45.4
38.4
35.5
48
0
10
20
30
40
50 7Transforming Child Nutrition
Children with SAM require thorough assessment and clinical examination for identifying complications
(Figure 3) like oedema, loss of appetite, severe anaemia, pneumonia, diarrhoea, dehydration, cerebral palsy,
tuberculosis, HIV, and heart disease, and any other danger signs (according to IMNCI algorithm). If any of
these are present, it is classified as SAM with medical complication, and the child is referred for inpatient
management. If the child with SAM has no associated medical complication, it can be managed in the
outpatient/community setting with care at home. Evidence shows that about 85-90% children with severe
acute malnutrition do not have medical complications when they are identified early through active case-
finding, or through sensitizing and mobilizing communities to access decentralized services themselves,
and can be treated at home.
It is important to recognise that malnutrition is preventable and treatable, and therefore, there is an urgent
need to have mechanisms in place for early detection of growth faltering and for taking corrective measures
before the child progresses to severe grades of malnutrition. Children who have already developed SAM
require immediate curative care closer to their homes in the community settings to prevent further
complications. However, children with SAM who have also developed medical complications need to be
treated at the health facilities/NRCs.
Figure 3: Assessment and clinical examination for identifying complications
ANY OTHER
DANGER SIGNGS
(ACCORDING
TO IMNCI
ALGORITHM)
HEART DISEASE
HIV
CEREBRAL
PALSY
DIARRHOEA
DEHYDRATION
TuberculosisPNEUMONIA
SEVERE
ANAEMIA
LOSS OF
APPETITE
OEDEMA
Children with SAM
require thorough
assessment and
clinical examination
for identifying
complications like 8Transforming Child Nutrition
1.1 Approaches for Management of Children with Acute Malnutrition
There are two approaches for management of children with acute malnutrition (Figures 4 and 5).
Inpatient or Facility-Based Management of Acute Malnutrition: Only
about 10-15% children with SAM suffer from medical complications and require
inpatient care. Inpatient management at NRCs is effective in reducing case fatality
rates. NRCs have already been established in many states to provide specialised
care, while other states are in the process of setting them up or integrating the
protocols in the existing paediatrics care.
Community-Based Management of Acute Malnutrition (CMAM): The
majority of severely malnourished children who do not have medical complications
can be managed in the community setting. In addition, children discharged from
the NRC can also continue to be cared for in the community setting after initial
phase of stabilisation and onset of recovery phase. Community-based management
is also important from another perspective. Under the best of circumstances, the
NRCs will not be able to provide care to the entire case load of children with SAM in
each district or state, as NRCs are meant for facility-based management of the SAM
children with medical complications only. Inability of the caregivers to stay in the
NRC for a considerable period till the child is on the way to recovery is also a reason
for incomplete treatment/recovery of admitted children in NRCs. There is, thus, a
need to establish continuum of care at the community level. Community-based
care will complement the services delivered through NRCs. This will create scope
for most children with SAM to be provided with care in the community setting
itself, thus reducing the load on resources and health facilities.
1
2
Figure 4: Two approaches for management of children with acute malnutrition 9Transforming Child Nutrition
Screening with weight-for-height
/ length (all under-five children)
NormalSAM
Medical Assessment with
support from ANM: Check for
bilateral pitting oedema, visible
medical complications, and
other medical complications
Appreciate and encourage
positive behaviors
Counseling on Maternal, Infant
and Young Child Feeding
practices. Continue micronutrient
supplementation as per routine
programme guidelines
MAM
Care Provision for 12/16 weeks (6
services) and Follow-up after 4 weeks
1. Antibiotics and de-worming
2. Energy & nutrient dense food/
Double THR
3. Weekly home visits & interpersonal
counselling
4. Micronutrient supplementation
5. Weekly/Fortnightly weight for
height by AWW and health check up
by ANM
6. Follow-up
SAM with medical
complications
Refer and
Treatment
at NRC
SAM without medical
complications
Children who don’t
respond under
CMAM or in
case any medical
complications arise
Figure 5: Approaches for management of children with acute malnutrition
1.2 Principles for Management of Children with
Acute Malnutrition at Community Level
Community-based management is founded on the understanding that if children with MAM/SAM are
identified in the early stages, then treatment can be provided at community level, thereby averting medical
complications in these children. Community-based management, therefore, focuses on the timely detection
and addressing of acute malnutrition in early stages, before the metabolic and immunological aspects
become severe enough to warrant inpatient treatment.
The community-based care programme builds on the existing local capacity and resources of the Health
and Anganwadi Services systems, providing easy access to services and making appropriate care available
within the community setting as long as needed.
Community-based care is linked with facility-based care through referrals; children developing medical
complications can be referred to a nearby health facility, for example, a Primary Health Center (PHC) or
Community Health Center (CHC) with the availability of medical officers for further outpatient/inpatient
care, and even NRCs, wherever available. Those discharged from NRCs are enrolled into the community-
based programme for continuation of care and nutritional rehabilitation. 10Transforming Child Nutrition
Community-Based Management of Acute Malnutrition (CMAM) is based on the principle that children should
receive timely and appropriate care and assistance, especially if they are facing health risks (Figures 6 and 7).
The core operating principles of CMAM are as follows.
Maximum coverage
and access
To achieve the greatest
possible coverage
by making services
accessible to the
maximum possible
proportion of children
in need.
Timeliness
To begin case-finding
and treatment before
additional medical
complications occur
and the prevalence
or complexity of SAM
escalates.
Sectoral integration
To be integrated with other
programmes especially prevention
interventions, including health
and nutrition education;
protection, promotion and
support of optimal breastfeeding;
complementary feeding and
hygiene and sanitation practices.
Capacity building
To build existing
structures through
collaboration,
training and ongoing
support rather than
establishing parallel
systems
Appropriate care
To provide simple,
effective outpatient care
for children who can be
treated at home while
identifying children
who need clinical care
(inpatient treatment).
Care for as long as needed
To ensure that children stay in
the programme or are linked with
existing services until they have
recovered or get timely referral,
as and when needed. By building
local capacity and integrating the
programme with existing health
and anganwadi service system,
CMAM also aims to ensure that
effective treatment remains
available for as long as malnutrition
is a public health concern in the
population.
Figure 6: Core operating principles of Community-Based Management of Acute Malnutrition Figure 7: Comprehensive integrated package of services under community-
based programme for children with severe wasting/growth faltering
Nutrient-dense
food/ Take home
ration (THR)
Interpersonal
counselling
Referral for medical
complication
Assessment of medical
complication
Monthly growth
monitoring & promotion
(GMP) and screening
Regular monitoring
for progress or
deterioration (weekly/
fortnightly)
Medicines, antibiotics,
deworming, iron &
folic acid (IFA) and
vitamin A 12Transforming Child Nutrition 13Transforming Child Nutrition
Thematic Areas for Community-Based
Management of Acute Malnutrition2
Thematic areas under Community-Based Management of Acute Malnutrition (CMAM) are
categorised as follows (Figure 8)
Figure 8: Key thematic areas under CMAM Programme
Key Components for
CMAM Programme
Community
Mobilization/
Awareness
Medical
Management
Nutritional
Management
Nutrition and
Health Education
Recording
and Reporting
Multisectoral
Engagement
Capacity Building
Monitoring
Appetite Test
Screening
Scalability,
Replicablity and
Sustainability 14Transforming Child Nutrition 15Transforming Child Nutrition
Methodology for Development of
the Compendium
3
To understand the programme implementation approaches adopted by states, NITI Aayog
reached out to state governments. A Google form was developed to capture different aspects of
CMAM programme implemented by states, such as capacity building, screening and identification,
community mobilization, nutritional care and management, medical management, nutrition
and health education and scaling of the programme (Figure 9). Information on challenges
faced, strategies to mitigate those challenges, and practices under each state’s respective CMAM
programme were also captured through the Google form. The form was shared with nodal
department of all the state governments within India, in December 2021. Information received
from different states of India on the practices of CMAM has been collated in this document. The
Google form used to capture the information is appended in Annexure 1.
Figure 9: CMAM programme implementation approaches
Capacity
Building
Scaling
of the
programme
Screening and
identification
Nutritional
care and
management
Nutrition
and health
education
Community
mobilization
Medical
management 16Transforming Child Nutrition 17Transforming Child Nutrition
Status of CMAM Implementation
in India4
As per the information received from the states, CMAM programme is operational in different
states by different names, varying with regards to its scale of implementation and salient features.
State-wide implementation of the CMAM programme has been reported by Assam, Bihar,
Chandigarh, Chhattisgarh, Gujarat, Haryana, Maharashtra, Jharkhand, Madhya Pradesh, Odisha,
Rajasthan, Telangana, Uttar Pradesh and Meghalaya. In other states, it has been implemented on
a smaller scale catering to few districts (Figure 10). Details of CMAM implementation in several
states of India is summarized in Table 1.
Figure 10: Status of implementation of CMAM programme across India
Andaman &
Nicobar Islands
Chandigarh
Jammu
and Kashmir
Ladakh
Haryana
Himachal
Pradesh
Uttarakhand
Punjab
Jharkhand
West
Bengal
Sikkim
Yanam
(Puducherry)
Karaikal
(Puducherry)
Mahe (Puducherry)
Kerala
Telangana
Karnataka
Lakshadweep
Rajasthan Uttar Pradesh
Delhi
Bihar
Andhra
Pradesh
Tamil
Nadu
Odisha
Goa
Mizoram
Tripura
Chhattisgarh
Madhya Pradesh
Arunachal
Pradesh
Nagaland
Meghalaya
Manipur
Assam
Maharashtra
Gujarat
Dadra,
Nagar Haveli,
Daman and Diu 18Transforming Child Nutrition
S.
No.
State State-wide
implementation
Scale of
implementation of
CMAM programme
Name of the district(s)Title of the CMAM
programme in the state
1Assam Yes State-wide All districts Community Based
Program for Children
with Severe Acute
Malnutrition (CP-SAM)
2Bihar No 6 districts Purnea, Araria, Begusarai,
Katihar, Sheikhpura,
Sitamarhi
Samvardhan:
Comprehensive
Health and Nutrition
Interventions for
Community Care of
SAM
3Chandigarh No 4 high risk areasBapu dham colony (East),
Hallomajra (West), Dhanas
(North), Maloya (South)
Chatur Dishai Poshan
on Wheels
4ChhattisgarhYes State-wide in
phased manner
17 districts in first phase:
Durg, Mohla-Manpur-
Ambagadh Chowki,
Mahasamund, Kanker,
Kondagaon, Bastar, Bijapur,
Dantewada, Narayanpur,
Korba, Bilaspur, Raigarh,
Surguja, Jashpur, Koriya,
Kawardha (Kabirdham),
Balrampur
Community Based
Management for
Children with Severe
Acute Malnutrition (CC-
SAM)
5Gujarat Yes State-wide All districts and 8
Corporations
Kuposhan Mukt
Gujarat Maha
Abhiyaan – Integrated
management of Severe
Acute Malnutrition
6Haryana Yes State-wide All districts Strategy for
Identification &
tracking of SAM & MAM
Children
7Jharkhand Yes State-wide in
phased manner
6 districts in first phase:
West Singhbhum, Godda,
Sahibganj, Simdega,
Chatra, Latehar
Known as:
»Johar Poshan in
West Singhbhum
district (launched on
31
st
March 2021)
»SAAMAR
programme
(launched on 29
th
December 2021
)
Table 1: Status of Implementation of CMAM Programme in India 19Transforming Child Nutrition
S.
No.
State State-wide
implementation
Scale of
implementation of
CMAM programme
Name of the district(s)Title of the CMAM
programme in the state
8Madhya
Pradesh
Yes State-wide All districts Mukhya Mantri Baal
Aarogya Samvarshan
Karyakram (IMAM
- Integrated
Management of Acute
Malnutrition)
9MaharashtraYes State-wide All districts Village Child
Development Center
(VCDCs)
10Odisha Yes State-wide All districts Community-Based
Management of Acute
Malnutrition (CMAM)
11Rajasthan Yes State-wide in
phased manner
Accelerated action in 20
priority districts: Udaipur,
Dungarpur,Chittorgarh,
Pratapgarh, Banswara,
Rajasmand, Jodhpur,
Jaisalmer, Jalore, Barmer,
Pali, Sirohi, Jaipur, Tonk,
Bundi, Baran, Karauli,
Dholpur, Alwar, Bharatpur
Acute Malnutrition
Management Action
(AMMA) Programme
12Telangana Yes State-wide All districts Supervised
Supplementary
Feeding Programme
(SSFP)
13Uttar PradeshYes State-wide All districts SAMBHAV
14Meghalaya Yes State wise All districts Collaborative Actions
to improve nutrition
status of SAM and MAM
children in Meghalaya 20Transforming Child Nutrition 21Transforming Child Nutrition
Thematic Areas on CMAM
across India5
5.1. Community mobilization for
strengthening CMAM
For a successful CMAM programme, coverage is key. It is important to reach each and every child
under five years of age. To ensure the best possible coverage, understanding of the community is
crucial, as people have diverse educational and economic backgrounds. Laying the groundwork
for CMAM requires a range of activities designed to help implementers interact with the
community, especially families of SAM and MAM children.
It is crucial that the community is aware of the signs of malnutrition, the preventive and curative
services available, and the process and the benefits of the services for children. Families of at-
risk children should be encouraged to seek and continue appropriate care. A range of activities
designed to help AWWs, ASHAs, ANMs and Anganwadi Services Supervisors interact with the
community and families help build a relationship with them and foster their participation in the
programme. The mobilisation process covers three activities: community sensitisation, follow-up
and on-going sensitisation (Figure 11).
Figure 11: Stages in community mobilization process
Community
sensitisation
Community
Follow up
On-going
sensitisation
based on feedback 22Transforming Child Nutrition
Some of the creative and innovative community mobilization processes followed across different states of
India are discussed in the section below:
5.1.1 Community mobilization through media and showcasing videos
(Jharkhand)
5.1.2 Mobilization through utilizing community platforms (Jharkhand,
Maharashtra, Meghalaya)
i. In Jharkhand, the Information and Public Relations Department (IPRD) is involved in
disseminating IEC messages.
i. In Jharkhand, platforms like the Village Health, Sanitation and Nutrition Day (VHSND) at the
Anganwadi Centre (AWC), Ratri Chaupals (community meetings held at night), Gram Sabhas,
and SHG meetings are being utilised by frontline workers to inform community members about
the CMAM programme. Let’s look at these closely:
ĥRatri Chaupal meetings are organized in the evening for community awareness on nutrition
issues including anaemia, dietary diversity and WASH practices, during which IEC materials,
videos and LED vans are used. District-level officers also participate in these awareness
meetings.
ĥAt the AWC level, cooking demonstrations are organized by AWWs in groups of 10-15
women, focusing on enhancing dietary diversity using locally-available ingredients.
ĥCommunity-related issues are discussed by 20–25-gram sangathan women in SHG meetings
held twice in a month. They use flip-books to share information about malnutrition with
the community members. Under the Poshan Abhiyaan, regular sensitization activities are
conducted. These include seminars and workshops undertaken during Poshan Pakwada
and Poshan Maah, during the months of March and September respectively, for community
mobilization.
ĥThe Johar Poshan Van, with an LED
screen, is leased by the district for
90 days @ Rs. 8000/day to showcase
videos and spread awareness about
malnutrition, breastfeeding and
anaemia in the weekly haat bazaar,
bus stand and public gathering
areas. The district has a structured
weekly route plan for LED vans to
ensure all the areas are covered.
The following films are being
displayed through the LED van:
Anemia Mukt Bharat (AMB) video,
Mother’s Absolute Affection (MAA)
video, breastfeeding and nutrition
videos, COVID precaution-related videos, Poshan Abhiyaan animation video and CMAM video,
Zindagi fir muskurayegi (Figure 12).
Figure 12: Use of LED Van in Jharkhand for
showcasing videos for spreading awareness 23Transforming Child Nutrition
The initiatives have led to increased awareness, ownership, and participation among community
members and greater utilization of available services and platforms by the family for children.
ii. In Maharashtra, frontline functionaries and officers of Department of Women and Child
Development (DWCD) and the Public Health Department (PHD) organize and participate in the following:
ĥCommunity-based events (CBEs), home visits and Growth Monitoring and Promotion (GMP) sessions.
ĥOther initiatives being undertaken in the state for community awareness include Mata Baithak (Mother’s meeting), Bal Kopra (designated food corner at AWCs or at home), promotion of Paras Bagh (nutri-gardens to improve dietary diversity), and the Muth Bhar Dhanya (contribution of a fistful of grain) campaign.
iii. Meghalaya took the collaborative approach of involving the Self-Help Groups (SHGs) and Village Organisations (VOs) of the National Rural Livelihood Mission (NRLM) for community mobilisation.
ĥSHG members were mainly involved in the mobilization of women with children below 6 years of age, whereby such women are advised to take their children to the Anganwadi Centres for physical check-ups.
ĥSome of the SHGs and VOs were also trained by the Social Welfare Department (Women and Child Development) on the identification of SAM and MAM children. They were able to identify SAM and MAM children with the support of the ASHA, AWW and ANM.
ĥBased on the recommendation, the SHGs also took responsibility of transferring cases to the PHCs or CHCs. Apart from this, SHGs were also involved in awareness programmes, rallies, and other programmes during the Poshan Maah celebrations.
Furthermore, during visits, community-based events and VHSNDs, the SHGs/VOs push malnutrition as a special agenda to be discussed during the meeting. The SHGs/VOs and AWWs were instrumental in mobilizing parents, especially mothers, to encourage weighing and monitoring their children’s health status on a regular basis.
ĥDissemination media used include radio, TV, miking (subtitled) and hoardings. Coordination with the representatives of district- and block-level public relations department is being done for larger-scale dissemination and awareness generation (Figure 13).
Figure 13: Ratri chaupal: Community awareness
through discussion on health and nutrition 24Transforming Child Nutrition
5.1.3 Community mobilization through participatory learning
approach, involvement of local bodies and use of IEC tools
(Madhya Pradesh)
i. In Madhya Pradesh, mobilization is strengthened by the convergence between concerned
departments at the village level through different initiatives:
ĥSanjhi Sehat: Participatory Learning and Action (PLA) to empower women’s groups to
improve feeding practices. The PLA approach encourages community to identify and
take ownership of their children’s health concerns. This is executed in a series of meetings
conducted by trained frontline workers who encourage community members to participate,
interact and learn by utilizing visual tools and interactive games.
ĥPoshan Sarkar: Participation and leadership of local bodies/gram panchayats and urban
bodies in the nutrition campaign innovations.
ĥPoshan Matka: Community members contribute nutritious, locally available grains/
vegetables/fruits for malnourished children in their community.
ĥPoshan Mitra: Local people/officers of different departments take responsibility for
improving the nutritional status of the children.
ii. Community-based Information Education Communications (IEC) tools like community growth
chart (wasting-based) are used effectively on village immunization days to create awareness
among community members. It was used to show the nutritional status of SAM/MAM children
to their mother/caretaker and to demonstrate in the individual and group counselling sessions.
iii. A convergent action plan for every village was prepared for the orientation of the members of
VHSNC, Joint Forest Management Committee (JFMCs), Sahyognin Matra Samiti (SMS) and other
local committees on the prevalence of malnutrition, its underlying and immediate causes, and
community responsibility and ownership to address it.
iv. Orientation of VHSNCs, Panchayati Raj Institution (PRI) and local committee members was also
done to build their capacity, thereby increasing their engagement in local nutrition governance.
The initiatives of convergence of different departments have led to greater mobilization, improved participation, and more empowerment among women’s groups to identify SAM and MAM children.
5.1.4 Community mobilization through innovative activities (Bihar)
The AWWs, ASHA and ANM organized community outreach meetings, supported by village leaders, Panchayati Raj Institution (PRI) members and other village resource persons to share information and experience with the village leaders and the community members about CMAM programme prior to its launch. The purpose of the meetings was community sensitization; to create understanding, to communicate importance of their participation and to own the programme. Subsequent meetings were held once a month on the occasion of VHSND or other contact points to reinforce the importance of CMAM. 25Transforming Child Nutrition
These initiatives in Bihar resulted in improved participation of community members in programme
activities like screening and nutrition-education sessions. This also improved the understanding of
community members about dietary diversity, age-appropriate feeding of children, care practices,
including micronutrient supplementation and hygiene, food safety and home augmentation of food
Under the Samvardhan programme in Bihar, social behavior change regarding nutritional practices
is at the core of all efforts. Nutritional treatment under Samvardhan programme is based on the
augmentation of the diet available at home as well as improving the understanding of caregivers
on the frequency, diversity and adequacy of the food to be given to children. Therefore, following
community mobilization activities are planned to provide information about a child’s diet and care
practices to improve community awareness:
ĥCommunity Meetings – On the day of annprashan, community meetings are organized
and male members from the families are also invited to attend the meeting- to enhance
their understanding on nutrition and care practices. These meetings are organized at AWC by
AWWs and ASHA to demonstrate the low-cost food recipes and to display food groups to the
caregivers and other community leaders of PRIs.
ĥFood basket game – A food basket game is organized at AWCs by AWWs, ASHA and Lady
Supervisors (LSs) under the leadership of resource persons from Dr. Rajendra Prasad Central
Agricultural University (DRPCAU), Pusa. AWWs and ASHA invite family members (both male
and female) of acutely malnourished children. During this game, there are two kinds of
baskets placed in front of caregivers, one with nutritious food items like leafy vegetables, eggs,
peanuts, seasonal fruits and sattu powder (protein-rich flour made from powdered chana or
other cereals and pulses) and the other basket with junk food items like chips, chocolates,
or puffs. Parents are then asked to choose the food basket for their children to assess their
nutritional knowledge. They choose the food items and are asked the reason behind the
selection. Choosing nutritious food items leads to positive reinforcement by the AWWs,
whereas the selection of junk food signifies the need for guidance. In this manner, this game
opens up a discussion about the nutritive value of food items given to children (Figure 14).
Figure 14: Glimpses from the food basket game played with the
caregivers of children with MAM/SAM to create awareness in Bihar
ĥPoshan Prahari Award– A Poshan Prahari is identified at the community level. They can be
a mother, field functionary, lady supervisor, PRI or JEEViKA didi. They are awarded for their
significant work done in the identification of nutritional status, improvement of the acutely
malnourished children, and community mobilization. 26Transforming Child Nutrition
5.1.5 Creation of ICDS mascot (Uttar Pradesh)
In the state of Uttar Pradesh, under the
SAMBHAV programme, the community
mobilization and awareness components
have been led by the AWWs, and in 2022,
the Integrated Child Development Scheme
(ICDS) mascot “Aanchal” was created for
taking forward the communication around
the wasting agenda.
The SAMBHAV campaign focuses on a
different determinant of wasting each
month – like maternal nutrition in July, infant
and young child feeding in August and
importance of care during first 1000 days –
from conception to two years of child’s life
(hand washing, kitchen gardens, diarrhoea
and care during illness) in September.
The ICDS mascot Aanchal has a) enabled the targeted population to better understand the programme, and b) increased awareness and transfer of relevant information about nutrition across the population. 27Transforming Child Nutrition
5.2. Screening and Identification
Regular and optimal screening at the community level is imperative for timely diagnosis and management
of malnutrition. If not identified timely, severe wasting in children may lead to an increased risk of morbidity
and mortality. Currently, in India, all children aged 0-59 months are being screened at regular intervals in
the community settings at AWCs by frontline health workers (AWWs, ASHA and ANMs). Children are usually
screened based on weight-for-height Z score and the presence of bilateral pitting oedema. The use of MUAC
for screening of children with SAM is not endorsed by the Ministry of Women and Child Development
(MoWCD). The use of MUAC as a rapid screening tool to detect wasting in children can be restricted to only
emergency situations, like the COVID-19 pandemic or natural disasters.
During Village Health, Sanitation, and Nutrition Day (VHSND) SAM and MAM children are checked for medical
complications and those with medical complications or poor appetite are referred to NRCs or Malnutrition
Treatment Centre (MTC). In contrast, children without medical complications are enrolled in the CMAM
programme. Screening efforts need to be strengthened to enhance coverage. In this section, we describe
the strategies adopted by different states for improved screening of children in communities under the
CMAM programme.
5.2.1 Multiple modes of screening (Gujarat)
i. In Gujarat, screening for children with SAM is undertaken in the following ways (Figure 15).
The comprehensive efforts for screening took the limelight, where all the field-level functionaries were engaged in the identification process. The strategy helped identify, refer and treat children with SAM in mission mode at the community as well as facility level.
Screening for
children with
SAM undertaken
Screening by Rashtriya Bal
Swasthya Karyakram (RBSK)
teams
Initial screening and identification of
children is done by the Rashtriya Bal
Swasthya Karyakram (RBSK) teams/
medical officers and ANM. ANM also
performs screening of the children
(U5) for identification of SAM based
on weight-for-height Z scores and
bilateral pitting oedema.
Passive screening in OPDs
Passive screening is done in all
Outpatient Department (OPD) facilities
at the Primary Health Center (PHC)/
Community Health Center (CHC)/ Sub-
Divisional/Sub-District Hospital (SDH)
and District Hospital (DH), including
the paediatric ward for identification of
cases.
Active screening in community
ASHAs and AWWs conduct active
screening each month, and prepare
a line list of children. ASHA and ANM
maintain the records of the identified
children. This line list is provided to ANM
for further screening and identification
of children with MAM and SAM. Through
this initiative, ANMs have to screen only
the children line listed by
ASHAs and AWWs during VHSND.
Screening in
campaign mode
Campaign mode (conducting a
screening drive across state at a notified
time) is also a part of the CMAM strategy
in Gujarat, through which all the children
under five years are screened for SAM.
Figure 15: Screening for children with SAM 28Transforming Child Nutrition
5.2.2 Joint screening drive by Department of Women and Child
Development and the Public Health Department (Maharashtra)
5.2.3 Fixed screening days (Madhya Pradesh, Haryana)
i. In Maharashtra, routine growth monitoring has been strengthened for screening of children
and the nutritional status of children is tracked as per standard charts, using formula-based Excel
sheets or the Poshan Tracker. If a child is categorized as SAM by AWWs, he/she is reassessed by
health functionaries (Medical Officer or ANM).
Joint screening drive is also undertaken in the state to intensify screening for SAM during the
monsoon season, between 15 June to 30 August. The DoWCD and PHD work in close coordination
at all levels to ensure an effective screening drive. The newly-identified children are admitted to
Village Child Development Centre (VCDCs) or Nutrition Rehabilitation Centers (NRCs) followed
by efforts for improving their nutritional status. This initiative has scaled up the identification
of children with SAM by more than two-fold. Considering the effectiveness of the convergence
between DWCD and PHD, the joint screening drive has been promoted in the upcoming period,
and it has been supplemented with the execution of treatment protocol and tracking, using end-
to-end SAM management software.
In Madhya Pradesh, the weight and length/height of all children are measured between day 11 to
20 of every month under regular growth monitoring service through the ICDS. Name-wise details
of children with MAM and SAM are recorded in the registers and in a dedicated android application
(called Sampark IMAM Module. Following efforts are made to strengthen the identification of SAM
children in Madhya Pradesh (Figure 16).
In Haryana, children are screened for MAM and SAM using weight and height measurements by
AWWs and ASHAs on VHSND and every saturday of the week. The compiled reports of SAM/MAM
children are shared with Rashtriya Bal Swasthya Karyakram (RBSK) team by lady supervisor of ICDS.
Children with SAM having complications are admitted to NRCs/District Early Identification Centres
(DEIC) at district hospitals/private hospitals.
This initiative led to the identification of 8000 SAM children in June and 19000 August 2021.
These efforts led to name-wise tracking and identification of children with SAM under IMAM programme. Despite COVID-19, about 1 lakh children with SAM and more than 4 lakh children with MAM were identified and treated under IMAM (during 2020-21).
Use of community
growth chart (wasting)
and demonstrating
nutritional status of
SAM/MAM children to
their mothers.
Involving the
community in
vazan melas
Provision of
simplified WHO
Z score wasting
table in the
Hindi language
Repeated
training of
FLWs on the
identification
of SAM
Figure 16: Steps to strengthen the identification of SAM children 29Transforming Child Nutrition
5.2.4 Bimonthly screening on Village Health, Sanitation & Nutrition
Days (VHSND) (Telangana)
5.2.5 Intensive screening by special team (Chandigarh)
In Telangana, two Village Health,
Sanitation & Nutrition Days (VHSND) are
organized every month at AWCs.
The first VHSND is dedicated to growth
monitoring, organized collectively by
ASHA and AWW, during which height,
weight and MUAC measurements of all
children aged 0-59 months are obtained.
Due to COVID-19 lockdown in March 2020,
the routine growth monitoring under
ICDS had halted and the identification of
children with wasting at village-level got
disrupted.
MUAC tapes were introduced as a
screening tool across the state keeping the
minimal risk of corona virus transmission.
Children below 6 months who are identified as SAM are referred to NRC by the Anganwadi
worker through ANMs and children aged 7-59 months undergo Appetite Test at AWC on the day
of screening (Figure 17).
The second VHSND is organized as per National Health Mission (NHM) micro-plan by ANM for
ante-natal care and immunization activities.
An innovative pilot project was launched on 20 September 2021, for providing care to malnourished
children including the following:
ĥOutreach camps were conducted on Wednesdays on a weekly basis, as a multi-convergence
approach wherein peripheral doctors and field functionaries of the Health Department and
Social Welfare Department as well as a team of doctors (paediatrics and dieticians) from
Dietetics Department, Government Multispeciality Hospital (GMSH) sector-16 Chandigarh,
are present. Children are screened for severity of malnutrition, and those who require
inpatient care are proposed to be admitted to NRC at Department of Paediatrics, GMSH-16
Chandigarh. Dietary counselling was given to the mothers and caregivers on-the-spot by
dieticians. Each child was measured and provided care at their doorstep. Take-away food
(ration) was provided to beneficiaries by functionaries of the Social Welfare Department and
their intake and compliance was monitored by field workers.
As a result of this special multi-convergence approach to treatment, there has been upswing in
detection by intensive screening and convenient domiciliary treatment of SAM/MAM children.
Figure 17: Screening and identification of children
with SAM in Jharkhand 30Transforming Child Nutrition
5.2.6 Formation of core village health team for identification of
MAM/SAM children (Meghalaya)
The ASHA, AWW and ANM, SHGs/VOs and the ICDS Supervisor form the core village health team.
They work together for the identification and management of SAM children. 480 VOs were trained
by the Social Welfare Department on identification of SAM & MAM children. These SHGs & VOs
play a vital role in mobilizing women to bring their children for screening. The core team members
coordinate effectively, keeping each other informed about their activities and the local health
status and assist each other with various tasks, such as organizing village health sanitation days
and encouraging visits to the Anganwadi centres and sub-centres for regular monitoring of a child’s
health status.
During September 2020, 358,056 (85%) children between 0 to 5 years were weighed. As a result of
this exercise, the number of SAM and MAM children identified in September 2020 was 1,788 and 16,327 respectively.
Such concerted efforts resulted in the identification of 1.2 lakh and 91,000 SAM cases in June and September 2021 rounds respectively under SAMBHAV campaign.
5.2.7 SAMBHAV-Three month long intensive campaign (Uttar Pradesh)
In Uttar Pradesh, “Vazan Divas” is organized on the first tuesday of every month, dedicated to
growth monitoring and identification of children with undernutrition inclusive of SAM/MAM. Keeping in mind the Government of India priority on wasting, the Department of ICDS, Uttar Pradesh introduced a novel initiative by the name of “SAMBHAV”, which is a three-month-long
intensive campaign (July-September) focusing on the identification, health check-up, referral and community-based care of SAM/MAM children. The implementation phase is preceded by a weighing/screening campaign in the month of June.
ĥIn 2021, the Department of ICDS successfully managed to provide essential anthropometry equipment for identifying SAM/MAM cases. Screening of all eligible under-five children present in the community for SAM/MAM was done using weight for height/length criteria and through the Poshan Tracker. In 2021, two special screening drives were conducted: one in June and another in September during Poshan Maah.
To strengthen the screening process, rigorous capacity building of field supervisory staff on the correct use of Anthropometric Devices was undertaken through local videos demonstrating the use of Growth Monitoring Devices (GMDs) and reference charts as ready reckoners for identification of wasting grade. AWWs were trained to use the Poshan Tracker application as a tool for reporting the SAM/MAM cases, for an external assessment of the quality of growth monitoring session, and to feed the learnings into the departmental reviews.
Overall, the states have adopted innovative practices with respect to the screening and identification
of children with SAM at the community level. There has been involvement from both Health and
WCD/ICDS departments for screening of children and identification of SAM. Additionally, in a few
states, RBSK team has also been involved in improving the quality of screening. These provide
compelling case studies and playbooks which can be adopted by other states as well.
5.2.7 Sambhav-Three month long intensive campaign (Uttar Pradesh) 31Transforming Child Nutrition
5.3. Appetite Test
Usually, SAM children with medical complications or infection have a loss of appetite due to physiological
changes. Appetite test helps in identifying children with SAM with underlying medical complications.
Appetite test is carried out to decide the future course of treatment. Child is offered recipes made from Take-
Home Ration (THR)/locally-available food items like Khichdi/any hot cooked meal or milk for the appetite
test. If the child is able to eat/drink the offered food with eagerness, the child is considered to have passed
the appetite test. On passing the appetite test, the child is enrolled in the community-based programme,
otherwise, referred to NRC for further treatment. 32Transforming Child Nutrition
Different states have adopted slightly different method of testing, as mentioned in Table 2.
State Who
conducts
it?
Where? What
food
used?Steps followed Amount
offered
Deciding
criteria
for
passing
the test
Bihar
AWW At CMAM clinic
during VHSND
Locally-
prepared
energy-
dense food
or locally
available
food items
like khichdi/
any hot
cooked meal
or milk.
1. The test is to be
conducted in a
separate quiet area.
2. Explain to the mother/
caregiver the purpose
of the appetite test and
how it is carried out.
3. Ask the mother/
caregiver to wash her/
his hands.
4. The mother/
caregiver needs to sit
comfortably with the
child in her/his lap.
5. The child should not
have taken any food for
last two hours.
6. The test usually takes a
short time but may last
up to one hour.
7. Offer small amount
of locally prepared
energy-dense food or
food items like khichdi/
any hot cooked meal
or milk to the child,
encouraging the child
all the time.
8. If the child refuses, then
the mother/caregiver
should continue to
quietly encourage the
child.
9. The child must not be
forced to eat during
the test.
10. The child should have
free access to safe
drinking water while
he/she is eating the
offered food.
Not
specified
If the child
is able to
eat/drink
the offered
food with
eagerness
Table 2: Method adopted for conducting appetite test by the states 33Transforming Child Nutrition
State Who
conducts
it?
Where? What
food
used?Steps followed Amount
offered
Deciding
criteria
for
passing
the test
Chhattisgarh
AWW At CMAM clinic
during VHSND
EDF (Energy-
Dense Food)
prepared
with THR
or locally
available
food items
like Khichdi/
any hot
cooked meal
or milk.
1. The test should
be conducted in a
separate quiet area.
2. Explain to the mother/
caregiver the purpose
of the appetite test
and how it will be
carried out.
3. Ask mother/caregiver
to wash her/his hands.
4. The mother/caregiver
should sit comfortably
with the child on her/
his lap.
5. The child should not
have taken any food for
last two hours.
6. The test usually takes
a short time but may
take up to one hour.
7. Offer a small amount of
energy-dense food or
locally available food
items like Khichdi/
any hot cooked meal
or milk to the child,
encouraging the child
all the time.
8. If the child refuses,
then the mother/
caregiver should
continue to quietly
encourage the child.
9. The child must not be
forced to take the EDF
(Energy Dense Food)
or any other diets
being used for the test.
10. The child should have
free access to safe
drinking water while
he/she is taking
the EDF.
Not
specified
If the child
is able to
eat/drink
the offered
food with
eagerness 34Transforming Child Nutrition
State Who
conducts
it?
Where? What
food
used?Steps followed Amount
offered
Deciding
criteria
for
passing
the test
Jharkhand
AWW During VHSNDTHR/Hot
cooked meal
e.g., halwa
1. The child should not
have eaten any food for
last two hours.
2. The test should
be conducted in a
separate quiet area.
3. Explain to the mother/
caregiver the purpose
of the appetite test and
how it will be carried
out.
4. Ask mother/caregiver
to wash her/his hands.
5. The mother/caregiver
should sit comfortably
with the child in her/
his lap.
6. The test usually takes
a short time but may
take up to one hour.
7. The child should be
offered a small amount
of food prepared with
THR, with constant
encouragement.
8. If the child refuses,
then the mother/
caregiver should
continue to quietly
encourage the child.
9. The child must not be
forced to take the food
being used for the
appetite test.
10. The child should have
free access to safe
drinking water while
he/she is taking the
food for appetite test.
Not
specified
If the child
eats the
offered
food with
eagerness. 35Transforming Child Nutrition
State Who
conducts
it?
Where? What
food
used?Steps followed Amount
offered
Deciding
criteria
for
passing
the test
Madhya
Pradesh
AWW At CSAM clinic
during
VHSND
Available
THR such
as halwa,
balahaar and
khichdi
1. The child should not
have taken any food for
last two hours.
2. The test should
be conducted in a
separate quiet area.
3. Explain to the mother/
caregiver the purpose
of the appetite test
and how it will be
carried out.
4. Ask mother/caregiver
to wash her/his hands.
5. The mother/caregiver
should sit comfortably
with the child on her/
his lap.
6. The test usually takes
a short time but may
take up to one hour.
Also, should offered
small amount of food
prepared with THR to
the child, encouraging
the child all the time
during the appetite
test.
7. If the child refuses,
then the mother/
caregiver should
continue to quietly
encourage the child.
8. The child must not be
forced to take the food
being used for the
appetite test.
9. The child should have
free access to safe
drinking water while
he/she is taking the
food for appetite test.
Not
specified
If the child
is able to
eat the
offered
food with
eagerness. 36Transforming Child Nutrition
State Who
conducts
it?
Where? What
food
used?Steps followed Amount
offered
Deciding
criteria
for
passing
the test
Odisha
AWW At CMAM clinic
during VHSND
Food
prepared
with
Augmented
THR/locally
available
food items
like khichdi/
any hot
cooked meal
or milk.
1. The test should
be conducted in a
separate quiet area.
2. Explain to the mother/
caregiver the purpose
of the appetite test and
how it will be carried
out.
3. Ask mother/caregiver
to wash her/his hands.
4. The mother/caregiver
should sit comfortably
with the child on her/
his lap.
5. The child should not
have taken any food
for last two hours, else
wait for some time.
6. The test usually takes
a short time but may
take up to one hour.
7. Offer a small amount
of food prepared with
augmented THR or
locally available food
items like Khichdi/
any hot cooked meal
or milk to the child,
encouraging the child
all the time during the
appetite test.
8. If the child refuses,
then the mother/
caregiver should
continue to quietly
encourage the child.
9. The child must not be
forced to take the food
being used for the
appetite test.
10. The child should have
free access to safe
drinking water while
he/she is taking the
food for appetite test.
Age band
7-18
months:
at least
15 grams
19-36
months:
at least
30 grams
37-59
months:
at least
50 grams
If the child
is able to
eat/drink
the offered
food with
eagerness 37Transforming Child Nutrition
State Who
conducts
it?
Where? What
food
used?Steps followed Amount
offered
Deciding
criteria
for
passing
the test
Telangana
Anganwadi
Teacher
(AWT)
At Supervised
Supplementary
Feeding
Program (SSFP)
session during
VHSND
Balamrutham
plus
1. The test should
be conducted in a
separate quiet area.
2. Explain to the mother/
caregiver the purpose
of the appetite test
and how it will be
carried out.
3. Ask mother/caregiver
to wash her/his hands.
4. The mother/caregiver
should sit comfortably
with the child on her/
his lap.
5. The child should not
have taken any food for
last two hours.
6. The test usually takes
a short time but may
take up to one hour.
7. Offer a small amount
of balamrutham plus
to the child based on
the age of the child,
encouraging the child
all the time.
8. If the child refuses,
then the mother/
caregiver should
continue to quietly
encourage the child.
9. The child must not
be forced to take the
balamrutham plus.
10. The child should have
free access to safe/
portable drinking
water while he/she
is taking the food for
appetite test.
Children
(7-18
months):
at least
15 grams
Children
(19-36
months):
30 grams
Children
(37-59
months):
50 grams
The child
should eat
the offered
amount
based on
the age
within one
hour. 38Transforming Child Nutrition
5.4. Medical Management
Few children with SAM may have medical
complications which may or may not be
apparent. If not diagnosed and managed
timely, they may lead to increased risk of
mortality. Timely medical assessment and
management is, therefore, crucial.
Usually, under CMAM programme, medical
assessment of the identified cases is done
by ANM. Children having any medical
complication or any danger signs are referred to
NRC/MTC/health facility for further treatment.
Those without any medical complications
are managed at the level of community by
frontline workers (Figure 18).
In Assam, Bihar, Chhattisgarh, Gujarat, Jharkhand, Madhya Pradesh, Rajasthan and Odisha, children identified
as SAM are examined for the presence of medical complications by ANM at “CMAM Clinic” on VHSND. ANM
assesses the child for any danger/emergency signs and refers the child to NRC if any of the signs are present.
If child doesn’t require immediate referral, ANM undertakes further medical examination. The medical
examination includes assessment of oedema, appetite, vomiting, temperature, respiratory rate, anaemia,
superficial infections, alertness, and hydration status. ANM observes and asks the mother/caregiver about
complaints like cough, fever, diarrhoea, lethargy, convulsions, skin infections, or eye complaints.
Figure 18: Medical assessment of a child with SAM
being done in Jharkhand 39Transforming Child Nutrition
If a child with SAM shows no medical complications, he/she is treated as per the protocol at the community
level, and medicines are provided as per the IMNCI protocol. Through other national programmes and
schemes, children are provided with vitamin-A syrup, multivitamin syrup, and iron syrup, if required.
Complete medicine package given under CMAM programme in states is summarized in Table 3.
Medicine
Bihar
Chhattisgarh
Jharkhand
Assam
Gujarat
Maharashtra
Madhya
Pradesh
Odisha
Rajasthan
Telangana
Uttar Pradesh
Amoxycillin
Albendazole
Folic acid
Iron Folic acid syrup
Multivitamin syrup
Vitamin A
Zinc
Paracetamol*
ORS*
Table 3: Medicines given CMAM programme across different states of India
Table 4: Details of dosage of medicines
DrugWhenWeight or age of the childDose
Amoxycillin Syrup
(125 mg / 5 ml)
First dose on
enrollment (to be
prescribed by ANM)
and then for home (two
times daily for five days)
3 – 4.9 kg2.5 ml twice a day
5 – 6.9 kg5 ml twice a day
7 – 9.9 kg7.5 ml twice a day
10 – 12.9 kg10 ml twice a day
13 – 15.9 kg12.5 ml twice a day
16 – 18.9 kg15 ml twice a day
Details of dosage of medicines are explained in detail in Table 4 below. 40Transforming Child Nutrition
DrugWhenWeight or age of the childDose
Albendazole (400
mg / 10 ml)
Once on enrollmentLess than 1 year Not to be given
1-2 years5 ml / 200 mg once
2-5 years10 ml / 400 mg once
Iron Folic Acid
(1 ml of Iron and
Folic Acid Syrup
containing 20 mg
elemental iron and
100 mcg Folic Acid)
Biweekly 6 months to 5 years 1 ml Iron and Folic
Acid syrup
Vitamin A (100000
IU/ 1 ml)
One dose on admission
if not given during last
1 month
6-12 months100000 IU/ 1 ml
Above 12 months200000 IU/ 1 ml
Multivitamin syrupDaily for 90 days 6 months to 5 years 5 ml
*Paracetamol and ORS are not routinely given. Paracetamol and ORS will be given as per the complications
of fever and diarrhoea if required. They are to be used only if needed as per standard dosage prescribed
under IMNCI. ORS dose: 5 ml/kg body weight in every 30 minutes for the first 2 hours. 41Transforming Child Nutrition
5.5. Nutritional Management
Nutritional management is a critical component for SAM and MAM children for improved recovery at the
community level. These children have additional nutritional needs in terms of calories and proteins to regain
the loss. For successful rehabilitation, food provided should achieve intakes (compliance for consumption)
that will promote catch-up growth and improve immune function.
Different states in India have adopted different food options to be given to SAM and MAM children aged 6-59
months without medical complications under their CMAM programme. Largely, the food given to children
with SAM includes THR, dry ration or ready-to-eat supplement packets, which are distributed by frontline
workers in AWCs in specific amounts at regular intervals.
Nutrition protocols followed under CMAM programme for the nutritional management of children is
discussed in this section.
5.5.1 Under Samvardhan Programme- Amylase-rich food and
standardized energy-dense recipes (Bihar)
5.5.2 Age-specific energy-dense Take Home Ration (Chhattisgarh)
In Bihar, under the Samvardhan Programme, dry ration (rice, dal and soyabean) is provided under
the SNP of ICDS to children younger than 6 years. Mothers of children with SAM are counselled to
prepare amylase-rich food by soaking, germination, roasting and grinding of wheat and whole
green gram and to be used for making products called as balahar, sattu laddu and paushtik laddu.
These are the products demonstrated by AWW to mothers at AWCs during SAM sessions (organized
15 days after SAM Clinic).
Additionally, sesame seeds/peanuts and jaggery are also provided to children. Roasted flax seed
powder, which can be added to khichdi, rice or dal or sprinkled on the roti, is promoted as a protein
supplement. Dr. Rajendra Prasad Central Agricultural University (DRPCAU), Pusa have standardized
some energy-dense recipes for demonstration including semolina kheer and halwa, vegetable
khichdi, vegetable parantha, spinach parantha, besan cheela, meetha cheela, rice kheer, pua, thekua,
sweet and namkeen daliya, and upma. During the home visits done by AWW, there is focus on finding
out the dietary practices of children and consumption of any home-made energy-dense nutritious
product, promotion of optimum dietary practices and counselling on appropriate feeding practices.
In Chhattisgarh, all children are given state-prescribed energy-dense THR as per the child’s age at
AWCs during VHSND.
A packet of THR weighing 1200g is given every week to all children (~170g/day), while children with
SAM enrolled in CC-SAM aged 6 months-3 years are given 200g of THR per day and children aged 3
to 5 years are given 75g THR per day along with hot cooked meal of 430 calories and 11g of protein.
100g of energy-dense THR comprises of wheat (30g), soyabean (10g), bengal gram (20g), sugar
(27g), soyabean oil fortified (5g), peanuts (5g), ragi (3g), providing 12.7g protein and 410 calories. 42Transforming Child Nutrition
5.5.3 Provision of Ready to Eat (RTE) food supplement and Third meal
along with regular THR (Madhya Pradesh)
In Madhya Pradesh, there is provision of regular THR (khichdi premix), Ready-to-Eat (RTE) food
supplements and Third meal (which is enriched with locally available nutritious grains, vegetables,
and ghee/oil).
ĥRTE food supplement packets are given to children with SAM aged 6-36 months include
halwa premix (made from wheat, soya, sugar, sorghum, green gram, finger millet and edible
oil; @ 125 g/beneficiary, i.e. 625 g for a week), baal aahar premix (made from wheat, soya,
edible oil, finger millet, rice, bengal gram flour and sugar; @ 125 g/beneficiary i.e. 625 g for a
week) and Khichdi Premix (made from rice, soya, green gram, pearl millet, edible oil & spices
@125 g /beneficiary i.e. 625 g for a week).
ĥThird meal includes premixes like dalia mix (made from wheat, moong daal, jaggery), paushtik
sattu (made from wheat flour, jau, groundnuts, soya, chana dal, rice, sugar and khadya daal)
and gudh patti/chikki (made from roasted gram, peanuts and jaggery). Nutritious eatables
such as grains and fruits collected in poshan matka are also distributed. Community and
poshan mitra also provide protein-rich foods.
5.5.4 Augmented THR (Odisha)
5.5.5 Balamrutham Plus formulated by ICMR-NIN (Telangana)
In the state of Odisha, each child with SAM is provided with 100 – 250 gm per day of augmented
THR as per body weight, once every fortnight and seven eggs every week (1 per day) by the
AWW. Ingredients used in the preparation of the augmented THR (per 100g) include wheat (30g),
groundnut (10g), bengal gram (10g), sugar (15g), vegetable oil (15g), milk powder (20g). 100g of THR
provides 462.0 calories, 16.0g protein and 20.1g fat. The augmented ICDS THR is ready to consume.
For young children, 100g of THR powder can be mixed with 60ml of lukewarm water or milk to
make semi-solid consistency porridge. Routine recommended for consumption of augmented THR,
egg and home cooked food is as follows: morning 8 AM augmented THR (1/2 of recommended
amount), 10 am boiled egg, 12 PM freshly prepared home food/food at AWC, afternoon 2 PM
augmented THR, evening 4 PM homemade snacks / fruits, 6 PM augmented THR and night 8 PM
freshly prepared home food. Follow-ups are conducted on a weekly basis through home visits by
AWWs to assess their feeding and growth status.
In Telangana, under the Supervised Supplementary Feeding Programme (SSFP), children with SAM
and MAM are given balamrutham plus 4 times per day along with home available foods, under
the supervised supplementary feeding programme. The standard consumption for children with
severe acute malnutrition is 125 kcal/kg body weight. 43Transforming Child Nutrition
Findings from the sensory evaluation study
revealed that balamrutham plus had better
acceptability in terms of appearance, colour,
texture, flavor, taste, and palatability. Shelf-life
study of the product also showed absence of
harmful microorganisms, with total bacterial
count within the reference range (Table 5).
Balamrutham plus is formulated by ICMR-NIN specifically for children with SAM and MAM, using
wheat, groundnut, bengal gram, skim milk powder, sugar, oil and rice flakes with an energy
content of 703 kcal/150g and 15.6g of protein. It is fortified with vitamin B-1, B-2, B-12, calcium,
vitamin-A, folic acid, iron, niacin and zinc.
Anganwadi teachers calculate the number of packets a child needs per month according to
the current weight of the child. She also instructs the caregivers about the number of spoons,
consistency, and frequency of feed. During the first week of admission in the SSFP programme,
the Anganwadi teacher asks the caretaker/mother to feed the child at AWC during daytime so
that they can observe how the mother is feeding and provide guidance to them.
Balamrutham plus was developed looking at the increased prevalence of SAM in the state
from 5% in NFHS-4 to 8.5% in NFHS-5. Balamrutham plus was developed using the following
parameters:
ĥThe average body weight of SAM and MAM children based on NFHS-4 database
ĥCalculation of energy and protein requirements based on the body weight
ĥDeriving gaps in the intakes of protein and energy from National Nutrition Monitoring
Bureau (NNMB) 2012 data
ĥModifying the existing THR of balamrutham to balamrutham plus to address the gaps in
energy and protein requirements
ĥConducting shelf-life analysis, acceptability and sensory evaluation of consumption of
required portion of balamrutham plus (Figure 19).
Balamrutham plus is given to
SAM children at a frequency
of 4 times per day along
with home available foods.
The standard consumption
for children with severe acute
malnutrition is 125 kcal/kg
body weight.
Balamrutham plus is given
to MAM children at a
frequency of 2 times
per day along with home
available foods. The
standard consumption
for children with moderate
acute malnutrition is 75
kcal/kg body weight.
Children without MAM
and SAM are given
routine balamrutham
under the ICDS
programme.
Figure 19: Door-step supply of balamrutham plus
during COVID-19 44Transforming Child Nutrition
State Nutritional Supplement Quantity / dose
Bihar Amylase rich food, dry ration (rice, dal and
soyabean) + balaahar, sattu laddu and
paushtik laddu
Existing quantity of dry ration /
THR along with counselling for
enhancement / recipes
Chhattisgarh Energy dense THR: 100g of THR comprise-
wheat (30g), soyabean (10g), bengal gram
(20g), sugar (27g), soyabean oil fortified
(5g), peanuts (5g) and ragi (3g)
Additional THR: 200 gram per
day for 6-to-36-month child and
75 gram per day (along with hot
cooked meal) for 3-to-6-year child
Madhya Pradesh Provision of regular THR, RTE and a third
meal (enriched with locally available
nutritious grains, vegetables, and ghee/
oil). For children aged 6-36 months: RTE
food supplement packets of halwa premix,
baal aahar premix and khichdi premix
are given. Third meal includes dalia mix,
paushtik sattu and gudh patti/chikki.
Additional THR as per the body
weight
Telangana THR-balamrutham plus (wheat,
groundnut, bengal gram, skim milk
powder, sugar, oil rice flakes with energy
content of 703 kcal/150 grams and 15.6
grams of protein)
For SAM: 30 to 90g (as per weight
of the child) 4 times a day
For MAM: 30 to 75g (as per weight
of the child) 2 times a day
Odisha Augmented THR and egg. 100g packet
include- wheat (30g), groundnut (10g),
bengal gram (10g), sugar (15g), vegetable
oil (15g) and milk powder (20g)
THR as per the body weight (100
to 250gper day) and one egg daily
(including Saturday and Sunday).
Table 5: Nutritional supplement provided to children with SAM in different states of India under
CMAM programme. 45Transforming Child Nutrition
5.6. Follow-up
Under the CMAM programme, regular follow-ups are done for children with SAM/MAM by frontline workers.
Follow-ups take place while the children with SAM/MAM are still in the programme, and even after they are
discharged from the programme, to monitor their progress, prevent relapse and take timely action. Follow-up
visits are used to monitor the child’s weight gain, ensure intake of food supplements and medicines, assess
development of medical complications, ensure timely referral (if needed) and conduct counselling sessions
with the caregivers of children on important aspects of nutritional management. The protocol of follow-up
under CMAM varies slightly across different states. Some of the practices are summarized in Table 8.
In addition to the practices of the states mentioned in Table 8, in Chandigarh, monitoring is done by a team
of doctors every Wednesday. Weekly weight record is maintained and the children are also monitored by field
workers under the supervision of their supervisors/senior officials.
In Haryana, timeline has been given to the AWWs for regular follow-ups. They also fill the details of children in
Poshan monitoring card.
5.6.1 Regular follow-up of children on a monthly basis for two years
after discharge (Gujarat)
ĥFollow-up in CMAM programme is done on a weekly basis during the programme to monitor the
progress of enrolled children. Common monitoring indicators measured in CMAM programme
are weight, bilateral pitting oedema, feeding pattern, weekly counselling, weight-for-height
SD score and monthly check-up for any medical complications/oedema.
ĥIf any child has lost weight or develops any medical complication during weekly follow-up,
further medical assessment of the SAM child is done for medical complications. These children
are then referred to facility NRC for further management.
ĥIndicators like cured, not cured, defaulter, death and medical transfer are measured as output
indicators after 8 weeks of treatment in CMAM programme. SAM Children are discharged on
the same criteria as they are admitted/enrolled in CMAM programme (Figure 20).
Figure 20: Regular follow-up of children on a monthly basis after discharge
After maximum
duration of treatment
(8 weeks) children with
SAM are discharged if
WHZ score >-2SD (If admitted by WHZ <- 3SD)
1
2
3
Child is clinically well
No oedema for last two weeks 46Transforming Child Nutrition
5.6.3 Weekly follow-up for 12 weeks (Madhya Pradesh)
5.6.4 Weekly home visits by AWW to Follow up SAM Children
(Uttar Pradesh)
Weekly follow-up is done in Madhya Pradesh for up to 12 weeks during the programme to monitor
the progress of enrolled children. Common monitoring indicators measured in CMAM programme
include anthropometric measurements, compliance to nutritional supplements, medicines and
health counseling. After being discharged from the programme, monthly follow-ups are done
during VHSND for three months.
In Uttar Pradesh, when the child is enrolled in the programme, weekly home visit is done by AWW
for demonstration of food, assessing progress, interpersonal counselling, and dietary assessment
of SAM children.
Fortnightly visits for monitoring the progress of enrolled children are conducted for up to 12
weeks. After getting discharged, monthly follow-up visits by AWW take place for 3 months, wherein
monthly VHSND/sub-centre-based follow-up by ANM is done to assess the overall progress and
medical condition (Table 6).
5.6.2 Follow-up for 16 weeks for SAM and 8 weeks for MAM
(Telangana)
Child-wise progress is monitored regularly by Anganwadi workers at AWC and recorded in SSFP
mobile application along with SAM/MAM card until the beneficiaries are discharged from the
programme.
ĥFor SAM children, routine visit to AWC is done weekly in the first month and then fortnightly,
while for MAM children it is fortnightly.
ĥThe maximum duration of stay in SSFP is 16 weeks for SAM and 8 weeks for MAM child.
ĥPost-discharge follow-up is scheduled for children who reach above -2 SD (WHZ).
The children can be enrolled in the Supplementary Nutrition Programme of ICDS (i.e THR
balamrutham plus for children aged <24 months and Hot Cooked Meal at AWC for >24 months) and
their growth can be monitored every month during the first 6 months after discharge.
ĥIf SAM child does not recover from the CMAM programme after 8 weeks, the child is discharged
and classified as non-responder and is further referred to a higher health facility for detailed
investigations.
After 8 weeks of CMAM programme, children are regularly followed up on a monthly basis for two
years after discharge from the programme. Children discharged from the CMAM programme are
enrolled in the Supplementary Nutrition Programme (SNP) of the ICDS and their growth monitoring
is done on a monthly basis during VHSND. 47Transforming Child Nutrition
Table 6: Protocol of follow-up under CMAM programme across different states of India
State While the child is in
CMAM
After discharge from
CMAM
Activities undertaken
during follow-up visits
Duration of
follow-up
Frequency of
follow-up
Duration of
follow-up
Frequency
of follow-up
Gujarat 8 weeks Weekly
monitoring
of weight,
bilateral pitting
oedema,
feeding
pattern and
counseling.
Monthly
monitoring
of weight for
height SD
score and
checking for
any medical
complications/
oedema.
2 years Monthly 1. If a child has lost weight
or develops any medical
complication during weekly
follow-up, further medical
assessment of the SAM
child for danger signs,
medical complications is
done. These children are
then referred at facility
NRC/CMTC for further
management.
2. Children discharged from
the CMAM programme
are enrolled in the
Supplementary Nutrition
Programme (SNP) of the
ICDS and their growth
monitoring is done on
a monthly basis during
VHSND.
Telangana 16 weeks
for SAM
&
8 weeks for
MAM
Weekly
follow-up
at AWC by
Anganwadi
teacher for
SAM children
in the first
month
and then
fortnightly
visits.
Fortnightly
visits for
children.
First
6months
after
discharge
Monthly 1. Distribution of food
supplements
2. Growth monitoring
3. Recording in SSFP mobile
application along with
SAM/MAM card.
4. Health and nutrition
education
5. Evaluation of balamrutham
plus consumption each
week 48Transforming Child Nutrition
State While the child is in
CMAM
After discharge from
CMAM
Activities undertaken
during follow-up visits
Duration of
follow-up
Frequency of
follow-up
Duration of
follow-up
Frequency
of follow-up
Madhya
Pradesh
12 weeksWeekly 3 monthsMonthly
follow-ups
during
VHSND
1. Anthropometric
measurements
2. Assessing compliance to
nutritional supplements,
and medicines
3. Nutrition and health
counseling
Uttar
Pradesh
12 weeksWeekly
home visits
by AWW for
demonstration
of food to
be given to
children
&
Fortnightly
visits for
monitoring
the progress
of enrolled
children
3 monthsMonthly by
AWW
Two levels of follow up are
proposed as part of SAMBHAV
strategy:
1. Weekly follow-up as home
visits by AWWs – focused
on assessing progress,
dietary assessment, and
interpersonal counselling.
2. Monthly VHSND/sub-
centre-based follow-up by
ANM – to assess the overall
progress and medical
condition.
Bihar 16 weeksFortnightly6 monthsMonthly by
AWW
Weighing at AWC, assessment
for bilateral pitting oedema
and other illness, feeding
demonstration and individual
counselling of caregiver
Assam 12 weeksWeekly 1 month Weekly by
AWW
Anthropometric
measurements, appetite
test, micronutrient
supplementation, counselling
Chhattisgarh16 weeksWeekly 6 monthsMonthly by
AWW
Anthropometric
measurements, check for
oedema, history of illness and
loss of appetite, micronutrient
supplementation, counselling
on health and nutrition issues
including use of THR 49Transforming Child Nutrition
State While the child is in
CMAM
After discharge from
CMAM
Activities undertaken
during follow-up visits
Duration of
follow-up
Frequency of
follow-up
Duration of
follow-up
Frequency
of follow-up
Jharkhand 16 weeksFortnightly4 monthsMonthly by
AWW
Anthropometric
measurements, history of
illness, counselling
Maharashtra12 weeksWeeklyMonthly by
AWW
Anthropometric
measurements, history of
illness, provision of energy
dense nutritious food,
counselling
Odisha 16 weeksWeekly 6 monthsMonthly by
AWW
Anthropometric
measurements, check for
oedema, history of illness and
loss of appetite, counselling
on health and nutrition issues
including use of THR
Rajasthan 16 weeks Weekly 4 months Fortnightly
by ASHA
and
monthly by
ANM
Anthropometric
measurements, check for
oedema, history of illness and
loss of appetite, counselling
on health and nutrition issues 50Transforming Child Nutrition
Some of the innovative strategies for health and nutrition education being followed in different states are
as follows:
5.7.1 Counselling and Nutrition toolkit for dietary recommendation
(Bihar)
Under the Samvardhan programme of Bihar, NHE has two activities: Individual counselling of the
caregiver and education sessions for the caregivers. Education sessions for caregivers are organized
using audio-visual aids on a fortnightly-basis in AWCs and during monthly VHSND.
ĥPrinted IEC materials and cooking demonstrations are organized at AWC during the monthly
VHSND.
ĥNutrition toolkit has also been developed for counselling sessions, used by AWWs during
CMAM sessions/clinics. The nutritional toolkit has details about dietary recommendations for
normal children as well as ways to improve diets for the children with SAM/MAM using locally
available food items. The kit also contains recipes demonstrated by AWWs in SAM sessions as
well as during home visits of the children.
5.7. Nutrition and Health Education (NHE)
Nutrition and Health Education-cum-counselling is an important component of CMAM programme.
Caregivers of children with MAM/SAM are provided structured, individual as well as group counselling on
key topics of health and nutrition. This takes place at the time of follow-ups done by AWW or ANM during
home visits, CMAM clinics, VHSND and poshan panchayats. The aim of counselling sessions is to equip
children’s caregivers with adequate knowledge for adherence to the protocol for management of children
with MAM/SAM at home, to prevent undernutrition among other children in the family and to maintain
a sustainable change in the household-level feeding and care practices. Frontline workers use existing
counselling materials such as flipbooks, IEC videos and counselling cards during the counselling sessions.
The AWW and ASHA, supported by the ANM, explain the caregivers about the following aspects of the
community care programme in Table 7.
Table 7: Health and Nutrition Education
Nutrition and health education at the time of admission
Nutrition and health education during follow-up visits
Information about food, basic hygiene and antibiotics treatment at home
How to enrich/augment home foods
Use of local ingredients suitable for the child
Continued feeding during illness and importance of
frequent feeding 51Transforming Child Nutrition
5.7.2 Counselling by AAA to improve the maternal and child health
(Gujarat)
In Gujarat, social behavior change communication and counselling is done by AAA at the community
level to improve the maternal and child health components.
ĥDuring the weekly follow-up visits of children with SAM, ASHA workers counsel the mothers/
caregivers about consumption of balshakti fortified THR, homemade food to be given after
SAM child completes the recommended dose, handwashing and hygiene practices, medicine
protocol, and the importance of continued breastfeeding during illness, and age-appropriate
complementary feeding practices.
ĥThey also provide counselling on referral if needed, GMP and on practices to prevent relapse
and reoccurrence of malnutrition
Key topics
covered
Causes of SAM and why children need diversified locally-
available food with the right quality and frequency
How to prepare home-based nutrient-enriched food for
children
How to give iron folic acid syrup at home, and
The importance of vaccination and maintaining hygiene
Figure 21: Key topics covered under sessions by AAA
West Singhbhum district in Jharkhand is a tribal district with many hard-to-reach areas. Under
the Johar Poshan Programme, this district was specifically targeted for creating awareness in the
community to improve nutrition and health behavior with focus on breastfeeding, complementary
feeding, anaemia, maternal nutrition, hygiene and sanitation and immunization. With support from
UNICEF and State Center of Excellence (SCOE-SAM), Rajendra Institute of Medical Sciences (RIMS)
has compiled a package of communication material and a structured plan to create awareness
through individual/group counseling and through mass- and mid-media activities.
To improve acceptance and reach of the nutrition messaging, videos and documents are translated
into local tribal language. Following comprise the package of communication material is enumerated
in Figure 22 further.
5.7.3 Sessions by AAA using tools and flip books (Jharkhand)
In Jharkhand, NHE sessions are conducted by AWW, ASHA and ANM using essential nutrition flip-
book, ILA counselling tool and MAA flip-book. Information given to the caregivers of children with SAM is recorded by AWW in the follow-up and treatment register (Figure 21). 52Transforming Child Nutrition
Figure 23: Glimpse from a Nutrition and Health
Education session conducted in Maharashtra
5.7.4 Digital platform-based outreach strategy-“Tarang Suposhit
Maharashtracha” (Maharashtra)
In Maharashtra, AWWs, ASHAs, and ANMs are proactively working at the village level for providing
NHE during home visits, CBEs, and other SBCC activities. The DoWCD has initiated the special CBEs
focused on children with SAM in high-burden blocks. The focus is not just on curative aspects but also
on ensuring the further development of a child and avoiding relapse.
Due to COVID-19 and associated measures in the state, the DoWCD, Government of Maharashtra
(GOM), adopted a digital platform-based outreach strategy through the initiative of “Tarang Suposhit
Maharashtracha”. It is a digital platform for continuing interface with potential programme participants
for nutritional and early childhood development counselling even during the ongoing COVID-19
pandemic.
Jindagi Phir Muskuraigi video
that explains a comprehensive
approach to address
malnutrition in the district
MAA video focusing
on breastfeeding and
complementary feeding
Anemia Mukt Bharat communication
package adapted to the local language
Poshan Abhiyaan
animation video series
Johar Poshan video
that explains key
steps involved in the
CMAM programme
Nutrition during
COVID-19 videos
developed in local
language
Complementary feeding
booklet for individual and
group counselling
Essential nutrition practices flip-book for
individual and group counselling
Package of
communication
materials
1
2
3
4
5
6
7
8
Figure 22: Package of communication material 53Transforming Child Nutrition
5.7.5 Use of digital counseling toolkit (Telangana)
In Telangana, caregivers are sensitized about nutrition care, feeding techniques, diet quality,
complementary feeding and WASH practices. Digital counselling toolkit is a part of SSFP, used by
the AWT during follow-up visits of children with SAM. Posters with key messages are also displayed
at AWCs and AWT that delivers the messages to the caregivers during every point of contact. During
every fortnightly SSFP visit, AWT conducts the feeding demonstration and extends handholding
support for mothers to improve the responsive feeding.
Details of NHE innovative sessions conducted in different states of India are summarized in Table 8.
S.
No.
State By Whom WhereTools used
i. Bihar AWW AWC and home visit
ĥAudio-visual aids
ĥPrinted IEC materials
ĥCooking demonstration
ĥNutrition toolkit
ii.Gujarat AWW & ANM AWCCounseling on breastfeeding,
hygiene, cooking methods, intake of
medicine and THR daily dose
ASHA During weekly follow-
up visits
iii.MaharashtraAWWs, ASHAs,
& ANMs
During home visits,
CBEs, and other SBCC
activities
Digital platform-
ĥInteractive Voice Response (IVR)
helpline
ĥAuto-generated broadcast calls/
SMS, and
ĥWhatsApp Chatbot
iv.Jharkhand AWW, ASHA &
ANM
AWC, public
gatherings
ĥEssential nutrition flipbook
ĥILA counselling tool and
ĥMAA flip-book
v. Telangana AWT AWC (follow-up visits)
ĥDigital counselling tool kit
ĥPoster (with key messages)
ĥFeeding demonstration
Table 8: Nutrition and Health Education implementation in different states of India
It encompasses the Interactive Voice Response (IVR) helpline, auto-generated broadcast calls/ SMS,
and a Whatsapp Chatbot. The platform is leveraged for counselling, social auditing, and as a tool to
empower parents to assess the nutritional condition of their children. The platform is also being used
to ensure system-generated follow-up with parents with respect to increasing demand for growth
monitoring sessions at AWCs and their counselling. It is also utilized to capture feedback from parents
regarding the interventions such as inter alia, the consumption of energy-dense nutritious packets,
and counselling (Figure 23). 54Transforming Child Nutrition
5.8.1 SAMPARK application for data management and reporting
system (Madhya Pradesh)
In Madhya Pradesh, details of enrolled SAM children are recorded in Bal Poshan Pragati Patra (BPPP).
Further, the state has developed an android-based application (called Sampark) for the efficient
collation and monitoring of data. The data of SAM and MAM children related to enrollment, weekly
and monthly follow-ups, socio-demographic details and family details are recorded in the application.
Data validation and deletion of duplicate entries is undertaken by Child Development Project Offices
(CDPOs) and Lady Supervisors. The dashboard is available on the WCD website for which login details
are provided to the state officials, district collectors, DPOs, CDPOs, and supervisors. It was developed
by RCoENRRT, All India Institute of Medical Sciences (AIIMS) Bhopal, DWCD MP, NHM MP with support
from UNICEF. The application is being maintained by a dedicated team of android and web developers
at DWCD. The application can be downloaded and installed from the department’s MIS page
(Figure 24).
The information regarding the grade change (in nutritional status) of SAM and MAM children, weekly follow-up, and death (if any), along with NRC referral, is available on the dashboard of the Sampark application. All children added in the application are classified as SAM, MAM or normal as per WHO WFH Z score criteria under the ‘Child’s Detail’ tab. A few registration details of the children like date of registration, anthropometric measurements, result of appetite test, the assessment of oedema, and medical examination done by ANM are also entered. Through the application, it is easy to flag the children discharged from NRC so that AWW can immediately act to provide services to those children (Figure 25).
Figure 24: Android based Sampark Application
5.8. Technology-Enabled Recording and
Reporting System
Recording and reporting serve an important function of assessing the progress of programme, to track the
progress of individual cases, assess the larger outcomes, and provide feedback to relevant stakeholders to
fill the gaps in service delivery and programme implementation. Different reporting formats and techniques
are being used in different states to capture and analyse data.
The flow of reporting usually starts from field-level workers to supervisors, followed by block-level, district-
level and state-level assimilation of reports. Usually, the reporting formats are used to capture the following
information about children enrolled in the CMAM programme: Child’s socio-demographic information (such
as child’s name, age, gender, religion, name and age of parents, occupation of parents, birth history, family
income, family history and other household information), child’s anthropometric details like weight and
height / length, details on feeding regimen, immunization history and medical examination. 55Transforming Child Nutrition
5.8.2 Use of management information system (Rajasthan)
In Rajasthan, adoption
of MIS was warranted
due to the modality of
current reporting which
was bottom-heavy, relying
completely on competence
of AWW and lady
supervisors. The reporting
was delayed because the
data moved in hard copies
in Rapid Reporting System
(RRS) and Monthly Progress
Reports (MPRs), and AWWs
and lady supervisors would
compile all reports in sector
meetings, which generally
take place in the first
week of the next month.
As a result, reporting was
delayed (Figure 26).
The dashboard of the
Sampark application
is hosted at the WCD
website and login
details are provided
to the state officials,
district collectors,
DPOs, CDPOs and
supervisors for cleaning
of duplication and
real-time monitoring.
The information
related to
grade change
(nutritional
status), weekly
follow-up, and
deaths (if any)
are reflected on
the application
dashboard.
More than
80,000 SAM
children and
4,00,000
MAM children
were enrolled
in the IMAM
programme
during 2020-21.
Figure 25: Dashboard details of Sampark Application
Components
adopted for
Management
Information
System
Two reporting
formats; one for
line-listing and
other for summary
reporting on KPIs
1
Digitization is
done in Google
Sheets
3
The digitization
is done at the
block level
2
Hierarchical access
of Google Sheets
where the District
Coordinator of
NNM gave edit
rights to the Block
Coordinator
4
Figure 26: Components of MIS 56Transforming Child Nutrition
The reporting formats for field functionaries were carefully and comprehensively drafted; after several
rounds of iterations these were finalized for printing and hard copies were provided at all AWCs in the
20 districts.
The flow from field level was fast-forwarded by allowing AWWs and lady supervisors to share legible
photos through common messenger applications like WhatsApp in their dedicated sector-wise
groups, substantially reducing delays in reporting. At the block level, the information is digitized by
dedicated Data Entry Operators of NNM at block/sector office.
For capacity building on MIS, 6 rounds of orientation, reorientation, refreshers of the AMMA programme
and reporting framework are conducted. The final product consists of 35 Google Sheets for line listing
and 20 district-wise Google Sheets for summary reporting (Figure 27).
As of 2021, more than 20,000 children were being tracked in line listing sheets. As per summary reports, 80% of screening was done in these 20 districts, of which 1,49,641 children were identified as having MAM and 9,195 children as having SAM.
5.8.3 Real-time data entry and monitoring system through SSFP
Application (Telangana)
In Telangana, a real-time data entry and monitoring system through SSFP application is established
to collect data directly from AWCs. Cure rate, mortality rate, defaulter rate and average weight gain (g/
kg/day) are outcome indicators of the programme. The periodic data on specific outcome indicators
are collected using SSFP-MIS and analyzed monthly.
Figure 27: Reporting format used in Rajasthan 57Transforming Child Nutrition
5.9. Monitoring and Supervision
This chapter highlights the monitoring process being followed in different states to track progress and quality
of service delivery under CMAM programme. Monitoring visits are conducted as per the microplan, and a
structured tool is designed to observe and record the details of logistics including equipment, recording
and reporting formats, THR and medicine supplies, knowledge and skills of frontline functionaries (FLWs)
on identification and classification of nutritional status, services provided to enrolled children in CMAM
programme and outcome of the programme.
Then FLWs are provided with hands-on training on the identified gaps, and the block and district level
officials are offered recommended actions on improving service delivery. The data is used during the
structured reviews at the district and state level for corrective actions. Regular field visits are conducted by
District Programme Officers (DPOs)/District Social Welfare Office (DSWO), CDPOs and Supervisors to monitor
progress of CMAM programme. Roles and responsibilities at different levels in the state for monitoring and
supervision are provided in Table 9. Details of the monitoring process being followed are discussed and
summarized in Table 10.
Role of State Coordination Group (Committee from DWCD, DoHFW, CoE, PRI, Tribal, Water and sanitation departments)
Role at District level (DPO/ DSWO to monitor the implementation of the programme)CDPO to be
designated as
the focal point
Role of Lady
Health Visitor
(LSVs) and the
Anganwadi
Supervisors
Establishing
technology-
driven monitoring
system
ĥProvide technical
support for
planning and
implementation.
ĥFacilitate
convergence
between various
departments for
training, referrals
and linkages,
recording and
reporting,
supportive
supervision.
ĥFacilitate any
procurement e.g.,
procurement of
equipment, food.
ĥReview progress of
implementation.
ĥPlanning of
services in
discussion.
ĥFund flow and
positioning
of manpower,
trainings.
ĥInfrastructure
strengthening.
ĥQuarterly
review of the
programme
performance.
ĥFacilitate
training
of health
workers and
AWWs.
ĥEnsure
linkages
between the
SAMTUs and
the CMAM
programme.
ĥMonitor data
from the
blocks and
report to
the district/
state on a
periodic basis
and share
with PHC in-
charge/BMO.
ĥEnsure the
quality of
services and
facilitate the
supply and
logistics by
coordinating
with the
authorities at
the Block and
District level.
ĥResponsible
for finalisation
of the monthly
reports from
the AWCs.
ĥEnsure and
monitor
community
mobilisation
activities.
ĥApplication and
management
information
system is
crucial for
reaching the
unreached,
improving
service delivery
as well as
supervision,
monitoring and
counselling
actions with
impact on
accelerating
improvement
in child
nutrition
situation.
Table 9: Role and responsibilities at different levels in state 58Transforming Child Nutrition
5.9.1 In-person monitoring by sector, block, district officials and
by CSOs (Rajasthan)
In Rajasthan, in-person monitoring is done by sector, block and district officials and by Civil Society
Organizations (CSOs). Platforms for monitoring include Maternal Child Health and Nutrition (MCHN)
sessions and sector level meeting (Figure 28).
Implementing Partners (5 CSO
partners) are monitoring MCHN
sessions and sector meetings in their
respective areas, and the feedback is
shared with the DD ICDS office.
Figure 28: Platforms for monitoring sessions and sector level meeting
Sector-level officials
(LS) monitor the
work of AAAs on
monthly basis and
on selected
MCHN day.
Block-level officials
(CDPOs and Poshan
Abhiyaan staff)
monitor the AMMA
activities at AWCs
on MCHN day
District-level officials
(Deputy Director
- DD and Poshan
Abhiyaan staff)
monitor the AMMA
activities at AWCs on
MCHN Day. 59Transforming Child Nutrition
5.9.3 Field visits and telemonitoring to monitor the progress of the
programme (Telangana, Haryana)
5.9.2 Weekly granular monitoring by Principal Secretary, Social
Welfare, Community & Rural Development & Health Department
(Meghalaya)
i. In Telangana, field visits and telemonitoring are done by National Institute of Nutrition (NIN)
team to monitor the progress of the programme. The sector supervisors (CDPO) also visit AWCs for
supportive supervision and streamline the supply of balamrutham plus. Women Development and
Child Welfare Department conducts quarterly review meetings on the implementation of SSFP. The
review is chaired by the Commissioner WCD along with District Collectors, District Welfare Officers,
CDPOs, ICDS supervisors, state-level officers, NIN and UNICEF. The field findings of the programme
are shared for corrective actions.
ii. In Haryana, for reporting and recording, four different formats have been developed which are
given to AWWs. Name-wise monthly and weekly reports of SAM children are collected from AWWs.
Telemonitoring of the parents of SAM children is also being done by DPOs.
The weekly granular monitoring of SAM and MAM children at the state level is done by the Principal
Secretary, Social Welfare, Community & Rural Development, and Health Department, often chaired
by the Chief Minister. This exercise is unprecedented at the State level and at this frequency. These
weekly review meetings witnessed the attendance of representatives of three departments involved
in the process of management of SAM and MAM children, namely, Social Welfare Department
(Women and Child Development) through the ICDS Officials, Community and Rural Development
Department through the NRLM programme staff and the Health Department officials. These reviews
have inculcated a sense of responsiveness and urgency. The officials also took more ownership of
the problem and developed local solutions. A culture of synergy and collaboration is being created
between the three departments.
The block-level teams collected data from AWWs, and supervisors regularly reviewed registers during
their interactions in the field or in monthly sector meetings, communicating the importance of home
visits and maintenance of records. Reports were then shared with district ICDS teams and the state
team for documentation and analysis.
5.9.4 Dual monitoring system (Uttar Pradesh)
In Uttar Pradesh, two modes of monitoring are undertaken: first, departmental monitoring by ICDS
supervisory staff and second, external monitoring with the support of development partners.
5.9.5 Monitoring using Kobo Toolbox platform (Bihar)
In Bihar, monitoring and supportive supervision are periodically undertaken by SCoE, UNICEF as well
as district and state officials. The monitoring findings are recorded using Kobo Tool box application and data findings are disseminated in meetings of Health and WCD Department. Findings are also shared with District Magistrate (DM) and Sub-Divisional Magistrate (SDM) (Table 10). 60Transforming Child Nutrition
S.
No.
State Monitoring
format
By whomFrequency
i.Bihar Kobo Tool box
/ Kobo Collect
application
Government officials (LS,
CDPOs) and 3 technical
resource persons from DRPCAU
and PUSA.
Every AWC is visited quarterly
by a technical resource person.
Lady supervisors and CDPOs visit
AWCs as per their own plans of
monitoring.
ii.MeghalayaGranular
monitoring
Principal Secretary, Social
Welfare, C&RD & Health
Department chaired by Chief
Minister
Weekly
iii.JharkhandStandard
supportive
supervision
checklist
SCoE-SAM, RIMS and UNICEF
team
District Social Welfare Officer
and Civil Surgeon
Visit to minimum 5 admitted
children
CDPO and Medical OfficerVisit to minimum 8 admitted
children in the block
Lady Supervisors Visit to minimum 10 admitted
children in the sector
Development partners and
other
Visit to minimum 10 admitted
children in the sector
iv.RajasthanKobo collect
application
Sector-Level Officials Monthly
Block-Level officials MCHN Day
District-Level officialsMCHN Day
5 CSO partners MCHN Day & sector meetings
v.TelanganaTelemonitoring NIN TeamQuarterly
vi. HaryanaTelemonitoring DPOsMonthly
Table 10: Summary of process of monitoring of CMAM activities adopted in different states of India 61Transforming Child Nutrition
5.10. Multisectoral Convergence
Success of CMAM requires active participation of multiple stakeholders from different government
departments. In different states, CMAM is being implemented with the active participation of Health &
Family Welfare Department, with the lead taken by the Department of Women and Child Development.
Feeding of augmented THR, logistics costs, and counselling are looked after by the Department of WCD.
Treatment and medicine portion is managed by the Department of Health. Active support is also provided
by the Panchayati Raj Department in community mobilization process, while the development partners are
engaged in monitoring and data validation.
5.10.1 Multisectoral engagement between the Social Welfare and
Health Department (Assam, Rajasthan)
i. In Assam, there is multisectoral engagement between the Social Welfare Department (for registering
children under CMAM programme, conduct weight-for-height screening, giving counselling to
beneficiaries and paying home visits to children registered under CMAM programme) and Health
Department (involved in micronutrient and antibiotics supply and administration to children
registered under CMAM programme; ANMs are responsible for the medical assessment of all
children with SAM identified by AWW). Coordination between both departments is vital to ensure
children receive health and nutrition-related services. A draft statement of purpose (SOP) for the
identification of SAM, referral to NRC and CMAM programme has also been developed.
ii. In Rajasthan, convergence with Department of Health played a pivotal role in the success of AMMA
programme. It not only ensured regular supervision from ANMs but also helped in troubleshooting
the problem of lack of GMDs in the state. It also proved useful for streamlining and integrating
monitoring by AMMA programme officers at the block and district level on MCHN –day within
the regular monitoring system. District Nutrition Convergence Planning Committee, under the
chairmanship of District Collector and Deputy Director ICDS as member-secretary, reviews all
nutrition-related programmes and schemes with all line departments at the end of every quarter.
5.10.1 Multisectoral engagement between the Social Welfare and
Health Department (Assam, Rajasthan) 62Transforming Child Nutrition
5.10.2 Convergence in Department of Health and Family Welfare and
Department of ICDS in Samvardhan Programme (Bihar) and SAMBHAV
programme (Uttar Pradesh)
i. In Bihar, Samvardhan Programme in Purnea was led by the Department of Health, in close association
with Department of ICDS. The focal point of services was AWC and majority of the services were
to be delivered through AWWs and ANMs. SAM Clinic was organized on VHNDs in the presence of
AWW/ASHA. In these clinics, ANMs verified children with SAM, referred them to NRC (if needed)
or enrolled them in CMAM programme based on the medical condition and appetite of the child.
Along with these two departments, JEEVIKA (JEEVIKA didi) was involved in the programme
implementation with prime responsibility of community mobilization and imparting health and
nutrition education regarding Infant and Young Child Feeding (IYCF) and care of SAM children.
Block-level convergence meetings were planned on a quarterly basis, under the chairmanship of
BDO. In these meetings, block- and sector-level officials of the Department of Health and ICDS,
JEEVIKA and PRIs discussed programme challenges and mitigation efforts. Similarly, in district-
level review meetings, the programme review was conducted under the leadership of the district
magistrate with all concerned departments and key programme outcome indicators and processes
were discussed.
ii. In Uttar Pradesh, the Health and ICDS departments work in close coordination for CMAM
implementation. Health department is undertaking the medical management part of the
intervention both at the community and facility levels. There are separate departmental guidelines
for Health and ICDS departments, that describe the actions, roles, and responsibilities of both
departments. Joint Health and ICDS department meetings are organized for sensitizing the district
officials and reviewing programme progress.
The integration between two departments is critical for the success of the interventions such as
screening, identification, mobilization and nutrition management, and medical management. The
first phase of SAMBHAV served as a good learning experience. The future strategy involving several
other line departments is under development.
5.10.3 Involvement of Department of Women and Child Development
(DWCD), Public Health Department, Rural & Tribal Department, PRI
members in implementation of programme (Maharashtra, Meghalaya)
i. In Maharashtra, the following departments are involved in the implementation of the Village
Child Development Centre (VCDC) programme: DWCD (for screening, provision of food, follow
up, counselling, home visits), PHD (for supporting medical check-ups, certification of children with
SAM, providing medical treatment and referral services for children with medical complications,
and counselling services), Rural Development Department (for mobilizing the local funds and
logistics to ensure timely and uninterrupted supply of medicines), PRI members (for community
mobilization for growth monitoring sessions and follow-up processes), and Tribal Development
Department [for financial support in tribal districts through Panchayat Extension to Scheduled
Areas (PESA) funds and other local funds]. 63Transforming Child Nutrition
5.10.1 Multisectoral engagement between the Social Welfare and
Health Department (Assam, Rajasthan)
ĥIn Assam, there is multisectoral engagement between the Social Welfare Department (for
registering children under CMAM programme, conduct weight-for-height screening, giving
counselling to beneficiaries and paying home visits to children registered under CMAM
programme) and Health Department (involved in micronutrient and antibiotics supply and
administration to children registered under CMAM programme; ANMs are responsible for
the medical assessment of all children with SAM identified by AWW). Coordination between
both departments is vital to ensure children receive health and nutrition-related services. A
draft statement of purpose (SOP) for the identification of SAM, referral to NRC and CMAM
programme has also been developed.
ĥIn Rajasthan, convergence with Department of Health played a pivotal role in the success of
AMMA programme. It not only ensured regular supervision from ANMs but also helped in
5.10.4 Engagement of concerned departments and development
partners (Gujarat)
In Gujarat, UNICEF supported the Department of Health and Family Welfare (DoHFW) technically
throughout the programme planning and through developing strategy, implementation plan,
training package and guidelines, capacity development, monitoring and supportive supervision, MIS
development and joint review for the overall strengthening of CMAM programme across the State.
Faculty of Preventive and Social Medicine (PSM) Department of GMERS Medical College were involved
in capacity building at the district level and for supportive supervision and monitoring CMAM
programme implementation at district level across Gujarat.
State Institute of Health and Family Welfare (SIHFW), District Training Team (DTT) and District Training
Centers (DTC) teams collaborated to strengthen capacity building at state, district and block level
trainings. National Centre of Excellence for Integrated Management of Severe Acute Malnutrition
(IMSAM) technically supported state government, UNICEF and State Center of Excellence in developing
new THR-based recipes as nutritional therapy for treating SAM children without any complication at
the community level.
State Centre of Excellence (SCoE) was established jointly in collaboration with UNICEF and DoHFW
for supporting the IMSAM programme implementation, monitoring and supportive supervision and
joint review at the state level. DoHFW in convergence with DWCD helped in the field implementation
for CMAM programme for community mobilization, anthropometric assessments, screening children
with SAM, home visits, counselling, joint review, and supply of THR.
Additionally, government officials from various departments have been involved in a few districts
for the adoption of SAM children. It has helped in child-wise monitoring ensuring desired
weight gain and support to the families. As part of community participation, Muth Bhar Dhanya
(Contribution of a fistful of grain) has been promoted to ensure community ownership towards
the children.
ii. In Meghalaya, sectoral meeting, involving CDPO, MO, BDO, LS, ANM, AWWs ASHAs, Block
Programme Managers (NRLM), Village Heads, VO Leaders, is held on a monthly basis. The sectoral
meeting is intended to facilitate teamwork between the Health Department, Community & Rural
Department, Social Welfare Department and communities. Block Development Officers, CDPOs
and Block Medical Officers are specifically requested to attend the meetings of priority facilities.
Deputy Commissioners oversee and give approval for the sectoral meeting schedule of each block
within their district, ensuring that there is a set day and time for these meetings each month. 64Transforming Child Nutrition
ĥIn Assam, there is multisectoral engagement between the Social Welfare Department (for
registering children under CMAM programme, conduct weight-for-height screening, giving
counselling to beneficiaries and paying home visits to children registered under CMAM
programme) and Health Department (involved in micronutrient and antibiotics supply and
administration to children registered under CMAM programme; ANMs are responsible for
the medical assessment of all children with SAM identified by AWW). Coordination between
both departments is vital to ensure children receive health and nutrition-related services. A
draft statement of purpose (SOP) for the identification of SAM, referral to NRC and CMAM
programme has also been developed.
ĥIn Rajasthan, convergence with Department of Health played a pivotal role in the success of
AMMA programme. It not only ensured regular supervision from ANMs but also helped in
5.11.1 Training in small batches and hybrid mode (Odisha, Chhattisgarh)
During the COVID-19 pandemic, the training of field functionaries faced a setback due to COVID-19 related restrictions. This led to delays in the implementation and scale-up of CMAM in states like Chhattisgarh and Odisha. In order to continue the momentum of CMAM training even at the time of COVID-19, the states of Chhattisgarh and Odisha conducted training in virtual or hybrid mode to equip frontline workers with the right knowledge and skills for identifying and providing treatment to SAM children. The practices on training and capacity building adopted by both the states at the time of COVID-19 restrictions are highlighted in this section.
i. In Odisha, CMAM pilot project was implemented in Nabarangpur & Koraput districts.
5.11. Capacity Building
Continued communication and routine information exchange, coupled with technical guidance, should be
ensured for stronger capacities and effective implementation of CMAM programme in India. The practices
on capacity building followed in different states of India are as follows:
One-day
orientation training
programme on
the effectiveness
of community-
based treatment
programmes to
treat children aged
6-59 months with
uncomplicated
SAM using
alternative energy-
dense foods.
Three-day
district-level
orientation
training on the
implementation
of comprehensive
CMAM
programme.
Two-day
orientation
training
of SHG
members on
preparation
of augmented
THR.
Virtual training of
Medical Officers,
District Programme
Manager (DPM)
NHM, Reproductive
and Child Health
(RCH) team, RBSK
manager and
team and block
programme
manager from
NHM on CMAM
protocol.
One-day block-
level training
of frontline
workers on the
implementation
of CMAM
programme by
district trainers.
Training guides were prepared in English and translated into the local language for circulation
among grassroot-level workers. After the hybrid training, knowledge of master trainers (LHV,
CDPOs and LS) was assessed using a pre-training and post-training test, which showed an
improvement in the knowledge from 48.2% to 83.7% in Nawarangpur and from 53.7% and 89.5%
in Koraput. In all sector meetings, CMAM is an agenda point for discussion and doubt-clearing
sessions are also held.
ii. In Chhattisgarh, due to COVID-19 restrictions, trainings were initially limited as per instructions
from the DoWCD. During the launch of the programme in January 2021, special permission was
taken by Director, WCD to allow training of frontline workers on CCSAM programme in small
batches with the precautions to contain spread of COVID-19 infection. Hence, precautions for
respiratory hygiene like mask-wearing and use of sanitizer were simultaneously ensured along
with monitoring of training through district and state officials.
Decentralization of trainings was done by conducting trainings at sector level to ensure maximum
participation. Further, a staggered approach was adopted for screening of children for SAM
identification and help was taken from the AIIMS team to ensure high coverage, timely detection
and enrollment of children in CSAM programme. 65Transforming Child Nutrition
5.11.2 Bi-annual district level training (Assam)
5.11.3 Multiple rounds of training and training based on challenges
faced in field (Rajasthan)
5.11.4 Cascade-mode training (Bihar, Gujarat, Maharashtra, and
Jharkhand)
In Assam, with support from UNCIEF, in 2021, two rounds of training were conducted for all districts
and state-level officials (including DSWOs, CDPOs, Supervisors and Poshan Abhiyan coordinators)
under the innovation head of POSHAN Abhiyaan for 15 districts. Further, in the division-wise
Training of Trainers (ToT) programme at the state level, one resource person from each project has
been trained on CMAM for conducting further training at the project/district level. Trainings was
also organised for sector supervisors and other ICDS staff. Trainings is conducted every 6 months.
In Rajasthan, six rounds of orientation, reorientation and refreshers of the AMMA programme and
reporting framework have been conducted. An MIS framework was introduced and discussed with
all Deputy Directors (DDs) of 20 districts in an in-person orientation.
This was followed up by a phased zoom-video conference of ToTs in which a total of 1344 participants
from 20 districts were trained. This included 28 DC/DPA, 81 CDPO, 632 LS, 292 NTT and 66 monitors
from CSO partners. There were also continuous refresher training sessions held online to troubleshoot
challenges that are emerging in the field.
i. In Jharkhand, a cascade training approach was followed at the district level. A pool of district-level
master trainers was created with support from SCoE-SAM, Rajendra Institute of Medical Sciences
(RIMS) and UNICEF. The master trainers and resource person from RIMS and UNICEF supported
during block-level training. State-level monitors from UNICEF and RIMS monitor training at block
level to ensure quality. Two-day face-to-face trainings were conducted at the district level to
build capacity of ICDS and Health functionaries. Refresher training and orientation are conducted
at 6-months interval or on need basis (Figures 29 to 31).
ĥPreparation: A training package consisting of training module, formats, registers, and
presentations in local language, counselling book and Essential Nutrition Practices during
COVID-19 flipbook has been developed.
ĥResource person: Internal and external personnel & officials from medical college empaneled
at SCoE-SAM provide technical support at State/District training.
Micro-Plans of training have been developed after reviewing the number of participants, details
of the venue, finalization of batches with names of resource persons. Agenda was developed in
consultation with the districts. 66Transforming Child Nutrition
SCoE –SAM, RIMS with
support from UNICEF,
collaborated with
Government, NCoE, other
State Medical Colleges,
Birsa Agriculture University
(Nutrition Dept), Empaneled
external retired paediatricians
as resource person Created
a pool of 86 Resource Persons
for supporting CMAM
trainings
National
Centre of
Excellence
for SAM
Management,
New Delhi
Birsa
Agricultural
University,
Jharkhand
RIMS (Dept of
PSM, Paediatrics
& Obs & Gynae)
External resource
person
All other
5 Medical
Colleges of
Jharkhand
Resource
Pool
Figure 29: Resource Pool for capacity building
Figure 30: Tool used in CMAM trainings in West Singhbhum District, Jharkhand 67Transforming Child Nutrition
ii. In Bihar, trainings were conducted in cascade mode where first master-level trainings were
organised by the Department of Health in coordination with ICDS Department. National Centre of
Excellence for Management of Severe Acute Malnutrition (NCoE-SAM), Kalawati Saran Children’s
Hospital (KSCH), New Delhi was the technical agency for developing the training module and
imparting training through skilled trainers. Thereafter, separate batches for frontline workers
were formed.
Each of the cadres received training from Master Trainers with one representative from
KSCH, New Delhi who was present as observer to oversee the quality of training delivery.
One-day orientation of the programme was also conducted for the community mobiliser
of JEEVIKA and NRC staff as per their roles in the programme.
Training on management of malnutrition under 6 months of infants were also organized. Training
for frontline workers is organised every six months. During the COVID-19 period, trainings were
organised through the virtual mode, reverting to offline training soon after services opened up.
iii. In Gujarat, training is an integral part of the CMAM roll-out plan. Master trainers and training
packages were created for the CMAM programme. Cascade trainings were planned and executed
at the State, District, Block and PHC level. Satellite Communication (SATCOM) sessions were also
planned on a regular basis to reiterate the key messages on the identification of children with
SAM, monthly screening, CMAM programme implementation, Medicine and Nutrition Therapy,
monitoring, supervision, review, follow up and strengthening MIS for CMAM programme across
Gujarat.
iv. In Maharashtra, a separate training module was developed for VCDCs. The cascading model
of training was followed. At the state level, selected ICDS supervisors, CDPOs, THOs, and MOs
were trained as master trainers. These master trainers conducted training at the block level. The
frontline functionaries i.e., AWWs, ANMs were trained at the ICDS beat or PHC level. After the
initial intensive training programme, based upon the district-specific need, the refresher training
programmes were conducted.
Figure 31: Capacity building in Jharkhand 68Transforming Child Nutrition
5.11.5 Hands-on training (Telangana)
In Telangana, AWTs, Sector Supervisors, ANMs and MOs were trained on implementing the SSFP.
Hands-on training was also given to workers in the selected districts on screening and identification
of SAM & MAM, use of weight-for-height growth chart, conducting appetite test, assessment of
oedema, conducting counselling sessions with caregivers, referral, monitoring and discharge.
Three-day training programme was organized for AWTs and Sector Supervisors in every ICDS project
area. Refresher training is also given to all the frontline functionaries through T-SAT (Telangana State
Network) programme.
5.11.6 Collaboration with the National Institute of Public Cooperation
and Child Development (NIPCCD) for capacity building (Meghalaya)
In Meghalaya, capacity building of functionaries on identification and management of SAM/MAM
children was conducted in collaboration with the National Institute of Public Cooperation and Child
Development (NIPCCD).
Capacity building was conducted for the state-level functionaries and through them the field-level
functionaries were trained. Through this training programme 5896 AWWs of the State were taught
about SAM and MAM children identification and management through module 8 and 13 of the
Incremental Learning Approach (ILA).
Handholding support was provided to the field functionaries whereby the District Project Officers
(DPOs), CDPOs, and supervisors were physically present with selected AWWs (those who still needed
guidance) during the weighing and measuring process so that the measurements were correctly
undertaken. 69Transforming Child Nutrition
5.12.2 Madhya Pradesh
5.12.3 Odisha
In Madhya Pradesh, the IMSAM programme was initiated with 9 districts and scaled up across the
entire state (52 districts).
In Odisha, the CMAM programme has been scaled-up across 30 districts. The augmented THR or
therapeutic food is being prepared by the Women SHGs of the respective the district, indicating the
sustainable nature of the feeding component of the programme
5.12.4 Maharashtra
In Maharashtra, VCDC is already scaled-up throughout the State. The team is now focusing on quality
monitoring through building data systems such as dedicated software for end-to-end management of children with SAM.
5.12.5 Telangana
In Telangana, the programme was initiated in 2 districts and scaled-up across 7 districts in the state
by WDCW Department.
5.12. Scalability, Replicability and Sustainability
5.12.1 Gujarat
In Gujarat, between April to June 2016, CMAM programme was piloted in 4 districts. SAM children
enrolled in CMAM programme were managed at community level. Out of 798 SAM children who completed 8 weeks treatment in CMAM programme, 433 (54.87%) children were cured. This successful CMAM pilot was then immediately scaled up across select blocks of 13 tribal districts and then across all talukas of 13 tribal districts in a phased manner. The CMAM programme was then scaled up across Gujarat covering 33 districts and 8 corporations in second phase.
Between April to June 2016 CMAM programme
was piloted in
4 districts
798 SAM
children
completed 8 weeks
treatment
433
children
were cured
54.87% 70Transforming Child Nutrition
5.12.6 Jharkhand
In Jharkhand, Johar Poshan programme is being
scaled up in all AWCs of the West Singhbhum district.
Similar model has been adopted in Godda district and
community-based programme Suposhit Godda was
launched in October 2021 using district funds.
Johar Poshan programme relies on the existing ICDS and
Health department structure without any programme-
specific additional human resources. The medicines,
micronutrients, and food are also already available in the
existing government structure; therefore, it does not put
additional financial burden. Currently the programme is
district-funded.
SAAMAR (Strategic Action for Alleviation of Malnutrition
and Anaemia Reduction) programme has been
launched in the state in a phased manner, with phase
I focusing on 5 districts. It will be scaled up across the
state strategically (Figure 32).
Figure 32: CMAM programme being
scale-up in the entire states in phased
manner as SAAMAR programme
5.12.7 Rajasthan
Following points make the programme more scalable, sustainable and replicable based on the
experiences from Rajasthan (Figure 33).
Figure 33: Points included in Programme to be more scalable, sustainable and replicable
No new platform was developed
separately for this programme. This
was integrated in the existing MCHN
structure itself. This saves a lot of
functionaries’ time, helps skip many
operational challenges and serves
as a good example of unified policy
actions.
The AMMA programme activities on
MCHN day are carefully aligned and
integrated with regular activities of
ANM, AWW and ASHA workers. Doing
so only broadened their existing job
mandate instead of introducing new
workload.
The MIS developed is based on
Google Sheets which can be easily
integrated with any of the existing
or newly-developed reporting tools,
ensuring scalability and replicability
of the programme in the reporting
and monitoring systems.
Treatment of children is based on
locally-available, home-based,
energy-dense feeding and not
external supplements, thereby
increasing the programme’s
sustainability. 71Transforming Child Nutrition
5.12.8 Uttar Pradesh
In Uttar Pradesh, the SAMBHAV programme is already a state-wide initiative implemented across all
75 districts. The future strategy for SAMBHAV proposed two biannual campaigns; first, a three-month
long campaign between July-September, and second, a one-month campaign in December, with an
assessment between two rounds. The focus will be on all categories of malnourished children which
include LBW, SAM, SUW under 5 years. The SAMBHAV strategy is conceptualized in a way to utilize
existing programme opportunities with greater focus on the intersectoral engagement, improved
capacities, and a 360-degree communication approach to mobilize and engage the community.
Journey of different Indian states for CMAM programme scale is illustrated in Figure 34.
2016
2020
2018
2019
20212022
2022
2022
2019
2020
2020
2017
2018-19
20202021
Rajashthan
Uttar
Pradesh
CMAM piloted
in 5 districts
CMAM Piloted
in 4 districts
Scaled up across
select blocks of
13 districts
Scaled up to 9
districts
Plan for scale-
up covering 22
districts
Plan for scale-up
in 7 more districts
Replicated in
West Singhbhum
EDNF based
programme
C-SAM piloted
districts
2 districts
SSFP piloted
in 2 districts
CMAM piloted in
khutpani district
IMAM
programme
Implemented
in 20 districts
State wide
Implementation
(33 districts)
State wide
Implementation
(33 districts and
8 corporations)
State wide
Implementation
(52 districts)
State wide
Implementation
Plan to scale-up
in entire state in
Phased manner
(Phase 1 with
districts)
State wide
Implementation of
AMMA programme
(33 districts)
State wide
implementation
Replicated in
Godda districts
Assam
Odisha
Gujarat
Maharashtra
Madhya
pradesh
Telangana
Jharkhand
Figure 34: CMAM programme scale-up across the states 72Transforming Child Nutrition 73Transforming Child Nutrition
Community-Based Management of
Infants (Under 6 months) with Severe
Acute Malnutrition
6
Evidence from India suggests that a large proportion of the nutrition-risk observed in children
6-59 months, can be predicted by the nutrition-risk seen in the first six months of life. Cohort data
from India shows that two-third of children with wasting at 12 and 24 months have had wasting
at one or more points during the first six months of life. Evidence also suggests that interventions
delivered during child’s early life are more likely to succeed faster, with better and sustainable
outcomes. Both facility-based and community-based interventions are required to manage the
children who are at risk. Additionally, children who are discharged from facilities such as Special
Newborn Care Units (SNCUs), or those born with low birth weight or preterm are at risk and need
quality care during follow-up and at community level.
Several states like Maharashtra, Chhattisgarh, Madhya Pradesh and Bihar have prioritised care for
infants (under six months) who are at nutrition-risk and initiated efforts to improve the care and
services. Low birth-weight babies who do not fall under the criteria of admission in facility-based
care, require support regarding breastfeeding counselling and follow-up.
Samvardhan, a programme for Community-Based Management of Acute Malnutritionin
U6M infants, was initiated in Bihar because parents were not keen on inpatient treatment.
Development of guidelines and recording formats based on current national and international
resources were prepared. Capacity building and training of the frontline workers (ANMs, ASHA
and ASHA facilitators and AWWs ) were undertaken as per National HBNC & IYCF guidelines. Other
steps included hand-holding support to AWWs during supportive supervision visits, baseline
assessment and provision of care to children by counseling their mothers by FLWs (Figure 35).
Enrolling severely underweight
(SUW)/SAM and moderately
malnourished children having
difficulty in feeding
Monthly screening and
identification of severe and
moderate malnutrition in
children
Monitoring nutritional and health
status of children every 15 days
Home visits by ASHA as per
HBNC programme
Discharge from the
programme
Figure 35: Key activities for management of U6M infants under Samvardhan programme 74Transforming Child Nutrition 75Transforming Child Nutrition
Challenges Faced during
Implementation7
There are several challenges with respect to the implementation of community-based programme
for the management of children with SAM and MAM. Some of the key challenges, along with
the innovative strategies used by the states to overcome those challenges, are discussed in this
section.
i. Community engagement and participation
In Madhya Pradesh, Maharashtra, Odisha, and Bihar, lack of awareness among community
members and less participation from community members have been reported as a challenge.
In Madhya Pradesh, strengthening of community involvement is being done using Poshan
Sarkar approach (local nutrition governance). The Chief Minister appealed to all gram panchayats
to participate in Poshan Sarkar and also released an annual report of IMAM programme for
dissemination and effective engagement of more stakeholders.
In Odisha, poor community participation has been observed due to compulsive engagement of
mother/caregivers in cultivation or other household engagement and due to cultural taboos. To
overcome this, in Odisha, community meetings are held at the village level for mass awareness to
ensure uptake and utilization of the available CMAM services.
In Assam, due to COVID-19, group meetings and community-based events have not been held in
the community, due to which it’s not easy to do group counselling. To overcome this, strategies
like priority home visits, telephonic calls, WhatsApp messages were adopted.
ii. Lack of knowledge and skills in frontline workers on essentials of CMAM
Another challenge in effective implementation of CMAM pertains to poor knowledge and skills
of frontline workers in obtaining accurate anthropometric measurements (reported from Odisha
and Madhya Pradesh) and lack of availability of GMDs. To overcome this challenge, in Odisha, a
video in Odia was prepared on growth monitoring modules with support from UNICEF.
Field functionaries across the state are now being trained on growth monitoring, identification
and management of SAM and improving IYCF. Virtual zoom meetings are also held from time-to-
time to orient and clear doubts of field functionaries.
In Madhya Pradesh too, measures were taken for overcoming gaps with respect to skills and
capacity of FLWs in obtaining correct anthropometric measurements. They have also ensured
100% availability of medicines and supplements with support of the Health Department.
iii. Training, mindset and resource-related constraints
In Gujarat, there were initial challenges in the state with respect to the use of balamrutam.
There were additional challenges in adapting to the changes in modalities of the programme
and the introduction of new processes,for instance, the shift in MIS from E-mamta to TECHO+
(Technology Enabled Community Health Operations – Gujrat Government application).
Monitoring of CMAM in field and engagement of health officials and functionaries in COVID-19
related activities further created limitations. 76Transforming Child Nutrition
These challenges were overcome using the following strategies:
ĥConducting trainings in cascade mode for all the FLFs on CMAM programme.
ĥUpdating and revising guidelines under CMAM programme along with orientation/sensitization
sessions planning through use of SATCOM platform.
ĥIntegration of CMAM module in TECHO software.
ĥDevelopment of joint MIS for tracking SAM children in entire state in convergence with DWCD and
having joint convergence planning and review of CMAM programme across all levels.
In Haryana, there were challenges faced with respect to capacity building/trainings and refresher trainings
due to lack of funds. Parents of children with SAM were also not willing to bring their child for check-up/
admission to District Hospitals/Private Hospitals/NRCs. To overcome this, government vehicles were used for
bringing children for health check-up to facilities.
A similar challenge of lack of willingness of parents was also reported in Jammu and Kashmir due to
prevalent social taboos and practices, such as consulting local charlatans. Measures were taken by the state
government to create awareness among masses through radio, television and hoardings (prepared in local
languages). Health department was involved in the process by nominating CDPOs as nodal officers for ruling
out malnourished cases.
In Jharkhand, COVID-19 related restriction delayed the process of scale-up of CMAM programme in the
state due to poor involvement and less availability of ANMs, inability to conduct face-to-face trainings,
closure of AWCs, interrupted THR supply and cessation of GMP activities. To overcome these challenges,
following measures were taken:
iv. Integration challenges for multisectoral engagement and linkages (Figure 36).
In Chhattisgarh, engagement of frontline workers in COVID-19 vaccine duties led to disruption of CCSAM
services. Additionally, limited ownership of Health Department and convergence for CCSAM programme
and reluctance of workers due to new protocols defined under the programme also posed numerous
challenges in the implementation of CCSAM programme in the state. The proposed solution is conducting
regular intersectoral meetings, with the involvement of higher district officials like DM and SDM in TLs to
ensure convergence and overcoming of reported challenges.
Conducting online training with the
support from SCoE-RIMS and UNICEF.
Following COVID-19 appropriate
behavior during enrollment of a child.
Ensuring availability of masks, gloves,
and sanitizers for frontline workers.
Doorstep delivery of THR, nutrition counselling
during home visit, assess improvement in child
during home visit.
1
2
3
4
Figure 36: Multisectoral engagement and linkages 77Transforming Child Nutrition
In Maharashtra, the following challenges were observed: lack of convergence between health and ICDS
functionaries at all levels for ensuring accurate identification of children with SAM, lack of continuous
support from health functionaries at all levels in terms of certification and timely delivery of medicines, lack
of additional financial support from Gram Panchayat Development Plan (GPDP), PESA and DPDC for delivery
of medicines and other logistics, and inadequate data systems for end-to-end management of children with
SAM and understanding child-wise progress.
These affect the overall process of review, monitoring, and programme improvement. Need-based counselling
of caregivers concerning the management of children with SAM and the requirement of flexibility in CBEs
and SBCC campaign are also needed.
Lastly, strong linkages with NRCs through referral system for children with medical complications and those
who have not recovered through VCDCs need to be established. Following measures have been actioned in
the state to overcome these challenges (Figure 37).
In Rajasthan, challenges were faced while conducting offline training sessions due to COVID-19 pandemic
and GMP activities due to lack of GMDs and increased reliance on MUAC. There was a need for integrating
Joint Monitoring plans of Health and ICDS in existing system for speeding up data collection.
Continuous implementation of joint screening: The Department of WCD and the Department
of PHD work in close coordination at all levels to ensure the effectiveness of the screening
drive. It will help in the proper identification and certification of children with SAM. The crux of
the strategy was reshuffling of health and ICDS supervisory personnel, to bring transparency
and quality in the screening, and thereby fetch volume.
Continuous official communication through letters and government
resolutions to leverage local funds towards children with SAM.
Supplementing the treatment protocol and tracking with strong data systems of dedicated
software for end-to-end management of children with SAM management.
Initiation of the special CBEs focused on children with SAM in high-burden blocks. The
focus is not just on the curative aspects but also on ensuring the further development
of a child and avoiding relapse.
Care beyond NRC: The department ran a pilot project where the paediatric ward at the
hospital was supported to function as a facility to treat SAM children along with its ongoing
services. This was achieved by rationalizing the human resources, providing Standard F75 and
F100 WHO Medical Nutrition Therapy in the paediatric ward, and using an open-source digital
data collection, storage and reporting system.
Figure 37: Challenges observed in Maharashtra 78Transforming Child Nutrition
To overcome these challenges, refresher training of FLWs on COVID-19-appropriate behavior was conducted.
Frequency of online trainings was increased to compensate for the lack of offline trainings due to COVID-19.
Mapping of inventory and convergence with other departments and civil society organizations for action on
lack of GMDs were also undertaken. Continuous troubleshooting through social media messaging channels
and regular refresher and review meetings with block and district officials were also held.
v. Challenges related to the system, field functionaries and community
In Bihar, the following challenges came up in GMP activities: lack of functional GMDs, lack of knowledge
regarding the usage of machines and care of equipment, no system for calibration of equipment in ICDS,
lack of fair policy for annual maintenance of equipment, issues regarding identification and follow-up of
children with SAM. Regarding medicine supplies, distribution system is weak with respect to availability of
medicines at block level and ANM at field level.
Some medicines which are not a part of the essential drug list or which don’t have a regular supply chain
mechanism (like vitamin A, folic acid and multivitamin syrup) cannot be procured to be distributed to
children. There is also limited knowledge and capacity of field functionaries which affects the quality of
services delivered in the field.
There are issues in reporting, as preparing reports based on the recorded information and compilation from
AWC level to District level is cumbersome. There is no demand at the community level regarding nutrition
services like growth monitoring, nutrition counselling and annaprashan.
All these challenges can be divided in three categories i.e., system-level, field functionaries-level and
community-level (Figure 38).
For the system-
level challenges,
the system needs
to be strengthened
through fair policy
for equipment,
medicine supplies
and convergence
with other
departments.
A web-based MIS
can be a solution for
problems related to
reporting. Monitoring
of children with SAM
should be aligned
with the poshan
tracker and report
should be generated
on the basis of data
entered.
For field functionaries-
level issues, straining
need should be
assessed and
training should be
imparted as per the
knowledge level of
the functionaries, the
same methods and
duration of training
cannot be used for
different knowledge-
level functionaries.
Figure 38: Challenges categorised at various levels in Bihar 79Transforming Child Nutrition
Further investigation for better understanding of these challenges is warranted to develop solutions to
strengthen the programmes and improve the outcomes.
In Uttar Pradesh, the community-based programme for SAM was scaled up across the state through the
SAMBHAV campaign. At-scale implementation of the programme faced the following challenges: Closure of
AWCs due to COVID-19, engagement of districts in COVID-19 management and vaccination, impact on the
screening quality due to the late roll-out of GMDs, difficulty in ensuring capacities of 1.8 lacs AWWs across
the state, Additionally, the transition of paper-based reporting to technology-driven reporting using the
poshan tracker for AWWs is a challenging and time-consuming process, requiring considerable support and
handholding.
Necessary programmatic adjustments are being made considering the challenges in the first phase
of implementation of SAMBHAV programme. The next phase will continue to focus on strengthening
the capacities of the FLWs on GMDs, the use of poshan tracker and quality of home visits to improve
screening, service delivery and reporting; dedicated communication strategy to influence the demand
and mobilization (Figure 39).
Ensuring compliance to the protocol at the family
level especially for feeding, which also depends on
uninterrupted and efficient supply chain of foods and
medicines, besides focused counselling
Slower and lower recovery among these children, which could
be due to some physiological peculiarities of Indian children,
weaker compliance to the protocol, as well as nutrient
composition of the foods used for nutritional rehabilitation.
Common
challenges
1
2
Figure 39: Common challenges faced during implementation of SAMBHAV programme 80Transforming Child Nutrition 81Transforming Child Nutrition
The Way Forward8
Community-Based Management of Acute Malnutrition (CMAM) is an effective tool for combating
malnutrition. Several states have taken proactive steps in this direction by developing guidelines. Since
malnutrition is prevalent across the country, it is imperative to develop national guidelines on Community-
Based Management of Acute Malnutrition. In order to strengthen the existing CMAM programme in an
effective manner, the states can take the following actions (Figure 40).
Enhancing the capacity of
community health workers to
effectively screen and identify cases
of acute malnutrition by providing
regular training, ensuring the
availability of standardized tools,
and promoting the use of validated
measurement techniques.
Ensuring access to
prompt and effective
management by
developing CMAM
programme/
guidelines in all states
and union territories.
Special focus should
be accessibility of
programme in hard-
to-reach areas through
creative methods like
mobile clinics and
community outreach
programmes.
Recent research and recommendations
advocate for updating and improving
treatment protocols for acute malnutrition;
optimize dosage and duration of medicine and
food; monitor treatment response; manage
complications/comorbidities; incorporate herbal
bio-enhancers into food products to enhance
bioavailability and bioefficacy of nutrients in food.
Establishing robust supply
chain systems to ensure the
uninterrupted availability of
Take-Home Ration, medicines, and
other essential supplies. Improved
forecasting, procurement, storage,
and distribution mechanisms will
prevent stockouts and wastage.
Enhancing data collection
and monitoring systems
to track program
performance, treatment
outcomes, and coverage.
Regularly analyses of
data for identifying
bottlenecks, monitor
progress, and inform
evidence-based decision-
making. Invest in
robust monitoring and
evaluation mechanisms
to generate high-
quality data for program
improvement.
Fostering collaboration
among various stakeholders,
including government
agencies, non-governmental
organizations, development
partners, and community-based
organizations.
1
2
34
5
6
Proactive
Steps for
CMAM
Figure 40: Actions followed-up for proactive steps in various states under CMAM programme 82Transforming Child Nutrition
ANNEXURES
Annexure 1: Google form used to capture information from different states of India on CMAM
Community Based Management of children with Severe Acute Malnutrition(C-MAM) - Practices in India
* Required
Email *
Background Information
1. Name of the State
2. Geography of implementation *
State-wide
»Select districts
»Select blocks
If implemented in districts or blocks, mention the name of the districts
3. Title of the CMAM programme in the State (e.g., in Rajasthan it is called Acute Malnutrition Management Action
AMMA programme) *
4. Background (Geographical information, Health and Nutritional status of U5Y children)
5. Baseline Situation (Situation before the introduction of the practice) *
Steps of Management of children with MAM and SAM in community
6. Describe community awareness/sensitization/mobilization process
7. Screening Process- Anthropometric parameters (Method adopted and Process involved)
8. Special effort/Practice for finding the SAM cases
9. Result of special efforts for finding the SAM cases
10. Medical Assessment process
11. Appetite test
12. Details of Nutritional Treatment
13. Place of nutritional treatment
14. Selected Anganwadi centers in an ICDS project are designated as VCDCs.
15. Nutritional Product Name (Ingredients, quantity, Nutritive value, frequency of distribution, dose, packets weight
and packets distributed)
16. Mention the nutritional products details given to SAM children
17. Mention the nutritional products details given to MAM children
18. Medical treatment. Mention the condition that require medical management at community level, dose and
duration 83Transforming Child Nutrition
19. Follow-up while in CMAM programme (frequency and lasts how long, follow-up after discharge (where /who
conducts)
20. Health and Nutrition education. (By whom, frequency of counselling, mode of counselling)
Capacity building
21. Capacity building process
22. Mention the frequency of training
Sectoral Integration
23. Involvement of multisectors, any integration happened /who are involved /Process and benefits of that
integration
Monitoring and Reporting
24. Recording and reporting details
25. Mention if any methods of monitoring (telemedicine/helplines/ call center)
26. Please provide the details of monitoring (By whom, frequency, feedback and follow-up)
Practices
27. Describe practices on any of the components of community management and result of practice (400 words)
28. Scalability, replicability and sustainability plan
29. Challenges faced
30. Plans to overcome the challenge
31. Share hyperlinks/references to get more details, tools, background documents
32. Share appropriate Pictures – high resolution photographs as images
33. Share contact details of person for more information, details, guidance 84Transforming Child Nutrition
Annexure 2: Nutrient composition of Balamrutham Plus used for children with SAM under
CMAM programme in Telangana
Under the Supervised Supplementary Feeding Program (SSFP) protocol, 200 ml milk and one egg per
day are also provided to MAM/SAM children along with the balamrutham plus ration, which meets
the protein requirements. Balamrutham plus is a powder prepared by dissolving in equal amount of
lukewarm water to form a paste.
IngredientGrams / 100 gram
Skimmed milk powder13.3
Groundnut3.3
Oil20
Sugar20
Roasted wheat26.7
Bengal gram3.3
Rice flakes13.3
NutrientPer 100 gm
Energy (Kcal)460
Protein (g)11
Calcium (mg)419
Iron (mg)9.1
Zinc (mg)6.3
Vitamin A (mg)0.2
Vitamin B1 (mg)0.5
Vitamin B2 (mg)0.6
Vitamin C (mg)15.7
Vitamin B12 (mcg)0.7
Folic acid (mcg)36.1
Niacin (mg)5.5 85Transforming Child Nutrition
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