Severe and moderate acute malnutrition detection in a rural hospital pediatric outpatient clinic and their comparison with the IAP charts: a two-year study




IAP chart, Moderate acute malnutrition, MUAC, Severe acute malnutrition, WHO growth charts


Background: Children with moderate acute malnutrition (MAM) have an increased list of mortality, infections and impaired physical and cognitive development compared to well-nourished children. The Objectives of this study were to diagnose Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM) using WHO growth charts as a criterion and to compare the WHO classification with the IAP classification in the diagnosis of SAM and MAM.

Methods: A two-year duration cross-sectional study conducted in Pediatric outpatient clinic of a rural hospital from January 2013 to December 2014. In case of moderate acute malnutrition (MAM) was diagnosed as weight-for-height >-3 but <-2 Z scores of the median according to WHO growth standards. We defined MAM as mid-upper am circumference (MUAC) of >11.0 cm and <12.5 cm with no bilateral pitting edema and SAM as MUAC less than 11.5 cm. We compared the values with the IAP charts for diagnosis of malnutrition. Our set up is not a nutrition rehabilitation centre, feeding programmes were not implemented.

Results: The distribution of prevalence of SAM and MAM differs significantly across three age groups studied (P-value <0.001). However, it did not differ significantly between boys and girls aged between 6 months to 6 years (P-value >0.05). Of 90 SAM cases, 55 cases (61.1%) had Grade 1 IAP grade of malnutrition, 28 cases (31.1%) had Grade 2 IAP grade of malnutrition, 7 cases (7.8%) had Grade 3 IAP grade of malnutrition. None of the SAM cases fell in Grade 4 IAP. The distribution of prevalence of SAM and MAM differs significantly across various IAP grades of malnutrition (P-value <0.001).

Conclusions: The IAP charts used for diagnosing malnutrition did not have any comparative value with the WHO charts used for the SAM MAM detection. WHO grading of SAM and MAM is more sensitive than IAP grading in early diagnosis of under nutrition and facilitate early treatment. Not having a targeted nutrition-specific intervention to address MAM in this set up places these children with MAM at excessive risk of adverse outcomes. Further preventive and curative approaches should urgently be considered.


Chang CY, Trehan I, Wang R, Thakwalakwa C. Children successfully treated for moderate acute malnutrition remain at risk for malnutrition and death in the subsequent year after recovery. J Nutr. 2013;143(2):215-20.

Shams Z, Zachariah R, Enarson DA, Satyanarayana S. Severe malnutrition in children presenting to health facilities in an urban slum in Bangladesh. Public Health Action. 2012;2(4):107-11.

Maurya M, Singh DK, Ra Ri, Mishra PC. An experience of facility-based management of severe acute malnutrition in children aged between 6-59 months adopting the World Health Organization recommendations. Indian Pediatr. 2014;51(6):481-3.

Shewade H, Sunderamurthy B, Jayakumar N, Ramadoss P. Prevalence of severe acute malnutrition among under-five children: a community-based cross-sectional study from Puducherry, India. Indian J Maternal Child Health. 2012;15(1):1-9.

James P, Sadler K, Wondafrash M, Argaw A. Children with moderate acute malnutrition with no access to supplementary feeding programmes experience high rates of deterioration and no improvement: results from a prospective cohort study in rural Ethiopia. PloS One. 2016;11(4):1-26.

Shareef FM, Manoj JM. Application of WHO MUAC for age: Z score in diagnosis of SAM in Indian children; a comparative study with IAP classification. J Pediatr Res. 2016;3(12):882-6.

Patel B, Gandhi D. WHO classification detecting more severe malnutrition: a comparative study with IAP classification. Indian J Basic Applied Med Res. 2016;5(2):628-34.

Shankar P, Thakur JS, Bhatia SS. Pilot testing of WHO child growth standards in Chandigarh: Implications for India’s child health programmes. Bulletin of the World Health Organization. 2009;87:116-22.

Sahu S, Ganeshkumar S, Bhat VB, Premarajan KC, Sarkar S, Roy G, et al. Malnutrition among under- five children in India and strategies for control. J Nat Sci Biol Med. 2015;6(1):8-23.






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