rare td | ge, | nfeered .

oy ORAR GeeaoT Harcral aret felcors Harerel Abhiyan

@ Ministry of Ministry of Scheee
he ono
Health and Women and eeee =
LL sta Daan Family Welfare Child Development

Protocol for
MANAGEMENT of
MALNUTRITION IN CHILDREN
 PROTOCOL FOR
PROTOCOL FOR MANAGEMENT
MANAGEMENT OF
OF MALNUTRITION
MALNUTRITION IN
IN CHILDREN
CHILDREN

—–”‹–‹‘
Nutrition ‹•is ƒacknowledged
‘™Ž‡†‰‡† ƒ•
as ‘‡
one ‘ˆ
of –Š‡
the ‘•–
most ‡ˆˆ‡ –‹˜‡ ‡–”›
effective entry ’‘‹–•
points ˆ‘”
for ’Š›•‹
physicalƒŽ ƒ†
and
‹–‡ŽŽ‡ –—ƒŽ ‰”‘™–Š
intellectual growth ƒ†
and †‡˜‡Ž‘’‡–Ǥ
development. It– ‹•
is ƒ
a ‡›
key —•–ƒ‹ƒ„Ž‡
Sustainable ‡˜‡Ž‘’‡–
Development Goal.‘ƒŽǤ ’–‹—
Optimum
ƒ†ƒ’’”‘’”‹ƒ–‡—–”‹–‹‘‹•‡••‡–‹ƒŽˆ‘”™‘‡ƒ†
and appropriate nutrition is essential for women and children Š‹Ž†”‡–‘•—”˜‹˜‡ǡ–Š”‹˜‡ƒ†„”‡ƒ
to survive, thrive and break
–Š‡‹–‡”‰‡‡”ƒ–‹‘ƒŽ › Ž‡‘ˆƒŽ—–”‹–‹‘ƒ†’‘‘”Š‡ƒŽ–Š‹–Š‡
the intergenerational cycle ‘—‹–›Ǥ
of malnutrition and poor health in the community.

Malnutrition
Malnutrition

ƒŽ—–”‹–‹‘
Malnutrition ‹• is ‘‡
one ‘ˆ
of –Š‡
the ‘•–
most ‹’‘”–ƒ– ŠƒŽŽ‡‰‡• ˆƒ
important challenges ‹‰ contemporary
facing ‘–‡’‘”ƒ”› India.
†‹ƒǤ Š‹Ž‡
While
ƒŽ—–”‹–‹‘‹•™‹†‡Ž›
malnutrition is widely —•‡†–‘†‡• ”‹„‡—†‡”—–”‹–‹‘ǡ‹–ƒ
used to describe –—ƒŽŽ›”‡’”‡•‡–•„‘–Š—†‡”
under nutrition, it actually represents both under
ƒ†
and ‘˜‡”
over —–”‹–‹‘Ǥ
nutrition. Š‹Ž‡
While —†‡”Ǧ—–”‹–‹‘
under-nutrition ”‡•—Ž–•
results ˆ”‘
from ‹ƒ†‡“—ƒ–‡ ‘•—’–‹‘ǡ ’‘‘”
inadequate consumption, poor
ƒ„•‘”’–‹‘‘”‡š ‡••‹˜‡Ž‘••‘ˆ—–”‹‡–•ǡ‘˜‡”Ǧ—–”‹–‹‘”‡•—Ž–•ˆ”‘‡š
absorption or excessive ‡••‹˜‡‡‡”‰›ƒ†
loss of nutrients, over-nutrition results from excessive energy and
ˆƒ–‹–ƒ‡Ǥ
fat intake. ‹–Š–Š‡‘„•‡”˜‡†—–”‹–‹‘
With the observed nutrition –”ƒ•‹–‹‘‹–Š‡’‘’—Žƒ–‹‘ǡ
transition in the population, „‘–Š—†‡”ƒ†‘˜‡”Ǧ
both under and over-
—–”‹–‹‘ ‘Ǧ‡š‹•–ǡ ƒ•
nutrition co-exist, as ‡˜‹†‡–
evident ˆ”‘
from –Š‡
the †ƒ–ƒ
data ˆ”‘
from ƒ–‹‘ƒŽ
National •—”˜‡›•Ǥ
surveys. Š‡
The ’”‘‰”ƒ‡
programme
‰—‹†‡Ž‹‡•†‡–ƒ‹Ž‡†‹–Š‹•†‘ —‡–Š‘™‡˜‡”†‡ƒŽ‡š Ž—•‹˜‡Ž›™‹–Š—†‡”Ǧ—–”‹–‹‘Ǥ
guidelines detailed in this document however deal exclusively with under-nutrition.

Under-nutrition and
Under-nutrition and the
the Nutrition
Nutrition Gap
Gap

†‡”Ǧ—–”‹–‹‘‹• ƒ—•‡†„›•‡˜‡”ƒŽ†‡–‡”‹ƒ–••—
Under-nutrition is caused by several determinants suchŠƒ•Ž‘™ˆƒ‹Ž›‹
as low family income,‘‡ǡŽƒ”‰‡ˆƒ‹Ž›
large family
•‹œ‡ǡ
size, ‰‡†‡”
gender „‹ƒ•ǡ Šƒ‰‹‰ crop
bias, changing ”‘’ ’ƒ––‡”•
patterns †—‡
due –‘
to ˜ƒ”‹‘—•
various ”‡ƒ•‘•
reasons Ž‡ƒ†‹‰
leading –‘
to †‹‡–ƒ”›
dietary
‹„ƒŽƒ
imbalance,‡ǡƒ ‡••–‘ˆ‘‘†ǡŽ‘••‘ˆ–”ƒ†‹–‹‘ƒŽˆ‘‘†Šƒ„‹–•ǡŽƒ
access to food, loss of traditional food habits, lack‘ˆ‘™Ž‡†‰‡‡–
of knowledge etc. Ǥ‘‘”Š‡ƒŽ–Š
Poor health
‘†‹–‹‘• •—
conditions suchŠ ƒ•
as †‹ƒ””Š‘‡ƒ
diarrhoea ƒ†
and ƒƒ‡‹ƒ
anaemia Šƒ˜‡
have ƒ ƒ• ƒ†‹‰ ‡ˆˆ‡
a cascading effect– ™Š‹
whichŠ ’‡”’‡–—ƒ–‡•
perpetuates
—†‡”Ǧ—–”‹–‹‘Ǥ
under-nutrition.

Forms of
Forms of Childhood
Childhood Undernutrition
Undernutrition

†‡”
Under —–”‹–‹‘
nutrition ‹ Š‹Ž†”‡ „‡Ž‘™
in children below ˆ‹˜‡
five ›‡ƒ”•
years ‘ˆ
of ƒ‰‡
age ‹
in ’‘’—Žƒ–‹‘•
populations ‹•
is ‡ƒ•—”‡†
measured „›
by –Š”‡‡
three
ƒ–Š”‘’‘‡–”‹
anthropometric  ‹†‹ ‡• ™Š‹
indices whichŠ ƒ”‡
are „ƒ•‡†
based ‘
on ƒ ‘’ƒ”‹•‘ ‘ˆ
a comparison of –Š‡
the ‡ƒ•—”‡†
measured Š‡‹‰Š–
height ƒ†
and
™‡‹‰Š–‘ˆ–Š‡ Š‹Ž† compared
weight of the child ‘’ƒ”‡†–‘–Š‡
to the WHO†‡ˆ‹‡†”‡ˆ‡”‡
defined reference‡Š‡‹‰Š–ƒ†™‡‹‰Š–‘ˆ Š‹Ž†”‡
height and weight of children
‘ˆ–Š‡•ƒ‡ƒ‰‡ƒ†•‡šǤŠ‡•‡–Š”‡‡‹†‹
of the same age and sex. These three indices, ‡•ǡ˜‹œǤǡȋ‹Ȍ™‡‹‰Š–Ǧˆ‘”Ǧƒ‰‡ǡȋ‹‹ȌŠ‡‹‰Š–ȀŽ‡‰–ŠǦˆ‘”Ǧ
viz., (i) weight-for-age, (ii) height/ length-for-
ƒ‰‡ǡȋ‹‹‹Ȍ™‡‹‰Š–Ǧˆ‘”ǦŠ‡‹‰Š–ȀŽ‡‰–Šƒ”‡—•‡†–‘‹†‡–‹ˆ›—†‡”™‡‹‰Š–ǡ•–—–‹‰ƒ†™ƒ•–‹‰ǡ
age, (iii) weight- for-height/ length are used to identify underweight, stunting and wasting,
”‡•’‡ –‹˜‡Ž›Ǥ
respectively.

Underweight: †‡”™‡‹‰Š–
Underweightǣ Underweight can ƒ ”‡•—Ž–
result ˆ”‘‡‹–Š‡” Š”‘‹  ‘”
from either chronic or ƒacute
—–‡ ƒŽ—–”‹–‹‘
malnutrition ‘”
or „‘–ŠǤ
both.
—†‡”™‡‹‰Š– Š‹Ž†Šƒ•ƒ™‡‹‰Š–Ǧˆ‘”Ǧƒ‰‡Ǧ•
An underweight child has a weight-for-age Z-score‘”‡ƒ–Ž‡ƒ•––™‘•–ƒ†ƒ”††‡˜‹ƒ–‹‘•„‡Ž‘™
at least two standard deviations below
–Š‡‡†‹ƒȋǦʹȌˆ‘”–Š‡‘”Ž† ‡ƒŽ–Š”‰ƒ‹œƒ–‹‘ȋ
the median (-2 SD) for the World Health Organization (WHO) ȌŠ‹Ž† ”‘™–Š–ƒ†ƒ”†•Ǥ
Child Growth Standards.

e Moderate Underweight
Moderate Underweight (MUW)(MUW) ‹•†‡ˆ‹‡†ƒ•™‡‹‰Š–Ǧˆ‘”Ǧƒ‰‡„‡–™‡‡Ǧʹƒ†Ǧ͵
is defined as weight-for-age between -2 and -3 SD
ƒ•’‡” ‰”‘™–Š•–ƒ†ƒ”†Ǥ
as per WHO growth standard.
e Severe Underweight
Severe Underweight (SUW)‹•ƒ ‘†‹–‹‘‹™Š‹
(SUW) is a condition in whichŠƒ Š‹Ž†Šƒ•ƒ˜‡”›Ž‘™™‡‹‰Š–‹
a child has a very low weight in
”‡Žƒ–‹‘–‘ƒ‰‡ȋ• ‘”‡‘ˆδǦ͵Ȍǡƒ•’‡”
relation to age (Z score of < - 3 SD), as per WHO child
Š‹Ž†‰”‘™–Š•–ƒ†ƒ”†•Ǥ
growth standards.

1
 ƒ‹Ž—”‡ –‘
Stunting: Failure
Stunting: to ƒachieve
Š‹‡˜‡ ‡š’‡ –‡† Š‡‹‰Š–ȀŽ‡‰–Š
expected height/length ƒ• ‘’ƒ”‡† –‘
as compared to Š‡ƒŽ–Š›ǡ
healthy, ™‡ŽŽǦ
well-
‘—”‹•Š‡† Š‹Ž†”‡ ‘ˆ –Š‡ •ƒ‡ ƒ‰‡ ‹• ƒ •‹‰ ‘ˆ •–—–‹‰Ǥ–—–‹‰ ‹• ƒ ‹†‹
nourished children of the same age is a sign of stunting. Stunting is an indicator of linear ƒ–‘” ‘ˆŽ‹‡ƒ”
‰”‘™–Š”‡–ƒ”†ƒ–‹‘Ǥ
growth retardation. It–‹•ƒ‹†‹ ƒ–‘”‘ˆ
is an indicator Š”‘‹ ‰”‘™–Šˆƒ‹Ž—”‡ƒ••‘
of chronic growth failure associated‹ƒ–‡†™‹–Šƒ—„‡”‘ˆ
with a number of
Ž‘‰Ǧ–‡”
long-term factors including chronic insufficient nutrient intake, frequent ‹ˆ‡
ˆƒ –‘”• ‹ Ž—†‹‰ Š”‘‹  ‹•—ˆˆ‹ ‹‡– —–”‹‡– ‹–ƒ‡ǡ ˆ”‡“—‡– –‹‘ ƒ†
infection and
‹ƒ’’”‘’”‹ƒ–‡ˆ‡‡†‹‰’”ƒ –‹ ‡•Ǥ•–—–‡† Š‹Ž†Šƒ•ƒŠ‡‹‰Š–Ǧˆ‘”Ǧƒ‰‡Ǧ• ‘”‡–Šƒ–‹•ƒ–Ž‡ƒ•–
inappropriate feeding practices. A stunted child has a height-for-age Z-score that is at least
–™‘•–ƒ†ƒ”††‡˜‹ƒ–‹‘•ȋǦʹȌ„‡Ž‘™–Š‡‡†‹ƒˆ‘”–Š‡
two standard deviations (-2 SD) below the median for the WHOŠ‹Ž† ”‘™–Š–ƒ†ƒ”†•Ǥ
Child Growth Standards.

Wasting: ƒ•–‹‰
Wasting: Wasting ‹†‹ ƒ–‡• current
indicates —””‡– ‘”
or ƒacute
—–‡ ƒŽ—–”‹–‹‘
malnutrition ”‡•—Ž–‹‰
resulting ˆ”‘
from ˆƒ‹Ž—”‡
failure –‘
to ‰ƒ‹
gain
™‡‹‰Š–‘”ƒ –—ƒŽ™‡‹‰Š–Ž‘••Ǥ—„‘’–‹ƒŽ
weight or actual weight loss. Suboptimal Infantˆƒ–ƒ†‘—‰ Š‹Ž† care
and Young child ƒ”‡ƒ†ˆ‡‡†‹‰’”ƒ –‹ ‡•
and feeding practices
‹ Ž—†‹‰ ‹ƒ†‡“—ƒ–‡
including ‘’Ž‡‡–ƒ”› ˆ‡‡†‹‰
inadequate complementary feeding ‹
in ‘Ž†‡”
older ‹ˆƒ–•
infants ƒ†
and ›‘—‰ Š‹Ž†”‡ ˆ”‘
young children from ͸ 6
‘–Š•–‘ʹ›‡ƒ”•‘ˆƒ‰‡ǡ”‡’‡ƒ–‡†‡–‡”‹
months to 2 years of age, repeated enteric ƒ†”‡•’‹”ƒ–‘”›–”ƒ
and respiratory tract–‹ˆ‡ –‹‘•ƒ”‡•‘‡‘ˆ–Š‡
infections are some of the
ˆƒ –‘”• Ž‡ƒ†‹‰
factors leading –‘
to ‡˜‡”‡  —–‡ ƒŽ—–”‹–‹‘
Severe Acute Malnutrition ȋȌ
(SAM) ‹ Š‹Ž†”‡Ǥ ƒ•–‹‰
in children. Wasting ‹
in ‹†‹˜‹†—ƒŽ
individual
Š‹Ž†”‡ƒ†’‘’—Žƒ–‹‘‰”‘—’• ƒ Šƒ‰‡”ƒ’‹†Ž›ƒ†•Š‘™•ƒ”‡†•‡ƒ•‘ƒŽ˜ƒ”‹ƒ–‹‘•
children and population groups can change rapidly and shows marked seasonal variations
ƒ••‘ ‹ƒ–‡† ™‹–Š
associated Šƒ‰‡• ‹
with changes in ˆ‘‘†
food ƒ˜ƒ‹Žƒ„‹Ž‹–›
availability ‘”
or †‹•‡ƒ•‡
disease ’”‡˜ƒŽ‡
prevalence‡ –‘
to ™Š‹
whichŠ ‹–
it ‹•
is ˜‡”›
very
•‡•‹–‹˜‡Ǥ™ƒ•–‡† Š‹Ž†Šƒ•ƒ™‡‹‰Š–Ǧˆ‘”ǦŠ‡‹‰Š–Ǧ• ‘”‡ƒ–Ž‡ƒ•––™‘•–ƒ†ƒ”††‡˜‹ƒ–‹‘•
sensitive. A wasted child has a weight- for-height Z-score at least two standard deviations
ȋǦʹȌ„‡Ž‘™–Š‡‡†‹ƒˆ‘”–Š‡
(-2 SD) below the median for the WHOŠ‹Ž† ”‘™–Š–ƒ†ƒ”†•Ǥ
Child Growth Standards.

e Moderate Acute
Moderate (MAM) †‡ˆ‹‡†ƒ•™‡‹‰Š–Ǧˆ‘”ǦŠ‡‹‰Š–„‡–™‡‡Ǧʹƒ†
Malnutrition (MAM)
Acute Malnutrition defined as weight-for-height between -2 and
Ǧ͵ƒ•’‡”
-3 SD as per WHO‰”‘™–Š•–ƒ†ƒ”†Ǥ
growth standard.
e Severe Acute
Severe (SAM) ‹•
Malnutrition (SAM)
Acute Malnutrition is ƒ ‘†‹–‹‘ ‹
a condition in ™Š‹
whichŠ ƒ Š‹Ž† Šƒ•
a child has ƒ
a ˜‡”›
very Ž‘™
low
™‡‹‰Š–‹”‡Žƒ–‹‘–‘Ž‡‰–ŠȀŠ‡‹‰Š–ȋ• ‘”‡‘ˆδ Ǧ͵Ȍǡƒ•’‡”  Š‹Ž†
weight in relation to length/height (Z score of < - 3 SD), as per WHO child growth ‰”‘™–Š
•–ƒ†ƒ”†•Ǥ‹•ƒ•‡˜‡”‡ˆ‘”‘ˆ™ƒ•–‹‰Ǥ
standards. SAM is a severe form of wasting.

”‘™–Š Faltering
Growth ƒŽ–‡”‹‰ ‡ƒ•
means ‰”‘™–Š
growth ”ƒ–‡
rate „‡Ž‘™
below –Š‡
the •–ƒ†ƒ”†
standard ˆ‘”
for ƒ Š‹Ž†ǯ• ƒ‰‡
a child’s age
Ƭ‰‡†‡”Ǥ
& gender. It–ƒ›‹ Ž—†‡„‘–Š™‡‹‰Š–ƒ†Ž‡‰–ŠȀŠ‡‹‰Š–ƒ”‡Ž‘™‡”–Šƒ•–ƒ†ƒ”†Ǥ
may include both weight and length/height are lower than standard.

Implications of
Implications of Undernutrition
Undernutrition

†‡”—–”‹–‹‘Šƒ•ƒƒ†˜‡”•‡‹’ƒ
Undernutrition has an adverse impact –‘ƒŽŽ•–ƒ‰‡•‘ˆ–Š‡Ž‹ˆ‡ › Ž‡ǡ„—–•‘‡‘ˆ–Š‡
on all stages of the life cycle, but some of the
‘•–†ƒƒ‰‹‰‡ˆˆ‡
most damaging effects–•‘ occur—”ˆ”‘ ‘ ‡’–‹‘–‘ͳͲͲͲ†ƒ›•‘ˆƒ‰‡Ǥ”‡˜‡–‹‘‹•‹’‘”–ƒ–
from conception to 1000 days of age. Prevention is important
ƒ––Š‹•–‹‡Ǥ‡•‹†‡• ‘–”‹„—–‹‰•‹‰‹ˆ‹
at this time. Besides contributing ƒ–Ž›–‘
significantly Š‹Ž†‘”–ƒŽ‹–›ǡ‹””‡˜‡”•‹„Ž‡„”ƒ‹†ƒƒ‰‡
to child mortality, irreversible brain damage
can occur in this period of life. Both underweight and •–—–‹‰
ƒ ‘ —” ‹ –Š‹• ’‡”‹‘† ‘ˆ Ž‹ˆ‡Ǥ ‘–Š —†‡”™‡‹‰Š– ƒ† stunting •‡–
set ‹
in ‡ƒ”Ž›ǡ
early, ‹
in –Š‡
the ˆ‹”•–
first ʹ
2
›‡ƒ”•ǡ™Š‡–Š‡ Š‹Ž†‡‡†•–‘„‡ˆ‡†ƒ†‡“—ƒ–‡Ž›ƒ†ƒ’’”‘’”‹ƒ–‡Ž›ƒ†‹•ƒŽ•‘‡š’‘•‡†–‘
years, when the child needs to be fed adequately and appropriately and is also exposed to
ˆ”‡“—‡–‡’‹•‘†‡•‘ˆ‹ˆ‡
frequent episodes of infections, –‹‘•ǡ’ƒ”–‹ —Žƒ”Ž›†‹ƒ””Š‡ƒǤ
particularly diarrhea. In India,
†‹ƒǡ–Š‡Š‹‰Š‡•–„—”†‡‘ˆ—†‡”
the highest burden of under
—–”‹–‹‘‘ —”•„‡–™‡‡„‹”–Šƒ†–™‘›‡ƒ”•‘ˆƒ‰‡Ǣ–Š‡”‡ˆ‘”‡ǡ’”‡˜‡–‹˜‡‡ƒ•—”‡•‡‡†
nutrition occurs between birth and two years of age; therefore, preventive measures need
–‘’”‡†‘‹ƒ–Ž›ƒ††”‡••
to predominantly address children Š‹Ž†”‡—†‡”ʹ›‡ƒ”•Ǥ‘”‡‘˜‡”ǡ’”‡˜‡–‹‘‘ˆ—†‡”—–”‹–‹‘
under 2 years. Moreover, prevention of under nutrition
†—”‹‰
during –Š‹•
this ’‡”‹‘†
period ‹•is ‹’‘”–ƒ–
important ƒ† and ”‡“—‹”‡•
requires ‹‹–‹ƒ–‹˜‡•
initiatives –‘
to ‡•—”‡
ensure –Šƒ– Š‹Ž†”‡ ƒ”‡
that children are „‘”
born
Š‡ƒŽ–Š›ƒ†™‹–Šƒ†‡“—ƒ–‡™‡‹‰Š–Ǥ
healthy and with adequate weight. Once‡ children Š‹Ž†”‡•‡––Ž‡‹–‘ƒ‰”‘™–Š
settle into a growth curve—”˜‡ƒ––Š‡‡†‘ˆʹ
at the end of 2
›‡ƒ”•ǡ‹–‹•’ƒ”–‹ —Žƒ”Ž›†‹ˆˆ‹
years, it is particularly —Ž––‘•Š‹ˆ––Š‡Ž‹‡ƒ”‰”‘™–Š’ƒ––‡”—’™ƒ”†ǡƒ†”‡
difficult to shift the linear growth pattern upward, and recover ‘˜‡”ˆ”‘
from
•–—–‹‰Ǥ †‡‡†ǡ ƒ––‡’–•
stunting. Indeed, attempts –‘ to ‘˜‡”ˆ‡‡†
overfeed •— suchŠ children
Š‹Ž†”‡ ‡–ƒ‹Ž
entail ƒ
a ”‹•
risk ‘ˆ
of –Š‡
them „‡ ‘‹‰
becoming
‘˜‡”™‡‹‰Š–
overweight ™‹–Šwith Š‹‰Š‡”
higher ’”‘’‡•‹–›
propensity –‘ to †‡˜‡Ž‘’
develop ‘Ǧ ‘—‹ ƒ„Ž‡ †‹•‡ƒ•‡•
non-communicable diseases ƒ• as ƒ†—Ž–•ǡ
adults,
‹ Ž—†‹‰†‹ƒ„‡–‡•ǡŠ›’‡”–‡•‹‘ƒ†
including ƒ”†‹‘˜ƒ• —Žƒ”†‹•‡ƒ•‡Ǥ
diabetes, hypertension and cardiovascular disease.
2
Š‡”‡ˆ‘”‡ǡ‹–‹• ”‹–‹ ƒŽ–‘’”‡˜‡–—†‡”Ǧ—–”‹–‹‘ǡƒ•‡ƒ”Ž›ƒ•’‘••‹„Ž‡ǡƒ
Therefore, it is critical to prevent under-nutrition, as early as possible, across”‘••–Š‡Ž‹ˆ‡ › Ž‡ǡ
the lifecycle,
–‘ƒ˜‡”–‹””‡˜‡”•‹„Ž‡ ——Žƒ–‹˜‡‰”‘™–Šƒ††‡˜‡Ž‘’‡–†‡ˆ‹
to avert irreversible cumulative growth and development deficits ‹–•–Šƒ–‹’ƒ
that impact –ƒ–‡”ƒŽƒ†
maternal and
child survival and health. It undermines the achievement of optimal learning ‘—–
Š‹Ž† •—”˜‹˜ƒŽ ƒ† Š‡ƒŽ–ŠǤ – —†‡”‹‡• –Š‡ ƒ Š‹‡˜‡‡– ‘ˆ ‘’–‹ƒŽ Ž‡ƒ”‹‰ ‘‡•
outcomes
†—”‹‰‡Ž‡‡–ƒ”›‡†—
during elementary education,ƒ–‹‘ǡ‹’ƒ‹”•ƒ†—Ž–’”‘†— –‹˜‹–›ƒ†—†‡”‹‡•‰‡†‡”‡“—ƒŽ‹–›Ǥ
impairs adult productivity and undermines gender equality.

Strategies to
Strategies to tackle
tackle undernutrition
undernutrition among
among children
children

Š‡ ‘˜‡”‡– Šƒ•

The Government has –ƒ‡
taken •‡˜‡”ƒŽ
several ‹‹–‹ƒ–‹˜‡•
initiatives –‘
to „”‡ƒ
break –Š‡
the ‹–‡”‰‡‡”ƒ–‹‘ƒŽ
intergenerational cycle › Ž‡ ‘ˆ
of
ƒŽ—–”‹–‹‘Ǥ†‘’–‹‰ƒŽ‹ˆ‡Ǧ
malnutrition. Adopting a life-cycle› Ž‡ƒ’’”‘ƒ
approach,Šǡ‹–‡”˜‡–‹‘•Šƒ˜‡„‡‡†‡•‹‰‡†–‘‡‡––Š‡
interventions have been designed to meet the
—–”‹–‹‘ƒŽ
nutritional ”‡“—‹”‡‡–•
requirements ‘ˆ of ƒ†‘Ž‡• ‡– ‰‹”Ž•ǡ
adolescent girls, ’”‡‰ƒ–
pregnant ™‘‡ǡ
women, Žƒ –ƒ–‹‰ ‘–Š‡”•
lactating mothers ƒ†and
Š‹Ž†”‡–Š”‘—‰Š•‡˜‡”ƒŽ•
children through several schemesŠ‡‡•Ž‹‡
like POSHAN „Š‹›ƒƒǡ‰ƒ™ƒ†‹‡”˜‹
Abhiyaan, Anganwadi Services, ‡•ǡScheme
Š‡‡ˆ‘”
for
†‘Ž‡• ‡– Girls
Adolescent ‹”Ž• ƒ†
and ”ƒ†Šƒ
Pradhan ƒ–”‹
Mantri ƒ–”—
Matru ƒ†ƒƒ
Vandana ‘Œƒƒ
Yojana ȋȌ
(PMMVY) ƒ•as †‹”‡
direct– –ƒ”‰‡–‡†
targeted
‹–‡”˜‡–‹‘•–‘ƒ††”‡••–Š‡’”‘„Ž‡‘ˆƒŽ—–”‹–‹‘‹–Š‡
interventions to address the problem of malnutrition in the country. ‘—–”›Ǥ


POSHAN„Š‹›ƒƒ™ƒ•Žƒ—
Abhiyaan was launched on 8 –Š ƒ”
Š‡†‘ͺ MarchŠʹͲͳͺǡ™‹–Šƒƒ‹–‘ƒ
2018, with an aim to achieve Š‹‡˜‡‹’”‘˜‡‡–
improvement
‹—–”‹–‹‘ƒŽ•–ƒ–—•‘ˆ†‘Ž‡• ‡– ‹”Ž•ǡ”‡‰ƒ–‘‡ƒ†ƒ –ƒ–‹‰‘–Š‡”•‹ƒ–‹‡
in nutritional status of Adolescent Girls, Pregnant Women and Lactating Mothers in a time
„‘—†ƒ‡”„›ƒ†‘’–‹‰ƒ•›‡”‰‹•‡†ƒ†”‡•—Ž–‘”‹‡–‡†ƒ’’”‘ƒ
bound manner by adopting a synergised and result oriented approach.ŠǤ Further, —”–Š‡”ǡ–Š‡‡ˆˆ‘”–•
the efforts
—†‡”
under the Supplementary Nutrition Programme under Anganwadi Services and 
–Š‡ —’’Ž‡‡–ƒ”› —–”‹–‹‘ ”‘‰”ƒ‡ —†‡” ‰ƒ™ƒ†‹ ‡”˜‹ ‡• ƒ† POSHAN 
„Š‹›ƒƒ
Abhiyaan ™‡”‡
were ”‡Œ—˜‡ƒ–‡†
rejuvenated ƒ† ‘˜‡”‰‡† ƒ•
and converged as Ǯƒ•Šƒ ‰ƒ™ƒ†‹ ƒ†
‘Saksham Anganwadi and 
POSHAN ʹǤͲǯ
2.0’
ȋ‹••‹‘‘•ŠƒʹǤͲȌ–‘ƒ††”‡••–Š‡ ŠƒŽŽ‡‰‡•‘ˆƒŽ—–”‹–‹‘‹
(Mission Poshan 2.0) to address the challenges Š‹Ž†”‡ǡƒ†‘Ž‡•
of malnutrition in children, ‡–‰‹”Ž•ǡ
adolescent girls,
’”‡‰ƒ–
pregnant ™‘‡
women ƒ†
and Žƒ –ƒ–‹‰ ‘–Š‡”•
lactating mothers –Š”‘—‰Š
through a ƒ •–”ƒ–‡‰‹
strategic  •Š‹ˆ–
shift ‹
in —–”‹–‹‘ ‘–‡– ƒ†
nutrition content and
†‡Ž‹˜‡”›ƒ†„› ”‡ƒ–‹‘‘ˆƒ
delivery and by creation ‘˜‡”‰‡–‡ecosystem
of a convergent ‘•›•–‡–‘†‡˜‡Ž‘’ƒ†’”‘‘–‡’”ƒ
to develop and promote practices –‹ ‡•–Šƒ–
that
—”–—”‡Š‡ƒŽ–Šǡ™‡ŽŽ‡••ƒ†‹—‹–›Ǥ
nurture health, wellness and immunity.

‘•Šƒ
Poshan ʹǤͲ
2.0 ˆ‘ —•‡• ‘
focuses on ƒ–‡”ƒŽ
Maternal —–”‹–‹‘ǡ ˆƒ– ƒ†
Nutrition, Infant and ‘—‰
Young Š‹Ž† ‡‡†‹‰ ‘”•ǡ
Child Feeding Norms,
”‡ƒ–‡–
Treatment ‘ˆof Ȁ
MAM/SAM ƒ† and ‡ŽŽ‡••
Wellness –Š”‘—‰Š
through 
AYUSH. Ǥ It– ”‡•–•
rests ‘
on –Š‡
the ’‹ŽŽƒ”•
pillars ‘ˆ
of
‘˜‡”‰‡ ‡ǡ ‘˜‡”ƒ ‡ǡ ƒ† ƒ’ƒ ‹–›Ǧ„—‹Ž†‹‰Ǥ   „Š‹›ƒƒ ‹•
Convergence, Governance, and Capacity-building. POSHAN Abhiyaan is the key pillar for –Š‡ ‡› ’‹ŽŽƒ” ˆ‘”
—–”‡ƒ
OutreachŠ ƒ†
and ™‹ŽŽ ‘˜‡” ‹‘˜ƒ–‹‘•
will cover innovations ”‡Žƒ–‡†
related –‘
to —–”‹–‹‘ƒŽ
nutritional •—’’‘”–ǡ
support, ICT  ‹–‡”˜‡–‹‘•ǡ
interventions,
‡†‹ƒ†˜‘ ƒ ›ƒ†‡•‡ƒ” Šǡ‘—‹–›—–”‡ƒ Šƒ†
Media Advocacy and Research, Community Outreach and Jan Andolan. ƒ†‘ŽƒǤ

†‡”
Under ‘•Šƒ
Poshan ʹǤͲǡ
2.0, ˆ‘ —• ‹•
focus is ‘
on †‹‡–
diet †‹˜‡”•‹–›ǡ
diversity, ˆ‘‘†food ˆ‘”–‹ˆ‹ ƒ–‹‘ǡ Ž‡˜‡”ƒ‰‹‰
fortification, leveraging –”ƒ†‹–‹‘ƒŽ
traditional
•›•–‡•
systems ‘ˆof ‘™Ž‡†‰‡
knowledge ƒ† and ’‘’—Žƒ”‹œ‹‰
popularizing —•‡use ‘ˆof ‹ŽŽ‡–•Ǥ
millets. —–”‹–‹‘
Nutrition ƒ™ƒ”‡‡••
awareness •–”ƒ–‡‰‹‡•
strategies
—†‡”‘•ŠƒʹǤͲƒ‹–‘†‡˜‡Ž‘’•—•–ƒ‹ƒ„Ž‡Š‡ƒŽ–Šƒ†™‡ŽŽǦ„‡‹‰–Š”‘—‰Š”‡‰‹‘ƒŽ‡ƒŽ
under Poshan 2.0 aim to develop sustainable health and well-being through regional meal
’Žƒ•–‘„”‹†‰‡†‹‡–ƒ”›‰ƒ’•Ǥ
plans to bridge dietary gaps. Further,—”–Š‡”ǡ‰”‡ƒ–‡”‡’Šƒ•‹•‹•„‡‹‰‰‹˜‡‘–Š‡—•‡‘ˆ‹ŽŽ‡–•
greater emphasis is being given on the use of millets
ˆ‘”’”‡’ƒ”ƒ–‹‘‘ˆ
for preparation of Hot ‘–‘‘‡†‡ƒŽƒ†ƒ‡
Cooked Meal and Take Home ‘‡”ƒ–‹‘•ȋ‘–”ƒ™”ƒ–‹‘Ȍƒ–‰ƒ™ƒ†‹
rations (not raw ration) at Anganwadi
‡–”‡• ˆ‘”
centres for ”‡‰ƒ–
Pregnant ‘‡ǡ
Women, ƒ –ƒ–‹‰ ‘–Š‡”•
Lactating Mothers ƒ† and Š‹Ž†”‡
Children „‡Ž‘™
below ͸ 6 ›‡ƒ”•
years ‘ˆ
of ƒ‰‡ǡ
age, ĥ
as
‹ŽŽ‡–•Šƒ˜‡Š‹‰Š—–”‹‡– ‘–‡–™Š‹
millets have high nutrient content whichŠ‹ Ž—†‡•’”‘–‡‹ǡ‡••‡–‹ƒŽˆƒ––›ƒ
includes protein, essential fatty acid, ‹†ǡ†‹‡–ƒ”›ˆ‹„”‡ǡ
dietary fibre,
Ǧ‹–ƒ‹•ǡ
B-Vitamins, ‹‡”ƒŽ••—
minerals suchŠƒ• ƒŽ ‹—ǡ ‹”‘ǡ
as calcium, iron, œ‹
zinc, ǡ ˆ‘Ž‹
folic  ƒ ‹† ƒ†
acid and ‘–Š‡”
other ‹ ”‘Ǧ—–”‹‡–• –Š—•
micro-nutrients thus
Š‡Ž’‹‰–‘–ƒ Ž‡ƒƒ‡‹ƒƒ†‘–Š‡”‹ ”‘Ǧ—–”‹‡–†‡ˆ‹ ‹‡ ‹‡•‹™‘‡ƒ†
helping to tackle anaemia and other micro-nutrient deficiencies in women and children. As Š‹Ž†”‡Ǥ•
’‡”
per –Š‡
the  Š‡‡ Guidelines
Scheme —‹†‡Ž‹‡• ‹••—‡†
issued ˆ‘”
for ‹••‹‘
Mission ƒ•Šƒ
Saksham ‰ƒ™ƒ†‹
Anganwadi Ƭ & ‘•Šƒ
Poshan ʹǤͲǡ
2.0, ‹ŽŽ‡–•
millets
‡‡†–‘„‡ƒ†ƒ–‘”‹Ž›•—’’Ž‹‡†ƒ–Ž‡ƒ•–‘ ‡ƒ™‡‡ƒ†•—‹–ƒ„Ž›‹–‡‰”ƒ–‡†‹ƒ‡
need to be mandatorily supplied at least once a week and suitably integrated in Take Home ‘‡
ƒ–‹‘ȋ‘–”ƒ™”ƒ–‹‘Ȍƒ†
Ration (not raw ration) and Hot ‘–‘‘‡†‡ƒŽ‹ƒ’ƒŽƒ–ƒ„Ž‡ˆ‘”Ǥ
Cooked Meal in a palatable form.

3
‘–Š‡”‡›’Žƒ‘ˆ–Š‡„Š‹›ƒƒƒ”‡–Š‡‘•Šƒƒ–‹ƒ•‘”—–”‹Ǧ‰ƒ”†‡•–Šƒ–ƒ”‡„‡‹‰
Another key plank of the Abhiyaan are the Poshan Vatikas or Nutri-gardens that are being
•‡–
set —’
up ƒacross
”‘•• –Š‡ ‘—–”› –‘
the country to ’”‘˜‹†‡
provide ‡ƒ•›
easy ƒ†
and ƒˆˆ‘”†ƒ„Ž‡
affordable ƒaccess
‡•• –‘
to ˆ”—‹–•ǡ
fruits, ˜‡‰‡–ƒ„Ž‡•ǡ
vegetables,
‡†‹ ‹ƒŽ’Žƒ–•ƒ†Š‡”„•Ǥ
medicinal plants and herbs.

Framework and
Framework and Specific
Specific Details
Details of
of Supplementary
Supplementary Nutrition
Nutrition

Š‡
The •‡”˜‹ ‡• ’”‘˜‹†‡†
services provided ”‡ ‘‰‹œ‡ –Šƒ–
recognize that –Š‡”‡
there ‹•
is ƒ
an ‹–‡”‰‡‡”ƒ–‹‘ƒŽ › Ž‡ ‘ˆ
intergenerational cycle of —†‡”
under
—–”‹–‹‘ǡ‡‡†‹‰ƒ ‘’”‡Š‡•‹˜‡Š‡ƒŽ–Šƒ†™‡ŽŽ‡••ƒ’’”‘ƒ
nutrition, needing a comprehensive health and wellness approach,Šǡ covering
‘˜‡”‹‰–Š‡‡–‹”‡Ž‹ˆ‡
the entire life
› Ž‡‘ˆ‰”‘™–Šǡ™‹–Šƒˆ‘
cycle of growth, with a focus—•‘ ”‹–‹ ƒŽ’‡”‹‘†•‘ˆ—–”‹–‹‘ƒŽ˜—Ž‡”ƒ„‹Ž‹–›ƒ†‘’’‘”–—‹–›
on critical periods of nutritional vulnerability and opportunity
ˆ‘”
for ‡Šƒ ‹‰ Š—ƒ
enhancing human †‡˜‡Ž‘’‡–
development ’‘–‡–‹ƒŽǤ
potential. Š‡ ‘’”‡Š‡•‹˜‡ Š‡ƒŽ–Š
The comprehensive health ƒ†
and ™‡ŽŽ‡••
wellness
ƒ’’”‘ƒ
approachŠ‹ Ž—†‡•–Š‡ˆ‘ŽŽ‘™‹‰ǣ
includes the following:

 —’’‘”–ˆ‘”ƒ†‘Ž‡• ‡–‰‹”Ž•‹
Support for adolescent Ž—†‹‰–Š‡‹”—–”‹–‹‘ƒ†•‹ŽŽ‹‰Ǥ
girls including their nutrition and skilling.

 ”‡Ǧ„‹”–Š
Pre-birth —–”‹–‹‘
nutrition •—’’‘”–
support –‘
to ’”‡‰ƒ–
pregnant ™‘‡
women ƒ†
and ’‘•–Ǧ„‹”–Š
post-birth –‘
to Žƒ –ƒ–‹‰
lactating
‘–Š‡”•Ǥ
mothers.

 ”‘‘–‹‘‘ˆ‡ƒ”Ž›‹‹–‹ƒ–‹‘‘ˆ„”‡ƒ•–ˆ‡‡†‹‰ƒ†‡š Ž—•‹˜‡„”‡ƒ•–
Promotion of early initiation of breastfeeding and exclusive breast ˆ‡‡†‹‰‹ͲǦ͸
feeding in 0-6
‘–Š‘Ž†‹ˆƒ–•Ǥ
month old infants.

 ”‘‘–‹‘‘ˆƒ‰‡Ǧƒ’’”‘’”‹ƒ–‡ƒ†ƒ†‡“—ƒ–‡ ‘’Ž‡‡–ƒ”›ˆ‡‡†‹‰•–ƒ”–‹‰ˆ”‘
Promotion of age-appropriate and adequate complementary feeding starting from
͸‘–Š•‘ˆƒ‰‡ƒŽ‘‰™‹–Š ‘–‹—‡†„”‡ƒ•–ˆ‡‡†‹‰ˆ‘”ʹ›‡ƒ”•‘”„‡›‘†Ǥ
6 months of age along with continued breastfeeding for 2 years or beyond.

 •—”‹‰†‹‡–ƒ”›ƒ†‡“—ƒ
Ensuring dietary adequacy›‹ Š‹Ž†”‡„‡–™‡‡͸–‘͹ʹ‘–Š•Ǥ
in children between 6 to 72 months.

 ”‡˜‡–‹‘ƒ†ƒƒ‰‡‡–‘ˆ‡ƒ”Ž› Š‹Ž†Š‘‘†‹ŽŽ‡••‡•
Prevention and management of early childhood illnesses

Š‡•‡‹–‡”˜‡–‹‘•ƒ”‡”‡’”‡•‡–‡†‹–Š‡ ‹‰—”‡„‡Ž‘™ǣ
These interventions are represented in the Figure below:

4
 SAM Management

Complementary

SAM Management

Diarrhoea prevention
and treatment— ORS
& Zinc

Pneumonia
prevention

Breastfeeding: Early,
Exclusive for 6 m,
continuing

SAM Management Immunization

Home based
newborn care
with extra care of
LBW 0-6 months
Postnatal care
LBW care: KMC eo...
Pre-birth &
post-birth
(Mothers)

Figure: Comprehensive
Figure: Comprehensive health
healthth and
and w
wellness approach
wellness approach towards
towards life
life cycle
cycle of
of growth

5
PROTOCOL FOR
PROTOCOL FOR ASSESSMENT
ASSESSMENT AND MANAGEMENT OF
AND MANAGEMENT OF MALNUTRITION
MALNUTRITION IN
IN CHILDREN
CHILDREN

Step-1: Growth
Step-1: Growth Monitoring
Monitoring

 †‡–‹ˆ‹ ƒ–‹‘ ‘ˆ

Identification of ƒŽ‘—”‹•Š‡† Š‹Ž†”‡ •Š‘—Ž†
malnourished children should „‡
be †‘‡
done —•‹‰
using –Š‡ ”‘™–Š
the Growth
‘‹–‘”‹‰
Monitoring †ƒ–ƒ
data ȋ‡‹‰Š–Ǧˆ‘”ǦŠ‡‹‰Š–
(Weight-for-height ƒ†and ‡‹‰Š–Ǧˆ‘”Ǧ‰‡ȌǤ
Weight-for-Age). Š‡
The ƒ–Š”‘’‘‡–”‹
anthropometric 
‡ƒ•—”‡‡–•‘ˆ Š‹Ž†”‡ȋ(Height
measurements of children ‡‹‰Š–ƒ†‡‹‰Š–Ȍ•Š‘—Ž†„‡‡–‡”‡†‡ƒ
and Weight) should be entered eachŠ‘–Š‹–Š‡
month in the

POSHAN”ƒ ‡”†ƒ–ƒƒƒ‰‡‡–ƒ’’Ž‹
Tracker data management applicationƒ–‹‘„›–Š‡–‘‹†‡–‹ˆ›–Š‡
by the AWW to identify the †‡‰”‡‡
degree
‘ˆƒŽ—–”‹–‹‘ƒ†‘‹–‘”‰”‘™–ŠǤ
of malnutrition and monitor growth.
 ‡˜‡”‡ƒ
Severe acute—–‡ƒŽ—–”‹–‹‘ȋȌ‹•†‡ˆ‹‡†„›˜‡”›Ž‘™™‡‹‰Š–Ǧˆ‘”ǦŠ‡‹‰Š–ȀŽ‡‰–ŠȋǦ
malnutrition (SAM) is defined by very low weight-for-height/length (Z-
•score
‘”‡„‡Ž‘™Ǧ͵‘ˆ–Š‡‡†‹ƒǢ
below-3 SD of the median; WHO child Š‹Ž†‰”‘™–Š•–ƒ†ƒ”†•Ȍ‘”„›˜‹•‹„Ž‡•‡˜‡”‡
growth standards) or by visible severe
™ƒ•–‹‰
wasting ‘” or „›
by –Š‡
the ’”‡•‡
presence‡ ‘ˆ
of —–”‹–‹‘ƒŽ
nutritional ‘‡†‡ƒǤ
oedema. ‡˜‡”‡
Severe —†‡”™‡‹‰Š–
underweight ȋȌ
(SUW) ‹•
is
†‡ˆ‹‡†„›˜‡”›Ž‘™™‡‹‰Š–Ǧˆ‘”Ǧ‰‡ȋǦ•
defined by very low weight-for-Age (Z-score ‘”‡„‡Ž‘™Ǧ͵‘ˆ–Š‡‡†‹ƒǢ
below-3 SD of the median; WHO child Š‹Ž†
‰”‘™–Š•–ƒ†ƒ”†•ȌǤ
growth standards).
 ‘”‹†‡–‹ˆ‹
For ƒ–‹‘‘ˆ
identification Š‹Ž†”‡ǡƒactive
of SAM children, –‹˜‡•screening
”‡‡‹‰•Š‘—Ž†„‡†‘‡„›Ȁ
should be done by AWW/ASHA
–Š”‘—‰Š
through Š‘—•‡
house –‘
to Š‘—•‡
house ˜‹•‹–
visit Ž‘‘‹‰
looking ˆ‘”
for ’”‡•‡ ‡Ȁƒ„•‡ ‡ ‘ˆ
presence/absence of „‹Žƒ–‡”ƒŽ
bilateral ’‹––‹‰
pitting
‘‡†‡ƒ ȗ ‘” •‡˜‡”‡ †‡‰”‡‡ ‘ˆ ™ƒ•–‹‰Ǥ ƒ••‹˜‡ • ”‡‡‹‰ ‹• †‘‡
oedema* or severe degree of wasting. Passive screening is done during Growth †—”‹‰ ”‘™–Š
‘‹–‘”‹‰Ȁ‹ŽŽƒ‰‡
Monitoring/Village Health,‡ƒŽ–Šǡƒ‹–ƒ–‹‘ƒ†—–”‹–‹‘ƒ›•ȋ
Sanitation and Nutrition Days (VHSND) Ȍˆ‘” Š‹Ž†”‡ȋ͸Ȃ
for children (6-
ͷͻ‘–Š•Ȍƒ†Ž‘‘‹‰ˆ‘”’”‡•‡
59 months) and looking for presence/ ‡Ȁƒ„•‡
absence‡‘ˆ„‹Žƒ–‡”ƒŽ’‹––‹‰‘‡†‡ƒ‘”•‡˜‡”‡
of bilateral pitting oedema or severe
†‡‰”‡‡‘ˆ™ƒ•–‹‰Ǥ
degree of wasting.
ȗŽ•‘‘™ƒ•—–”‹–‹‘ƒŽ‡†‡ƒƒ†‡†‡ƒ–‘—•ƒŽ—–”‹–‹‘ǡ„‹Žƒ–‡”ƒŽ’‹––‹‰‡†‡ƒ‹•‹†‡–‹ˆ‹‡†
*Also known as nutritional edema and edematous malnutrition, bilateral pitting edema is identified
™Š‡–Š—„’”‡••—”‡ǡƒ’’Ž‹‡†–‘–Š‡–‘’•‘ˆ„‘–Šˆ‡‡–ˆ‘”–Š”‡‡•‡ ‘†•ǡŽ‡ƒ˜‡•ƒ‹†‡–ƒ–‹‘‹–Š‡
when thumb pressure, applied to the tops of both feet for three seconds, leaves an indentation in the
ˆ‘‘–ƒˆ–‡”–Š‡–Š—„‹•Ž‹ˆ–‡†Ǥ
foot after the thumb is lifted.
 ˆ–‡”‹†‡–‹ˆ‹
After ƒ–‹‘‘ˆ
identification Š‹Ž†”‡—•‹‰
of children ”‘™–Š‘‹–‘”‹‰ƒ–ƒǡ’’‡–‹–‡–‡•–•ŠƒŽŽ„‡
using Growth Monitoring Data, Appetite test shall be
ƒ””‹‡†‘—–„›–Š‡ˆ‘”ƒŽŽ
carried Š‹Ž†”‡‹‘”†‡”–‘ƒ••‡••ˆ‘”–Š‡’”‡•‡
out by the AWW for all SAM children in order to assess for the presence‡‘ˆ
of
‡†‹
medicalƒŽ complications.
‘’Ž‹ ƒ–‹‘•Ǥ
 Screening
”‡‡‹‰‘ˆ Š‹Ž†”‡ƒ–•Ȁ‹Ǧ’ƒ–‹‡–™ƒ”†•‹Š‡ƒŽ–Šˆƒ
of children ‹Ž‹–‹‡•—•‹‰™‡‹‰Š–Ǧˆ‘”Ǧ
at OPDs/in-patient wards in health facilities using weight-for-
Š‡‹‰Š–ƒ†™‡‹‰Š–Ǧˆ‘”Ǧƒ‰‡‡ƒ•—”‡‡–••ŠƒŽŽƒŽ•‘„‡†‘‡Ǥ
height and weight-for-age measurements shall also be done.
 Š‹Ž†”‡„‡Ž‘™͸‘–Š••ŠƒŽŽ„‡ƒƒ‰‡†ƒ•’‡”’”‘–‘
Children below 6 months shall be managed as per protocol‘Ž‰‹˜‡‹Annexure-IǤ
given in Annexure-lI.

Step-2: Appetite
Step-2: Appetite Test
Test for
for SAM
SAM Children
Children
 ’’‡–‹–‡
Appetite –‡•–
test •ŠƒŽŽ
shall „‡ ƒ””‹‡† ˆ‘”
be carried for  Š‹Ž†”‡ „›
SAM children  ‹
by AWW in –Š‡
the ’”‡•‡
presence‡ ‘ˆ
of
’ƒ”‡–Ȁˆƒ‹Ž›‡„‡”Ǥ
parent/family member.
 ‡•–‹•–‘„‡ ƒ””‹‡†‘—–‹ƒ’‡ƒ
Test is to be carried ‡ˆ—ŽȀ“—‹‡–ƒ”‡ƒ‘ˆ–Š‡‰ƒ™ƒ†‹‡–‡”•ȋȌǤ
out in a peaceful/ quiet area of the Anganwadi Centers (AWC).
 Š‡
The ƒ’’‡–‹–‡
appetite –‡•–
test •ŠƒŽŽ„‡ ƒ””‹‡† ‘—–
shall be carried out —•‹‰
using –Š‡ ‘– ‘‘‡†
the Hot Cooked ‡ƒŽȀ
Meal/THR ƒ˜ƒ‹Žƒ„Ž‡
available ƒ–
at
Ǥ
AWC.
  Š‹Ž†”‡™Š‘ˆƒ‹Ž–Š‡ƒ’’‡–‹–‡–‡•–•ŠƒŽŽ„‡”‡ˆ‡””‡†–‘Ǥ
SAM children who fail the appetite test shall be referred to NRC.
 Š‹Ž†”‡
Children ™Š‘
who ’ƒ••
pass –Š‡
the ƒ’’‡–‹–‡
appetite –‡•–
test •ŠƒŽŽ
shall „‡
be ‡”‘ŽŽ‡†
enrolled ĥ
as „‡‡ˆ‹ ‹ƒ”› —†‡”
beneficiary under –Š‡
the
—’’Ž‡‡–ƒ”›
Supplementary —–”‹–‹‘
Nutrition ”‘‰”ƒ
Program ƒ†
and ƒŽ•‘
also ”‡ˆ‡””‡†
referred –‘
to PHC ‡†‹
MedicalƒŽ ‘ˆˆ‹ ‡” ˆ‘”
officer for
‡†‹
medicalƒŽƒ••‡••‡–Ǥ
assessment.

6
 e Refer to Annexure-II ˆ‘”†‡–ƒ‹Ž•‘ˆ’’‡–‹–‡‡•–Ǥ
‡ˆ‡”–‘Annexure-II for details of Appetite Test.

Step-3: Medical
Step-3: Medical Assessment
Assessment
e ˜‡”› Š‹Ž†™Š‘’ƒ••‡•–Š‡ƒ’’‡–‹–‡–‡•–ƒ†ƒŽŽ
Every SAM child Š‹Ž†”‡•ŠƒŽŽ„‡•
who passes the appetite test and all SUW children ”‡‡‡†
shall be screened
ˆ‘”Š‡ƒŽ–Š•–ƒ–—•„›Ȁ‡†‹ ƒŽˆˆ‹ ‡”‘ˆ ™‹–Š‹͵Ǧͷ†ƒ›•‘ˆƒ’’‡–‹–‡–‡•–ƒ–
for health status by ANM/Medical Officer of PHC within 3-5 days of appetite test at

PHC–‘‹†‡–‹ˆ›ƒ›Š‡ƒŽ–Š‹••—‡•‘”Š‹††‡‹ˆ‡ –‹‘‘”†ƒ‰‡”•‹‰•Ǥ
to identify any health issues or hidden infection or danger signs.
e Š‹Ž†”‡
Children ™‹–Š
with ƒ›
any ‡†‹
medicalƒŽ complication
‘’Ž‹ ƒ–‹‘ •Š‘—Ž†
should „‡
be ”‡ˆ‡””‡†
referred –‘
to –Š‡
the ‡ƒ”‡•–
nearest Š‡ƒŽ–Š
health
ˆƒ ‹Ž‹–›ˆ‘”‡†‹
facility for medicalƒŽƒƒ‰‡‡–ƒ†ˆ—”–Š‡”–”‡ƒ–‡–‘ˆ•‹ ‡••Ǥ
management and further treatment of sickness.
e ˆƒ–•Ž‡••–Šƒ͸‘–Š•‘ˆƒ‰‡™Š‘ƒ”‡˜‹•‹„Ž›™ƒ•–‡†‘”‘‡†‡ƒ–‘—•‘”–‘‘™‡ƒ
Infants less than 6 months of age who are visibly wasted or oedematous or too weak
‘”
or feeble –‘
ˆ‡‡„Ž‡ to •— Ž‡ǡ •Š‘—Ž†
suckle, should „‡be ‹‡†‹ƒ–‡Ž›
immediately ”‡ˆ‡””‡†
referred –‘
to –Š‡
the ‡ƒ”‡•–
nearest Š‡ƒŽ–Š
health
ˆƒ ‹Ž‹–›Ȁ ˆ‘”
facility/NRC for ‡˜ƒŽ—ƒ–‹‘
evaluation ƒ†
and –”‡ƒ–‡–
treatment „›
by  ȀȀǤ Further,
ASHA/AWW/ANM. —”–Š‡”ǡ •‡˜‡”‡Ž›
severely
—†‡”™‡‹‰Š–ȋȌ
underweight (SUW) children Š‹Ž†”‡‘ˆͲǦ͸‘–Š••Š‘—Ž†ƒŽ•‘„‡”‡ˆ‡””‡†–‘†‹”‡
of 0-6 months should also be referred to NRC directly –Ž›
ˆ‘”ˆ—”–Š‡”ƒƒ‰‡‡–ƒ•’‡”
for further management as per WHO‰—‹†‡Ž‹‡•Ǥ
guidelines.
e ‡ˆ‡”–‘Annexure-III
Refer to Annexure-III ˆ‘”†‡–ƒ‹Ž•Ǥ
for details.

Step-4: Decide
Step-4: Decide level
level of
of care
care

Degree of
Degree of Malnourishment
Malnourishment Level of
Level of care
care

‘†‡”ƒ–‡  —–‡ ƒŽ—–”‹–‹‘

Moderate Acute Malnutrition ȋȌǡ
(MAM), ‹Ǥ‡Ǥǡ
i.e, ‡‹‰Š–Ǧˆ‘”Ǧ
Weight-for- | ‘„‡ƒƒ‰‡†ƒ–
To be managed at AWC
‡‹‰Š–„‡–™‡‡Ǧʹ–‘Ǧ͵
Height between -2 SD to -3 SD
‡˜‡”‡
Severe  —–‡ ƒŽ—–”‹–‹‘
Acute Malnutrition ȋȌ
(SAM) ™‹–Š‘—–
without ‡†‹
MedicalƒŽ | ‘„‡ƒƒ‰‡†ƒ–
To be managed at AWC
‘’Ž‹ ƒ–‹‘ǡ ‹Ǥ‡Ǥǡ
Complication, i.e.  ‡‹‰Š–Ǧˆ‘”Ǧ ‡‹‰Š– δ
Weight-for-Height < Ǧ͵
-3 
SD ƒ†
and ’ƒ••‡†
passed
’’‡–‹–‡‡•–
Appetite Test
‡˜‡”‡
Severe Acute—–‡ƒŽ—–”‹–‹‘ȋȌǡ‹Ǥ‡Ǥǡ‡‹‰Š–Ǧˆ‘”Ǧ ‡‹‰Š–δ
Malnutrition (SAM), i.e., Weight-for-Height < | ‘„‡ƒƒ‰‡†ƒ–
To be managed at NRC
Ǧ͵
-3 
SD ™‹–Š
with ‡†‹
MedicalƒŽ ‘’Ž‹ ƒ–‹‘• ƒ†Ȁ‘”
Complications and/or ”‡•‡
Presence‡ ‘ˆ
of
„‹Žƒ–‡”ƒŽ
bilateral ’‹––‹‰
pitting ‘‡†‡ƒ
oedema ƒ†Ȁ‘”
and/or Ž‘••
loss ‘ˆ
of ƒ’’‡–‹–‡
appetite ȋˆƒ‹Ž‡†
(failed
ƒ’’‡–‹–‡–‡•–Ȍ
appetite test)
‘†‡”ƒ–‡
Moderate †‡”™‡‹‰Š–
Underweight ȋȌǡ
(MUW), ‹Ǥ‡Ǥǡ
ie. ‡‹‰Š–Ǧˆ‘”Ǧ‰‡
Weight-for-Age | ‘„‡ƒƒ‰‡†ƒ–
To be managed at AWC
„‡–™‡‡Ǧʹ–‘Ǧ͵
between -2 SD to -3 SD
‡˜‡”‡
Severe †‡”™‡‹‰Š–
Underweight ȋȌǡ
(SUW), ‹Ǥ‡Ǥǡ
i.e,  ‡‹‰Š–Ǧˆ‘”Ǧ‰‡
Weight-for-Age δ
< Ǧ͵
-3 
SD | ‘„‡ƒƒ‰‡†ƒ–
To be managed at AWC
™‹–Š‘—–‡†‹
without MedicalƒŽ‘’Ž‹ ƒ–‹‘
Complication

Step-5: Nutritional
Step-5: Nutritional Management:
Management:

e ŽŽ
All Š‹Ž†”‡™Š‘ˆƒ‹Žƒ’’‡–‹–‡–‡•–ƒ†Ȁ‘”™‹–Š‡†‹
SAM children who fail appetite test and/or with medicalƒŽ complications
‘’Ž‹ ƒ–‹‘•ȋ„ƒ•‡†‘
(based on
‡†‹
MedicalƒŽ••‡••‡–ƒ––‡’Ǧ͵Ȍ•Š‘—Ž†„‡”‡ˆ‡””‡†–‘ˆ‘”ˆ—”–Š‡”ƒƒ‰‡‡–Ǥ
Assessment at Step-3) should be referred to NRC for further management.
e ŽŽ children
All Š‹Ž†”‡ †‹ƒ‰‘•‡†
diagnosed ™‹–Š
with ǡ
MAM, 
MUW ƒ†
and 
SUW •ŠƒŽŽ
shall „‡
be ‡”‘ŽŽ‡†
enrolled —†‡”
under –Š‡
the
—’’Ž‡‡–ƒ”›
Supplementary —–”‹–‹‘
Nutrition ”‘‰”ƒ‡
Programme ƒ–
at –Š‡ ‰ƒ™ƒ†‹ ‡–‡”
the Anganwadi Center ƒ†
and •Š‘—Ž†
should „‡
be

7
 ’”‘˜‹†‡†
provided •—’’Ž‡‡–ƒ”›
supplementary —–”‹–‹‘
nutrition ĥ
as ’‡”
per –Š‡
the —–”‹–‹‘
nutrition ‘”• ‘–ƒ‹‡† ‹
norms contained in
Schedule-II
Š‡†—Ž‡Ǧ ‘ˆ–Š‡ƒ–‹‘ƒŽ ‘‘†‡ —”‹–› –ǤŠ‡†‡–ƒ‹Ž•ƒ”‡ƒ•—†‡”ǣ
of the National Food Security Act. The details areas under:

‰‡Ȁ
Age/ ›’‡
Type | ‡”
Ener | ”‘–‡‹
Protei | ‘–ƒŽ
Total ƒ”
Car | ‡”‡ƒ
Cerea | ƒŽ
Calci ‹ ‹
Zin ”‘
Iro ‹‡–ƒ”
Dietar | ‹–ƒ
Vita ‹–ƒ
Vita ‹–ƒ
Vita
Š›•‹‘Ž‘‰‹
PhysiologicalƒŽ ‘ˆ
of ‰›
gy ȋ‰Ȍ
n (g) ƒ–
Fat „‘Š
boh | 1 Ž —
um c 
n ›
y ‹
min ‹
min ‹
min
”‘—’
Group ‡ƒŽ
Meal ȋ
(kcalƒŽ ȋ‰Ȍ
(g) ›†”
ydr | ǣ—Ž•‡
:Pulse | ȋ‰Ȍ
(mg) ȋ‰
(mg | ȋ‰
(mg | ‘Žƒ–‡| A
Folate ͸
B6 ͳʹ
B12
Ȍ
) ƒ–‡
(2) ƒ–‹‘
Ratio Ȍ
) Ȍ
) ȋρ‰Ȍ
(ug) ȋρ‰Ȍ
(ug) | ȋρ‰Ȍ
(ug) | ȋρ‰Ȍ
(ug)
ȋ‰Ȍ
§
†‡”‘—”‹•Š‡
Undernourishe | 
THR ͶͲͲ
400 ͳͷǦʹͲ
15-20 | ͳͷǦͳͺ
15-18 | ͵ͷ
35 ʹǣͳ
2:1 ʹͲͲ
200 ͳǤͷ
1.5 ͳǤͷ
1.5 ͷͲ
50 ͳͳͷ
115 ͲǤ͵ͷ
0.35 | ͲǤ͸͸
0.66
† Š‹Ž†”‡ ȋ͸Ǧ
d children (6-
ͳʹ‘–Š•Ȍ
12 months)
†‡”‘—”‹•Š‡
Undernourishe | 
THR ͹ͲͲ
700 ʹͷǦ͵Ͳ
25-30 | ʹͷǦ͵Ͳ
25-30 | ͹Ͳ
70 ʹǣͳ
2:1 ʹ͹Ͳ
270 ʹ
2 Ͷ
4 ͹Ͳ
70 ͳʹͲ
120 ͲǤͷͷ
0.55 | ͲǤ͸͸
0.66
† Š‹Ž†”‡ ȋͳǦ͵
d children (1-3
›‡ƒ”•Ȍ
years)
†‡”‘—”‹•Š‡
Undernourishe | 
MS Ϊ
+ | ͺͲͲ
800 ʹͷǦ͵Ͳ
25-30 | ʹͷǦ͵Ͳ
25-30 | ͹Ͳ
70 ʹǣͳ
2:1 ͵ͲͲ
300 ͵
3 ͸
6 ͺͲ
80 ͳ͸Ͳ
160 ͲǤ͸͸
0.66 | ͳǤʹͶ
1.24
† Š‹Ž†”‡ȋ͵Ǧ͸
d children (3-6 | 
HCM
›‡ƒ”•Ȍ
years) Ϊ
+

THR

THR:ǣƒ‡
Take Home‘‡ƒ–‹‘Ǣǣ‘”‹‰ƒ
Ration; MS: Morning Snack;Ǣ HCM: ǣ Hot‘–‘‘‡†‡ƒŽ
Cooked Meal

 ‹–Š
With ”‡•’‡
respect – –‘
to –Š‡
the ƒ„‘˜‡
above –ƒ„Ž‡ǡ
table, ‹–
it ƒ›
may „‡
be ‘–‡†
noted –Šƒ–
that –Š‡
the 
PDCAAS •score ‘”‡ ȋ”‘–‡‹
(Protein
‹‰‡•–‹„‹Ž‹–›
Digestibility Corrected Amino Acid Score) shall be between 0.8 to 1.0 to ‡•—”‡
‘””‡ –‡† ‹‘  ‹†  ‘”‡Ȍ •ŠƒŽŽ „‡ „‡–™‡‡ ͲǤͺ –‘ ͳǤͲ –‘ ensure
’”‘˜‹•‹‘ˆ‘”Š‹‰ŠǦ“—ƒŽ‹–›’”‘–‡‹ƒ•’”‘˜‹†‡†‹ Š‡†—Ž‡Ǧ
provision for high-quality protein as provided in Schedule-II of NFSA, 2013. ‘ˆ ǡʹͲͳ͵Ǥ
 For ‘” 
SAM Š‹Ž†”‡
Children ȋ͸ (6 ‘–Š•
months –‘ to ͸6 ›‡ƒ”•Ȍ
years) ™‹–Š‘—–
without ‡†‹medicalƒŽ complications,
‘’Ž‹ ƒ–‹‘•ǡ –Š‡ the
—–”‹–‹‘ƒŽ•–ƒ†ƒ”†••—‰‰‡•–‡†‹
nutritional standards suggested in Schedule-II Š‡†—Ž‡Ǧ ‘ˆ–Š‡ƒ–‹‘ƒŽ
of the National Food ‘‘†‡ —”‹–›
Security Act–ƒ›
may
„‡ˆ‘ŽŽ‘™‡†ȋƒ•‡–‹‘‡†‹–ƒ„Ž‡ƒ„‘˜‡Ȍǡ™Š‹
be followed (as mentioned in table above), whichŠ‹•ƒƒ††‹–‹‘ƒŽƒŽŽ‘™ƒ
is an additional allowance‡ˆ‘”–Š‡ for the
 Š‹Ž†™Š‘‹•
SAM child ‘•—‹‰”‡‰—Žƒ”ˆ‘‘†ƒ–Š‘‡Ǥ
who is consuming regular food at home. However, ‘™‡˜‡”ǡ‹ˆ–Š‡ Š‹Ž†‹••—’’‘•‡†
if the child is supposed
–‘
to ”‡ ‡‹˜‡ –Š‡
receive the ‡–‹”‡
entire †ƒ›ǯ•
day’s ˆ‘‘†
food ˆ”‘
from –Š‡
the ‰ƒ™ƒ†‹
Anganwadi ‡–‡”ǡ
Center, –Š‡ Š‹Ž† •Š‘—Ž†
the child should „‡be
’”‘˜‹†‡†‡”‰›̷ͳʹͲ
provided Energy @120 Kcal/kg ƒŽȀ‰„‘†›™‡‹‰Š–Ȁ†ƒ›ȋ
body weight/day (Ref: Technical report
Ref: Technical report of
of NIN:
NIN: Revision
Revision
of Food
of Food and
and Nutrition
Nutrition norms
norms under
under Schedule
Schedule IIII of
of the
the National
National Food
Food Security
Security Act,
Act, 2013,
2013,
prepared in collaboration with Department of Food and Public Distribution, Ministry of
prepared in collaboration with Department of Food and Public Distribution, Ministry of
Consumer Affairs, Food and Public Distribution, October, 2022).
Consumer Affairs, Food and Public Distribution, October, 2022 ȌǤ
 Š‹Ž‡ ‘•–”— –‹‰ †‹‡–•ˆ‘”ƒŽ‘—”‹•Š‡†
While constructing diets for malnourished children,Š‹Ž†”‡ǡ –Š‡’”‹ ‹’Ž‡•‘ˆ
the principles of †‹‡–
diet †‹˜‡”•‹–›
diversity
•Š‘—Ž†
should „‡be ˆ‘ŽŽ‘™‡†
followed –ƒ‹‰
taking ‹–‘ ‘•‹†‡”ƒ–‹‘ ˜ƒ”‹‡–›ǡ
into consideration variety, „ƒŽƒ
balance‡ ƒ†
and ‘†‡”ƒ–‹‘ǡ
moderation, ˆ‘” for
–Š‡†‹ˆˆ‡”‡–„‡‡ˆ‹
the different beneficiary ‹ƒ”›‰”‘—’•ǤŠ‡ˆ‘‘†„ƒ•‡–••Š‘—Ž†‹
groups. The food baskets should include Ž—†‡†‹˜‡”•‡ˆ‘‘†•˜‹œǤǡ
diverse foods viz.,
‘„‹ƒ–‹‘‘ˆŽ‘
combination ƒŽŽ›•‘—”
of locally sourced ‡† cereals
‡”‡ƒŽ•ƒ†‹ŽŽ‡–•ǡ’—Ž•‡•ƬŽ‡‰—‡•ǡ—–•Ƭ•‡‡†•ǡ
and millets, pulses & legumes, nuts & seeds,
˜‡‰‡–ƒ„Ž‡•
vegetables ‹ Ž—†‹‰ Ž‡ƒˆ›
including leafy ˜‡‰‡–ƒ„Ž‡•ǡ
vegetables, ƒ†
and ‡‰‰•Ǥ
eggs. •‡
Use ‘ˆ
of ‘”‡
more –Šƒ
than ‘‡
one –›’‡
type ‘ˆ
of ˆ‘‘†
food
ˆ”‘
from ‡ƒeachŠ ‘ˆ
of –Š‡
the ˆ‘‘†
food ‰”‘—’•
groups ‘ on ”‘–ƒ–‹‘
rotation ‹•
is •—‰‰‡•–‡†
suggested –‘ to ’”‘‘–‡
promote †‹˜‡”•‹–›
diversity ™‹–Š‹
within
‡ƒ
eachŠ‘ˆ–Š‡•—‰‰‡•–‡†ˆ‘‘†‰”‘—’•ǤŠ‘Ž‡Ȁ‹‹ƒŽŽ›Ȁƒ’’”‘’”‹ƒ–‡Ž›’”‘
of the suggested food groups. Whole/minimally/appropriately processed ‡••‡†‰”ƒ‹
grain
ƒ†
and ‰”ƒ
gram ƒ”‡are •—‰‰‡•–‡†
suggested –‘ to „‡
be ‹ Ž—†‡† –‘
included to ƒš‹‹œ‡
maximize —–”‹‡– ‘–‡– ƒ†
nutrient content and
ƒ˜ƒ‹Žƒ„‹Ž‹–›Ǥ
availability.
 ‹Žǡ
Milk, ‰‰
Egg ƒ†
and ‘–Š‡” —Ž–—”ƒŽŽ› ƒacceptable
other culturally ‡’–ƒ„Ž‡ •‘—”
sources ‡• ‘ˆ
of ’”‘–‡‹
protein ƒ›
may „‡
be ’ƒ”–
part ‘ˆ
of –Š‡
the
•—’’Ž‡‡–ƒ”›
supplementary —–”‹–‹‘
nutrition ƒ•as –Š‡•‡
these ’”‘˜‹†‡
provide ‰‘‘†
good ƒ‘—–•
amounts ‘ˆ of ƒ‹‘
amino ƒacids
‹†• ƒ†
and ˆƒ––›
fatty
ƒacids
‹†•‡••‡–‹ƒŽˆ‘”„‘–Š’Š›•‹
essential for both physicalƒŽƒ† ‘‰‹–‹˜‡†‡˜‡Ž‘’‡–Ǥ
and cognitive development.

8
  ”—‹–• Ž‹‡
Fruits Žƒǡ Guava,
like Amla, —ƒ˜ƒǡ ƒƒƒǡ
Banana, ƒ’ƒ›ƒǡ
Papaya, ‡–
etc.,Ǥǡ ƒ”‡
are ‹’‘”–ƒ–
important •‘—” ‡• ‘ˆ
sources of ‹–ƒ‹Ǧ
Vitamin- 
C
ƒ†‹–ƒ‹Ǧƒ†ƒŽ•‘’”‘‘–‡–Š‡ƒ„•‘”’–‹‘‘ˆ
and Vitamin-A and also promote the absorption of Iron; ”‘ǢŠ‡
hence‡–Š‡•‡•Š‘—Ž†„‡’ƒ”–
these should be part
‘ˆ•—’’Ž‡‡–ƒ”›—–”‹–‹‘Ǥ
of supplementary nutrition.
 Š‘Ž‡
Whole ‹Žmilk ’‘™†‡”
powder ‹•is •—‰‰‡•–‡†
suggested –‘ to „‡
be ‹ Ž—†‡† ƒ††‹–‹‘ƒŽŽ›
included additionally ˆ‘”for ƒŽ‘—”‹•Š‡†
malnourished
Š‹Ž†”‡–‘‹’”‘˜‡’”‘–‡‹“—ƒŽ‹–›ƒ†
children ‘–”‹„—–‹‘‘ˆ‘–Š‡”„‹‘Ǧƒ
to improve protein quality and contribution –‹˜‡•–‘•—’’‘”–
of other bio-actives to support
”‡ ‘˜‡”›Ǥ
recovery.
 ƒŽ‘‹Ž•Š‘—Ž†‘–„‡—•‡†ǡƒ†‘‹Ž•‘Ž†Ž‘‘•‡ȋ™Š‹
Palm oil should not be used, and oil sold loose (whichŠ could ‘—Ž†„‡ƒ†—Ž–‡”ƒ–‡†Ȍ•Š‘—Ž†
be adulterated) should
ƒŽ•‘‘–„‡—•‡†Ǥ
also not be used.
 ‘ ƒŽŽ› ƒ˜ƒ‹Žƒ„Ž‡
Locally available ˜‡‰‡–ƒ„Ž‡•
vegetables ƒ†
and ‰”‡‡
green Ž‡ƒˆ›
leafy ˜‡‰‡–ƒ„Ž‡•
vegetables Ž‹‡like –‘ƒ–‘‡•ǡ — —„‡”ǡ
tomatoes, cucumber,
•’‹ƒ
spinach,Šǡ ˆ‡—‰”‡‡ǡ
fenugreek, ƒƒ”ƒ–Šǡ
amaranth, ‡– etc.,Ǥǡ •Š‘—Ž†
should „‡be ’”‘˜‹†‡†
provided ™Š‹ whichŠ ™‹ŽŽ
will –ƒ‡
take careƒ”‡ ‘ˆ
of
‡••‡–‹ƒŽ‹ ”‘—–”‹‡–•Ž‹‡‹–ƒ‹•ǡ ‘Ž‹  ‹†ǡ ”‘ǡƒ‰‡•‹—ǡ‡–
essential micronutrients like Vitamins A, Folic Acid, Iron, Magnesium, etc. Ǥ
 —–”‹–‹‘—•”‡
Nutritious recipes ‹’‡•„ƒ•‡†‘–Š‡—–”‹–‹‘‘”•ƒ†Ž‘
based on the nutrition norms and localƒŽ™Š‘Ž‡•‘‡ˆ‘‘†•ƒ›„‡
wholesome foods may be
ˆ‘”—Žƒ–‡†„›”‡•’‡
formulated by respective –‹˜‡–ƒ–‡ ‘˜‡”‡–‡’ƒ”–‡–•Ǥ
State Government Departments.
 In ‘”†‡”
order –‘to ‡‡–
meet –Š‡
the —–”‹–‹‘
nutrition ‘”•
norms •—‰‰‡•–‡†
suggested ‹ in –Š‡
the –ƒ„Ž‡
table ƒ„‘˜‡ǡ
above, –Š‡
the •—‰‰‡•–‡†
suggested
ˆ‘‘†„ƒ•‡–•ƒ›„‡”‡ˆ‡””‡†ǡ™Š‹
food baskets may be referred, whichŠƒ”‡’Žƒ are placed‡†ƒ–Annexure-IV.
at Annexure-IV.

Step-6: Medical
Step-6: Medical Management:
Management:

 ŽŽ –Š‡
All the  Š‹Ž†”‡ ™‹–Š‘—–
SAM children without ‡†‹
medicalƒŽ complications
‘’Ž‹ ƒ–‹‘• ƒ†
and  Š‹Ž†”‡ ™Š‘
SUW children who ‡‡†
need
‡†‹
medicalƒŽ care
ƒ”‡ƒ•’‡”–Š‡ƒ••‡••‡–†‘‡ƒ–•–‡’Ǧ͵•ŠƒŽŽ„‡–”‡ƒ–‡†ƒ•’”‡• ”‹„‡†„›
as per the assessment done at step-3 shall be treated as prescribed by
–Š‡‡†‹
the MedicalƒŽˆˆ‹ ‡”Ǥ
Officer.

Step-7: Nutrition,
Step-7: Nutrition, Health
Health Education
Education and
and counseling
counseling including
including WASH
WASH practices:
practices:

 ”‘™–ŠˆƒŽ–‡”‹‰‹
Growth Š‹Ž†”‡•–ƒ”–•ƒ–ƒ‡ƒ”Ž›ƒ‰‡ǡ‘ˆ–‡†—”‹‰–Š‡ˆ‹”•–•‹š‘–Š•
faltering in children starts at an early age, often during the first six months
‘ˆ
of Ž‹ˆ‡ǡ
life, ĥ
as ‹ŽŽ—•–”ƒ–‡†
illustrated ‡ƒ”Ž‹‡”Ǥ
earlier. ”‡ƒ•–ˆ‡‡†‹‰
Breastfeeding –‘‰‡–Š‡”
together ™‹–Š ‘’Ž‡‡–ƒ”› ˆ‡‡†‹‰
with complementary feeding
Š‡Ž’•’”‡˜‡–‹‘‘ˆƒŽ—–”‹–‹‘Ǥƒ”Ž›‹‹–‹ƒ–‹‘ƒ†‡š
helps prevention of malnutrition. Early initiation and exclusive Ž—•‹˜‡„”‡ƒ•–ˆ‡‡†‹‰•Š‘—Ž†
breastfeeding should
„‡
be ‹–‡•‹˜‡Ž›
intensively ’”‘‘–‡†
promoted ˆ‘” Š‹Ž†”‡ —’
for children up –‘
to –Š‡
the ƒ‰‡
age ‘ˆ
of ͸
6 ‘–Š•ǡ
months, ˆ‘ŽŽ‘™‡†
followed „›
by ƒ‰‡Ǧ
age-
ƒ’’”‘’”‹ƒ–‡ƒ†ƒ†‡“—ƒ–‡ ‘’Ž‡‡–ƒ”›ˆ‡‡†‹‰ˆ”‘͸‘–Š•‘ˆƒ‰‡ƒŽ‘‰™‹–Š
appropriate and adequate complementary feeding from 6 months of age along with
‘–‹—‡†„”‡ƒ•–ˆ‡‡†‹‰ˆ‘”ʹ›‡ƒ”•‘”„‡›‘†Ǥ
continued breastfeeding for 2 years or beyond.
 Š‡
The ’ƒ”‡–•
parents ƒ† ƒ”‡‰‹˜‡”• ‘ˆ
and caregivers of –Š‡ Š‹Ž† •Š‘—Ž†
the child should „‡be •‡•‹–‹œ‡†
sensitized ‘on —–”‹–‹‘ǡ
nutrition, ˆ‡‡†‹‰
feeding
’”ƒ –‹ ‡ǡ†‹‡–“—ƒŽ‹–›ǡ
practice, ˆƒ–ƒ†‘—‰Š‹Ž†
diet quality, Infant and Young Child Feeding‡‡†‹‰’”ƒ –‹ ‡•‹
practices Ž—†‹‰“—ƒŽ‹–›ƒ†
including quality and
ƒ†‡“—ƒ
adequacy› ‘ˆ
of ƒ‰‡Ǧƒ’’”‘’”‹ƒ–‡
age-appropriate ‘’Ž‡‡–ƒ”›
Complementary Feeding ‡‡†‹‰ ȋ—•‡
(use ‘ˆ
of ˆ‘—”
four ‘”
or ‘”‡
more ˆ‘‘†
food
‰”‘—’•Ȍǡƒ–‡”ǡƒ‹–ƒ–‹‘Ƭ
groups), Water, Sanitation & Hygiene,›‰‹‡‡ǡȋ
(WASH) Ȍ’”ƒ –‹ ‡•ȋ—•‡‘ˆ•ƒˆ‡†”‹‹‰™ƒ–‡”ǡ
practices (use of safe drinking water,
’‡”•‘ƒŽ
personal Š›‰‹‡‡ǡ
hygiene, Šƒ†
hand ™ƒ•Š‹‰ǡ
washing, —•‡use ‘ˆof –‘‹Ž‡–•ǡ Ž‡ƒŽ‹‡•• ‘ˆ
toilets, cleanliness of Š‘‡
home ƒ† and
•—””‘—†‹‰•ƒ†‘–Š‡”ˆ‘‘†•ƒˆ‡–›’”ƒ
surroundings and other food safety practices, –‹ ‡•ǡ‡– ǤȌǤ
etc.).
  ƒ–‡”‹ƒŽ•
IEC materials Ƭ & ˜‹†‡‘•
videos •ŠƒŽŽ
shall „‡
be —•‡†
used „›
by •
AWWs †—”‹‰
during Š‘‡
home ˜‹•‹–•
visits ƒ†
and ‰”‘—’
group
‘—•‡Ž‹‰ƒ–Ǥ
counseling at AWC.
 —”‹‰
During Š‘‡
home ˜‹•‹–•ǡ
visits, •
AWWs •ŠƒŽŽ
shall †‡‘•–”ƒ–‡
demonstrate ˆ‡‡†‹‰
feeding ’”ƒ –‹ ‡• ƒ†
practices and Šƒ†Š‘Ž†
handhold –Š‡ the
‘–Š‡”•–‘‹’”‘˜‡”‡•’‘•‹˜‡ˆ‡‡†‹‰ǡ
mothers to improve responsive feeding, counsel ‘—•‡Ž‘–Š‡”Ȁ ƒ”‡‰‹˜‡”•Ǥ
mother/caregivers.

9
  —”‹‰
During ˆ‘ŽŽ‘™Ǧ—’ǡ
follow-up, ‹–
it •Š‘—Ž†
should „‡
be •–”‡••‡†
stressed –Šƒ–
that –Š‡•‡ Š‹Ž†”‡ ƒ”‡
these children are ƒ–
at ”‹•
risk ‘ˆ
of ”‡’‡ƒ–‡†
repeated
‹ˆ‡ –‹‘• ƒ†
infections and ’”‘‡
prone –‘to ‰”‘™–Š
growth ˆƒŽ–‡”‹‰
faltering ƒ†
and –Š‡”‡ˆ‘”‡ǡ
therefore, –Š‡
the ‹’‘”–ƒ
importance‡ ‘ˆ
of
ƒ’’”‘’”‹ƒ–‡ Š‹Ž† care
appropriate child ƒ”‡ ’”ƒ –‹ ‡• ƒ†
practices and –‹‡Ž› ƒ”‡ „›
timely care by –Š‡ ƒ”‡‰‹˜‡”• ‡‡†•
the caregivers needs –‘
to „‡
be
‡’Šƒ•‹œ‡†Ǥ
emphasized.

Step-8: Visit
Step-8: Visit by
by AWW and Referral:
AWW and Referral:

Ȉ Š‡’”‘‰”‡••‘ˆ–Š‡
The progress of the child Š‹Ž†•ŠƒŽŽ„‡‘‹–‘”‡†”‡‰—Žƒ”Ž›„›ƒ†”‡
shall be monitored regularly by AWW and recorded ‘”†‡†‹–Š‡
in the
‘•Šƒ”ƒ
Poshan Tracker. ‡”Ǥ
Ȉ ˜‡”›Ȁ
Every SAM/SUW child Š‹Ž†•ŠƒŽŽ„‡˜‹•‹–‡†ƒ†‘–Š‡”Ȁ
shall be visited and mother/caregiver ƒ”‡‰‹˜‡”•ŠƒŽŽ„‡ ‘—•‡Ž‡†‘
shall be counseled on
™‡‡Ž›„ƒ•‹•†—”‹‰–Š‡ˆ‹”•–‘–Šˆ‘ŽŽ‘™‡†„›ˆ‘”–‹‰Š–Ž›˜‹•‹–•Ǥ
weekly basis during the first month followed by fortnightly visits.
Ȉ For ‘”Ȁ
MAM/MUW childrenŠ‹Ž†”‡ˆ‘”–‹‰Š–Ž›˜‹•‹–••ŠƒŽŽ„‡ˆ‘ŽŽ‘™‡†Ǥ
fortnightly visits shall be followed.
Ȉ Ifˆ ƒ›
any ȀȀ
MAM/MUW/SUW child Š‹Ž† ”‡ˆŽ‡
reflects–• Š‡ƒŽ–Š
health ‹••—‡•
issues ‘”
or ‰”‘™–Š
growth ˆƒŽ–‡”‹‰ǡ
faltering, •—suchŠ
Š‹Ž†”‡ƒ›„‡”‡ˆ‡””‡†–‘‡†‹
children may be referred to MedicalƒŽˆˆ‹ Officer‡”‘ˆ–Š‡‡ƒ”‡•–Š‡ƒŽ–Šˆƒ ‹Ž‹–›ˆ‘”ˆ—”–Š‡”
of the nearest health facility for further
‡˜ƒŽ—ƒ–‹‘ƒ†‡†‹
evaluation and medicalƒŽƒƒ‰‡‡–Ǥ
management.
Ȉ Š‡
The ȀȀȀ
MAM/MUW/SUW/SAM Š‹Ž†”‡ Children ‡”‘ŽŽ‡†
enrolled ‹ in –Š‡
the —’’Ž‡‡–ƒ”›
Supplementary —–”‹–‹‘
Nutrition
’”‘‰”ƒƒ–ƒ›‡‡†–‘„‡–”ƒ•ˆ‡””‡†–‘–Š‡
program at AWC may need to be transferred to the PHC/CHC Ȁ ˆ‘”‡˜ƒŽ—ƒ–‹‘ƒ†ˆ‘”
for evaluation and for
ˆ—”–Š‡”‡˜ƒŽ—ƒ–‹‘ƒ†ƒƒ‰‡‡–‹
further evaluation and management in case ƒ•‡‘ˆǣ
of:
Ȉe ‡˜‡”‡‡†‹
Severe medicalƒŽ complication
‘’Ž‹ ƒ–‹‘‘”ƒ‘”‡š‹ƒ
or anorexia
Ȉe Fever
‡˜‡”ȋε͵ͻ†‡‰”‡‡Ȍ‘” ›’‘–Š‡”‹ƒȋδ͵ͷ†‡‰”‡‡Ȍ
(>39 degree C) or Hypothermia (< 35 degree C)
Ȉe ‡˜‡”‡’‡—‘‹ƒ
Severe pneumonia
Ȉe ‹ƒ””Š‡ƒȋ‘”‡–Šƒͷ™ƒ–‡”›•–‘‘Ž•‹ͳʹŠ”•Ȍ‘”•Š‘™‹‰•‹‰•‘ˆ†‡Š›†”ƒ–‹‘
Diarrhea (More than 5 watery stools in 12 hrs) or showing signs of dehydration
Ȉe ‡˜‡”‡ƒ‡‹ƒ
Severe anemia
Ȉe ‘–ƒŽ‡”–ǡ— ‘• ‹‘—•ǡƒ’ƒ–Š‡–‹
Not alert, unconscious, apathetic, ǡ convulsions
‘˜—Ž•‹‘•
Ȉe Appearance
’’‡ƒ”ƒ ‡‘ˆ‘‡†‡ƒ
of oedema
Ȉ¢ ‘–‡ƒ–‹‰ˆ‘”–Š”‡‡ ‘•‡ —–‹˜‡†ƒ›•
Not eating for three consecutive days
Ȉe ‡‹‰Š–Ž‘••ˆ‘”–™‘ ‘•‡ —–‹˜‡™‡‡•
Weight loss for two consecutive weeks
Ȉe Failure
ƒ‹Ž—”‡–‘‰ƒ‹™‡‹‰Š–ˆ‘” ‘•‡ —–‹˜‡–™‘™‡‡•
to gain weight for consecutive two weeks
Ȉe ‘Ǧ”‡ ‘˜‡”›ƒˆ–‡”–Š”‡‡‘–Š•‹–Š‡
Non-recovery after three months in the care ƒ”‡’”‘‰”ƒ
program

Step-9: Duration
Step-9: Duration of
of Monitoring
Monitoring

Š‡
The ‘†‡”ƒ–‡Ž›
moderately ƒ†
and •‡˜‡”‡Ž›
severely ƒŽ‘—”‹•Š‡† Š‹Ž†”‡ ‡”‘ŽŽ‡†
malnourished children enrolled —†‡”
under –Š‡
the —’’Ž‡‡–ƒ”›
Supplementary
—–”‹–‹‘”‘‰”ƒ‡ƒ–•ŠƒŽŽ„‡‘‹–‘”‡†—–‹Žǣ
Nutrition Programme at AWC shall be monitored until:

(1)
ȋͳȌ Ȁ Š‹Ž† completes
MAM/MUW child ‘’Ž‡–‡•ʹ‘–Š•ƒˆ–‡”ƒ Š‹‡˜‹‰‘”ƒŽ™‡‹‰Š–ȀŠ‡‹‰Š–Ǥ
2 months after achieving normal weight/height.
(2)
ȋʹȌ Ȁ Š‹Ž†—’–‘–Š‡ƒ‰‡‘ˆ͸›‡ƒ”•Ǥ
SAM/SUW child up to the age of 6 years.

Step-10: Follow-up
Step-10: Follow-up Care
Care

Ȉ ‘ŽŽ‘™Ǧ—’•ŠƒŽŽ„‡†‘‡ˆ‘”–Š‡
Follow-up Š‹Ž†”‡™Š‘„‡
shall be done for the children ‘‡‘”ƒŽ™‡‹‰Š–ȀŠ‡‹‰Š–Ǥ
who become normal weight/height.

10
10
 Ȉ Š‹Ž†”‡
Children •ŠƒŽŽ
shall –Š‡
then „‡ ‘–‹—‡† –‘
be continued to „‡
be ‡”‘ŽŽ‡†
enrolled —†‡”
under —’’Ž‡‡–ƒ”›
Supplementary —–”‹–‹‘
Nutrition
”‘‰”ƒƒ†’”‘˜‹†‡•‡”˜‹ ‡•ƒ•’‡”‡š‹•–‹‰’”‘–‘
Program and provide services as per existing protocol. ‘ŽǤ
Ȉ ‡‹‰Š–ƒ† ‡‹‰Š–•ŠƒŽŽ„‡‘‹–‘”‡†‡˜‡”›‘–ŠǤ
Weight and Height shall be monitored every month.

Other Key
Other Key Points
Points

 Š‡‹”‡
The Director–‘”ȋȌ•ŠƒŽŽ‡•—”‡—†‡”–ƒ‹‰–”ƒ‹‹‰ǡ
(WCD) shall ensure undertaking training, capacity ƒ’ƒ ‹–›„—‹Ž†‹‰ǡ‡ˆˆ‡
building, effective –‹˜‡
‹’Ž‡‡–ƒ–‹‘ǡƒ†ƒ‡Ǧ„ƒ•‡†
implementation, and name-based ‘‹–‘”‹‰ monitoring ‘ˆ–Š‡Ȁ
of the SAM/MAM children Š‹Ž†”‡ƒ†•ŠƒŽŽ
and shall
ƒŽ•‘–ƒ‡—’‡‡†Ǧ„ƒ•‡†ƒ••‡••‡–‘ˆ–Š‡’”‘‰”ƒǤ
also take up need-based assessment of the program.
 Buddy Mother
Buddy Concept: —††›
Mother Concept: Buddy ‘–Š‡”
Mother ‘ Concept‡’– ‹•
is ‘‡
one ‘ˆof –Š‡
the „‡•–
best ’”ƒ –‹ ‡•
practices
‡’Ž‘›‡†„›–Š‡–ƒ–‡‘ˆ••ƒˆ‘”–Š‡ƒƒ‰‡‡–‘ˆȀ
employed by the State of Assam for the management of SAM/MAM children. Š‹Ž†”‡Ǥ In–Š‹•ǡ
this,
–Š‡‘–Š‡”‘ˆƒŠ‡ƒŽ–Š›
the mother of a healthy child Š‹Ž†„‡ ‘‡•–Š‡„—††›‘–Š‡”‘ˆƒƒŽ‘—”‹•Š‡†
becomes the buddy mother ofa malnourished child Š‹Ž†‘ˆ
of
–Š‡
the •ƒ‡
same ‰ƒ™ƒ†‹
Anganwadi center ‡–‡” ƒ†
and –Š‡›
they ‡‡–
meet ‘on ™‡‡Ž›
weekly „ƒ•‹•
basis ƒ†
and †‹• —•• ƒ„‘—–
discuss about
˜ƒ”‹‘—•’”ƒ
various practices–‹ ‡•”‡Žƒ–‡†–‘—–”‹–‹‘Ǥ
related to nutrition.
 –ƒ–‡•Ȁ•
States/UTs •ŠƒŽŽ
shall ‡•—”‡
ensure –Š‡ the “—ƒŽ‹–›
quality ‘ˆ of —’’Ž‡‡–ƒ”›
Supplementary —–”‹–‹‘
Nutrition „‡‹‰
being ’”‘˜‹†‡†
provided
‡‡–•
meets the norms of food safety as well as nutrient composition to ‡•—”‡
–Š‡ ‘”• ‘ˆ ˆ‘‘† •ƒˆ‡–› ƒ• ™‡ŽŽ ƒ• —–”‹‡– ‘’‘•‹–‹‘ –‘ ensure
‘•‹•–‡– “—ƒŽ‹–› ƒ† —–”‹–‹˜‡ ˜ƒŽ—‡ ’‡” •‡”˜‹‰Ǥ Š‡
consistent quality and nutritive value per serving. The Supplementary Nutrition —’’Ž‡‡–ƒ”› —–”‹–‹‘
’”‘˜‹†‡†
provided •ŠƒŽŽ
shall „‡be –‡•–‡†
tested ˆ”‘ from FSSAI   ‘™‡†Ȁ”‡‰‹•–‡”‡†Ȁ‡’ƒ‡ŽŽ‡†Ȁ
owned/registered/empanelled/NABL
ƒaccredited
”‡†‹–‡†Žƒ„‘”ƒ–‘”›Ǥ
laboratory. ƒ†‘–‡•–‹‰—•–„‡
Random testing must be conducted ‘†— –‡†„›‰ƒ™ƒ†‹‡”˜‹
by Anganwadi Services ‡•
ˆ— –‹‘ƒ”‹‡• ƒˆ–‡”
functionaries after ”‡ ‡‹’– ‘ˆ
receipt of •–‘
stock ƒ–
at –Š‡
the 
AWC ‘” or ƒ–
at –Š‡
the Ž‘
Block ‡˜‡ŽǤ ‰ƒ™ƒ†‹
Level. Anganwadi
‡”˜‹ ‡• ˆ—
Services –‹‘ƒ”‹‡•ǡ ‹Ǥ‡Ǥǡ
functionaries, i.e. 
CDPO ‘”—’‡”˜‹•‘”
or Supervisor •ŠƒŽŽ shall †”ƒ™
draw –Š‡
the •ƒ’Ž‡•
samples ƒ• as ’‡”–Š‡
per the
’”‡• ”‹„‡† ’”‘
prescribed ‡†—”‡ ƒ†
procedure and •‡†
send –Š‡
the •ƒ’Ž‡
sample ˆ‘”
for –‡•–‹‰
testing –‘
to ƒ a_FSSAI 
‘™‡†Ȁ”‡‰‹•–‡”‡†Ȁ‡’ƒ‡ŽŽ‡†Ȁ
owned/registered/empanelled/NABL ƒaccredited ”‡†‹–‡† Žƒ„‘”ƒ–‘”›Ǥ
laboratory. Š‡ The ’‡”‹‘†‹
periodicity ‹–› ‘ˆ
of
•ƒ’Ž‡
sample –‡•–‹‰
testing •ŠƒŽŽ
shall „‡
be ‘ once‡ ‹
in ƒa “—ƒ”–‡”
quarter ‘ˆ of ƒ
an ƒ—ƒŽ
annual ›‡ƒ”ǡ
year, ’‡”
per ’”‘Œ‡
project.–Ǥ Š‡
The
–”‡ƒŽ‹‹‰ —‹†‡Ž‹‡• ‹••—‡†
Streamlining Guidelines issued „›by –Š‡the ‹‹•–”›
Ministry ‘ on ͳ͵ 13‘  January,
–Š ƒ—ƒ”›ǡ ʹͲʹͳ
2021 ƒ›may „‡be
”‡ˆ‡””‡†ˆ‘”ˆ—”–Š‡”†‡–ƒ‹Ž•Ǥ
referred for further details.
 Š‡”‘Ž‡•ƒ†”‡•’‘•‹„‹Ž‹–‹‡•‘ˆˆ—
The roles and responsibilities of functionaries –‹‘ƒ”‹‡•ƒ”‡ƒ–Annexure-VǤ
are at Annexure-V.

11
11
 Annexure-I
Annexure-!

ˆƒ–•—†‡”͸‘–Š•
Infants under 6 months

Y
‘‘ˆ‘”•‹‰•‘ˆ•‡”‹‘—••‹ ‡••Ȁ‰‡‡”ƒŽ†ƒ‰‡”•‹‰•
Look for signs of serious sickness/general danger signs |

f ’
General danger
General danger signs/serious
signs/serious medical
medical ‘‰‡‡”ƒŽ†ƒ‰‡”•‹‰•Ȁ‘•‡”‹‘—•
No general danger signs/no serious
complication present
complication present ‡†‹
medicalƒŽ complication
‘’Ž‹ ƒ–‹‘

”‘˜‹†‡
Provide ’”‡Ǧ”‡ˆ‡””ƒŽ
pre-referral –”‡ƒ–‡–
treatment ƒ†
and ”‡ˆ‡”
refer
—”‰‡–Ž›
urgently –‘
to –Š‡
the ‡ƒ”‡•–
nearest Š‡ƒŽ–Š
health ˆƒ ‹Ž‹–›
facility
••‡••—–”‹–‹‘ƒŽ”‹•„›Ž‘‘‹‰ˆ‘”‘–Š‡”•‹‰•
Assess nutritional risk by looking for other signs
’”‘˜‹†‹‰’‡†‹ƒ–”‹
providing pediatric •‡”˜‹ ‡•
services
‘ˆ
of ‹ŽŽ‡••‡•Ȁˆ‡‡†‹‰
illnesses/feeding
ƒ••‡••‡–Ȁ™‡‹‰Š–Ȁƒ–‡”ƒŽ
assessment/weight/maternal ‘†‹–‹‘
condition
ƒ••‡••‡–ƒ•’‡”–ƒ„Ž‡„‡Ž‘™Ƭ ƒ–‡‰‘”‹œ‡ƒ•ǣ
assessment as per table below & categorize as:

| : i
–
At •‡˜‡”‡
severe ”‹•
risk ˆ‘”
for –
At ‘†‡”ƒ–‡
moderate’ ”‹•
risk ˆ‘”
for ‘–
Not ƒ–
at ”‹•
risk ‘ˆ
of
ƒŽ—–”‹–‹‘
malnutrition ƒŽ—–”‹–‹‘
malnutrition ƒŽ—–”‹–‹‘
malnutrition

x 4
†‹– ‹
Admit in ƒ
a ˆƒ ‹Ž‹–›
facility Outpatient care
Outpatient care /Anganwadi-
/Anganwadi- Home care
Home care asas HBNC/HBYC
HBNC/HBYC
based care
care
”ƒ‹•‡
Praise ‘–Š‡”ǡ
mother, ‘—•‡Ž
Counsel ˆ‘”
for
™‹–Š
with 
NRC ‘”
or based
—–”‹–‹‘ƒŽ ‘—•‡ŽŽ‹‰Ƭ
Nutritional counselling & ‡š Ž—•‹˜‡  ǡ Š›‰‹‡‹ 
exclusive BF, hygienic practices’”ƒ –‹ ‡•
 Ȁ –”ƒ‹‡†
IYCF/MAA trained ‘—•‡Ž –‘ ƒ––‡†   ˆ‘”
ˆ‘ŽŽ‘™Ǧ—’ƒ•ƒ†˜‹•‡†‹
follow- up as advised in Counsel to attend VHSND for
•–ƒˆˆ
staff ‰”‘™–Š
growth ‘‹–‘”‹‰
monitoring Ƭ
& _ –‹‡Ž›
timely
Ȁ 
HBNC/HBYC
 ‹—‹œƒ–‹‘
immunization

12
12
 At Severe Nutritional
At Severe Nutritional Risk
Risk At Moderate
At Moderate Nutrition
Nutrition Risk
Risk Not at
Not at Nutritional
Nutritional Risk
Risk
(Any of
(Any of the
the following)
following) (Any of
(Any of the
the following)
following)

e ‘–ƒ„Ž‡–‘ˆ‡‡†
Notable to feed  ‹”–Š™‡‹‰Š–ͳͺͲͲǦδʹͷͲͲ‰
Birth weight 1800-<2500 g ‹”–Š™‡‹‰Š–εʹǤͷ‰ƒ†
Birth weight >2.5 Kg and
e ›‰‡‡”ƒŽ†ƒ‰‡”•‹‰
Any general danger sign
ȋ(IMNC]I)
 Ȍ  ‘†‡”ƒ–‡Ȁ•‡˜‡”‡
Moderate / severe e š Ž—•‹˜‡Ž›„”‡ƒ•–‡†
Exclusively breasted
ƒŽ—–”‹–‹‘ȋδǦʹȀ‘”
malnutrition (<-2SD W/A or 
AND
e ‹”–Š™‡‹‰Š–δͳͺͲͲ‰
Birth weight <1800 gm ȀȌ
W/L)
†—”‹‰ˆ‹”•–‘–Š
during first month e 
WFA‘”
or WFH αεʹ
=>2SD
 ‘”‡‰ƒ‹‡†„‹”–Š™‡‹‰Š–„›
No regained birth weight by
e ‡‹‰Š–Ž‘••„‡–™‡‡–™‘
Weight loss between two †ƒ›ͳͶ
day 14 e ƒ•‰ƒ‹‡†εαͳʹͷ‰
Has gained >=125 gm
‘•‡ —–‹˜‡˜‹•‹–•ƒˆ–‡”ʹ
consecutive visits after 2"4† ˆ”‘Žƒ•–˜‹•‹–
from last visit AND
™‡‡‘ˆŽ‹ˆ‡‡˜‡ƒˆ–‡”
week of life even after  –ƒ–‹
Static ™‡‹‰Š–„‡–™‡‡–™‘
weight between two
‘•‡ —–‹˜‡˜‹•‹–•‡˜‡ƒˆ–‡”
consecutive visits even after e ‘ƒ–‡”ƒŽ
No maternal
—–”‹–‹‘ƒŽ ‘—•‡Ž‹‰
nutritional counseling —–”‹–‹‘ƒŽȀ
—–”‹–‹‘ƒŽ ‘—•‡Ž‹‰
nutritional counseling nutritional /
e –ƒ–‡™‡‹‰Š–ˆ‘”–Š”‡‡
State weight for three ’•› Š‘•‘ ‹ƒŽ‹••—‡•
psychosocial issues
‘•‡ —–‹˜‡˜‹•‹–•‡˜‡
consecutive visits even  ”‡ƒ•–ˆ‡†™‹–Šƒ›‘ˆ–Š‡
Breastfed with any of the
ƒˆ–‡”—–”‹–‹‘ƒŽ
after nutritional
ˆ‘ŽŽ‘™‹‰ˆ‡‡†‹‰’”‘„Ž‡•
following feeding problems
‘—•‡Ž‹‰
counseling ‘‘”ƒ––ƒ Š‡–
>
 Poor attachment
e —††‡Ž‘••‘ˆ™‡‹‰Š–
Sudden loss of weight
>
 ‘–•— Ž‹‰‡ˆˆ‡
Not suckling –‹˜‡Ž›
effectively
ȋŽ‘••‘”‡–ŠƒͳͲΨˆ”‘
(loss more than 10% from
’”‡˜‹‘—•”‡ ‘”†‹ƒ
previous record ina >
 ‡••–Šƒͺ„”‡ƒ•–ˆ‡‡†•‹
Less than 8 breastfeeds in
™‡‡Ȍ
week) ʹͶŠ‘—”•
24 hours

e Šƒ”’†”‘’ƒ ”‘••‰”‘™–Š
Sharp drop across growth >
 ‡ ‡‹˜‡•‘–Š‡”ˆ‘‘†•‘”
Receives other foods or
—”˜‡Ž‹‡
curve line †”‹•
drinks

e ‘‰‡‹–ƒŽƒ‘ƒŽ‹‡•
Congenital anomalies >
 ”ƒŽ—Ž ‡”•Ȁ‘”ƒŽ–Š”—•Š
Oral ulcers/oral thrush
‹–‡”ˆ‡”‹‰ˆ‡‡†‹‰
interfering feeding
 ‘–„”‡ƒ•–ˆ‡†ƒ–ƒŽŽ‘”‹š‡†
Not breastfed at all or mixed
ˆ‡‡†‹‰™‹–Šƒ›‘ˆ–Š‡
feeding with any of the
ˆ‘ŽŽ‘™‹‰
following

>
 ‹Ž‹ ‘””‡ –Ž›‘”
Milk incorrectly or
—Š›‰‹‡‹ ƒŽŽ›’”‡’ƒ”‡†
unhygienically prepared

>
 ‹˜‹‰‹•—ˆˆ‹
Giving ‹‡–
insufficient
”‡’Žƒ ‡‡–ˆ‡‡†•
replacement feeds

>
 •‹‰ƒˆ‡‡†‹‰„‘––Ž‡
Usinga feeding bottle

>
 †˜‡”•‡ƒ–‡”ƒŽ
Adverse maternal
’•› Š‘•‘ ‹ƒŽˆƒ
psychosocial –‘”
factor

13
13
 Annexure-II
Annexure-II

Appetite Assessment
Appetite and Test
Assessment and Test

A. Assessment
A. of Adequacy
Assessment of Adequacy of
of Appetite:
Appetite:

”‡•‡
Presence‡‘”ƒ„•‡
or absence‡‘ˆ‰‘‘†ƒ’’‡–‹–‡‹–Š‡ Š‹Ž†™‹–ŠŠƒ•ƒ˜‡”›‹’‘”–ƒ–„‡ƒ”‹‰‘
of good appetite in the child with SAM has a very important bearing on
’Žƒ‹‰
planning Š‹•ȀŠ‡”
his/her –”‡ƒ–‡–
treatment ƒ†
and ”‡Šƒ„‹Ž‹–ƒ–‹‘Ǥ
rehabilitation. Š‹Ž†”‡
Children ™Š‘
who Šƒ˜‡
have ‰‘‘†
good ƒ’’‡–‹–‡
appetite ƒ†
and ƒ”‡
are
ƒ„Ž‡–‘‡ƒ–ƒ†‡“—ƒ–‡ƒ‘—–‘ˆˆ‘‘†
able to eat adequate amount of food can ƒ„‡ƒƒ‰‡†‹–Š‡Š‘‡•‡––‹‰•™‹–Š–Š‡•—’’‘”–
be managed in the home settings with the support
‘ˆ•Ȁ
of AWWs/ASHAs. •ǤŠ‹Ž†”‡ǡ™Š‘”‡ˆ—•‡–‘‡ƒ–‘’–‹ƒŽŽ›ǡ™‹ŽŽ‡‡†–‘„‡”‡ˆ‡””‡†–‘Ǥ
Children, who refuse to eat optimally, will need to be referred to NRC.

†‡“—ƒ
Adequacy›‘ˆƒ’’‡–‹–‡‹•–‡•–‡†„›ƒ’’‡–‹–‡‡•–Ǥ
of appetite is tested by an Appetite Test. Inƒ’’‡–‹–‡‡•–ǡ•’‡ ‹ˆ‹‡†ƒ‘—–‘ˆ
an Appetite Test, specified amount of
ˆ‘‘†‹•‘ˆˆ‡”‡†
food is offered –‘–Š‡ Š‹Ž†™Š‘‹•–Š‡
to the child who is then ‘„•‡”˜‡†ƒ•–‘Š‘™Š‡Ȁ•Š‡ƒ –‹˜‡Ž› consumes
observed as to how he/she actively ‘•—‡•–Š‡
the
ˆ‘‘†Ǥ
food.

B. Indication:ŽŽ
B. Š‹Ž†”‡ȋ‡‹‰Š–Ǧˆ‘”Ǧ
Indication: All SAM children ‡‹‰Š–δǦ͵Ȍ™‹ŽŽ—†‡”‰‘’’‡–‹–‡‡•–Ǥ
(Weight-for-Height <-3SD) will undergo Appetite Test.

C. Where
C. Where the
the Appetite Test to
Appetite Test to be
be done:
done:

Ȉe Š‡’’‡–‹–‡‡•–™‹ŽŽ„‡ ƒ””‹‡†‹ƒ•‡’ƒ”ƒ–‡“—‹‡–ƒ”‡ƒ‘ˆ–Š‡‰ƒ™ƒ†‹‡–‡”•
The Appetite Test will be carried in a separate quiet area of the Anganwadi Centers
ȋȌǤ
(AWC).

Ȉ¢ Š‡
The 
AWW •Š‘—Ž† ‘˜‹ ‡ –Š‡
should convince the ‘–Š‡”•Ȁ ƒ”‡‰‹˜‡”• –‘
mothers/ caregivers to „”‹‰
bring –Š‡ Š‹Ž† –‘
the child to Ǥ
AWC.
‘™‡˜‡”ǡ‡˜‡ƒˆ–‡”ʹǦ͵ƒ––‡’–•„›–Š‡ǡ‹ˆ–Š‡
However, even after 2-3 attempts by the AWW, if the childŠ‹Ž††‘‡•‘––—”—’ƒ–ǡ
does not turn up at AWC,
–Š‡ ’’‡–‹–‡ ‡•–
the Appetite Test •Š‘—Ž†
should „‡ ‘†— –‡† ƒ–
be conducted at Š‘‡Ǥ
home. 
AWW ™‹ŽŽ
will ˜‹•‹–
visit –Š‡ Š‹Ž†ǯ• Š‘‡
the child’s home
ƒ””›‹‰–Š‡ˆ‘‘†ƒ˜ƒ‹Žƒ„Ž‡ƒ–ˆ‘”–Š‡’’‡–‹–‡‡•–ǤŠ‡‡•–ƒ›„‡
carrying the food available at AWC for the Appetite Test. The Test may be conducted ‘†— –‡†
™‹–Š–Š‡•—’’‘”–‘ˆ
with the support of ASHA.Ǥ

Ȉ¢ ‘
To ‹‹‹œ‡
minimize –Š‡
the –‹‡
time ‰ƒ’
gap „‡–™‡‡
between ‹†‡–‹ˆ‹ ƒ–‹‘ ‘ˆ
identification of 
SAM ƒ†
and ”‡ˆ‡””ƒŽ
referral ˆ‘”
for ˆ—”–Š‡”
further
ƒƒ‰‡‡–ǡ–Š‡’‡”‹‘†ˆ‘” ‘—‹ ƒ–‹‘„‡–™‡‡ƒ†•Š‘—Ž†‘–„‡
management, the period for communication between AWW and ANM should not be
‘”‡–Šƒʹ†ƒ›•Ǥ
more than 2 days.

D. Food
D. Food to
to be
be used
used in
in Appetite Test: ‘
Appetite Test: ƒŽŽ›ƒ˜ƒ‹Žƒ„Ž‡ˆ‘‘†‹–‡•ȋ
Locally ‘–‘‘‡†‡ƒŽ•ƒ†
available food items (Hot Cooked meals and
ƒ‡
Take Home Ration not raw ration) available at the Anganwadi Centers are –‘
‘‡ ƒ–‹‘ ‘–”ƒ™ ”ƒ–‹‘Ȍ ƒ˜ƒ‹Žƒ„Ž‡ ƒ– –Š‡ ‰ƒ™ƒ†‹ ‡–‡”• ƒ”‡ to „‡
be —•‡†
used ˆ‘”
for
’’‡–‹–‡‡•–Ǥ
Appetite Test.

E. How
E. How to
to conduct
conduct the
the Appetite Test:
Appetite Test:

ƒȌ
a) ‘–Š‡‡•–‹ƒ•‡’ƒ”ƒ–‡“—‹‡–ƒ† ‘ˆ‘”–ƒ„Ž‡ƒ”‡ƒ™Š‡”‡–Š‡
Do the Test in a separate quiet and comfortable Š‹Ž†™‹ŽŽ„‡‰‹˜‡—’
area where the child will be given up
–‘ƒŠ‘—”ˆ‘”‡ƒ–‹‰–Š‡‡•–†‹‡–Ǥ
to an hour for eating the Test diet.

„Ȍ
b) š’Žƒ‹–‘–Š‡‘–Š‡”Ȁ ƒ”‡‰‹˜‡”Š‘™–Š‡‡•–™‹ŽŽ„‡†‘‡Ǥ
Explain to the mother/caregiver how the Test will be done.

c)Ȍ Š‡‘–Š‡”Ȁ ƒ”‡‰‹˜‡”•Š‘—Ž†™ƒ•ŠŠ‡”Šƒ†•Ǥ

The mother/caregiver should wash her hands.

14
14
 †Ȍ
d) Š‡‘–Š‡”•‹–• ‘ˆ‘”–ƒ„Ž›™‹–Š–Š‡
The mother sits comfortably Š‹Ž†‘Š‡”Žƒ’ƒ†‘ˆˆ‡”•ˆ‡‡†Ǥ
with the child on her lap and offers feed.

‡Ȍ
e) Š‡ Š‹Ž†•Š‘—Ž†‘–Šƒ˜‡–ƒ‡ƒ›ˆ‘‘†ˆ‘”–Š‡Žƒ•–ʹŠ‘—”•Ǥ
The child should not have taken any food for the last 2hours.

ˆȌ
f) Š‡‡•–—•—ƒŽŽ›–ƒ‡•ƒ•Š‘”––‹‡„—–ƒ›–ƒ‡—’–‘‘‡Š‘—”Ǥ
The Test usually takes a short time but may take up to one hour.

‰Ȍ
g) Š‹Ž†”‡ƒ›„‡‘ˆˆ‡”‡†–Š‡‡•–ˆ‡‡†ƒ ‘”†‹‰–‘–Š‡„‘†›™‡‹‰Š–ǣδͷ‰Ȃͳͷ‰”ƒ•
Children may be offered the Test feed according to the body weight: < 5kg - 15 grams
ȋ͵–‡ƒ•’‘‘Ȍ‡•–ˆ‡‡†Ǣͷ–‘ͻǤͻ‰Ȃ͵Ͳ‰”ƒ•ȋ͸–‡ƒ•’‘‘Ȍ‡•–ˆ‡‡†Ǣƒ†ηͳͲ‰ȂͶͷ
(3 teaspoon) Test feed; 5 to 9.9 kg - 30 grams (6 teaspoon) Test feed; and 210 kg - 45
‰”ƒ•ȋͻ–‡ƒ•’‘‘Ȍ‡•–ˆ‡‡†Ǥ‡–‡ƒ•’‘‘‹•”‘—‰ŠŽ›‡“—‹˜ƒŽ‡––‘ͷ‰”ƒ•Ǥ
grams (9 teaspoon) Test feed. One teaspoon is roughly equivalent to 5grams.

ŠȌ
h) Š‡ Š‹Ž†—•–‘–„‡ˆ‘”
The child ‡†–‘–ƒ‡–Š‡ˆ‘‘†‘ˆˆ‡”‡†Ǥ
must not be forced to take the food offered.

‹Ȍ
i) Š‡ Š‹Ž† •Š‘—Ž†
The child should Šƒ˜‡
have ˆ”‡‡
free ƒaccess
‡•• –‘
to •ƒˆ‡
safe †”‹‹‰
drinking ™ƒ–‡”
water ™Š‹Ž‡
while Š‡Ȁ•Š‡
he/she ‹•
is –ƒ‹‰
taking –Š‡
the
–‡•–ˆ‡‡†Ǥ
test feed.

ŒȌ
j) Š‡–Š‡ Š‹Ž†Šƒ•ˆ‹‹•Š‡†ǡ–Š‡ƒ‘—––ƒ‡‹•Œ—†‰‡†‘”‡ƒ•—”‡†Ǥ
When the child has finished, the amount taken is judged or measured.

Ȍ
k) Š‡ Š‹Ž†•Š‘—Ž†Šƒ˜‡
The child ‘•—‡†‘•–ȋƒ–Ž‡ƒ•––Š”‡‡Ǧˆ‘—”–ŠȌ‘ˆ–Š‡‡•–ˆ‡‡†‘ˆˆ‡”‡†
should have consumed most (at least three-fourth) of the Test feed offered
ƒ•’‡”™‡‹‰Š––‘’ƒ••–Š‡‡•–Ǥ
as per weight to pass the Test.

ŽȌ ‘ŽŽ‘™‹‰ –Š‡
1) Following the ’’‡–‹–‡
Appetite ‡•–ǡ
Test, –Š‡ Š‹Ž† •Š‘—Ž†
the child should „‡
be ‘„•‡”˜‡†
observed ˆ‘”
for ͵Ͳ
30 ‹—–‡•
minutes ˆ‘”
for ƒ›
any
‹‡†‹ƒ–‡ƒ†˜‡”•‡‡˜‡–•Ǥ
immediate adverse events.

F. How
F. How to
to Interpret
Interpret the
the Appetite Test
Appetite Test

Appetite
Appetite Observation
Observation Action
Action

‘‘†
Good Š‹Ž†‡ƒ–•ˆ‘‘†ƒ‰‡”Ž›
Child eats food Eagerly ‘–‹—‡
Continue ‹ ‘—‹–› care
in community ƒ”‡ ƒ–
at
‰ƒ™ƒ†‹‡–‡”
Anganwadi Center

‘‘”
Poor Š‹Ž†
Child –ƒ‡•
takes ˆ‘‘†
food ™‹–Š
with ’‡”•‹•–‡–Š‹Ž† ƒ›
persistentChild ‘–‹—‡ ‹
may continue ‘—‹–›
in community
‡ ‘—”ƒ‰‡‡–
encouragement ƒ”‡ ƒ–
care ‰ƒ™ƒ†‹ ‡–‡”
at Anganwadi Center „—–
but —•–
must
„‡‘„•‡”˜‡† ƒ”‡ˆ—ŽŽ›ˆ‘”ƒ›™‡‹‰Š–
be observed carefully for any weight
Ž‘••‘” Ž‹‹ ƒŽ†‡–‡”‹‘”ƒ–‹‘
loss or clinical deterioration

‡ˆ—•‡†
Refused Š‹Ž†
Child ”‡ˆ—•‡•
refuses ˆ‘‘†
food ‡˜‡
even ƒˆ–‡””ƒ•ˆ‡”–‘
after/Transfer to NRC
’‡”•‹•–‡–‡ ‘—”ƒ‰‡‡–
persistent encouragement

 

15
15
 Annexure-III
Annexure-IlI

Assessment for
Assessment for Emergency/Danger
Emergency/Danger signs
signs –
-Action Protocol
Action Protocol
based on
based on Assessment
Assessment

Assessment
Assessment Findings
Findings Action to be
Action to be taken
taken

Danger signs
Danger signs e ‘–ƒ ‡’–‹‰ Feeds
Not accepting ‡‡†• ”‰‡–”‡ˆ‡””ƒŽ–‘
Urgent referral to
e ‡–Šƒ”‰›ƒ†ƒŽ–‡”‡†•‡•‘”‹—
Lethargy and altered sensorium ‡ƒ”‡•–
nearest
e ‡˜‡”‡ Š‡•–‹Ǧ†”ƒ™‹‰
Severe chest in-drawing ‡ƒŽ–Šˆƒ
Health ‹Ž‹–›
facility
e –”ƒ –ƒ„Ž‡Ȁ’‡”•‹•–‡–˜‘‹–‹‰
Intractable/persistent vomiting
e ‹•–‘”› ‘ˆ
History ‘˜—Ž•‹‘ ‹
of convulsion —””‡–
in current
‹ŽŽ‡••
illness
Respiratory Rate
Respiratory Rate e η͸Ͳ
260 ”‡•’‹”ƒ–‹‘•Ȁ‹—–‡
respirations/minute ‡ˆ‡””ƒŽ
Referral –‘
to ‡ƒ”‡•–
nearest
—†‡”ʹ‘–Š•Ǥ
under2months. Š‡ƒŽ–Šˆƒ ‹Ž‹–›
health facility
e η
>> ͷͲ
50 ”‡•’‹”ƒ–‹‘•Ȁ‹—–‡
respirations/minute
ˆ”‘ʹǦͳʹ‘–Š•Ǥ
from 2-12months.
e ηͶͲ”‡•’‹”ƒ–‹‘•Ȁ‹—–‡ˆ”‘ͳǦ
240respirations/minutefrom1-
ͷ›‡ƒ”•Ǥ
5years.
Temperature
Temperature e ε͵ͻ
>39 †‡‰”‡‡
degree ‡–‹‰”ƒ†‡
centigrade ‡ˆ‡””ƒŽ
Referral –‘
to ‡ƒ”‡•–
nearest
(Axillary)
(Axillary) ȋεͳͲʹǤʹ†‡‰”‡‡ ƒŠ”‡Š‡‹–ȌǤ
(>102.2degreeFahrenheit). Š‡ƒŽ–Šˆƒ ‹Ž‹–›
health facility
e δ͵ͷ
<35 †‡‰”‡‡
degree ‡–‹‰”ƒ†‡
centigrade
ȋδͻͷ†‡‰”‡‡ ƒŠ”‡Š‡‹–ȌǤ
(<95degreeFahrenheit).
 e ‡˜‡” Ǧ- ‹Ž†
Fever Mild –‘
to ‘†‡”ƒ–‡
moderate —’’Ž‡‡–ƒ”›
Supplementary
δ͵ͻ
<39 †‡‰”‡‡
degree ȋδͳͲʹǤʹ
(<102.2 †‡‰”‡‡
degree —–”‹–‹‘
Nutrition ”‘‰”ƒ
Program
ƒŠ”‡Š‡‹–ȌǤ
Fahrenheit).
e ‡’‡”ƒ–—”‡
Temperature „‡Ž‘™
below
͵͸Ǥͷ
36.5 †‡‰”‡‡ ‡–‹‰”ƒ†‡
degree centigrade
„—–
but ƒ„‘˜‡
above ͵ͷ 35 †‡‰”‡‡
degree
‡–‹‰”ƒ†‡Ǥ
centigrade.
Diarrhoea
Diarrhoea e ŽŽ
All †‹ƒ””Š‡ƒ
diarrhea ™‹–Š
with †‡Š›†”ƒ–‹‘ or ‡ˆ‡””ƒŽ–‘
dehydration ‘” Referral to
†‹ƒ””Š‘‡ƒŽƒ•–‹‰ͳͶ†ƒ›•‘”‘”‡
diarrhoealasting14daysormore ‡ƒ”‡•–Š‡ƒŽ–Š
nearest health
e ›•‡–‡”›
Dysentery ˆƒ ‹Ž‹–›
facility
e ‘‡‘”•‡˜‡”‡†‡Š›†”ƒ–‹‘
Some or severe dehydration
 e ‘†‡Š›†”ƒ–‹‘
No dehydration —’’Ž‡‡–ƒ”›
Supplementary
—–”‹–‹‘”‘‰”ƒ
Nutrition Program

Cough
Cough e ‘”‡–Šƒ–™‘™‡‡•
More than two weeks ‡ˆ‡””ƒŽ–‘‡ƒ”‡•–
Referral to Nearest
Š‡ƒŽ–Šˆƒ ‹Ž‹–›
health facility
Pallor
Pallor e ‡˜‡”‡ƒŽŽ‘”
Severe Pallor ‡ˆ‡””ƒŽ–‘‡ƒ”‡•–
Referral to Nearest
Š‡ƒŽ–Šˆƒ ‹Ž‹–›
health facility

16
16
  ‘‡ƒŽŽ‘”Ȁ‘ƒŽŽ‘”
Some Pallor/No Pallor —’’Ž‡‡–ƒ”›
Supplementary
—–”‹–‹‘”‘‰”ƒ
Nutrition Program

Oedema
Oedema  ‹Žƒ–‡”ƒŽ’‹––‹‰‘‡†‡ƒ
Bilateral pitting oedema ‡ˆ‡””ƒŽ–‘
Referral to
‡ƒ”‡•–Š‡ƒŽ–Š
nearest health
ˆƒ ‹Ž‹–›
facility
Skin
Skin  š–‡•‹˜‡
Extensive •‹
skin Ž‡•‹‘•Ȁ†‡—†‡† ‡ˆ‡””ƒŽ–‘
lesions/denuded Referral to
•‹
skin ‡ƒ”‡•–Š‡ƒŽ–Š
nearest health
ˆƒ ‹Ž‹–›
facility
Others
Others  ‘–Š‡”Ȁ ƒ”‡‰‹˜‡”‘–
Mother/caregiver ‘ˆ‹†‡–Ǥ
not confident. ‡ˆ‡””ƒŽ–‘
Referral to
 ‰‡Ž‡••–Šƒ•‹š‘–Š•
Age less than six months ‡ƒ”‡•–Š‡ƒŽ–Š
nearest health
 –ƒ–‹
Static  weight
™‡‹‰Š– ˆ‘”
for –Š”‡‡
three ˆƒ ‹Ž‹–›
facility
‘•‡ —–‹˜‡™‡‡•‘”™‡‹‰Š–Ž‘••
consecutive weeks or weight loss
ˆ‘”–™‘ ‘•‡ —–‹˜‡™‡‡•
for two consecutive weeks

17
17
 Annexure-IV
Annexure-IV

Suggested food
Suggested food baskets
baskets for
for provision
provision of
of Supplementary
Supplementary Nutrition
Nutrition to
to Malnourished
Malnourished
Children
Children

S.N | Category
S.N Category Type |
Type Cerea |
Cerea Pulse |
Pulse Green |
Green Vege |
Vege Nuts |
Nuts Cooki | Egg
Cooki Egg Whole
Whole
0.o. of
of Is &
ls & ss&& Leafy
Leafy tabl |
tabl && ng
ng (Nos) | Milk
(Nos) Milk
Meal |
Meal Millet |
Millet Legu |
Legu Vegeta |
Vegeta es
es Seed |
Seed Oils
Oils Powd
Powd
ss(g)
(g) | mes |
mes bles(g)
bles (g)| (g) |
(g) ss(g)
(g) | (8)
(g) er (g)
er (g)
(g)
(g)
ͳǤ Undernourished | 
1} †‡”‘—”‹•Š‡† THR ͵Ͳ
30 ͳͷ
15 Ͳ
0 Ͳ
0 ͳʹ
12 ͹Ǥͷ
7.5 ͳ
1 ͳͲ
10
Š‹Ž†”‡ȋ͸Ǧͳʹ
children (6-12
‘–Š•Ȍ
months)
ʹǤ Undernourished | 
2| †‡”‘—”‹•Š‡† THR ͸Ͳ
60 ͵Ͳ
30 Ͳ
0 Ͳ
0 ʹͲ
20 ͳͷ
15 ͳ
1 ʹͲ
20
Š‹Ž†”‡ȋͳǦ͵
children (1-3
›‡ƒ”•Ȍ
years)
͵Ǥ Undernourished | Ϊ
3] †‡”‘—”‹•Š‡† MS+_ | ͷͲ
50 ʹͷ
25 ʹͷ
25 ͷͲ
50 ͳͲ
10 ͳͲ
10 Ͳ
0 Ͳ
0
Š‹Ž†”‡ȋ͵Ǧ͸
children (3-6 
HCM
›‡ƒ”•Ȍ
years) THR | ͵Ͳ
 30 15
ͳͷ 0
Ͳ 0
Ͳ 12
ͳʹ 7.5
͹Ǥͷ 1
ͳ 10
ͳͲ

THR:ǣƒ‡ ‘‡ƒ–‹‘Ǣ
Take Home ǣ Hot
Ration; HCM: ‘–‘‘‡†‡ƒŽǢǣ‘”‹‰ƒ
Cooked Meal; MS: Morning Snack;ǢǣŠ‘Ž‡‹Ž‘™†‡”
WMP: Whole Milk Powder
 Š‡
The •—‰‰‡•–‡†
suggested ˆ‘‘†
food „ƒ•‡–•
baskets ‹in –Š‡
the –ƒ„Ž‡
table ƒ„‘˜‡
above ‹•
is ˆ‘”
for ’”‘˜‹•‹‘
provision ‘ˆ
of —’’Ž‡‡–ƒ”›
Supplementary
—–”‹–‹‘–‘ƒŽ‘—”‹•Š‡† Š‹Ž†”‡‹‘”†‡”–‘‡‡––Š‡—–”‹–‹‘‘”••—‰‰‡•–‡†‹
Nutrition to Malnourished children in order to meet the nutrition norms suggested in
–Š‡–ƒ„Ž‡ƒ––‡’Ǧͷ‘ˆ’”‘–‘
the table at Step-5 of protocol‘Žƒ„‘˜‡Ǥ
above.
 —ƒ–‹–›‘ˆˆ‘‘†‰”‘—’‹•‹–‡”•‘ˆ”ƒ™‡“—‹˜ƒŽ‡–•Ǥ
Quantity of food group is in terms of raw equivalents.
 ‹‹ƒŽŽ›’‘Ž‹•Š‡†Ƭƒ’’”‘’”‹ƒ–‡Ž›’”‘ ‡••‡†‰”ƒ‹Ƭ‰”ƒ‹••—‰‰‡•–‡†–‘‹’”‘˜‡
Minimally polished & appropriately processed grain & gram is suggested to improve
–Š‡ ‘–‡–Ƭƒ˜ƒ‹Žƒ„‹Ž‹–›‘ˆ˜‹–ƒ‹•ƒ†‹‡”ƒŽ•Ǥ
the content & availability of vitamins and minerals.
 ‡‰‰ƒ›„‡’”‘˜‹†‡†‘ƒŽŽ†ƒ›•–‘ƒŽŽƒ‰‡‰”‘—’•‹ˆ —Ž–—”ƒŽŽ›ƒacceptable.
One Egg may be provided on all days to all age groups if culturally ‡’–ƒ„Ž‡Ǥ—–•Ƭ
Nuts &
•‡‡†•Ȁ‹Žƒ›„‡’”‘’‘”–‹‘ƒ–‡Ž›‹ ”‡ƒ•‡†‹„‡‡ˆ‹ ‹ƒ”‹‡•‘– ‘•—‹‰‡‰‰•Ǥ
seeds/milk may be proportionately increased in beneficiaries not consuming eggs.
 It– ‹•
is •—‰‰‡•–‡†
suggested –‘
to ‹ Ž—†‡ ˆ”‡•Š
include fresh ™Š‘Ž‡
whole ˆ”—‹–•
fruits –‘
to –Š‡
the ‡š–‡–
extent ’‘••‹„Ž‡
possible –‘
to ‹’”‘˜‡
improve „‹‘Ǧ
bio-
ƒ˜ƒ‹Žƒ„Ž‡—–”‹‡–•Ǥ
available nutrients.
 Ifˆ‘—„Ž‡ ‘”–‹ˆ‹‡†ƒŽ–‹•—•‡†ǡ‹–™‹ŽŽ
Double Fortified ‘–”‹„—–‡ƒ††‹–‹‘ƒŽ‹”‘̷ͳ‰Ȁ‰‘ˆ•ƒŽ–Ǥ
Salt is used, it will contribute additional iron @ 1mg/g of salt.
 Ifˆ Fortified
‘”–‹ˆ‹‡†‹
Rice‡‘” ‘”–‹ˆ‹‡†Š‡ƒ–
or Fortified Ž‘—”‹•—•‡†ǡ‹–™‹ŽŽ
Wheat Flour ‘–”‹„—–‡ƒ††‹–‹‘ƒŽ‹”‘̷
is used, it will contribute additional iron @
ͲǤͲʹͺǦͲǤͲͶ͵‰Ȁ‰ǡƒ††‹–‹‘ƒŽˆ‘Ž‹
0.028-0.043mg/g, additional folic ƒacid ‹†̷ͲǤͲ͹ͷǦͲǤͳʹͷɊ‰Ȁ‰ƒ†ƒ††‹–‹‘ƒŽ˜‹–ƒ‹ͳʹ
@ 0.075-0.125ug/g and additional vitamin B12
̷ͲǤͲͲͲ͹ͷǦͲǤͲͲͳʹͷɊ‰Ȁ‰‘ˆ”‹
@ 0.00075-0.00125 ug/g of rice‡‘”™Š‡ƒ–ˆŽ‘—”Ǥ
or wheat flour.
 Ifˆ Fortified
‘”–‹ˆ‹‡† ‹Ž
Oil ‹•
is —•‡†ǡ
used, ‹–
it ™‹ŽŽ ‘–”‹„—–‡ ƒ††‹–‹‘ƒŽ
will contribute additional ˜‹–ƒ‹
vitamin 
A ̷
@ ͸ǤͲǦͻǤͻɊ‰Ȁ‰
6.0-9.9ug/g ƒ†
and
ƒ††‹–‹‘ƒŽ˜‹–ƒ‹̷ͲǤͳͳǦͲǤͳ͸Ɋ‰Ȁ‰ȋ‘”ͶǤͶǦ͸ǤͶ
additional vitamin D @ 0.11-0.16ug/g (or 4.4-6.41U/g) Ȁ‰Ȍ‘ˆ‘‹ŽǤ
of oil.
 Ifˆ Fortified
‘”–‹ˆ‹‡†‹Ž‹•—•‡†ǡ‹–™‹ŽŽ ‘–”‹„—–‡ƒ††‹–‹‘ƒŽ˜‹–ƒ‹̷ͲǤʹ͹ǦͲǤͶͷɊ‰ȀŽƒ†
Milk is used, it will contribute additional vitamin A @ 0.27-0.45ug/ml and
ƒ††‹–‹‘ƒŽ˜‹–ƒ‹̷ͲǤͲͲͷǦͲǤͲͲͺɊ‰ȀŽȋ‘”ͲǤʹͲǦͲǤ͵ʹ
additional vitamin D @ 0.005-0.008yug/ml (or 0.20-0.32IU/ml) ȀŽȌ‘ˆ‹ŽǤ
of milk.
(Ref: Technical
(Ref: Technical report
report of
of NIN:
NIN: Revision
Revision of
of Food
Food and
and Nutrition
Nutrition norms
norms under
under Schedule
Schedule II
II of
of the
the National
National
Food Security
Food Security Act, 2013, prepared
Act, 2013, prepared inin collaboration
collaboration with
with Department
Department ofof Food
Food and
and Public
Public Distribution,
Distribution,
Ministry of
Ministry of Consumer
Consumer Affairs, Food and
Affairs, Food and Public
Public Distribution,
Distribution, October,
October, 2022)
2022)

18
18
 Annexure-V
Annexure-V

Roles and
Roles and Responsibilities
Responsibilities of
of Functionaries
Functionaries at
at State
State level
level

Role of
Role of AWW:
AWW:

Ȉe ‡ ‘”†–Š‡™‡‹‰Š–ƒ†Š‡‹‰Š–‘ˆ–Š‡
Record the weight and height of the child Š‹Ž†‡˜‡”›‘–Šƒ†‡–‡”–Š‡†ƒ–ƒ‹–Š‡‘•Šƒ
every month and enter the data in the Poshan
”ƒ ‡”’’Ǥ
Tracker App.
Ȉe ‘†—
Conduct –ƒ’’‡–‹–‡–‡•–ˆ‘”ƒŽŽ•‡˜‡”‡Ž›—†‡”™‡‹‰Š–ƒ†•‡˜‡”‡Ž›™ƒ•–‡†
appetite test for all severely underweight and severely wasted children. Š‹Ž†”‡Ǥ
Ȉe ‡ˆ‡” Š‹Ž†”‡ ™‹–Š
Refer children with ’‘‘”
poor ƒ’’‡–‹–‡
appetite ȋˆƒ‹Ž‡†
(failed ƒ’’‡–‹–‡
appetite –‡•–Ȍ
test) ƒ†Ȁ‘”
and/or ’”‡•‡
presence‡ ‘ˆ‘‡†‡ƒ
of oedema ‘” or
‡†‹
medicalƒŽ complications
‘’Ž‹ ƒ–‹‘• –‘ to Ȁ‡ƒ”‡•–
NRC/nearest Š‡ƒŽ–Š health ˆƒ ‹Ž‹–› ˆ‘”
facility for ˆ—”–Š‡”
further ƒ••‡••‡–
assessment
‹‡†‹ƒ–‡Ž›Ǥ
immediately.
Ȉe ’ƒ”– ˆ”‘
Apart from –Š‡
the ”‡‰—Žƒ”
regular ‹†‡–‹ˆ‹ ƒ–‹‘Ȁ†‡–‡ –‹‘ ƒ†
identification/detection and ”‡ˆ‡””ƒŽ•ǡ
referrals, ‘–ŠŽ›
monthly ˜‹ŽŽƒ‰‡
village Š‡ƒŽ–Š
health
•ƒ‹–ƒ–‹‘ƒ†—–”‹–‹‘†ƒ›ȋ
sanitation and nutrition day (VHSND), Ȍǡ „‹ƒ—ƒŽ†‡Ǧ™‘”‹‰†ƒ›ǡ„‹Ǧƒ—ƒŽ˜‹–ƒ‹Ǧ
biannual de- worming day, bi-annual vitamin-A
•—’’Ž‡‡–ƒ–‹‘
supplementation ”‘—†•ǡ
rounds, ‡– etc.,Ǥǡ ƒ›
may ƒŽ•‘
also „‡
be —–‹Ž‹œ‡†
utilized ˆ‘”
for ‹†‡–‹ˆ‹ ƒ–‹‘Ȁ†‡–‡ –‹‘ ‘ˆ
identification/detection of
Š‹Ž†”‡™‹–ŠǤ
children with SAM.
Ȉe ƒƒ‰‡—–”‹–‹‘ƒŽ”‡“—‹”‡‡–•‘ˆƒŽ‘—”‹•Š‡†
Manage Nutritional requirements of malnourished children Š‹Ž†”‡ƒ–‰ƒ™ƒ†‹Ž‡˜‡ŽǤ
at Anganwadi level.
Ȉe ƒ‹–ƒ‹
Maintain the list of SAM children detected by her and maintain ˆ‘ŽŽ‘™Ǧ—’
–Š‡ Ž‹•– ‘ˆ  Š‹Ž†”‡ †‡–‡ –‡† „› Š‡” ƒ† ƒ‹–ƒ‹ follow-up ”‡ ‘”†•Ǥ
records.
•—”‡‹‡†‹ƒ–‡”‡ˆ‡””ƒŽ‘ˆ–Š‡
Ensure immediate referral of the SAM children Š‹Ž†”‡–‘–Š‡‡ƒ”‡•–Š‡ƒŽ–Šˆƒ
to the nearest health facility. ‹Ž‹–›Ǥ
Ȉe Šƒ”‡–Š‡Ž‹•–‘ˆ Š‹Ž†”‡‹†‡–‹ˆ‹‡†„›Š‡”™‹–Š
Share the list of SAM children identified by her with ASHAƒ†™‹–Š‹ʹ†ƒ›•ǡ–‘
and ANM within 2 days, to
Š‡Ž’‹–‹‡Ž›‡†‹
help in timely medicalƒŽ‡˜ƒŽ—ƒ–‹‘ƒ†”‡ˆ‡””ƒŽ„›Ǥ
evaluation and referral by ANM.
Ȉe ‘—•‡Ž–Š‡’ƒ”‡–•ƒ† ƒ”‡‰‹˜‡”•‘ˆ
Counsel the parents and caregivers Š‹Ž†”‡Ǥ
of children.


Role of
Role of ASHA
ASHA

Ȉ¢ —’’‘”–‹‘„‹Ž‹œƒ–‹‘ƒ†‰”‘™–Š‘‹–‘”‹‰‘ˆ
Support AWW in mobilization and growth monitoring of children. Š‹Ž†”‡Ǥ
Ȉe ƒ ‹Ž‹–ƒ–‡”‡ˆ‡””ƒŽ‘ˆ
Facilitate referral of SAM child Š‹Ž†–‘Ǥ
to NRC.
Ȉe ”‹‰ Š‹Ž†”‡–‘
Bring SAM children to PHCˆ‘”‡†‹
for medicalƒŽ‡šƒ‹ƒ–‹‘Ǥ
examination.
Ȉe ‘—•‡Ž
Counsel ˆƒ‹Ž‹‡•
families ƒ† ƒ”‡‰‹˜‡”• ƒ†
and caregivers and ‡•—”‡
ensure –Šƒ–
that –Š‡ Š‹Ž† ‰‡–•
the child gets ƒ†‹––‡†
admitted –‘to
 Ȁ Ȁ‹ˆ”‡ˆ‡””‡†Ǥ
CHC/PHC/NRC if referred.
Ȉe —’’‘”–‹ˆ—Žˆ‹ŽŽ‹‰Š‡””‘Ž‡‡ˆˆ‡
Support AWW in fulfilling her role effectively. –‹˜‡Ž›Ǥ
Ȉe ƒ›˜‹•‹––Š‡Ȁ
May visit the SAM/MAM child Š‹Ž†ƒ–Š‘‡‘
at home once‡‹ƒ‘–ŠƒŽ‘‰™‹–ŠǤ
in a month along with AWW.
Ȉe ‘—•‡Žƒ†‹–‡”ƒ
Counsel and interact –™‹–Š’ƒ”‡–•ƒ†ˆƒ‹Ž›‡„‡”•Ǥ
with parents and family members.
Ȉe ‡•‹–‹œ‡
Sensitize ‘–Š‡”•
mothers ƒ† ƒ”‡‰‹˜‡”• ‘
and caregivers on ƒ’’”‘’”‹ƒ–‡
appropriate ˆ‡‡†‹‰
feeding ’”ƒ –‹ ‡•ǡ Hygiene
practices, ›‰‹‡‡ ƒ†
and
•ƒ‹–ƒ–‹‘Ǥ
sanitation.
Ȉe •—”‡
Ensure ƒ†‹‹•–”ƒ–‹‘
administration ‘ˆ of ‹–ƒ‹Ȃ
Vitamin-A †”‘’•ǡ
drops, Ž„‡†ƒœ‘Ž‡
Albendazole –ƒ„Ž‡–•ǡ
tablets, IFA •›”—’
syrup ĥ
as ’‡”
per –Š‡
the
”‡ ‘‡†‡††‘•ƒ‰‡Ǥ
recommended dosage.
Ȉe  •ŠƒŽŽˆ‘ŽŽ‘™—’ƒŽŽȀ
ASHA shall follow up all SAM/MAM children Š‹Ž†”‡‹Š‡”ƒ”‡ƒǤ
in her area.

19
19
Role of
Role of ANM:
ANM:

Ȉe —”‹‰ ǡ‡˜ƒŽ—ƒ–‡
During VHSND, Š‹Ž†”‡‹†‡–‹ˆ‹‡†„›–Š”‘—‰Š
evaluate SAM children identified by AWW through Growth ”‘™–Š‘‹–‘”‹‰
Monitoring
ˆ‘”
for –Š‡
the ’”‡•‡
presence‡ ‘ˆ
of ‡†‹
medicalƒŽ complications
‘’Ž‹ ƒ–‹‘• ‹ Ž—†‹‰ ‘‡†‡ƒǤ
including oedema. Š‹Ž†”‡
Children ™Š‘•‡
whose ™‡‹‰Š–Ǧ
weight-
ˆ‘”ǦŠ‡‹‰Š–
for-height ‹•
is Ž‡••
less –Šƒ
than Ǧ͵
-3 
SD ƒ†
and ™‹–Š
with „‹Žƒ–‡”ƒŽ
bilateral ’‹––‹‰
pitting ‘‡†‡ƒǡ
oedema, ‘–Š‡”
other ‡†‹
medicalƒŽ
‘’Ž‹ ƒ–‹‘• ‘”
complications or ’‘‘”
poor ƒ’’‡–‹–‡
appetite ™‹ŽŽ
will „‡ ƒ–‡‰‘”‹œ‡† ƒ•
be categorized as ‡†‹ ƒŽŽ› complicated
medically ‘’Ž‹ ƒ–‡† 
SAM ƒ†
and
™‹ŽŽ„‡”‡ˆ‡””‡†–‘Ȁ‡ƒ”‡•–Š‡ƒŽ–Šˆƒ
will be referred to NRC/nearest health facility ‹Ž‹–›ˆ‘”ˆ—”–Š‡”ƒƒ‰‡‡–Ǥ
for further management.
Ȉe †‹‹•–‡”˜ƒ
Administer ‹‡•ƒ•’‡”‹—‹œƒ–‹‘•
vaccines as per immunization scheduleŠ‡†—Ž‡ƒaccording
‘”†‹‰–‘–Š‡ Š‹Ž†ǯ•ƒ‰‡Ǥ
to the child’s age.
Ȉe —”‹‰ ǡ•—’’‘”–‹’‡”ˆ‘”‹‰ƒ’’‡–‹–‡–‡•–Ǥ
During VHSND, support AWW in performing appetite test.

Role of
Role of CDPOs
CDPOs and
and Supervisors
Supervisors

Š‡
The 
CDPO •Š‘—Ž†
should „‡
be †‡•‹‰ƒ–‡†
designated ĥ
as –Š‡
the ˆ‘
focalƒŽ ’‘‹–
point ˆ‘”
for –Š‡ ƒ”‡ ’”‘‰”ƒ‡
the care programme ƒ–
at 
AWC –‘
to
‘‹–‘”ƒ†•—’‡”˜‹•‡–Š‡‹’Ž‡‡–ƒ–‹‘ƒ†™‹ŽŽŠƒ˜‡–Š‡ˆ‘ŽŽ‘™‹‰”‘Ž‡•ǣ
monitor and supervise the implementation and will have the following roles:

e ƒ ‹Ž‹–ƒ–‡ –”ƒ‹‹‰
Facilitate training ‘ˆ
of Š‡ƒŽ–Š
health ™‘”‡”•
workers ƒ†
and •
AWWs ‹ ‘‘”†‹ƒ–‹‘ ™‹–Š
in coordination with –Š‡
the Ž‘
Block
‡†‹
MedicalƒŽˆˆ‹ ‡”ȋȌ
Officer (BMO)
e •—”‡Ž‹ƒ‰‡•„‡–™‡‡–Š‡•ƒ†–Š‡
Ensure linkages between the NRCs and the community ‘—‹–› care ƒ”‡ƒ–•
at AWCs
e ‘‹–‘”†ƒ–ƒˆ”‘–Š‡„Ž‘
Monitor data from the blocks •ƒ†”‡’‘”––‘–Š‡‹•–”‹ –Ȁ–ƒ–‡‘’‡”‹‘†‹
and report to the District/State on periodic „ƒ•‹•ƒ†
basis and
•Šƒ”‡™‹–Š  Ǧ Šƒ”‰‡ȀǤ
share with PHC In-charge/BMO.
e ‘‡‘ˆ–Š‡‡›’‘‹–•–‘„‡‘‹–‘”‡†
Some of the key points to be monitored closely Ž‘•‡Ž›ƒ”‡ǣ
are:
Ȉe —„‡”‘ˆ‡™ƒ†‹••‹‘•‡ƒ
Number of new admissions eachŠ‘–Š month
Ȉe —„‡”‘ˆ Š‹Ž†”‡”‡ˆ‡””‡†–‘
Number of children referred to NRC
Ȉe ˜ƒ‹Žƒ„‹Ž‹–›‘ˆ†”—‰•ˆ‘”ƒƒ‰‡‡–™‹–Š†—”‹‰
Availability of drugs for SAM management with ANM during VHSND 
Ȉe ”ƒ•ˆ‡”„‡–™‡‡†‹ˆˆ‡”‡–’”‘‰”ƒ‡•ȋƒ†Ȍ
Transfer between different programmes (AWC and NRC)
Ȉe ƒ‹–‡ƒ
Maintenance‡‘ˆ”‡ ‘”†•
of records
e •—”‡–Š‡ƒ˜ƒ‹Žƒ„‹Ž‹–›‘ˆˆ— –‹‘ƒŽ‰”‘™–Š‡ƒ•—”‹‰†‡˜‹
Ensure the availability of functional growth measuring devices ‡•‹ƒŽŽ–Š‡•Ǥ
in all the AWCs.
e ƒ’ƒ ‹–›„—‹Ž†‹‰‘ˆ‘•
Capacity ”‡‡‹‰’”‘
building of AWW on screening ‡†—”‡ǡƒ’’‡–‹–‡–‡•–ƒ†
procedure, ‘—•‡ŽŽ‹‰Ǥ
appetite test and counselling.
e ‡˜‹‡™•–ƒ–—•‘ˆƬ
Review status of SAM & MAM children Š‹Ž†”‡†—”‹‰‡
during Sector,–‘”ǡ’”‘Œ‡
projects–•‡‡–‹‰•Ǥ
meetings.
e ‡˜‹‡™–Š‡”‡ˆ‡””ƒŽ ƒ•‡•ƒ†
Review the referral cases ‘‘”†‹ƒ–‡™‹–Š‡†‹
and coordinate with MedicalƒŽˆˆ‹ ‡”Ǥ
Officer.
e ‡˜‹‡™–Š‡’”‘‰”ƒ‘•‡–‹†‹
Review the program on set indicators, ƒ–‘”•ǡ‹Ǥ‡Ǥǡƒ†‹••‹‘•ǡ†‡ˆƒ—Ž–‡”•ǡ”‡
i.e., admissions, defaulters, recovery, ‘˜‡”›ǡƒ†
and
‘Ǧ”‡•’‘†‡–•ȌƬƒŽ•‘ ‘†— –ˆ‹‡Ž†˜‹•‹–•
non-respondents) & also conduct field visits

Role of
Role of Medical
Medical Officers
Officers

e ••‡••ƒŽŽ–Š‡ȀȀ
Assess Š‹Ž†”‡”‡ˆ‡””‡†ˆ”‘ˆ‘”’”‡•‡
all the SAM/MAM/SUW children referred from AWC for presence‡‘ˆ‡†‹
of medicalƒŽ
‘’Ž‹ ƒ–‹‘•ƒ†ˆ—”–Š‡”ƒƒ‰‡‡–Ǥ
complications and further management.
e ‘†—
Conduct – ƒa †‡–ƒ‹Ž‡†
detailed ‡šƒ‹ƒ–‹‘
examination ‘ˆ of –Š‡ Š‹Ž†Ǥ In case
the child. ƒ•‡ ‘ˆof ƒ›
any ‡†‹
medicalƒŽ
‘†‹–‹‘•Ȁƒ‹Ž‡–•ǡ –Š‡
conditions/ailments, the ‡†‹
medicalƒŽ ‘ˆˆ‹ ‡” •ŠƒŽŽ
officer shall –”‡ƒ–
treat –Š‡ Š‹Ž† ˆ‘”
the child for –Š‡
the ƒ‹Ž‡–•Ǥ
ailments. In
ƒ•‡ ‹–
case it ‹•
is ‘–
not ˆ‡ƒ•‹„Ž‡
feasible ˆ‘”
for –Š‡
the ‡†‹
medicalƒŽ ‘ˆˆ‹ ‡” –‘
officer to –”‡ƒ–
treat –Š‡ Š‹Ž† ƒ–
the child at –Š‡
the  PHC ȋ‹ˆ
(if –Š‡
the
‘†‹–‹‘‘ˆ–Š‡
condition Š‹Ž†‹•„‡›‘†–Š‡’—”˜‹‡™‘ˆ
of the child is beyond the purview of PHC–”‡ƒ–‡–Ȍ–Š‡‡†‹
treatment) the MedicalƒŽˆˆ‹ Officer‡”
•ŠƒŽŽ”‡ˆ‡”–Š‡ Š‹Ž†–‘–Š‡‡ƒ”‡•–Ǥ
shall refer the child to the nearest NRC.
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20
  ƒ•‡†
Based ‘ on –Š‡ Ž‹‹ ƒŽ ƒ••‡••‡–ǡ
the clinical assessment, ’”‘˜‹†‡
provide –”‡ƒ–‡–ǡ
treatment, ˆ‘ŽŽ‘™Ǧ—’
follow-up ‰—‹†ƒ
guidance‡ –‘
to
”‘–Ž‹‡ Functionaries
Frontline — –‹‘ƒ”‹‡•‘ˆ ƒ†
of ICDS ‡ƒŽ–Šƒ†’ƒ”‡–•Ȁ
and Health ƒ”‡‰‹˜‡”•Ǥ
and parents/caregivers.
 ‘‘”†‹ƒ–‡™‹–Š•ƒ†—’‡”˜‹•‘”•Ǥ
Coordinate with CDPOs and Supervisors.
 ‘–ŠŽ›
Monthly ’”‘‰”‡••
progress ”‡’‘”–
report •Š‘—Ž†
should „‡
be •—„‹––‡†
submitted –‘
to ‹•–”‹
District– ‡†‹
MedicalƒŽ ƒ† ‡ƒŽ–Š
and Health
ˆˆ‹ ‡”Ǥ
Officer.

Role of
Role of DPO/
DPO/ District
District Social
Social Welfare
Welfare Officer
Officer (DSWO)
(DSWO)

Ȁ™‹ŽŽ‘‹–‘”–Š‡‹’Ž‡‡–ƒ–‹‘‘ˆ–Š‡’”‘‰”ƒ‡‹–Š‡†‹•–”‹
DPO/DSWO will monitor the implementation of the programme in the district–ƒ†™‹ŽŽ
and will
Šƒ˜‡–Š‡ˆ‘ŽŽ‘™‹‰”‘Ž‡•ǣ
have the following roles:

 Žƒ‹‰‘ˆ•‡”˜‹ ‡•‹†‹•
Planning of services —••‹‘™‹–Š‹•–”‹
in discussion with District– Health
‡ƒŽ–Šˆˆ‹ ‡”
Officer
 —†ˆŽ‘™ƒ†’‘•‹–‹‘‹‰‘ˆƒ’‘™‡”ƒ†–”ƒ‹‹‰•
Fund flow and positioning of manpower and trainings
 ˆ”ƒ•–”— –—”‡•–”‡‰–Š‡‹‰ǡ‹ˆ”‡“—‹”‡†ƒ–
Infrastructure strengthening, if required at AWC
 —ƒ”–‡”Ž›”‡˜‹‡™‘ˆ–Š‡’”‘‰”ƒ‡’‡”ˆ‘”ƒ
Quarterly review of the programme performance‡

Role of
Role of District
District Administration
Administration

 Š‡‹•–”‹
The District–†‹‹•–”ƒ–‹‘•ŠƒŽŽ”‡˜‹‡™–Š‡’”‘‰”‡••‡˜‡”›‘–ŠǤ‡‡Ž›”‡˜‹‡™
Administration shall review the progress every month. Weekly review
‘ƒ†‡†‹
on a dedicatedƒ–‡††ƒ›ƒ›„‡‘”‰ƒ‹œ‡†ƒ–˜‹ŽŽƒ‰‡Ȁ—”„ƒ™ƒ”†Ž‡˜‡ŽǤ—ƒ”–‡”Ž›”‡˜‹‡™
day may be organized at village/urban ward level. Quarterly review
–‘„‡‘”‰ƒ‹œ‡†™‹–Š•–ƒ‡Š‘Ž†‡”†‡’ƒ”–‡–•ƒ–•–ƒ–‡Ž‡˜‡Ž—†‡”–Š‡Šƒ‹”ƒ•Š‹’
to be organized with stakeholder departments at state level under the Chairmanship
‘ˆ”‹ ‹’ƒŽ‡
of Principal ”‡–ƒ”›ǡƬ‡’–Ǥ
Secretary, WD&CW Dept.
 Š‡
The ‹•–”‹
District– ƒ‰‹•–”ƒ–‡
Magistrate •ŠƒŽŽ
shall „‡
be –Š‡
the ‘†ƒŽ
Nodal ‘‹–
Point ‹
in –Š‡
the †‹•–”‹
district– ˆ‘”
for ‘‹–‘”‹‰
monitoring
—–”‹–‹‘ƒŽ•–ƒ–—•ƒ†“—ƒŽ‹–›•–ƒ†ƒ”†•Ǥ
nutritional status and quality standards.
 Š‡
The Ȁ‘ŽŽ‡
DM/Collector –‘” •ŠƒŽŽ Šƒ‹”ǡ •—’‡”˜‹•‡
shall chair, supervise ƒ†and ‘‹–‘”
monitor –Š‡the ƒactivities
–‹˜‹–‹‡• ‘ˆ
of –Š‡
the ‹•–”‹
District–
—–”‹–‹‘
Nutrition ‘‹––‡‡Ǥ
Committee. Š‡ The ‡„‡”•
Members ‘ˆ of –Š‡
the ‹•–”‹
District– ‘‹––‡‡
Committee Šƒ˜‡ have –‘ to „‡
be
ƒ†ƒ–‘”‹Ž› ‡”–‹ˆ‹‡†—–”‹–‹‘‡š’‡”–•Ǥ
mandatorily certified nutrition experts.
 †‡”–ƒ‡
Undertake ‘˜‡”ƒŽŽ
overall ƒ†‹‹•–”ƒ–‹‘
administration ƒ† ‘‘”†‹ƒ–‹‘ ‘ˆ
and coordination of –Š‡
the —–”‹–‹‘
nutrition ’”‘Œ‡
project – ƒ†
and
‡•—”‡
ensure •‘‘–Š
smooth ƒ† and ‡ˆˆ‡ –‹˜‡ †‡Ž‹˜‡”›
effective delivery ‘ˆ of ƒŽŽ
all ‹–‡†‡†
intended •‡”˜‹ ‡• ‹
services in –Š‡
the ’”‘Œ‡
project –
Œ—”‹•†‹ –‹‘Ǥ
jurisdiction.
 ‘†—
Conduct – ’‡”‹‘†‹
periodic  ‘‹–‘”‹‰ǡ
monitoring, ‹ Ž—†‹‰ •—”’”‹•‡
including surprise •’‘–Ǧ Š‡ •ǡ collection
spot-checks, ‘ŽŽ‡ –‹‘ ‘ˆ
of •ƒ’Ž‡•
samples
ˆ‘”
for “—ƒŽ‹–›
quality –‡•–‹‰
testing ‘ˆof •—’’Ž‡‡–ƒ”›
supplementary —–”‹–‹‘
nutrition ȋ (THR ƒ†
and HCM) Ȍ ’”‘˜‹†‡†ǡ
provided, ‡•—”‹‰
ensuring
ƒ†‡“—ƒ–‡‡ƒ•—”‡•ˆ‘”ˆ‘‘†•ƒˆ‡–›ƒ†Š›‰‹‡‡ƒ”‡ˆ‘ŽŽ‘™‡†–Š”‘—‰Š‘—––Š‡•—’’Ž›
adequate measures for food safety and hygiene are followed throughout the supply
Šƒ‹ǡ ƒ••‡••‹‰
chain, assessing –Š‡the “—ƒŽ‹–›
quality ‘ˆof ’”‡Ǧ• Š‘‘Ž †‡Ž‹˜‡”›
pre-school delivery ‡– etc.,Ǥǡ –‘
to ‡•—”‡
ensure “—ƒŽ‹–›
quality ƒ†
and
—†‡”–ƒ‡‡
undertake necessary‡••ƒ”› course
‘—”•‡ correction.
‘””‡ –‹‘Ǥ
 ‘†—
Conduct – Joint
‘‹– Field
‹‡Ž† ‹•‹–•
Visits ™‹–Š
with ‡†‹
MedicalƒŽ ˆˆ‹ ‡” ȋȌƒ†
Officer (MO) and Joint ‘‹– ‡˜‹‡™
Review ‡‡–‹‰•
Meetings ‘ on
‘–ŠŽ›„ƒ•‹•ǡ‡•’‡ ‹ƒŽŽ›™‹–Š”‡‰ƒ”†•–‘
monthly basis, especially with regards to SAM children. Š‹Ž†”‡Ǥ





21
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Role of
Role of Community:
Community:

1. Panchayats
1. Panchayats
 Š‡
The ”‘Ž‡
role ‘ˆ
of ƒ Šƒ›ƒ–‹ ƒŒ
Panchayati •–‹–—–‹‘• ‹•
Raj Institutions is ˜‡”›
very ‹’‘”–ƒ–
important ˆ‘” for –Š‡
the •— ‡•• ‘ˆ
success of
—–”‹–‹‘ƒŽ –‡”˜‡–‹‘•Ǥ™ƒ”‡‡••‰‡‡”ƒ–‹‘‘–Š‡‡ˆˆ‡
nutritional Interventions. Awareness generation on the effects–•‘ˆƒŽ—–”‹–‹‘ƒ––Š‡
of malnutrition at the
‘•Šƒƒ
Poshan Panchayat Šƒ›ƒ–’Žƒ–ˆ‘”
platform can ƒ„‡–Š‡ˆ‹”•–•–‡’Ǥ
be the first step.
 ‡„‡”•
Members ‘ˆ of ƒ Šƒ›ƒ– ƒŒ
Panchayat •–‹–—–‹‘ ȋ
Raj Institution (PRI) Ȍ •Š‘—Ž†
should „‡ be ‹˜‘Ž˜‡†
involved –‘ to ‘–‹˜ƒ–‡ǡ
motivate,
‘„‹Ž‹œ‡ ‘—‹–› Ž‡ƒ†‡”•
mobilize community leaders ƒ†
and SHGs • ˆ‘”
for •—’’‘”–
support ƒ† and ’ƒ”–‹ ‹’ƒ–‹‘ ‹
participation in  ǡ
VHSND,
‡•—”‡–Š‡ƒ˜ƒ‹Žƒ„‹Ž‹–›‘ˆ
ensure the availability of clean Ž‡ƒƒ†•ƒˆ‡†”‹‹‰™ƒ–‡”ƒ†–‘‹Ž‡––‘–Š‡”‡•‹†‡–•‘ˆ
and safe drinking water and toilet to the residents of
–Š‡
the Gram”ƒ ƒ Šƒ›ƒ– ƒ†
Panchayat and •—’’‘”–
support –Š‡the Š‡ƒŽ–Š
health ƒ†and 
WCD ˆ— –‹‘ƒ”‹‡• ‹
functionaries in ™‘”‹‰
working
–‘™ƒ”†•DzƒŽ—–”‹–‹‘Ȃ
towards “Malnutrition - Free” ”‡‡dz Gram
”ƒƒ Šƒ›ƒ–•Ǥ
Panchayats.
 –
At –Š‡
the ‰”ƒ••”‘‘–•
grassroots Ž‡˜‡Žǡ
level, ƒ Šƒ›ƒ–• can
Panchayats ƒ •‡”˜‡
serve ƒ• as ƒ
a —•‡ˆ—Ž ‘˜‡”‰‡ ‡ ’Žƒ–ˆ‘”ˆ‘”
useful convergence platform for
‘–Š‡”• ”‘—’•ƒ† –‘†‹• —••‹••—‡•‘ˆ—–”‹–‹‘ƒ†™‡ŽŽ‡••ƒ†•‡•‹–‹œ‡
Mothers Groups and VHSNC to discuss issues of nutrition and wellness and sensitize
’‡‘’Ž‡ƒ„‘—––Š‡‹’‘”–ƒ
people about the importance‡‘ˆ—–”‹–‹‘ˆ‘”„‡‡ˆ‹
of nutrition for beneficiaries. ‹ƒ”‹‡•Ǥ
 
POSHAN  ƒ Šƒ›ƒ–• ƒ†
Panchayats and  • •ŠƒŽŽ
VHSNCs shall †‹•
discuss—•• –Š‡
the •‹–—ƒ–‹‘
situation ‘ˆof ƒŽ—–”‹–‹‘
malnutrition ‹ in –Š‡
the
”ƒƒ
Gram Šƒ›ƒ–ǡ‹
Panchayat, Ž—†‹‰•–ƒ–—•‘ˆ
including Š‹Ž†”‡ƒˆˆ‡
status of children –‡†„›ƒŽ—–”‹–‹‘ǡ–Š‡’”‘„ƒ„Ž‡
affected by malnutrition, the probable
ƒ—•‡•‘ˆƒŽ—–”‹–‹‘ƒ†‹’Ž‡‡–ƒ–‹‘‰ƒ’•–Šƒ–‡‡†–‘„‡ƒ††”‡••‡†Ǥ
causes of malnutrition and implementation gaps that need to be addressed.

2. Buddy
2. Buddy Mothers
Mothers
 —††›
Buddy •›•–‡
system „‡–™‡‡
between ‘–Š‡”
mother ‘ˆ of ƒ
a Š‡ƒŽ–Š›
healthy child Š‹Ž† ƒ†
and ‘–Š‡”
mother ‘ˆ of ƒ
a ƒŽ‘—”‹•Š‡†
malnourished
Š‹Ž† ƒ›
child may „‡be ‹–”‘†—
introduced,‡†ǡ ‡ƒ„Ž‹‰
enabling close Ž‘•‡ ƒ†
and Œ‘‹–
joint •—’‡”˜‹•‹‘
supervision ƒ† and ‡š Šƒ‰‡ ‘ˆ
exchange of
‰—‹†ƒ
guidance‡ „‡–™‡‡
between –Š‡ the „—††›
buddy ‘–Š‡”•
mothers ™‹–Šwith ”‡•’‡
respect – –‘
to Š‡ƒŽ–Š
health ‘ˆ
of –Š‡
the ƒŽ‘—”‹•Š‡†
malnourished
Š‹Ž†Ǥ
child.

ȗȗȗȗȗȗȗȗȗȗ
ORK AB AB RK KK RK

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 ”
Towards a new dawn

Ministry of Women & Child Development

Government of India