Red Flags
- Severe acute malnutrition (weight-for-height < -3 SD, MUAC <11.5 cm in 6–59 months, bilateral pitting oedema) — admit for inpatient stabilisation; F-75/F-100 therapeutic feeds; treat infection[1]
- Failure to thrive with crossing two centiles downward — investigate medical and social causes; do not assume normal variant[1]
- Vitamin A deficiency with eye signs (Bitot's spots, corneal ulcer) — emergency vitamin A 200,000 IU PO immediately; ophthalmology[1]
- Childhood obesity with metabolic features (acanthosis, hypertension, dyslipidaemia, fatty liver on USG) — investigate for T2DM and metabolic syndrome[1]
First-line treatment
Interventions
- Exclusive breastfeeding 0–6 months[1]Initiate within 1 hour of birth; on-demand feeding day and night; no other foods or fluids including water; warm support and counselling for difficulties (latch, supply, cracked nipples)
- Complementary feeding from 6 monthsIntroduce home-prepared complementary foods after 6 months while continuing breastfeeding. NIN 2024 gives minimum frequencies of twice daily at 6–8 months and three times daily at 9–24 months for breastfed children; non-breastfed children aged 6–24 months need at least four feeds daily in addition to milk. [2]
- Promote diverse, indigenous, minimally-processed diet[1]Millets, local grains, pulses, seasonal fruits and vegetables, dairy where consumed, eggs, fish; limit sugar, salt, and ultra-processed foods; family foods rather than special baby foods after 9–12 months
- Universal supplementation programmes[1]Vitamin A 100,000 IU PO at 9 months, then 200,000 IU 6-monthly until 5 years (UIP). Iron-folic acid syrup 8–10 mg elemental iron + 100 µg folic acid biweekly 6–59 months (Anaemia Mukt Bharat). Universal salt iodisation. Periodic deworming albendazole 400 mg 6-monthly 1–19 years
- Growth monitoring and counselling at every visit[1]Weigh and plot at every well-child visit; deviations (flat curve, crossing centiles, sudden drop) trigger nutritional assessment and intervention
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Vitamin A[1] | Fat-soluble vitamin | Not applicable — paediatric guideline | 9 months: 100,000 IU PO once. 1–5 years: 200,000 IU PO every 6 months. Acute SAM or measles: 200,000 IU PO × 3 doses (day 1, 2, 14) | Universal supplementation in high-deficiency settings (UIP); also given with measles vaccine; contraindicated in pregnancy |
| Iron-folic acid (paediatric formulation)[1] | Iron + B-vitamin combination | Not applicable — paediatric guideline | Anaemia Mukt Bharat: 8–10 mg elemental iron + 100 µg folic acid syrup biweekly 6–59 months; tablet weekly 5–10 years; treatment dose for IDA 3–6 mg/kg/day | Programme supplementation reduces IDA prevalence; treat IDA with elemental iron 3–6 mg/kg/day for 3 months |
| Albendazole (deworming)[1] | Anthelminthic (benzimidazole) | Not applicable — paediatric guideline | ≥12 months: 400 mg PO single dose every 6 months | National Deworming Day biannual programme 1–19 years; reduces helminth burden, anaemia, and malnutrition |
| F-75 / F-100 therapeutic milk (SAM inpatient) | Therapeutic feed | Not applicable — paediatric guideline | The October 2019 ICMR complicated-SAM STW gives initial oral feeds of 130 mL/kg/day. In rehabilitation at age ≥6 months, give F75 at least five times/day, increasing toward 150–200 kcal/kg/day (usually over 2–3 days), then F100 for the next 5–7 days with home-available foods. Below 6 months, the workflow says the same with return to exclusive breastfeeding wherever possible. [3] | Inpatient management of SAM at NRC/MTC per WHO 10-step protocol; outpatient via RUTF for uncomplicated SAM |
Vitamin A[1]
Fat-soluble vitamin
- Adult
- Not applicable — paediatric guideline
- Paediatric
- 9 months: 100,000 IU PO once. 1–5 years: 200,000 IU PO every 6 months. Acute SAM or measles: 200,000 IU PO × 3 doses (day 1, 2, 14)
Universal supplementation in high-deficiency settings (UIP); also given with measles vaccine; contraindicated in pregnancy
Iron-folic acid (paediatric formulation)[1]
Iron + B-vitamin combination
- Adult
- Not applicable — paediatric guideline
- Paediatric
- Anaemia Mukt Bharat: 8–10 mg elemental iron + 100 µg folic acid syrup biweekly 6–59 months; tablet weekly 5–10 years; treatment dose for IDA 3–6 mg/kg/day
Programme supplementation reduces IDA prevalence; treat IDA with elemental iron 3–6 mg/kg/day for 3 months
Albendazole (deworming)[1]
Anthelminthic (benzimidazole)
- Adult
- Not applicable — paediatric guideline
- Paediatric
- ≥12 months: 400 mg PO single dose every 6 months
National Deworming Day biannual programme 1–19 years; reduces helminth burden, anaemia, and malnutrition
F-75 / F-100 therapeutic milk (SAM inpatient)
Therapeutic feed
- Adult
- Not applicable — paediatric guideline
- Paediatric
- The October 2019 ICMR complicated-SAM STW gives initial oral feeds of 130 mL/kg/day. In rehabilitation at age ≥6 months, give F75 at least five times/day, increasing toward 150–200 kcal/kg/day (usually over 2–3 days), then F100 for the next 5–7 days with home-available foods. Below 6 months, the workflow says the same with return to exclusive breastfeeding wherever possible. [3]
Inpatient management of SAM at NRC/MTC per WHO 10-step protocol; outpatient via RUTF for uncomplicated SAM
Safety-net
- Exclusive breastfeeding for the first 6 months — water, gripe water, and supplementary feeds harm infant gut and reduce milk supply[1]
- Watch for slowing weight gain, lack of interest in food, lethargy, persistent diarrhoea, or recurrent infections — seek paediatric review[1]
- Limit sweetened drinks and ultra-processed snacks — they displace nutritious food and contribute to dental caries and overweight even in early childhood[1]
Referral criteria
- Severe acute malnutrition with complications (oedema, hypoglycaemia, hypothermia, pneumonia, sepsis, refusal to feed)Nutrition Rehabilitation Centre (NRC) or paediatric admission[1]
- Failure to thrive, persistent stunting, or growth faltering despite community-level supportPaediatric outpatient with social work involvement[1]
- Childhood obesity with metabolic featuresPaediatric endocrinology and dietitian[1]
- Suspected feeding disorder, congenital syndrome, or inborn error affecting nutritionPaediatric subspecialty[1]
Clinical summary
Breastfeeding, complementary feeding, supplementation, and screening for under- and over-nutrition in children aged 0–10 years.
References
- 1.ICMR-NIN Dietary Guidelines for Indians (2024 update); WHO/UNICEF Global Strategy for Infant and Young Child Feeding; IAP Standard Treatment Guidelines for Nutrition (2024)
- 2.Dietary Guidelines for Indians (2024). ICMR-NIN (2024)
- 3.Standard Treatment Workflow: Severe Acute Malnutrition with Medical Complications (October 2019). ICMR (2019)