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Pediatric undernutrition – Public health perspective
*Corresponding author: Radhika Mathur, Nutrition Rehabilitation Centre, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India. dr.radhikamathursharma@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Mathur R, Prabhu S, Vora AA, Bodhanwala M. Pediatric undernutrition – Public health perspective. Wadia J Women Child Health. 2025;4:28-36. doi: 10.25259/WJWCH_7_2025
Abstract
Child undernutrition remains a critical public health challenge in India, affecting millions of children and hindering the nation’s social and economic progress. Despite significant advancements in healthcare and nutrition programs, India continues to struggle with high rates of stunting, wasting, and underweight among children under 5 years of age. Factors such as poverty, food insecurity, inadequate and faulty child care, poor sanitation, and lack of awareness contribute to the crisis. Secondary causes of malnutrition also contribute to the burden of undernutrition and this group needs to be managed carefully. Infants are at risk of poor growth and development (also known as early growth failure) and are a population of babies whose early identification and intervention are crucial to prevent long-term consequences such as stunting, cognitive delays, and increased disease susceptibility. Key risk factors in such babies include poor maternal health and nutrition, preterm birth and low birth weight, inadequate breastfeeding, and lack of early stimulation and responsive parenting. The Indian government, along with international organizations, has implemented various interventions such as nutrition rehabilitation centers (NRCs) which are specialized healthcare facilities in India aimed at providing medical and nutritional care to children suffering from severe acute malnutrition (SAM). These centers play a crucial role in addressing child malnutrition by offering treatment, counseling, and follow-up care. The aim of this review is focused on understanding public health strategies to tackle pediatric undernutrition in our country. For community screening and management, Poshan Abhiyaan (National Nutrition Mission) to combat child malnutrition has been initiated. Key screening methods used in Poshan Abhiyaan 2.0 include anthropometric measurements like weight-for-age (underweight) for underweight children. Height-for-age (stunting) identifies chronic malnutrition and weight-for-height (wasting) detects acute malnutrition. Growth monitoring through Integrated Child Development Services (ICDS) and Anganwadi centers including monthly weight and height tracking of children is done under ICDS. The use of mother and child protection cards for recording growth trends is essential. Community-based screening by frontline workers such as anganwadi workers, accredited social health activists (ASHA), and auxiliary nurse midwives is conducted through regular home visits for identification of low birth weight, feeding difficulties, and signs of malnutrition. Digital tools and mobile applications such as Poshan tracker record real-time nutritional data for targeted interventions. Anemia Mukt Bharat Dashboard tracks anemia levels in children. Follow-up and referral protocol includes moderate acute malnutrition cases which are managed through home-based care and nutritional counseling and SAM cases which are referred to NRCs for specialized care.
Keywords
Pediatric undernutrition
Public health
Severe acute malnutrition
Severe stunting
Severe wasting
INTRODUCTION
Malnutrition refers to deficiency or excesses in nutrient intake, imbalance of essential nutrients, or impaired nutrient utilization. This review will discuss undernutrition which is highly prevalent in our country and public health strategies in place to tackle this problem. As per the National Family Health Survey (NFHS) 5, underweight prevalence is 32.1%, stunting is 35.5%, and wasting is 7.7% in children under 5 years of age.[1] We have not made much progress in these indicators as compared to the earlier NFHS 4. It is essential to design more specific interventions by focusing on the key determinants that may directly or indirectly influence malnutrition in India. This year’s United Nations Inter-agency Group for Child Mortality Estimation estimates also make clear that worldwide progress is slowing and that millions of children are still dying from preventable causes. Globally, in 2023, an estimated 4.8 million children died before the age of five, including 2.3 million newborns. These deaths are not inevitable. They are the result of unequal access to health care, nutrition, and protection, especially in the most fragile and underserved settings.[2]
Providing adequate nutrition is acknowledged as one of the most effective methods for optimum physical and intellectual growth and development, especially in the first 2 years of life where brain growth occurs to the tune of 80%, 50% of adult height is achieved by 2 years of age and weight quadruples by the end of 2 years.[3] Nutrition is a key Sustainable Development Goal 2 and aims for zero hunger by 2030. A study by Singh et al., study finds that 34% of children were stunted, 4% were overweight, and 66% were anemic. Stunting and anemia prevalence was higher in the central and eastern regions of India.[4] Given the intra-country spatial heterogeneity, the treatment also needs to be customized along with optimum and appropriate nutrition for women and children to lead a healthy life and break the intergenerational cycle of malnutrition and poor health in the community.
FORMS OF CHILDHOOD UNDERNUTRITION
Undernutrition in children below 5 years of age in the population is measured by three anthropometric indices which are based on a comparison of the measured height and weight of the child compared to the World Health Organization (WHO) defined reference height and weight of children of the same age and sex. These three indices, namely (i) weight-for-age, (ii) height/length-for-age, and (iii) weight-for-height/length, are used to identify underweight, stunting, and wasting, respectively.
Underweight
Underweight can result from either chronic or acute malnutrition or both. An underweight child has a weight-for-age Z-score of at least 2 standard deviations (SD) below the median (−2 SD) for the WHO Child Growth Standards. Moderate underweight is defined as weight-for-age between −2 and −3 SD/Z score as per the WHO growth standard. Severe underweight (SUW) is a condition in which a child has a very low weight in relation to age (D/Z score of <−3 SD), as per the WHO Child Growth Standards.[5]
Stunting
A stunted child has a height-for-age Z-score that is at least (−2 SD) below the median for the WHO Child Growth Standards. Failure to achieve expected height/length as compared to healthy, well-nourished children of the same age is a sign of stunting. Stunting is an indicator of linear growth retardation. It is an indicator of chronic growth failure associated with several long-term factors such as chronic insufficient nutrients to the fetus in utero or to the newborn after birth associated either with frequent infection or inappropriate feeding practices leading to chronic malnutrition.
Wasting
A wasted child has a weight-for-height Z-score at least (−2 SD) below the median for the WHO Child Growth Standards. Moderate acute malnutrition is defined as weight-for-height between −2 and −3 SD/Z score as per the WHO growth standards. Severe acute malnutrition (SAM) is a condition in which a child has a very low weight in relation to length/height (SD/Z score of <−3 SD), as per the WHO Child Growth Standards.[6]
SAM is a severe form of wasting. Wasting indicates acute malnutrition resulting from failure acute weight loss due to acute infections or repeated gastrointestinal/respiratory tract infections in children with suboptimal infant and young childcare and feeding practices usually from 6 months to 2 years of age. Wasting in individual children and population groups can change rapidly and shows marked seasonal variations associated with changes in food availability or disease prevalence to which it is very sensitive. In a tertiary care facility setup, most SAM cases are admitted with underlying illnesses such as cerebral palsy, cystic fibrosis, cleft lip/palate, tracheoesophageal fistulas, and laryngomalacia which add to the malnourished state of the child and have to be treated holistically.
IMPLICATIONS OF UNDERNUTRITION
Undernutrition has the most severe adverse effects on the first 1,000 days of a child’s life and therefore attempts should be made to prevent it during this period. It is one of the most important causes of child mortality and morbidity contributing to 55% of under 5 mortality.
Poor nutrition undermines the achievement of optimal learning outcomes during elementary education, impairs adult productivity, and affects gender equality contributing to poor disability-adjusted life year scores. Consumption of non-nutritious food (junk foods) can lead to non-communicable diseases (NCD) such as diabetes, hypertension, cardiovascular disease, and obesity/metabolic syndrome in the future.
The window of opportunity for correcting undernutrition exists only in the first 1,000 days of life as after 2 years of age stunting becomes irreversible.
There is a diverse etiology for the cause of primary SAM [Table 1]. In a study by Shahid et al., it was seen that maternal health and maternal education were the most important factors for enhancing the probability of child malnutrition, apart from many others.[7] This points toward a very wide area of intervention and opportunity for the public health system to work in.
| 1 | Inadequate fetal growth |
| Intra-uterine growth restriction and preterm birth | |
| 2 | Poor maternal nutrition |
| Poor nutrition before and during pregnancy and lactation | |
| Maternal micronutrient deficiencies | |
| Short maternal stature | |
| 3 | Maternal infections and mental health |
| Maternal infection during pregnancy (e.g., worm infestation, malaria, fluorosis, dengue) | |
| Mental health (e.g., depression) | |
| 4 | Inadequate breastfeeding practices |
| Delayed initiation of breastfeeding (rec: Within the 1sth) | |
| Non-exclusive breastfeeding (rec: For 6 months) | |
| Early cessation of breastfeeding (rec: Continued breastfeeding for up to 2 years) | |
| 5 | Inadequate complementary feeding practices |
| Late introduction of complementary foods (rec: At 6 months) | |
| Less than minimum recommended dietary diversity | |
| Less than minimum recommended feeding frequency | |
| Low intake of animal-source foods | |
| Poor micronutrient quality of complementary foods | |
| Low energy density of complementary foods | |
| High anti-nutrient content of complementary foods | |
| Feeding insufficient quantities | |
| Non-responsive feeding | |
| Inadequate feeding during and after illness | |
| 6 | Frequent diseases |
| Enteric infection: Diarrheal disease, environmental enteropathy, helminths infection | |
| Respiratory infections | |
| Malaria | |
| Reduced appetite/increase nutrient losses/impaired absorption due to infection | |
| Inflammation -environmental enteropathy | |
| 7 | Poor maternal and childcare practices (including during illness) |
| Adolescent pregnancy | |
| Short birth spacing | |
| Poor care practices for mother themselves during pregnancy -heavy workload or inadequate rest | |
| Inadequate early maternal child stimulation (pregnancy up to 2 years of age) |
|
| 8 | Inadequate household sanitation and food/water safety |
| Inadequate household access to improved sanitation facilities | |
| Inadequate access to safe water supplies | |
| Poor personal hygiene practices (handwashing at critical points – after using toilet, before cooking or eating) | |
| Unsafe disposal of child stools | |
| Unhygienic food and drinking water handling (no cool storage for cooked foods, no treatment of water at the point of use) | |
| Food and water contamination | |
| Lack of clean and safe child play area | |
| 9 | Agriculture and food systems |
| Inadequate food production and processing | |
| Limited access to and availability of foods (i.e., micronutrient-rich foods) | |
| Food prices and trade policy | |
| Inadequate food marketing regulations | |
| Food policy and legislation gaps -no regulation on salt or sugar content of food items | |
| Inadequate food fortification policy and legislation - targeted to mothers during pregnancy and lactation and young children during complementary feeding (6–24 months of age) | |
| Poor quality of supplementary foods targeting mothers during pregnancy and lactation and children during complementary feeding | |
| 10 | Political economy and governance |
| Poverty, income, and wealth | |
| Political instability -especially in socially insecure or conflict-affected areas | |
| Limited budget allocation for preventive and control measures of under-nutrition | |
| Limited employment and livelihoods -especially among marginalized population groups -ST/SC, etc. | |
| Limited access to and utilization of financial services | |
| Limited access to entitlements | |
| 11 | Social norms on gender and caste |
| Women/mother’s low social status | |
| Beliefs and norms: e.g., unfavorable norms during the first 1,000 days of life | |
| Poor social support networks: e.g., community support networks, mother-to-mother support systems, etc | |
| Discrimination (i.e., gender, caste, SC/ST, etc) | |
| 12 | Education |
| Poor access to quality education | |
| Low completion of secondary education of mothers | |
| Limited qualified teachers | |
| Limited qualified health educators | |
| Education infrastructure (e.g., secondary schools, training institutions, etc) | |
| 13 | Water, sanitation, and environment |
| Poor water and sanitation infrastructure and services | |
| Inadequate emergency preparedness | |
| Climate change -reduced water security and safety | |
| Natural and human-induced disasters (e.g., conflict-affected areas) – reduced access to WASH services |
|
| Increasing urbanization -low access to WASH services especially in urban slums | |
| Population density -reduced access to WASH services | |
| 14 | Health and nutrition care |
| Gaps in nutrition and healthcare systems and policies | |
| Inadequate policy and guidelines to deliver the ten essential nutrition interventions for the prevention of stunting and wasting | |
| Limited access to essential nutrition and health services | |
| Limited access to and delivery of ICDS programs | |
| Lack of qualified nutrition and healthcare service providers | |
| Limited availability of supplies (e.g., IFA and other nutrition commodities) |
|
| Poor ICDS and health infrastructure | |
| Inadequate communication and counseling skills of frontline workers and community-based organizations | |
| Labor migrations -limiting access to the essential nutrition and health services |
ICDS: Integrated Child Development Services, WASH: Water, sanitation, and hygiene, IFA: Iron and folic acid, SC: Scheduled caste, ST: Scheduled tribe
All causes of secondary SAM are usually due to either high metabolic rate/requirement or ineffective absorption or functional disability to take in adequate nutrition. These cases have to be approached in a multidisciplinary fashion.
INDIAN PUBLIC HEALTH INITIATIVES
India has been a leader in developing national food and nutrition databases (such as the Indian Food Composition Tables, 2017) and conducting research studies and surveys that track changes in agriculture, food, and nutrition. The country has also applied emerging knowledge and invested in nutrition intervention programs to (i) enhance food and nutrition security for its citizens, (ii) ensure that existing food supplementation programs deliver adequate food to bridge energy and nutrient gaps among vulnerable populations, and (iii) strengthen current nutrition interventions by integrating ongoing programs and introducing new ones, all aimed at preventing, detecting early, and effectively managing child undernutrition across the country.
ASSESSMENT GUIDELINES -NATIONAL HEALTH MISSION
Growth monitoring
Identification of malnourished children is done using Growth Monitoring data (weight-for-height and weight-for-age).
For identification of SAM children, active screening is done by Anganwadi workers (AWW)/accredited social health activists (ASHA) through house-to-house visits looking for the presence/absence of bilateral pitting edema or severe degree of wasting. Passive screening is done during growth monitoring/village health, sanitation, and nutrition days for children (6–59 months) VHSND, carried out monthly and the presence/absence of bilateral pitting edema or severe degree of wasting is specially noted.
After the identification of children using growth monitoring data, appetite test is carried out by the AWW for all SAM children and the child is assessed for the presence of medical complications.
Screening of children at outpatient department/in-patient wards in health facilities using weight-for-height and weight-for-age measurements. Based on the degree of malnutrition, the children are referred to different levels of care in the public health system [Table 2].
| Degree of malnourishment | Level of care |
|---|---|
| Moderate acute malnutrition, i.e., weight-for-height between − 2 SD and−3 SD | To be managed at AWC |
| SAM without medical complication, i.e., weight for height <−3 SD and passed appetite test | To be managed at AWC |
| SAM, i.e., weight for height <−3 SD with medical complications and/or presence of bilateral pitting edema and/or loss of appetite (failed appetite test) |
To be managed at NRC |
| Moderate underweight, i.e., weight for age between−2 SD and−3 SD | To be managed at AWC |
| Severe underweight, i.e., weight for age <−3 SD without medical complications | To be managed at AWC |
AWC: Anganwadi center, NRC: Nutrition rehabilitation center, SAM: Severe acute malnutrition, SD: Standard deviation
Appetite test for SAM children is carried out as per standard protocol
SAM children who fail the appetite test are referred to nutrition rehabilitation centers (NRC).
Children who pass the appetite test are enrolled as beneficiaries under the Supplementary Nutrition Program and also referred to the primary health centre (PHC) medical officer for medical assessment.
Medical assessment
Every SAM child who passes the appetite test and all SUW children are screened for health status to identify any health issues or hidden infection or danger signs.
Children with any medical complication are referred to the nearest health facility for medical management and further treatment of sickness.
Infants <6 months of age who are visibly wasted or edematous or too weak or feeble to suckle, should be immediately referred to the nearest health facility/NRC for evaluation. Further, SUW children of 0–6 months are referred to NRC directly for further management as per the WHO guidelines.
FEEDING MANAGEMENT OF SAM IN FACILITY
Stabilization phase
The milk feed F75 used during this phase promotes recovery of normal metabolic functions and nutrient imbalances. Rapid weight gain at this stage is dangerous. F75 contains 75 kcal/100 mL and 0.9 g protein/100 mL and it is not suited for weight gain. No other food should be given when on F75, only breastfeeding is permitted. The quantity given is 130 mL/kg/day in non-edematous children and 100 mL/kg/day in children with nutritional edema.
While on F75 to monitor:
Record each feed given and accepted
Amounts offered and leftover
Vomiting
Frequency and quantity of watery stool
Weight entered each day and plotted in multi-chart
Assess the degree of edema each day
Body temperature to be recorded regularly.
During the stabilization phase, diarrhea should gradually diminish and edematous children should lose weight.
Catch up phase
Readiness to enter the rehabilitation phase is signaled by a return of appetite, child may also smile and start losing edema, this usually starts about 2–7 days after admission. 150–185 kcal/kg/d is received from F-100 therapeutic milk for in-patient rehabilitation phase. For 2 days, keep the same volume of the catchup diet as that of the starter diet and later increase each feed by 10 mL. 3 hourly feeds (8 feeds) are given over 24 h. These can be 5 feeds of catch-up diet and 3 feeds of age-appropriate complementary feeds.
Children who develop any signs of complications should be shifted back to starter diet. Signs of complications are:
Any child gaining weight very rapidly >10 g/kg/day, indicating fluid retention.
Increasing edema
Child who does not have edema develops edema
Increase in size of the liver
Signs of fluid overload
Re-feeding diarrhea develops.
In cases of micronutrient deficiency:
Multivitamin supplement - Twice RDA
Folic acid - 5 mg on day 1, then 1 mg/d
Elemental zinc - 2 mg/kg/d
Copper - 0.3 mg/kg/d (if separate preparation is not available use commercial preparation containing copper)
Iron - Start daily iron supplementation after 2 days of child being on catch-up diet.
Give elemental iron in the dose of 3 mg/kg/d in two divided doses, preferably between the meals (do not give iron in the stabilization phase).[8]
COMMUNITY MANAGEMENT OF SAM
The parents and caregivers of the child are sensitized on nutrition, feeding practice, diet quality, infant and young child feeding practices including quality and adequacy of age-appropriate complementary feeding (use of five or more food groups), water, sanitation and hygiene, practices (use of safe drinking water, personal hygiene, hand washing, use of toilets, cleanliness of home and surroundings, other food safety practices, etc.).
Information, education and communication (IEC) materials and videos are used by AWWs during home visits and group counseling at AWC.
During home visits, AWWs demonstrate feeding practices and handhold the mothers to improve responsive feeding and counsel mother/caregivers.
During follow-up, it is stressed that these children are at risk of repeated infections and prone to growth faltering; therefore, the importance of appropriate childcare practices and timely care by caregivers needs to be emphasized.
Home nutrition management of SAM can be done using ready-to-use therapeutic food (RUTF)/energy-dense nutritive food (EDNF).[8]
RUTF/EDNF
RUTF is safe and cost-effective and was developed in 1996 for children with SAM based on the composition of F-100, the WHO-recommended diet for nutritional rehabilitation.
Energy dense nutritive food (EDNF) is currently used for nutritional rehabilitation of children with SAM in the community and hospital settings in the state of Maharashtra as per the community-based management of acute malnutrition guidelines and has been highly effective in promoting nutritional recovery in children with SAM. We categorically do not view RUTF as a substitute for best nutritional practices or normal household food, but to be used only as Medical Nutrition Therapy.
The benefits of RUTF are:
It provides all the nutrients required for recovery
It has a good shelf life and does not spoil easily even after opening. (24 h after opening one should discard it)
Since RUTF is not water based, the risk of bacterial growth is very limited, and consequently, it is safe to use without refrigeration at the household level
It is liked by children, safe and easy to use without close medical supervision
It can be used in combination with breastfeeding and complementary feeds with other best practices for infant and young child feeding in children above 6 months of age.[9]
An ideal community management of acute malnutrition (CMAM) should cover all the core components including prevention and curative strategies, RUTF-based management, screening and monitoring (using mid-upper arm circumference [MUAC]), prompt referrals to NRCs, community mobilization, and appropriate convergence with Integrated Child Development Services/Women and Child Development (WCD).
Mid-day meal (MDM) program
In 1995, the Central Government launched the National Program of Nutritional Support to Primary Education, commonly referred to as the MDM scheme, with the aim of improving children’s nutritional status and boosting their enrolment and attendance in schools.
National Food Security Act, 2013
Aimed at providing subsidized food grains to around two-thirds of the country’s 1.2 billion population. Under this act, individuals covered by the targeted public distribution system (TPDS) are entitled to receive 5 kg of cereals per person each month at subsidized rates (United States Dollar (USD) 0.05/kg for rice, USD 0.03/kg for wheat, and USD 0.02/kg for coarse grains). The TPDS extends its coverage to 75% of the rural population and 50% of the urban population.
Village Health Sanitation and Nutrition Committee (VHSNC)
The Government of India launched the National Rural Health Mission (NRHM) in April 2005. As part of this initiative, the VHSNC – formerly known as the Village Health and Sanitation Committee – was established to decentralize governance and empower local communities to enhance sanitation and nutrition in villages. Through the VHSNCs, “panchayats” (village councils) actively participate in overseeing health and public service delivery at the village level. The committees are responsible for monitoring the work and contributions of community health workers, including AWWs, ASHAs, and other public sector employees (such as those from the Water and Sanitation Department and Roads Department), to ensure the maintenance of sanitation and healthy environments. These health staff operate under the supervision and monitoring of the Panchayati Raj institutions.
Food Safety and Standard Authority of India (FSSAI)
The FSSAI was established by the Government of India on 5 September 2008 under the Food Safety and Standards Act, 2006. It offers technical support and scientific advice to the government for developing policies and programs related to food safety and nutrition. In addition, the FSSAI supplies micronutrients for food fortification and trains school staff to enhance the nutritional quality of MDM for children.
Rajiv Gandhi Scheme for the Empowerment of Adolescent Girls (RGSEAG)
The ministry of WCD started implementation of SABLA for the Government of India on 1 April 2011. RGSEAG has an aim to empower adolescent girls aged 11–18 years by promoting awareness about health, nutrition, adult reproductive, and sexual health, providing education in life skills and family welfare. It also provides iron and folic acid supplements under Reproductive and Child Health-2 and NRHM. This initiative will help break the inter-generational cycle of malnutrition. Targeting adolescent girls and their health will ensure healthier babies and a brighter future.
Village Health Nutrition Day
Once a month, ASHA workers, auxiliary nurse midwives, and AWWs mobilize villagers – particularly women and children – at anganwadi centers (AWCs) to engage with health personnel, learn about available healthcare services, and receive information on maternal and child health, nutrition, family planning, sanitation, and communicable diseases.
In addition, the government has launched the National Nutrition Mission (NNM) with a 3-year budget of USD 1,289 million starting from 2017 to 2018. The NNM is responsible for monitoring, supervising, setting targets, and coordinating nutrition-related initiatives across various Ministries. Its key goals include reducing stunting, undernutrition, anemia, and the incidence of low birth weight babies. The mission aims to create synergy among efforts, enhance monitoring, issue alerts for timely interventions, and motivate states and union territories to strengthen performance while guiding and supervising Ministries and local administrations to achieve the set objectives. Over 10 million people are expected to benefit from the program.[10]
UNDER 6 MONTHS MALNUTRITION OR EARLY GROWTH FAILURE IDENTIFICATION AND MANAGEMENT
In a study by Chopra et al., a strong direct relationship was found between diarrhea, exclusive breastfeeding, and the incidence of stunting, underweight, and wasting among children. Factors indirectly linked to these outcomes included the mother’s education, place of residence, and whether the pregnancy was planned. Identifying hotspots through spatial analysis could support the revival and adaptation of control strategies based on the specific needs of each geographic area. It is widely recognized that interventions targeting health and nutrition during the first 1,000 days of life are critical to preventing growth faltering in children.[11]
Infants at risk of poor growth and development include infants <6 months of age in any of the following categories with any of the following criteria:
Category 1: Infants with poor growth based on sequential measures
No weight gain or weight loss from one measurement to the next; or
Downward crossing of weight-for-age centile lines*; or
Insufficient weight gain (velocity standards** or grams/per specific time period***).
Category 2: Infants with poor anthropometry based on a single measure (if sequential measures not available)
Weight-for-age z-score (WAZ) <−2 SD; or
Weight-for-length z-score (WLZ) <−2 SD; or
Nutritional edema; or
MUAC <110 mm for infants between 6 weeks and <6 months of age.
Category 3: Infants with known risk factors for poor growth and development
Neurodevelopmental concerns; or
Infant feeding concerns; or
Maternal risk (physical or mental health problem(s) affecting caring practices); or
History of hospitalization.
Category 4: Infants at risk due to poor birth outcomes
Preterm birth; or
Low birth weight; or
Small for gestational age.
It is recommended to adopt the term “Infants at Risk of Poor Growth and Development” in clinical practice and health policy to promote a holistic, preventive approach that emphasizes early identification, reduces stigma, and encourages comprehensive care addressing both physical growth and developmental needs, in alignment with global health guidelines.
Early growth failure is strongly associated with increased risks of mortality, impaired cognitive development, and NCDs, such as cardiovascular disease, diabetes, and obesity in adulthood. In a study by Pratim Roy four antenatal visits antenatal care (ANC), institutional deliveries, full immunization, early breastfeeding, and adequate diet reduce the degree of malnutrition among children, and hence, public health interventions aiming at reducing these risks to promote healthier adult outcomes would be of much use.[12]
Adopting a comprehensive and integrated mother-infant dyad approach involves evaluating both the infant and the mother to provide more accurate diagnoses and effective intervention strategies. This approach has been shown to improve infant growth outcomes.
Serial plotting of anthropometric parameters on age- and gender-specific WHO multi-center growth reference study growth charts is recommended for monitoring the child’s growth. INTERGROWTH-21st standards are recommended for assessing PT infants up to 64 weeks postmenstrual age, after which the WHO Child Growth Standards are applicable.
A comprehensive feeding assessment should be conducted at every community and facility contact to identify and address breastfeeding and lactation challenges. In community settings, healthcare workers should observe breastfeeding sessions to assess infant positioning, attachment, and suckling. In facility settings, a more detailed assessment should be performed using tools like the WHO/United Nations Childrens Fund (UNICEF) Breastfeeding Assessment Tools or the Latch, Audible swallowing, Type of nipple, Comfort, Hold (LATCH) score.
Maternal physical health must be taken into account including her Body Mass index and any other medical conditions that might affect her caring for her child. Additionally maternal mental health screening must also be done as part of the overall care of the mother- infant dyad. Screening for maternal depression can be done using tools such as the patient health questionnaire-2 (PHQ-2) in community settings and PHQ-9 in hospital settings. Mothers who have a significant score should be referred to a higher center for further evaluation and confirmation.
Infants at risk of poor growth and development with serious medical complications should be admitted for inpatient care, while infants at risk of poor growth and development, including those with SAM, but without such complications, should receive targeted care in a community or outpatient care setting.
It is recommended to follow the WHO-recommended 10 essential steps of management for SAM in infants under 6 months requiring inpatient care. Infants at risk of poor growth and development who are not diagnosed with SAM should be managed according to standard guidelines, along with feeding assessment and support.
It is recommended to use broad-spectrum antibiotics in all infants at risk of poor growth and development.
Routine supplementation of Vitamin A, potassium, and magnesium is not recommended for infants at risk of poor growth and development. Infants at risk of poor growth and development and without prospects of breastfeeding should be supplemented with micronutrients, similar to older children, if they are managed with a locally prepared starter and catch-up diet.
For all infants at risk of poor growth and development, every attempt should be made to make breastfeeding exclusive and effective so that infant gains adequate weight. Whether the mother has sufficient or insufficient breastmilk output, the focus should be on addressing feeding problems by correcting position and attachment of breastfeeding through one-to-one counseling technique.
Infants at risk of poor growth and development and are admitted for inpatient care should be breastfed where possible and the mothers should be supported to breastfeed the infants. If an infant is mixed fed or top fed and there is a prospect of breastfeeding, support should be given to the mother or female caregiver to re-lactate by supplementary suckling technique.
Infants at risk of poor growth and development and without prospects of breastfeeding should be managed with pasteurized donor human milk (PDHM) or F-75/non-cereal-based starter diet during the stabilization phase. During the rehabilitation phase, they should receive either pasteurized human donor milk PDHM, F-75, or diluted F-100/non-cereal-based catch-up diet.
In situations where there are no prospects of breastfeeding (e.g., mother deceased or adopted babies), preferred feeding options include wet nursing by a healthy family member or PDHM. If these options are not feasible, recommended feeding options are infant formula, fresh animal milk, or single-toned dairy milk, depending on family situations and suitability. It is recommended to supplement multivitamin and iron in prophylactic dose when infants are managed on undiluted animal milk or packaged dairy milk.[13]
It is recommended that all infants under 6 months at risk of poor growth and development should be closely monitored until they are breastfeeding effectively or feeding well with replacement feeds and have sustained weight gain for at least two consecutive weekly visits and are followed up until 6 months of age.[13]
CONCLUSION
India’s public health initiatives to combat pediatric undernutrition reflect a comprehensive and evolving approach, combining policy reforms, community engagement, and intersectoral collaboration. Programs such as the MDM scheme, the National Nutrition Mission, and efforts led by grassroots health workers have significantly contributed to improving child health and nutrition outcomes. The integration of food fortification, targeted supplementation, enhanced maternal education, and improved healthcare access have created a strong foundation for addressing the complex factors driving undernutrition. However, continued investment, innovation, and regional customization of strategies remain critical to sustaining progress. By strengthening monitoring systems, fostering community participation, and prioritizing the first 1,000 days of life, India can further accelerate its efforts toward eradicating pediatric undernutrition and ensuring a healthier future for its children.
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
Patient’s consent not required as there are no patients in this study.
Conflicts of interest:
Dr. Minnie Bodhanwala is on the Editorial Board of the Journal.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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