To characterize the epidemiology of wasting and identify the main predictors of wasting, severe wasting and poor weight-for-height in children.

We analysed a nationally representative sample of 2028 children (Multiple Indicator Survey, 2010).

Royal Kingdom of Bhutan.

Children aged 0–23 months.

Wasting prevalence was significantly higher among infants aged 0–11 months than among children aged 12–23 months (12·0 v. 6·7 %; P=0·004) and among boys than girls (11·0 v. 7·5 %; P=0·04). Children from the Western region had 63 % higher odds of being wasted than children from the Central/Eastern regions (adjusted OR (AOR)=1·63; 95 % CI 1·14, 2·34). Poor feeding practices were among the most significant predictors of wasting and severe wasting. Children who were given prelacteal feeds in the first days of life had 2·5 times higher odds of being severely wasted than those who were not (AOR=2·49; 95 % CI 1·19, 5·19); inadequate complementary feeding in children aged 0–23 months was associated with 58 % higher odds of being wasted (AOR=1·58; 95 % CI 1·02, 2·47) and 2·3 times higher odds of being severely wasted (AOR=2·28; 95 % CI 1·13, 4·58). The association of poor infant feeding practices with wasting and severe wasting was particularly significant in infants (0–11 months).

Programmes for the detection and treatment of severely wasted children need to prioritize very young children (0–11 months), particularly in the Western region. Programmes for the prevention of wasting need to prioritize the improvement of complementary foods and feeding practices in children aged 6–23 months.

To assess the appropriateness of current mid upper-arm circumference (MUAC) cut-offs to identify children with severe acute malnutrition in India.

The analysis concerned 6307 children admitted to nutrition rehabilitation centres (2009–2011) where they received therapeutic care as per guidelines by WHO and the Indian Academy of Pediatrics.

States of Jharkhand, Madhya Pradesh and Uttar Pradesh, India.

Children aged 6–59 months with bilateral pitting oedema or weight-for-height Z-score (WHZ)<−3 or MUAC<115 mm at admission.

Children aged 6–23 months represented ~80 % of the admissions. Among them, the proportion with WHZ<−3 was similar to that with MUAC<115 mm (85·7 % v. 81·8 %); the proportion with MUAC<115 mm whose WHZ was <−3 was 82·6 %; and the proportion with WHZ<−3 whose MUAC<115 mm was 78·8 %. MUAC<115 mm was as effective as WHZ<−3 in identifying 6–59-month-old children with medical complications (32·2 % v. 31·6 %, respectively), the most important risk factor of death among oedema-free children. Furthermore, death rates in children with MUAC<115 mm were higher than in children with WHZ<−3 (0·61 % v. 0·58 %, respectively) and 91 % of the deaths among oedema-free children were deaths of children with MUAC<115 mm.

In populations similar to those included in our analysis, MUAC<115 mm appears to be an appropriate criterion to identify children with severe acute malnutrition who are at a greater risk of medical complications and death, particularly among children 6–23 months old.

To characterize the coverage of India's national vitamin A supplementation (VAS) programme and document its performance in reaching children in the districts with higher concentration of poor households (2006–2011).

Analysis of VAS programme coverage data collated and collected using standardized bottom-up procedures, data from India's Office of the Registrar General and Census Commissioner, and data from India's District Level Household Survey to compute exposure (poverty) and outcome (full VAS coverage) variables.

Seven Indian states with the highest burden of mortality in children (74 % of all deaths among under-5s in the country in 2006).

Children 6–59 months old.

Between 2006 and 2011, the mean full VAS coverage (two VAS doses per child per year) in these seven states increased from 44·7 % to 67·3 % while the number of districts with high (≥80 %) full VAS coverage increased from twenty-four (9·4 %) to 131 (51·4 %). The highest increases in full VAS coverage figures were recorded in the districts with the highest concentration of poor households. The estimated number of poor children (i.e. children living in households classified as poor) who did not receive two VAS doses annually decreased from 8·5 million in 2006 to 5·1 million in 2011 (40·3 % decrease); 2·5 million (49·1 %) of these children lived in the districts with the lowest proportion of poor households.

Despite significant improvements in VAS, a large number of Indian children are not benefitting yet from this life-protecting intervention, particularly among those who are potentially the most vulnerable. Future programme action needs to give priority to sub-district level units – blocks and villages – with higher concentrations of poor households.

To assess the effectiveness of facility-based care for children with severe acute malnutrition (SAM) in malnutrition treatment centres (MTC).

Early detection and treatment of SAM using locally adapted protocols; assessment of programme outcomes, including survival, default, discharge and recovery rates.

All forty-eight MTC in Jharkhand, India.

Children (n 3595) with SAM admitted to MTC (1 July 2009–30 June 2011).

Of children admitted, 55·0 % were girls, 77·7 % were 6–23 months old and 68·6 % belonged to scheduled tribes or castes; 34·4 % had oedema or medical complications. Of the 3418 programme exits, the proportion of children who died was 0·6 % (n 20), the proportion of children who defaulted was 18·4 % (n 628) and the proportion of children discharged was 81·0 % (n 2770). Children's average weight gain was 9·6 (sd 8·4) g/kg body weight per d and their average length of stay was 16·0 (sd 5·7) d. Among the 2770 children who were discharged from the programme, 39·4 % (n 1090) gained 15 % or more of their initial weight while 60·6 % (n 1680) gained less than 15 % of their initial weight.

MTC provide live-saving care for children with SAM as demonstrated by high survival rates. However, the protocols and therapeutic foods currently used need to improve to ensure the recovery of all discharged children. MTC should be reserved for children with complicated SAM; children with uncomplicated SAM should be admitted to a community-based programme for the management of SAM, at a lesser risk to children and a lesser cost to families and the health system.