Introduction 

Malnutrition remains a global health concern, affecting millions of infants and children worldwide. While malnutrition in older children is widely recognized, the alarming issue of malnutrition in infants under six months is often overlooked. This critical period of a child’s life is vital for growth and development, making early intervention essential. Unfortunately, the burden of wasting among Indian children in the first 6 months of life is not well-documented. Infants under the age of six months may exhibit various signs of malnutrition, including low birth weight (including premature birth), wasting, underweight, growth or feeding difficulties, and clinical illness. In India, the statistics reveal a concerning situation, with 27% of infants under six months being wasted or acutely malnourished (weight-for-length (WLZ) < -2), and 13% severely wasted (WLZ < -3). Additionally, 32% of infants are underweight (Weight-for-age (WAZ) < -2), and 10.6% are severely underweight (WAZ < -3) (Government of India, 2021). Furthermore, the prevalence of low-birth-weight infants stands at a staggering 18%, many of whom are already wasted or become wasted later. The rates of timely initiation of breastfeeding are low, with only 41.8% of children being breastfed within the first hour of birth, and exclusive breastfeeding is practiced by only 63.7% of infants under six months of age (Randev, 2020).

Unveiling the Etiology of Malnutrition Among Infants Less Than 6 Months of Age 

1. Inadequate Exclusive Breastfeeding Practices: One prominent etiological factor contributing to malnutrition in this age group is the practice of suboptimal breastfeeding. Exclusive breastfeeding for the first six months of life is crucial for providing optimal nutrition and protection against infections. However, challenges such as lack of knowledge, cultural beliefs, maternal employment, and aggressive marketing of breastmilk substitutes often impede exclusive breastfeeding rates. Studies have shown that suboptimal breastfeeding practices significantly increase the risk of malnutrition among infants (Victoria et al., 2016, Islam et al., 2018).
2. Maternal Malnutrition and Health Status: The nutritional status and overall health of mothers play a pivotal role in the etiology of malnutrition among infants. Maternal malnutrition, before and during pregnancy, can result in deficiencies of essential nutrients, which may cause prematurity or intrauterine growth retardation and directly affect the quality and quantity of breast milk. Term SGA (small for gestational age) and low birth weight babies are more likely to experiencing wasting and severe wasting (HRD, SAS & UNICEF). Furthermore, maternal illness and infections, particularly during pregnancy and lactation, can hinder the fetus’s and infant’s access to adequate nutrition and contribute to malnutrition (Bhutta et al., 2013). Addressing maternal malnutrition and improving maternal health is crucial for promoting infant nutritional well-being.
3. Infections and Illness: Infections and illnesses have a profound impact on the etiology of malnutrition among infants. The immature immune systems of infants under six months make them susceptible to infections, which can disrupt nutrient absorption, increase nutrient requirements, and reduce appetite. Common infections such as respiratory infections, diarrheal diseases, and malaria can lead to malnutrition in this age group (Caulfield et al., 2004). Addressing infections through improved healthcare access, vaccination and hygiene practices is essential in mitigating risk of malnutrition.
   

In addition to these factors, there are other identified factors like lower maternal education, caesarean section, low birth weight, gender and poverty and socioeconomic factors which contribute to malnutrition among infants less than 6 months of age. Infants under six months are particularly vulnerable to malnutrition due to their physiological immaturity, high nutritional needs, and exclusive reliance on breast milk. Wasting and severe wasting among this age group of young infants is significantly associated with increased risk of morbidity, mortality, and poor cognitive and physical development and thus it is imperative to address it. 

Current Context

While India has made significant strides in improving the survival rates of high-risk newborns and infants through the identification and management of illness withing dedicated facilities and targeted programs (Kumar et al., 2020), there remains room for improvement. The nutritional interventions in India have mainly targeted children aged 6 to 59 months, with facility-based management guidelines issued in 2011 to treat severe acute malnutrition among infants and young children aged 0-59 month. Various programs and platforms in India are aimed at detecting and managing early growth failure however, the utilization of these services often falls short of expectations. To address the needs of at-risk children, existing programs such as Home-Based Newborn Care and Home-Based Young Child Care should be strengthened and expanded to include actions for infants with malnutrition. Although infants with wasting in the first six months of life are also at high risk, they receive less frequent follow-up home visitation than low birth weight babies in the current program (as per HBNC/HBYC Guidelines, 2011).  

Progression

One intervention that can prevent and treat malnutrition in children under six months of age is optimal breastfeeding practices which include timely initiation of breastfeeding and exclusive breastfeeding up to 6 months of age. In fact, exclusive or predominant breastfeeding has been shown to reduce the risk of wasting in the first six months of life (WHO 2021). However, despite the recommended guidelines promoting optimal breastfeeding for the first six months, there is a low compliance rate due to factors such as lack of awareness, social norms, deeply rooted cultural practices, and inadequate support system. Additionally, many women in India suffer from anemia, which can have negative impacts on the mother’s health and increase the risk of low-birth-weight babies. Poor sanitation and hygiene practices also contribute to malnutrition, exposing infants to diarrheal infections and other illnesses that can affect their growth and development. Other key intervention includes improving maternal nutrition during pregnancy, addressing post-partum mental health issues, enhancing skills and knowledge of frontline workers on breastfeeding counselling and resolving challenges faced by mothers in breastfeeding. There is a need for enhanced community-based interventions that address the health and nutrition of both infants and mothers.

There is a great opportunity for further strengthening community-based interventions that focus on promoting the health and nutrition of both infants and mothers. While services for pregnant women primarily address physical ailments, there is a need for increased support for maternal mental health. It is important to address regional variations, improve service integration, and bridge the gaps in referral systems to ensure the seamless delivery of high-quality care. 

To enhance the effectiveness of community-based interventions, it is crucial to address practical constraints such as the limited availability of appropriate equipment and additional efforts are warranted to improve the skill levels of community health workers to ensure strengthened service delivery. 

In India, there is a pressing need for more evidence-based initiatives that specifically focus on the prevention, identification, and management of acute malnutrition in children under six months of age.  Addressing this gap will contribute to the overall well-being and healthy development of infants in the country (Chowdhury et al., 2021). 

Therapeutic approach calls for country-specific guidelines to address the issue of malnutrition among children under 6 months of age at community level (CMAM) and Indian growth standards for early identification of MAM and SAM children under 6 months. Development of a national guideline and protocol for the community-based management of early growth failure in infants under six months, based on the MAMI Care Pathway Package, spearheaded by the National Centre of Excellence for Management of Severe Acute Malnutrition at Kalawati Saran Children’s Hospital is very promising. The MAMI Care Pathway Package is tailored to the specific context by integrating its various components into the existing community-based programs.  

Conclusion

The nutritional needs of children under the age of six demand greater attention and emphasis than they currently receive. Implementing innovative and comprehensive strategies such as Community-Based Management of Acute Malnutrition for Infants (CMAMi) can prove highly beneficial in making a significant impact on the country’s malnutrition statistics. 

To acknowledge and address this, we at Action Against Hunger, India work with mothers, families, communities, and systems to foster requisite support, knowledge, and skills to assure optimal nutritional support to the children under 6 months. 

References  

1. India State-Level Disease Burden Initiative Collaborators. Nations within a nation: variations in epidemiological transition across the states of India, 1990-2016 in the Global Burden of Disease Study. Lancet. 2017; 390:2437–60.
2. World Health Organization. Updates on the Management of Severe Acute Malnutrition in Infants and Children. Guideline. 2013. Available at: https://www.who.int/publications/i/item/9789241506328 . Accessed on 17th April 2023. 
3. Knowledge Integration and Translational Platform at Research and Development, society for Applied Studies, new Delhi, India and UNICEF, India. Analysis of wasting and severe wasting and its associated risk factors among under-5 children in India.
4. Kumar P, Meiyappan Y, Rogers E, et al. Outcomes of hospitalized infants aged one to six months in relation to different anthropometric indices – an observational cohort study. Indian J Pediatr. 2020. https://doi.org/10.1007/s12098-020-03236-9 .
5. National Center of Excellence for Management of Severe Acute Malnutrition, Kalawati Saran Children’s Hospital LHMC, New Delhi. National Consultation on Addressing Acute Malnutrition 2021, New Delhi.
6. Mwangome M, Ngari M, Fegan G, et al. Diagnostic criteria for severe acute malnutrition among infants aged under 6 mo. Am J Clin Nutr. 2017; 105:1415–23. 
7. Mwangome M, Ngari M, Bwahere P, et al. Anthropometry at birth and at age of routine vaccination to predict mortality in the first year of life: a birth cohort study in Burkina Faso. PLoS One. 2019;14: e0213523.
8. Randev S. Malnutrition in Infants under 6 months: Is it time to change recommendations? Indian J Pediatr. 2020; 87(9):684–685.
9. Bhutta Z. A, Das J.K, Rizvi A, et al. Evidence-based intervention for improvement of maternal and child nutrition. What can be done and at what cost? The Lancet 2013; 382 (9890): 452-477.
10. Black R E, Victoria C G, Walker S P, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet 2013; 382 (9890): 427-451.