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close this bookHandbook for Emergencies - Second Edition (UNHCR, 1999, 414 p.)
close this folder15. Food and Nutrition
View the document(introduction...)
View the documentOverview
View the documentIntroduction
View the documentOrganization of Food Support
View the documentNutritional Assessments
View the documentGeneral Feeding Programme
View the documentSelective Feeding Programmes
View the documentInfant Feeding and use of Milk Products
View the documentKey References
View the documentAnnexes

Selective Feeding Programmes

· The objective of a selective feeding programme is to reduce the prevalence of malnutrition and mortality among the groups at risk;

· Selective feeding programmes provide extra food for the malnourished and at-risk groups - this food must be in addition to (not a substitute for) the general feeding programme;

· The programme must actively identify those who are eligible for the selective feeding programmes, using criteria described in this chapter.


Figure 2 - Response to food and nutritional needs

General Principles of Selective Feeding Programmes

49. Where malnutrition exists or the needs of the groups at risk cannot be met through the general ration, special arrangements are required to provide extra food. This is organized through different types of selective feeding programmes which take into account the degree of malnutrition and associated risks. In the emergency phase of an operation, selective feeding programmes are part of an emergency measure to prevent excess mortality. However, preventing excess mortality should be a combined strategy of selective feeding, public health and emergency health care. Ref. Figure 2.

The organization of these programmes should be integrated from the beginning with community and health services and especially with Mother and Child Health Care programmes (MCH).

50. Malnutrition develops particularly among infants, children, pregnant women, nursing mothers, the elderly and the sick. Their vulnerability stems from the greater nutrient requirements associated with growth, the production of breast milk, repair of tissues and production of antibodies. Malnutrition results in lower resistance to infection, which in turn results in further malnutrition. Small children are particularly susceptible to this cycle of infection and malnutrition. Sick children must eat and drink even if they do not have an appetite, are vomiting, or have diarrhoea. Because children are unable to eat a large volume of food, it is necessary to prepare food in a concentrated form (giving the required nutrients in less volume), and to provide more frequent meals.

51. Certain other groups or individuals may be at risk of malnutrition for social or economic reasons. These include unaccompanied children, the disabled, single-parent families, and the elderly, particularly those without family support. In some communities specific social or cultural practices and taboos may put constraints on meeting the nutritional needs of certain persons, for example pregnant women and nursing mothers or even sick children.

52. Even if the overall quantity of food is sufficient there may be other causes such as:

i. Inequities in the distribution system reducing access to food for certain groups;

ii. Inaccuracies in registration or unfair distribution of ration cards;

iii. Infections;

iv. Faulty feeding or food preparation habits.

Selective feeding programmes are not a substitute for an inadequate general ration.

53. The following types of selective feeding programmes are contemplated:

i. Supplementary Feeding Programmes (SFP)

a) Targeted SFP

b) Blanket SFP;

ii. Therapeutic Feeding Programmes.

To be effective, the extra ration provided must be additional to, and not a substitute for, the general ration.

Supplementary Feeding Programmes (SFP)

54. Targeted and blanket supplementary feeding programmes provide extra food to groups at risk, in addition to the general ration, as dry take-home or wet on-the-spot feeding for a limited period of time.

55. A targeted SFP aims to rehabilitate those who are moderately malnourished. These could be children adults or older persons and/or individuals selected on medical or social grounds, e.g. pregnant and nursing women and the sick. This is the most common type of supplementary feeding programme.

56. A blanket SFP provides a food (and/or micronutrient) supplement to all members of a certain vulnerable group regardless of their individual nutritional status in order to prevent a deterioration in the nutritional status of those groups most at risk (usually children under five, pregnant women and nursing mothers.

57. Supplementary feeding programmes can be implemented either by giving wet or dry rations.

Therapeutic Feeding Programmes (TFP)

58. A TFP aims to reduce deaths among infants and young children with severe protein-energy malnutrition (PEM). The forms of PEM are described in Annex 3. Generally the target group is children under 5 years with severe malnutrition. Therapeutic feeding can either be implemented in special feeding centres or in a hospital or clinic. TFP involves intensive medical and nutritional treatment. Therapeutic milk (TM) is used for treatment of severely malnourished children. However if TM is not available, high protein milk can be used (dried skimmed milk, oil and sugar) mixed with vitamin mineral supplements.

Starting a Selective Feeding Programme

59. The decision to start a selective feeding programme is based on the prevalence of malnutrition and other aggravating factors. Aggravating factors include high mortality (more than 1 person per 10,000 per day), measles epidemic, high prevalence of infectious diarrhoea, general ration below minimum requirements. The prevalence of malnutrition is assessed from the initial and ongoing nutrition assessments and surveys.

In all situations, remember that it is more important to address the root causes of malnutrition than to address symptoms through selective feeding programmes.

60. The effectiveness of these programmes will be severely compromised if an adequate general ration is not provided.


Figure 3 - Selective Feeding Programmes

61. Figure 3 provides guidance on deciding when to initiate selective feeding programmes. Clear criteria for the termination of these programmes should be defined from the beginning.

Identifying Those Eligible

62. Selective feeding programmes must be based on the active identification and follow up of those considered at risk. Beneficiaries can be identified by:

House to house visits to identify all members of a targeted group (e.g. children under five, elderly people);

Mass screening of all children to identify those moderately or severely malnourished;

Screening on arrival (for example with the registration exercise);

Referrals by community services and health services.

63. Table 2 below summarizes the main objectives, target groups and criteria for selection of beneficiaries of selective feeding programmes.

Table 2 - Types of Selective Feeding Progammes

Programme

Objectives

Criteria for selection and target group

Targeted SFP

· Correct moderate malnutrition
· Prevent moderately malnourished
from becoming severely
malnourished
· Reduce mortality and morbidity
risk in children under 5 years
· Provide nutritional support to
selected pregnant women and
nursing mothers
· Provide follow up service to
those discharged from therapeutic
feeding programmes

· Children under 5 years moderately malnourished:
- between 70% and 80% of the median
weight-for-height or:
- between -3 and -2 Z-scores weight-for-height
· Malnourished individuals (based on weight-for-height,
BMI, MUAC or clinical signs):
- older children (between 5 and 10 years)
- adolescents
- adults and elderly persons
- medical referrals
· Selected pregnant women (from date of confirmed
pregnancy) and nursing mothers (until 6 months after
delivery), for instance using MUAC <22 cm as a cut-off
indicator for pregnant women · Referrals from TFP

Blanket SFP

· Prevent deterioration of
nutritional situation
· Reduce prevalence of acute mal-
nutrition in children under 5 years
· Ensure safety net measures
· Reduce mortality and morbidity risk

· Children under 3 or under 5 years
· All pregnant women (from date of confirmed
pregnancy) and nursing mothers (until maximum
6 months after delivery
· Other at-risk groups

TFP

· Reduce excess mortality and
morbidity risk in children under
5 years
· Provide medical/nutritional
treatment for the severely
malnourished

· Children under 5 years severely malnourished:
- < 70% of the median weight-for-height and/or
oedema or:
- < -3 Z-scores weight-for-height and/or oedema
· Severly malnourished children older than 5 year adolescents and adults admitted based on available
weight-for-height standards or presence of oedema
· Low Birth Weight babies
· Orphans < 1 year (only when traditional care
practices are inadequate)
· Mothers of children younger than one year with breast
feeding failure (only in exceptional cases where
relactation through counselling and traditional alternative
feeding have failed)

64. The links between different selective feeding programmes and the criteria for entry and discharge from a programme are shown in figure 4 below.

Planning and Organizing a Selective Feeding Programme.

Organizing a Supplementary Feeding Programme

65. Supplementary feeding programmes can be implemented either by providing wet rations or dry rations.

i. Wet rations are prepared in the kitchen of a feeding centre and consumed on-site. The beneficiary, or child and caretaker, have to come for all meals to the feeding centre every day;

ii. Dry rations are distributed to take home for preparation and consumption. Rations are usually distributed once a week.

66. In most situations dry take-home SFP programmes are preferable. The advantages of dry instead of wet rations for SFP include:


Figure 4 - Admission and discharge Criteria

i. Much easier to organize;

ii. Fewer staff are needed;

iii. Lower risk of transmission of communicable diseases;

iv. Less time-consuming for the mother;

v. The mother's responsibility for feeding the child is preserved.

The ration for dry feeding however has to be higher than for wet feeding in order to compensate for sharing and substitution. Wet rations are typically given in situations where insecurity prevents dry rations from being taken home safely or where access to cooking facilities are limited. See Table 3 below for some of the main considerations when organizing a selective feeding programme.

Organizing a Therapeutic Feeding Programme

67. Therapeutic feeding programmes are either implemented in specially organized feeding centres or in hospitals or clinics. They involve intensive medical and nutritional treatment as well as rehydration. The programme should be easily accessible to the population, near to or integrated into a health facility. The treatment should be carried out in phases (see Table 3), the length of which depend on the severity of malnutrition and/or medical complications. At least during the first week of a TFP, care has to be provided on a 24-hour basis.

Table 3

Organization of Selective Feeding Programmes


Supplementary Feeding Programme

Therapeutic Feeding Programme

Organization

· On site wet feeding
· Same medical care

On site feeding
would usually only be
considered for
targeted SFP

· Take home dry
feeding

This is the preferred
option for both blanket
and targeted
programmes

· On site wet feeding
+
· Intensive medical care
+
· Psychological stimulation during
rehabilitation phase

Size of
extra ration

· 500-700kcal/
person/day, and

· 15-25 g protein

· 1,000-1,200
kcal/person/day, and

· 35-45 g protein

· 150 kcal/kg body-weight/day/
patient.
And
· 3-4 g protein per kg body-
weight/day/patient

Frequency
of meals

Minimum 2
meals/day

Ration distributed
once per week

Frequent meals.
Phase 1:8-10 meals over a 24 hour
period
Rehabilitation phase: 4-6 meats

68. One of the main constraints to the implementation of a TFP is the lack of experienced or insufficient staff to manage the programme. Proper training of both medical and non-medical personnel is essential before starting the programme. The refugees, particularly the mothers of patients, must be involved in managing the TFP centres.

Planning the quantity of food needed for selective feeding

69. The amount of food needed for the selective feeding programme will depend on:

i. The type of selective programme;

ii. The type of commodities;

iii. The expected number of beneficiaries.

70. This information should be based on precise demographic information and on the prevalence of malnutrition taken from the results of the nutritional survey. The nutritionist will advise on the appropriate commodities and type of programme.

71. However, in some circumstances, estimates on the prevalence of malnutrition and expected number of beneficiaries may need to be made for planning purposes, when for example a registration and nutrition assessment have not yet been carried out. See table 4 below for a projected demographic breakdown for a typical population.

72. If it is apparent that there is, or is likely to be, a major nutritional emergency, the following assumptions can be made for planning purposes:

i. 15 to 20% may suffer from moderate malnutrition;

ii. 2 to 3% may be severely malnourished;

iii. The breakdown of a typical population, by age, is as follows:

Table 4

Projected Breakdown by Age

age groups

% total population

0-4 or under 5

15-20%

Pregnant

1.5-3%

Lactating

3-5%

73. For example, to estimate the number of beneficiaries for a targeted SFP and TFP, both for children under 5 years:

If the total population = 30,000

Estimated number under 5 yrs = 4,500 -6,000(15-20%)

Estimated prevalence of moderate malnutrition (15%) gives 675-900 children

Estimated prevalence of severe malnutrition (2%) gives 90-120 children

With these numbers the estimated food requirements can be calculated by multiplying the estimated number of beneficiaries for each programme by the ration scale appropriate for each beneficiary, as follows:

Quantity of Commodity req. = Ration / person / day × no. benef. × no. days

Monitoring Selective Feeding Programmes

74. The effectiveness of impact of the selective feeding programme should be monitored at regular intervals.

75. Selective feeding programmes should be monitored and evaluated to assess their performance in relation to the established objectives9. Monitoring and evaluation will involve the regular collection and analysis of:

Process indicators such as attendance, coverage and recovery rates, to evaluate the success in implementation and trends in the programme over time;

Impact indicators such as malnutrition prevalence, mortality rate and numbers served, to evaluate the effectiveness and efficacy of the programme.

76. The effectiveness of selective feeding programmes can be measured through nutrition surveys and the regular collection of feeding centre statistics. Specific forms for monthly reporting on supplementary and therapeutic feeding programmes are attached as Annexes 4 and 5. A nutrition survey results form (weight-for-height) is also attached (Annex 6).

77. Trends in health and nutrition indicators can be related to many different factors. Actions in other sectors such as water, shelter, or community services may help explain a positive outcome.

9 For further reference, consult Chapter 8: Evaluation of Feeding Programmes in the MSF Nutrition Guidelines.

Criteria for Closing Programmes

78. Once the number of malnourished is significantly reduced, it may be more efficient to manage the remaining severely malnourished individuals through health facilities and through community based programmes. The specific criteria for closing each selective feeding programme will depend on the degree of success in reducing the main aggravating factors mentioned in Figure 3 and on the degree of integration between these feeding programmes and mother and child health (MCH) activities and other support services offered by the refugee community.

79. After closing selective feeding programmes, any deterioration of the situation should be detected by nutrition surveys undertaken at regular intervals and review of morbidity and mortality data. This is especially important if the overall situation remains unstable.