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close this bookNutrition Guidelines (MSF, 1995, 191 p.)
close this folderPart III Selective feeding programmes
View the document1. Justification for selective programmes
View the document2. Criteria for admission and discharge to selective feeding programmes
View the document3. Screening and selection
View the document4.Treatment in a therapeutic feeding centre
View the document5. Treatment in supplementary feeding programmes
View the document6. Implementation and management of a feeding centre
View the document7. Registration and monitoring
View the document8. Evaluation of feeding programmes
View the document9. Food management

1. Justification for selective programmes

Proper treatment of a patient with severe Protein-Energy Malnutrition (PEM) is crucial in order to avoid death. A review of hospital treatment provided to cases with severe malnutrition demonstrated that 20 - 30% of malnourished patients die in the hospital and a further one-third die after having left the hospital (after discharge or drop-out).

Some children reach the hospital too late and die almost immediately upon arrival. However, the great majority of deaths occur after the first days of hospitalization (usually 60 -70% of deaths) and should be preventable. Home based treatment of children with severe P EM has also proved to be largely unsuccessful, with high mortality rates, high rates of non-compliance and slow recovery.

During food crises, health services risk becoming overwhelmed by large numbers of severely malnourished: a specialized nutrition rehabilitation unit or Therapeutic Feeding Centre (TFC), attached to a hospital or health centre has proven to be the most effective means of managing such situations.

Adequate treatment of severe PEM is an intensive task. A combination of good quality medical care and a specialized feeding protocol is required.

A TFC comprises of an intensive care unit, where medical complications are treated, and where nutritional treatment is started. While in the intensive care unit, the child will receive 8 - 10 meals per 24 hours, day and night. When the child has passed the critical phase, he will be transferred to the day-care unit, which is open 8 - 9 hours a day, and where the child will receive 4 - 6 meals and medical care.

However, it is not always possible to organize a TFC in this way. Security problems, lack of competent staff or large numbers of severely malnourished children may mean that it is only possible to open day-care centres. Under these conditions, even though the intensive care of a 24-hour unit is lacking, the impact on mortality of daycare centres alone may still justify running a Therapeutic Feeding Programme (TFP).

In addition, Supplementary Feeding Programmes (SFPs) may be required to prevent moderately malnourished children becoming severely malnourished (targeted SFP) and to reduce the further deterioration of the nutritional situation (blanket SFP).

The planning and implementation of TFPs and SFPs is a step-by-step process. Although every situation has its own characteristics and requires a specific tailormade approach, these guidelines attempt to help the reader in making decisions to design and implement different types of feeding programmes.

2. Criteria for admission and discharge to selective feeding programmes

In contrast to <<normal>> situations, where the decision to admit an acutely malnourished child to a regular hospital may be based on subjective clinical criteria, the large numbers of malnourished children needing attention during emergency situations means that admission to TFPs and targeted SFPs must be based on clearly defined objective criteria (anthropometric).

The <<cut-off points>> to be used have to be set in agreement with national relief policies, taking into consideration the capacity of the programme and the possibilities for follow-up.

Blanket SFPs must serve clearly defined vulnerable groups - the members of which must be registered in a fair and systematic way. This chapter will not deal with registration of vulnerable groups but will focus on specific individual criteria for entry to targeted feeding programmes.

Admission Criteria

Admission criteria depend on the objectives of the programme and available resources. If programme resources are not certain or limited, it is necessary to employ more restricted admission criteria. In the course of a programme, admission criteria can be changed to reflect changing circumstances like increased general food availability. Admission criteria reflect characteristics of the individual child and are based on age and nutritional status.

Children are admitted along with an attendant, who should also receive food. If more than one severely malnourished child is found in a family, make sure that all other young children of that family are fed.

a. Age

- Under 5 years or, if age is unknown, height below 110 cm.

- In the case of malnourished infants below 6 months of age, the mother should be admitted to the targeted feeding programme together with the infant, because the nutritional status of young infants mainly depends on the nutritional status of the mother, and rehabilitation of the infant should take place through improved breast feeding.

- Malnourished older persons (children above 5 years, adults, elderly) may also be admitted depending on the situation and available resources.

b. Nutritional status

- Weight-for-Height < 70% of the median (or <-3 Z-Scores below the median reference value) = TFP

70 - < 80% of the median (or - 3 to < - 2 Z-Scores below the median reference value) = SFP

- Nutritional oedema: bilateral oedema on the lower legs and/or feet = TFP.

- If malnourished persons above 5 years of age are also admitted, nutritional status may be assessed clinically, since clear, unambiguous anthropometric criteria do not exist.

Treatment in TFCs is usually divided into 2 phases. All newly admitted severely malnourished children with associated pathology should start their treatment in a 24- hour intensive care unit (Phase I) according to the treatment schedule. Those without complications can usually start in day-care (Phase II).

Severely malnourished children usually die from complications. If the capacity of 24-hour intensive care units is limited, complications should be considered as a priority for admission. Suggested guidelines are listed below. However, use of clinical criteria requires more skilled staff.

Criteria for the selection of cases to be admitted to 24-hour intensive care units in TFCs

Less than 70% (or - 3 Z-Scores) weight-for-height in combination with one or more of the following complications:

- marasmic kwashiorkor
- severe dehydration
- persistent diarrhoea and/or vomiting
- extreme pallor, hypothermia, or <<shock>>
- signs of systemic, lower respiratory tract or other localized infection
- severe anaemia
- jaundice
- persistent loss of appetite
- severe lethargy
- age less than 12 months
- young children are particularly at risk from the adverse effects of malnutrition.

Children aged 5 years or more who are clinically assessed as suffering from malnutrition are usually admitted to SFPs, unless they also show signs of the more serious associated pathologies.

Criteria for transfer from 24-hour intensive care units (Phase I) to the day-care programme (Phase II) are given in Chapter 4, Part III.

Discharge Criteria

During food crises, it is important to keep a logical coherence in entry and exit criteria between SFPs and TFPs. This is necessary in order to define which children will receive which level of treatment and to set firm conditions for referral.

It is usual to discharge a child from the TFP to the SFP after he has reached > 80% W/H (or > - 2 Z-Scores) over 2 consecutive weighings. If there is no SFP, children should only be discharged once they have reached > 85% W/H (or > -1.5 Z-Scores) over 2 consecutive weeks. The most important criteria, however, is that the child shows a clearly ascending growth curve and is in a good general condition when he leaves the programme.

Discharge criteria from targeted SFPs are based on a W/H which is not associated with an unacceptable risk of morbidity or death under conditions prevailing in the community. The discharge criterium is usually 2 85% W/H (or 2 -1.5 Z-Score) during two - four consecutive weeks. If resources are limited, it may be decided to discharge children as soon as they reach 85% W/H.

In situations where general food rations are grossly inadequate (<1500 Kcal/person/day) and/or malnutrition prevalence is 2 20%, it is preferable not to discharge children from a SFP (blanket or targeted), until general food availability has improved. Centres should be organized so as to give maximum attention to the moderately malnourished children.

An example of a logical structure for criteria allowing integration of selective feeding programmes is given below:


FIGURE

Figure 13. Criteria for entry and exit from supplementary and therapeutic feeding programmes

Targeted feeding programmes prioritize malnourished children under 5, because of their greater vulnerability and because of their increased risk of dying. Nevertheless malnourished children exceeding this age limit or adolescents/adults may also be admitted as individual cases.

Only when the numbers of adolescents/adults needing treatment becomes of public health significance is it necessary to consider their treatment in a separate unit (see Annex 3).

If there is significant malnutrition in other age groups, this must to be taken into account in planning.

3. Screening and selection

Once a nutrition survey (using weight-for-height) has justified the opening of targeted feeding programmes, the quickest way to identify all eligible children is by means of a population screening of mid-upper arm circumference (MUAC):

1. Execute a MUAC screening of all children between 6 months and 5 years (or height < 110 cm) in the population (Instructions in Annex 2.).

2. All children whose MUAC is < 13.5 cm and/or oedema will be selected to have
their weight and height measured.

3. Children whose W/H is 70% - 79%(<- 2 Z-Scores) will be selected for supplementary feeding.

4. Children with W/H < 70% (< - 3 Z-Scores) and/or oedema, and/or those with MUAC < 110 mm will be selected for therapeutic feeding.

MUAC is a suitable tool for initial screening but admission to the feeding programmes should be based on W/H (see Fig. 14). However, because presence of bilateral oedema or a MUAC < 110 mm indicate an increased risk of death and acute malnutrition, these attributes also justify admission to a TFP, regardless of W/H.

· In a settled population, all households should be informed to bring their children below 5 years to the feeding centre for screening,
· or house mass screening can be organized,
· or regular screening can be performed through household visits of community health workers,
· or new arrivals in a refugee camp should be screened during their registration.


FIGURE

4.Treatment in a therapeutic feeding centre

First phase

Treatment of severe PEM involves intensive medical and nutritional treatment. Care must be taken to chose suitable sites for the shelter of the participants (both and their carers), which need to be accessible to the population and near a health facility. Treatment of severe PEM is divided into two phases:

· In the 24-hour care unit medical treatment, including rehydration, is started to control infection and reduce risk of mortality. At the same time the careful introduction of a sustenance level diet will prevent nutritional deterioration and allow normalization of disturbed metabolic functions and to prepare them to manage the large amounts of food given later during the rehabilitation phase.

Children admitted without medical complications can be admitted directly to the second phase if resources are limited.


FIGURE

Medical Treatment

Treatment and surveillance is focused on the main causes of death and towards correcting metabolic imbalances and vitamin deficiencies.

Main Causes of Death in Severe PEM.

- Dehydration
- Infection
- Hypothermia
- Hypoglycaemia
- Cardiac failure
- Severe anaemia

DEHYDRATION

Severe malnutrition is almost always accompanied by diarrhoea, resulting in severe dehydration and malabsorption. Dehydration is the most important cause of death in severely malnourished children. The diagnosis of dehydration in children with PEM is difficult, especially for those with kwashiorkor.

Signs of severe dehydration in children with PEM

- Child limp, apathetic or unconscious
- Rapid weak pulse
- Skin pale and cold, with decreased turgor
- Sunken eyes and fontanelle
- Dry mouth
- Absence of tears when crying
- Urine volume decreased

Give oral rehydration whenever possible and if necessary by a nave-gastric tube. Intravenous fluids are not recommended for use in treating severely malnourished children because there is serious danger of overloading the circulatory system, leading to pulmonary oedema and death. It is only in cases of very severe shock that one can give Ringer's lactate (Hartmann solution) or isotonic saline (1Oml/kg/hr for the first 2 hours), with extreme caution. The respiratory rate should be monitored every 30 minutes, because faster breathing is the earliest sign of cardiac overload (see Ref. 7).

Malnourished children tend to have an electrolyte imbalance with a major excess of sodium. Oral rehydration solutions should be reduced in sodium content in order to prevent sudden death from cardiac failure. Therefore, severely malnourished children need a different ORS formula than the one generally used (WHO ORS) for well-fed and moderately malnourished children.

The classical WHO ORS should be diluted to half-strength (i.e. 1 sachet diluted in 2 litres rather than 1 litre), and sugar (25g/litre) and potassium (2g/litre) added. Due to the potential danger of potassium overloading, potassium supplementation requires strict supervision.

Children with severe PEM are deficient in both potassium and magnesium, as well as other minerals (zinc, copper, selenium, iodine). A well balanced mix of different minerals is therefore necessary to restore deficiencies and electrolyte imbalances. Pre-formated sachets of a special ORS are now available for the treatment of severely malnourished and dehydrated children (see Annex 15).

INFECTION

Almost all severely malnourished children are suffering from infection (Ref. 19). The most frequent problems are:

· Respiratory tract infections
· Urinary tract infections
· Measles
· Gastrointestinal infections
· Malaria
· Skin infections
· Septicaemia

Respiratory, urinary and other infections are not easy to diagnose in severely malnourished children because the classical signs of infections (fever, pain, inflammation etc.) can be masked. Due to malnutrition, the immune systems are inhibited and the child does not have the normal defense mechanisms. A severely malnourished child can develop septicaemia without fever.

It is crucial to examine each child carefully on admission, and to keep examining them each day during the first phase of treatment. In the majority of cases, antibiotic treatment will be required (see Ref. 7 and 8).

The severe complications with measles for malnourished children leads to a very high case fatality rate (30%). Common complications with measles: bronchopneumonia, diarrhoea, stomatitis, otitis, laryngitis, vitamin A deficiency. As measles is so contagious, admission procedures should include systematic measles immunization for those who were not previously immunised. Severe malnutrition is NOT a contra-indication for measles immunization.

Malaria prophylaxis is not routinely given. However, in malaria endemic areas, during peak season, routine treatment for malaria for all children may be given. The choice of treatment will depend on the local pattern of drug resistance and national policy (see Ref. 7 and 8).

Persistent diarrhoea, which frequently accompanies severe malnutrition, is caused by atrophy of the intestinal mucosa and can only be treated by intensive nutritional rehabilitation itself.

HYPOTHERMIA

Hypothermia is a frequent cause of death, especially early in the morning. Severely malnourished children cannot regulate their body temperatures adequately and they <<cool>> very quickly when there is a drop in external temperature. Even in tropical climates, temperatures at night can fall very low in an open ward. Body temperature should be measured once or twice daily and the child should be kept warm: let the mother keep the child close and provide adequate supplies of blankets. Never wash a hypothermic child, not even with warm water.

HYPOGLYCAEMIA

Death by hypoglycaemia occurs frequently and most often at night. For this reason it is essential that there is regular feeding during day and night (at least 1 - 2 meals).

CARDIAC FAILURE

Cardiac failure can result from electrolyte disturbances, overload of fluids or severe anaemia.

The first two causes should not occur when a proper oral rehydration and nutritional rehabilitation scheme is followed. For the treatment of severe decompensated anaemia, see below.

SEVERE ANAEMIA

Malnourished children seem to tolerate anaemia remarkably well. Blood transfusions should not be given, because of the danger of over-loading the heart and transmission of HIV and other infections. Transfusion is only required in exceptional cases, when the child presents with symptoms of decompensation (see Ref. 7 and 16).

Folic acid (5 mg/day) should be given from the day of admission. Iron, however, should NOT be given during the first two weeks after admission. Iron repletion has an adverse effect on the course of some infections (by promoting bacterial growth and free radical formation). Iron overload carries a serious risk of death, especially in young children.

INTESTINAL PARASITES

Mebendazole should be given routinely, since most severely malnourished children suffer from worms. Do not give mebendazole to children younger than 12 months.

VITAMIN DEFICIENCIES

· Vitamin A:

Vitamin A deficiency is clearly associated with increased mortality. PEM is usually associated with low vitamin A body stores and often with frank vitamin A deficiency. Furthermore, vitamin A requirements are greatly increased during nutritional rehabilitation.

An oral therapeutic dose should be given (see Ref. 8). Children younger than 6 months should not be given vitamin A because of possible toxicity; supplements should also be given to mothers within 1 month of delivery and for those breastfeeding.

Be aware of possible excess (toxic) doses given to children who recently received a mass-dose of vitamin A: re-admissions, children referred from a SFP or children admitted shortly after a mass measles immunization campaign where vitamin A was distributed (see Ref. 17).

· Vitamin C:

In areas where the diet is limited in Vitamin C, or wherever cases of scurvy are reported, a curative dose of Vitamin C should be given on admission to each child followed by regular prophylaxis (see Ref. 7).

· Other Vitamin and micronutrient deficiencies:

Other vitamin and micronutrient deficiencies are common in some areas:

- Vitamin B1 (beriberi)
- Vitamin B6/PP (pellagra)
- Vitamin D (rickets)
- Iodine (goitre and cretinism)

If you face these kinds of deficiencies in the feeding centre they should be treated in accordance with MSF Clinical Guidelines (Ref. 7). In addition, a real control strategy should be formulated: active surveillance, treatment of cases, prevention through supplementation with tablets or food fortification and advocacy.

The specific pattern of medication for a child entering the TFC will depend on the locally defined essential drugs and any other medication prescribed after clinical examination.

Initiation of Nutritional Therapy

It takes time for the metabolic mechanisms of a severely malnourished child to readjust to food intake. Therefore, do not give too much protein and energy too early: because of its osmotic value, absorbed food increases body water, and therefore can cause cardiac failure and sudden death.

Feeds must be given in small amounts and frequently. Children should never be force fed: use the child's appetite as a guide.

FEEDING: COMPOSITION AND FREQUENCY

To allow readjustment of metabolic mechanisms, the child should stay in Phase I for a maximum of one week on a diet providing just enough energy and protein for maintenance: 100 kcal/kg/day and not more than 3g protein/kg/day.

During Phase I, food requirements have to be calculated individually, according to bodyweight and required meal frequency, and marked on the child's individual patient card. However, a ration providing 100 kcal/kg/day is not enough to allow weight gain and therefore should not be given for more than one week.

For practical purposes, use high energy milk (HEM) formula with an energy density of 1 kcal/ml. Aim to give 100 ml HEM/kg bodyweight/day; this is equivalent to providing 100 kcal and 2.9g protein/kg/day.

The total amount of 100 ml/kg/day should be provided through a high number of small feeds. An ideal distribution is:

· day 1 - 2: 12 feeds of 8 ml/kg (every 2 hours)

· day 3 - 7: 8 feeds of 12 - 15 ml/kg (every 3 hours)

If these frequencies are not possible, an absolute minimum is 6 feeds/day, of which at least 1 must be during the night.

Psychological stimulation of the child by its mother and by personnel is crucial in getting the child to eat again.


FIGURE

Guidelines for preparation of HEM are given in Annex 16.

NASO-GASTRIC FEEDING

Indications for nave-gastric feeding are:

- Complete anorexia
- Severe dehydration
- Child cannot drink (too weak)
- Repeated vomiting

Try to breastfeed or feed by spoon each time before resorting to feeding through the tube. If possible, try not to tube-feed for more than 3-4 days. The tube should be changed every 24 - 48 hours by trained health staff.

It is vital to take time to explain the necessity of tube feeding to the mother so that she accepts the feeding and does not take the child away.

MINERALS

A limitation of the HEM formula is that it does not contain sufficient potassium and other minerals which the malnourished child is depleted of. HEM should be supplemented with a sachet of the <<Mineral Mix>> (in development) (see Annex 15).

Until these mineral sachets are available, only potassium should be added to the HEM (2g KCL per 1000 ml HEM). The addition of potassium should be strictly controlled, because of the possible danger of potassium overloading. If fortification cannot be controlled, bananas should be added to the diet as a source of potassium.

FEEDING OF CHILDREN WITH DIARRHOEA

The idea that <<resting the gut>> is the best treatment for diarrhoea is not true. Milk in small frequent feeds stimulates the re-generation of the gut epithelium.

True lactose intolerance is rare, and only a small minority of children with true lactase deficiency will need to be given a lactose-free formula (K-Mix-II or fermented milk products).

DISCHARGE TO THE NEXT PHASE

Until medical complications (dehydration, systemic infections, risk of hypothermia or hypoglycaemia) are under control, the child will stay in the 24-hour intensive care unit for treatment and observation.

Once the medical complications are under control (which may even be within one day), the child can be transferred from the intensive care unit to day-care.

The indications for moving to the Second Phase of the TFP are recovery of appetite and a change of attitude/expression (i.e. the child loses his lethargy and becomes interested in the environment and may start to smile). (There does not have to be loss of oedema before movement to the Phase II).

Children should never stay in the First Phase for more than 7 days, since the 100 kcal/kg/day ration does not allow weight gain.

Second Phase

Once the child's appetite is recovering and medical complications are brought under control, he can be moved from the first to the second phase of treatment, which is a day-care treatment. Children arrive in the feeding centre early in the morning and return home in the late afternoon.

Nutritional Rehabilitations

QUANTITY

Children, when entering the second phase, have had acute infections treated and metabolic and electrolyte imbalances brought under control. They are now able to tolerate larger quantities of food and begin nutritional rehabilitation.

Whereas food intake is limited in the first phase (the objective being to restore metabolic functioning and control infections), the objective of treatment in the second phase is to restore normal weight-for-height as quickly as possible. Consequently, medical treatment is continued and larger quantities of food are provided to promote nutritional rehabilitation.

These children, if properly treated, can gain weight very quickly (up to about 20g/kg/day) which is 20 times the normal rate of weight gain at the age of one year. Almost all energy consumed above maintenance level (+ 90 kcal/kg/day) is used for building new body tissue (i.e. weight gain).

To achieve maximum weight gain, the recovery diet should provide a minimum of 200 kcal and 5g protein/kg bodyweight/day (= 10% protein calories). The increase in food intake should be smooth and progressive. Never force children to eat, children should be fed on demand and may consume up to 300 kcal/kg/day. Practically speaking, it may be impossible to calculate individual requirements based on body weight for each child, therefore one often distributes a standard large ration (i.e. 350 ml) for each meal to all children. Older/larger children, or those with a very good appetite, will need more than 350 ml per feed: therefore, always make a round for those who may want a second serving.

An important limitation to the amount eaten, is the capacity of the stomach, which puts an upper limit to the size of the feeds. Stomach volume has been estimated to be 3% of the total body weight. Thus, in a child weighing 6kg, the stomach capacity is approximately 180 ml. Therefore, the smaller the child, and the more malnourished, the smaller and more frequent the feeds should be.

COMPOSITION OF FEEDS

The aim is to devise a mixture, which, if fed in amounts which the children can take, will provide at least 200 kcal and 5g protein/kg bodyweight/day.

High energy milk (HEM) has suitable nutritional properties, providing 100 kcal and 2.9g protein per 100 ml.

HEM feeds can be alternated with porridge feeds, which are based on a blended food (e.g. CSM, WSB). A porridge should provide 100 - 150 kcal and 3 - 4g protein per

100 ml (10-12% protein calories). In order to prepare a semi-liquid porridge with required energy and protein density, DSM and oil should be added, as well as sugar for taste (recipe given in Annex 10). High-energy and -protein biscuits are also sometimes used as an easy (take home) meal.

Good weight gains have also been achieved on diets composed of local foods: local staples (cereal plus pulse) with meat/fish, vegetables and oil. These local meals will then replace the porridge meals. Experience has shown that local meals are very much appreciated by the children. A mixed diet is particularly preferred for older children from the second week on. A limitation to local meals is the energy density, which should provide enough energy to allow rapid growth, but should also be (semi)-liquid. Therefore, oil may be added to local foods to improve the characteristics.

All children should be able to eat a family-type diet when they leave the feeding centre. Transition to a family diet and meal frequency are therefore important aspects of nutritional rehabilitation. As the child improves, the diet should be replaced by local foods and meal frequency should be changed to come into line with family meal times.

A good diet will be composed of alternate HEM and porridge/local meal feeds.


FIGURE

Medical Treatment, Minerals and Vitamins

During the second phase, daily monitoring of the medical state is still necessary. Standard treatments and prophylaxis should continue to be given.

A supply of Iron is necessary to provide for an increase in red cell mass and may be given safely after the second week of treatment (ferrous sulphate 100 mg/day from day 15). Folic acid treatment (5 mg daily or the ferrous/folic complex) should be continued.

Other Vitamin supplements should preferably be supplied through a diet containing fresh vegetables and fruits, but may also be given by multivitamin tablets. If fresh vegetables and fruits cannot be given, supplementation with vitamin C tablets is necessary (125 mg per day).

In addition, if vitamin deficiencies are routinely found in new entrants, a real control strategy should be formulated: active surveillance, treatment of cases, prevention through supplementation with tablets or food fortification and advocacy.

Psychosocial Treatment

It is recommended to include psycho-social stimulation sessions in conjunction with the medical and nutritional therapy. Psychosocial stimulation improves the prognosis for recovery. While it may be difficult in emergencies, group play and singing/music/story sessions should be introduced and carers should be encouraged to play with and stimulate children.

Infant feeding in a TFP

It should be clear that breast feeding should be promoted and continued during the whole treatment course. If it is possible, breastfeeding should even be continued over the first critical phase when the child is ill and being fed by nave-gastric tube. Breast feeding has a proven protective role against dehydration during diarrhoea and facilitates rapid recovery of digestive and absorption capacities of the gut. Even in the early phases of treatment, breastmilk is absorbed well.

In infants, breast milk should be the main (and best) source of energy and protein during rehabilitation, only supplemented with HEM if necessary.

Breast milk production of the mother should therefore be stimulated by:

- sufficient feeding and liquid intake by the mother, as well as sufficient rest,
- HEM-milk formula feeds should be given ad libitum after each session on the breast.

Do not use artificial infant feeding formulas except for rare cases in which the mother is not able to breast feed (mother seriously ill or dead). Always try to look for a wet nurse. If the infant is given artificial milk, besides breastmilk, he is less motivated to suckle and therefore breastmilk production is decreased.

To inhibit the dangers of artificial feeding (diarrhoea, malnutrition), one has to strictly control the hygienic conditions and preparation (i.e. dilution) of the infant formula milk.

The young infant needs approximately 105 kcal and 2.8g protein/kg bodyweight/day. Energy content of the infant formula milk should be 70 kcal/100 ml milk. Therefore, the infant needs 150 ml/kg/day, divided over 5 - 6 meals given throughout the day.

An example for reconstituted and enriched milk formula for newborns (0 - 5 months) is seven below.


FIGURE

· Be sure that the DSM is vitamin A fortified.
· Reconstituted milk cannot be kept for more than 1 - 2 hours.
· Do not feed by bottle - bottles are forbidden in feeding centres. Feed children using a small spoon or syringe and teach the mother how to use a spoon.

5. Treatment in supplementary feeding programmes

Types of SFPs

Blanket and targeted supplementary feeding can take two forms:

1. Wet rations are prepared/cooked once or twice daily in the kitchen of a
feeding centre and consumed "on - site". The child has to be brought to the feeding centre every day by the mother.

2. Dry rations are distributed (usually weekly) to "take home" for preparation and consumption. Rations will be collected once a week.

WHEN TO DISTRIBUTE DRY OR WET RATIONS

In emergency situations, resources (staff, materials) are often limited, so the possibility of a dry feeding programme should always be considered first, or may even be the only feasible option.

There is no clear evidence to be found from the literature on which type of feeding programme is more effective in combatting malnutrition.

Some strengths of dry feeding are:

· When resources (staff, materials) are limited, dry feeding is easier to organize than a wet feeding programme (fewer staff needed per child served).

· A dry feeding programme can serve more children than a wet feeding programme.

· The risk of transmission of communicable diseases among highly vulnerable malnourished children in dry feeding programmes is far less than in wet feeding programmes.

· The time cost to mothers for participating in the programme is much less in a dry feeding programme.

· Improved accessibility and capacity usually means that there is better coverage of malnourished children in a dry feeding programme than in a wet feeding programme.

· The improved access of dry feeding programmes is particularly important when dealing with a dispersed population.

· In famine situations where people are still living in their homes, dry feeding helps to prevent displacement.

· Dry distribution keeps responsibility for feeding the child with the mother.

A wet feeding programme is justified in the following situations:

· When there is no other source of food, dry rations will disappear into the family pot or be diverted to the <<stronger>> household members.

· Firewood supply is a major problem.

· People have no cooking utensils.

· Security reasons: when it is feared that the women carrying their dry ration will be robbed on their way home.

Ration Size in SFPs

The ration provided in a SFP is meant as an addition, necessary to supplement the defective family diet, and to allow for catch - up growth. The supplement consumed should be at least 500Kcal (and 15 grams of protein) per day.

Often the child will not consume all of the distributed food: the distributed food will be shared with other household members (dry), or the food will (partly) substitute a regular meal at home (wet). Therefore, in order to make sure that the child actually consumes the required amount of food, the rations distributed should be well above the target amount.

Wet feeding

In wet feeding part of the ration is sometimes consumed in the feeding centre by accompanying siblings, or the meal at the feeding centre may be considered by the family as a substitute for a family meal - therefore the child is given less at home.

Therefore, in wet feeding programmes, rations should provide a target amount of 500 - 700 Kcal and 15 - 25g of protein/day. The quantity of protein is high: 10 - 15% of the energy is provided by protein. This is because it is assumed that the family meal is poor in protein supply (see Annex 16).

A young child (< 12 months of age) is unable to consume much more than 250 ml (300 Kcal) in one meal, because of his limited stomach size. Therefore, wet supplements should be given by at least 2 meals daily, and at times that do not coincide with family meals.

Children should be allowed to eat as much as they want if food is available. Food should also be provided to carers, especially if they are siblings, as they are also likely to be at risk.

Dry ration distribution

In dry ration distribution programmes, part of the ration will very likely be shared with siblings or other family members, or the meal prepared from the ration at home may not be a supplement but will substitute a normal family meal.

In dry ration distributions the intended ration should therefore be doubled or tripled to provide 1000 - 1200 Kcal and 35 - 45g of protein/day, in order to compensate for sharing and substitution (see Annex 16).

Ration Composition

· A supplementary meal should provide a balanced, high concentration of energy and protein: at least 1 kcal/ml and 10 - 15% of the energy provided by proteins. In addition the supplement should provide a balanced mix of essential micronutrients (vitamins and minerals).

A ration should contain a cereal or a blended food as a base (table below), providing the main source of energy and protein. The resulting porridge must be diluted to be (semi -)liquid, to be palatable for young and/or malnourished children, and yet retain a high energy and protein density. Therefore, the energy and protein density of the porridge must be increased by adding a high - protein source and a high - energy source (oil) in balanced amounts. The additional commodities should also provide the essential vitamins and minerals that are lacking in the cereal base. Sugar is usually added to increase energy density, but mainly to improve the taste. (The nutritional value of different food commodities is given in Annex 5).

The actual composition of the ration will depend on the availability (from donors and local markets) and acceptability (local food habits) of the commodities.


FIGURE

(*) Blended foods may be available through WFP or directly from donors. They are nutritionally valuable (fortified with vitamins and minerals), easy to transport and store, and can be very useful to initiate a SFP when appropriate local foods are lacking.

Examples of recipes for wet feeding and dry rations are given in Annex 16.

Whole - grain commodities (cereals, beans) must be ground before utilisation. Beans and groundnuts can be roasted before grinding to reduce necessary cooking time (firewood is often scarce in emergency situations).

Sometimes special high - energy/high - protein biscuits will be available from donors. Although their nutritional value is considerable, be aware that they can be rather popular with other family members and raise a good price on the market. Therefore, if a dry ration is offered, do not include the biscuits in the calculation of the ration size. These special biscuits are particularly useful for the initiation of wet SFPs in situations where other commodities are not immediately available and cooking is difficult.

Dry ration foods can be distributed either as separate ingredients, or as a mixture (premix). There are two reasons NOT to distribute the supplementary ration ingredients separately:

· During preparation at home, some of the separate ingredients may not be added to the porridge for the child, but may be consumed or traded by other family members, (especially sugar, oil and milk powder). The remaining ingredients do not make up a nutritionally balanced porridge allowing for rapid catch - up growth.

· Milk powder, given separately, may be diluted by the family with unboiled, contaminated water, which can be harmful. However, milk powder may be distributed in a premix, which also contains a cereal, as long as the milk powder is not the major component. The premix has to be boiled to be edible (because of the cereal), thereby minimising the risk of diarrhoea (see Annex 14).

A premix for dry ration distribution will include a cereal base, a high energy source and a high protein source. The premix can be stored at home for about 1 week if milk powder is included, otherwise premixes can usually be kept for 2 weeks. The porridge, once prepared, should not be kept for more than two hours. See Annex 14 for details about the premix preparation and expiry.

Wet meals should be timed so that they don't coincide with family meals, otherwise the meal at the centre will not supplement the child's family intake. Try to arrange meal times to fit in with the kitchen capacity (i.e. same meal times as TFPs with 2 shifts of children) and yet provide children with meals that suit the community meal and activity pattern.

Medical Care in Supplementary Feeding Programmes

Children can only recover effectively from malnutrition if proper care is taken of additional medical complications. Infections may often be an underlying cause of malnutrition. A feeding centre should be able to provide basic treatment on health post level or, if not, be attached to, or located near a health centre. A clinical investigation of all new admissions should be part of the standard procedures. Additionally, a nurse should make daily rounds in the feeding centre to identify sick children.

Mothers often have first contact with a health centre when their child is malnourished (often for another reason). Health centre staff should be able to recognize acute malnutrition and refer the child to a nearby feeding centre.

INDIVIDUAL MEDICAL TREATMENT

· Proper treatment of infections is essential for effective nutritional rehabilitation. The possibility of treating infections with antibiotics in SFPs depends on the level of the staff, otherwise children should be referred to local health facilities for treatment. Malaria should also be treated within the programme if staffing allows and severe cases of malaria referred if necessary. (For treatment protocols, see Ref. 7.)

· Children with diarrhoea and/or dehydration should be given oral rehydration therapy. Sometimes a special ORT - corner may be established in the feeding centre.(see Ref. 9)

· Treat vitamin deficiencies (vitamin A, C, B's) in the centres according to MSF Clinical Guidelines (Ref. 7). In addition, if vitamin deficiencies are routinely found in new entrants, a real control strategy should be formulated: active surveillance, treatment of cases, prevention through supplementation with tablets or food fortification and advocacy.

· For malnourished children suffering from anaemia, iron and folic acid should be
prescribed as necessary (see Ref. 7).

ROUTINE TREATMENT AND PROPHYLAXIS

Admission procedures should include a systematic check - up for measles immunization status (from immunization cards) and children should be immunized if they have not been immunized or if their status is uncertain (if the child is > 9 months).

Most malnourished children have low body stores of vitamin A, so an oral prophylactic dose of 200,000 IU oil - based vitamin A should be given routinely on admission, and repeated doses given every three months. Children < 6 months should not be given vitamin A if they are being breast fed. When infants less than 6 months old are not being breast fed, a supplementation with 50,000 IU of Vitamin A should be considered before they reach 6 months. Supplements should be given to the mother (as long as she is not pregnant) (See Ref. 1.) Children < 8 kg should receive doses of 100,000 IU (3 drops from an opened capsule of 200,000 IU).

Be aware of possible excess (toxic) doses given to children who recently received a mass - dose of vitamin A: children discharged from therapeutic feeding, readmissions, or children admitted shortly after a mass immunization campaign where vitamin A was distributed, or in populations where a lot of red palm oil is consumed.

Mebendazole (not for children < 1 year) should be given routinely on admission. (see Ref. 8).

OPTIONAL ROUTINE TREATMENT AND PROPHYLAXIS

In malaria endemic areas, where there is no resistance to chloroquine, chloroquine prophylaxis may be given routinely according to the prevailing protocol for that area. If there is a high degree of chloroquine resistance, other drugs may have to be used according to clinical guidelines or national protocols (See Ref. 7 for protocols).

If scurvy is a risk (high prevalence in the population or in the area), and no fresh foods are provided by the programme, vitamin C should be given routinely (125 mg per day or 500 mg/week).

In some circumstances, referral to a health centre may not be possible. In such cases a more extensive pharmacy will have to be kept in order to allow in - programme treatment - depending on level of staff and supervision.

Pregnant and lactating women

INCREASED NEEDS

Pregnant women have increased physiological needs and so are vulnerable to nutritional stress. Anaemia is the most important nutritional risk associated with pregnancy, but in emergency situations there is also a risk of PEM and vitamin and mineral deficiencies: iodine, vitamin A, B. C.

The possible consequences are:

- complications during pregnancy and delivery, associated with an increased maternal mortality risk,
- prematurity and low - birth weight, associated with increased morbidity and mortality risk for the child,
- low body stores of vitamins and minerals in the infant associated with a higher risk of nutritional deficiency diseases and impaired immunity in the child.

Lactating women need extra energy, fluids and nutrients to support breast milk production, which is in the order of 0.5 - 1.5 litres per day.

Although many women feel uncertain about their breast milk quantity and quality in any community, under normal circumstances production will be sufficient. Even when the mother has an insufficient energy intake, her own body reserves will be used for the production of breast milk. Only after prolonged insufficient energy intake will the production of breast milk be reduced or even cease. Stress (refugee situations, war) is another important factor reducing the quantity of breast - milk. It is possible, however, to restore breast feeding, even if it has been stopped, through good nutritional support, stimulation and sufficient rest.

WHEN TO OPEN AND CLOSE A SFP FOR PREGNANT AND LACTATING WOMEN

In case the three following criteria are met, a supplementary feeding programme for pregnant and lactating women would be justified:

- General food supply to the population is inadequate: food availability is < 2,100K cal/person/day,

- A nutrition survey indicates a malnutrition rate among children 6 - 59 months of age of 10% or more being <-2 Z-Scores (or < 80% of Median) Weight - for - Height, and/or having oedema,

- If all the malnourished children are covered and there is sufficient capacity to include pregnant and lactating women as beneficiaries.

A SFP for pregnant and lactating women can be closed when the general food supply is sufficient.

ADMISSION OF PREGNANT AND LACTATING WOMEN

Selection criteria

All pregnant women in their third trimester should be included in the programme. Evidence suggests that nutritional supplementation will have a positive effect on the birth weight of the child only in the third trimester of pregnancy.

Lactating women up to 6 months after delivery (the period when the infant is entirely dependent on breast feeding) should also be eligible for the feeding programme.

The admission of pregnant and lactating women should be coordinated with antenatal services.

Size of the programme

The number of eligible women will rarely be known, but can be estimated indirectly, based on an estimation of the number of infants (< 12 months of age) in the population.

In a <<normal>> third - world population approximately 4.5% of the population will be younger than 12 months. Those infants, born during the past 12 months, have mothers who are, or have been eligible for the SFP for a period of 9 months (last trimester of pregnancy + first 6 months of lactation). Assuming no big changes in fertility/birth rates, the number of pregnant and lactating women eligible for supplementary feeding can be estimated at 5% (allowing for miscarriages, etc.) x 9/12 = 3.75% of the population.

Example: In a refugee population of 20.000, 5% x 20,000 X 9/12 = 750 women are eligible for supplementary feeding.

Targeting

If the capacity of the programme is limited and cannot accommodate all 3rd trimester pregnant and lactating women, it may be necessary to target priority groups:

1. Lactating mothers of malnourished infants younger than six months.
2. Lactating mothers with young infants whose breast - milk production has stopped, or is reduced.
3. Pregnant and lactating mothers of malnourished children under 5 years.
4. All lactating mothers up to six months after delivery.
5. All pregnant mothers in the third trimester of pregnancy.

SUPPLEMENTARY RATIONS

Ration Size

The extra energy requirement for normal healthy pregnant women is 350 Kcal/day in the third trimester of pregnancy, and 550 Kcal/day for lactating women in the first 6 months after delivery. The supplementary ration should cover these extra requirements, and allow for rehabilitation of nutritional status of mother and child as well.

The recommended energy supplement is approximately 1,000 Kcal/day. This recommendation covers both pregnant and lactating women for practical reasons.

Ration composition

The supplementary ration should be a high - energy and high - protein food. Protein should provide about 15% of the total energy to allow for compensation of a protein deficient family diet. Extra supplementation of micro - nutrients (iron, folic acid, vitamin A and C) should be included in the ration.

The type of feeding (dry take home rations or wet on - site meals), should follow the decisions made for feeding programmes for young children. Keep in mind that dry take home rations, meant to supplement the mothers diet, may be shared with other household members or sold.

It is not necessary to offer women the same foods used to supplement the diets of children; the women may not like baby - porridge. If possible, use local foods, including tasty ingredients (like onions, green vegetables) to make the meal more acceptable to the women. Be aware of special food habits and taboos of pregnant and lactating women in the local community.

MEDICAL CARE AND MICRO - NUTRIENT DEFICIENCIES

In coordination with antenatal services, pregnant women should be checked by a nurse, midwife or doctor on admission to the feeding programme.

Always check if pregnant women are completely immunized against tetanus. If the tetanus immunization status is national guidelines (see Ref. 7).

Take the opportunity to check the young children, who usually accompany their mother, for measles immunization and other EPI immunizations.

All pregnant and lactating women should receive an iron/folic supplement (prophylactic dose), in both wet and dry feeding programmes. Women showing clinical signs of anaemia should receive a therapeutic dose (see Ref. 8).

Be aware of compliance problems in dry feeding programmes. Women with signs of severe anaemia (see Ref. 7) should be referred to medical services.

In endemic areas, routine Malaria prophylaxis may be provided to pregnant women in accordance with national protocols (see Ref. 7).

Pregnant and lactating women are among the highest risk groups in populations where scurvy is prevalent. Most GFD rations contain little or no vitamin C and there may be very limited alternative sources. If scurvy is prevalent in the community, provide vitamin C to pregnant and lactating women: 500 mg/day during their attendance in the programme.

A pregnant woman with depleted or low body stores of vitamin A will deliver a baby with even lower vitamin A reserves, and the amount of vitamin A provided in breast milk will be reduced. These newborns are at high risk of vitamin A deficiency.

However, during pregnancy (especially the first trimester) large doses of vitamin A can have teratogenic effects, possibly leading to fetal malformations. Vitamin A supplementation of pregnant women should only be initiated if any of the following criteria are met (indicating a high risk of vitamin deficiency in the population):

- Frank xerophthalmia (including night blindness) is present in the population,
- The population originates from a known or presumed vitamin A deficient area,
- The population is subsisting on relief food supplies deficient in vitamin A.
uncertain or incomplete, re - immunize according to

Pregnant women (without signs of vitamin A deficiency) are best supplemented through their diet or with small daily doses (< 10,000 IU). If this is not practically feasible, a large - dose (200,000 IU) supplement can be given immediately postpartum.

Pregnant women with clinical signs of Vitamin A deficiency should be referred to the local health facility.

Lactating women provide a major source of vitamin A for their infants through breast - feeding, but many women are themselves at high risk of deficiency. Consequently, lactating women should receive a large - dose supplement (200,000 IU) within 1 month of delivery.

It may be necessary to give specific prophylaxis for deficiency diseases in endemic areas or in specific circumstances (vitamin B. iodine).

6. Implementation and management of a feeding centre

Calculating the number of beneficiaries (See Chapter 3, Part III on Screening)

If exact numbers of malnourished children in a population are not known on nutrition survey (see Chapter 4, Part I and II).

Based on a nutrition survey, the target population of the different feeding programmes can be estimated:

- Total population under five = Total population x 20%

- Total population under five x Prevalence of severe acute malnutrition = Total number of severely malnourished children eligible for the TFP

- Total population under - five x Prevalence of moderate acute malnutrition = Total number of children eligible for the targeted SFP.

- Numbers eligible for blanket SFPs depend on which vulnerable groups are being targeted.

Calculating the number of facilities

In order for wet feeding centres to be run efficiently (cooking, feeding, medical and nutritional supervision of the children), feeding centres should not be too big (TFP: maximum 60 - 100 children; SFP: 250 children). The maximum capacity will depend on staff levels and skills and the number of children in intensive care. Above these numbers the programme loses efficiency. With larger numbers of children it is better to increase the number of centres. Moreover, increased numbers of centres allows better geographic accessibility and therefore improved coverage of severely malnourished children.

From this number, the programme needs can be calculated:

- No. of feeding centres:

TFP = 1 for every 60 - 100 malnourished children


Wet SFP = 1 for every 250 malnourished children Dry


SFP = 150/200 beneficiaries per day of distribution (750 - 1000 children/week)

- Food needs:

daily rations x number of children

- Personnel

- Materials & equipment

Example:

Food availability is very low and is expected to get worse over the next few months.

A nutrition survey has shown high rates of severe and moderate acute malnutrition. Therefore, it is decided to implement a TFP, a targeted wet SFP for malnourished under 5 years and a blanket dry SFP for all children under 5 and pregnant and lactating women.

Total camp population

50,000

Population under - five (20%)

10,000

Population of Preg. + Lact. women (5%)

2,500

Prevalence of severe acute malnutrition (<-3 Z-Scores W/H and/or oedema)

3 ± 1,5%

Number of severely malnourished children (for TFP)

10,00 x 3%=300

Prevalence of moderate acute malnutrition (- 3Z -- < - 2Z W/H)

15%

Number of moderately malnourished children (for targeted SFP)

10,000x15%=1,500

Number eligible for blanket SFP

12,500

300 children are eligible for the TFP

3 - 5 centres

1,500 children are eligible for targeted SFP

6 wet centres

12,500 people are eligible for the blanket SFP

15 - 20 distribution centres

The actual number of children attending the programme will depend on the accessibility.

Inform the population

Inform the population on the objectives of the programme by organizing meetings with community representatives and during mass screening sessions in the population. A good network of CHWs can also help promote community cooperation.

Construction and location

LOCATION

Feeding centres should be located near a health centre or hospital structure if possible. If there is need for more than 1 feeding centre, their location should be planned to improve accessibility of the programme to the population. Therapeutic and supplementary wet feeding centres need to be within 30 - 45 minutes walk of all the population to be served; dry ration distribution centres should be within a 2 hour walk of all the population to be served.

When several centres for dry feeding are established, it is necessary to choose distribution days carefully and properly identify eligible recipients to avoid double registration.

CONSTRUCTION

· Wet feeding programmes require tents or shelters made out of local materials and plastic sheeting. Buildings should be adapted to climate and the number of people expected to stay during the days and nights. (In refugee populations, the site

should allow for a sudden influx of new refugees). Big tents suffice in emergency situations (25 m2 for 12 persons). The whole area has to be fenced off and properly drained (see Annex 17 for lay - out plan).

- A special area for 'intensive care' should be organised in TFPs, where up to twenty children can stay during the early days and nights of their treatment (special areas may also be organized in wet SFPs for treatment of diarrhoea).

· Pharmacy, consultation room.
· Store - room for food commodities.
· Kitchen.
· Dry distribution centres need to ensure a logical flow of people so all registration and monitoring data is collected and food distributed in an efficient way, maximizing patient flow and minimizing food loss (see Annex 17).

WATER AND SANITATION

· Water sources should be protected and chlorinated.

· For wet feeding programmes, a supply of 30 litres of safe water/child/day is recommended, with an absolute minimum of 10 litres/child/day (cleaning centre, cleaning pots and pans, washing hands and children, preparing food, drinking water).

· For dry programmes 0.5 litre/person/day is required for hand washing and drinking - if water sources are not available make sure water is transported to the distribution site.

· A washing area within the wet feeding compound is necessary.

· Latrines can be built at thirty metres distance from the water supply, one for every 50 persons in a wet feeding programme (patients and carers). Bed - pots may be provided in the feeding centre for the smaller children. (Toilet facilities may also be necessary in dry feeding programmes).

Materials and Equipment

FEEDING AND REGISTRATION MATERIALS (See the content of the kits - Annex 22)

If the necessary cooking utensils are not available locally or if the time is limited, specially formulated nutrition kits are available from MSF or OXFAM.

OTHER MATERIAL

· Beds/mats, blankets, bed - nets,
· bed pots,
· lamps, torches,
· waste buckets, etc.,
· fuel (average quantity: 1 m^3 firewood to boil 1000 litres water), - precision weighing scale for KCl (or standard weighing cups).

Staff

Clear job - descriptions, responsibilities and working guidelines for both medical and non - medical personnel are crucial. If job - descriptions and tasks are not clear to the personnel, problems will inevitably arise.

Proper training of both medical and non - medical personnel is essential, before starting the programme. It is better to delay the opening of the centre for some days, until personnel are properly prepared. Continuous on - the - job training and regular formal training sessions for upgrading skills is necessary (see Ref. 11). It is essential to have a good supervision system. This will ensure that, on one hand, trained personnel will keep an adequate level of performance and, on the other hand, it will allow the identification of training needs.

When planning for personnel requirements, do not forget to schedule rest days.

Pharmacy (basic drugs)

Pharmacy requirements are for TFPs:

- Ringer's lactate or Hartmann solution
- ORS (sachet per 1000 ml)*
- Antibiotics (ampicillin, cotrimoxazole) (see Essential Drugs Guidelines, Ref. 8)
- Mebendazole (100 mg tab)*
- Metronidazole (250 mg tab)
- Chloroquine (100 mg tab or 150 mg tab, depending on the national protocol)*
- Vitamin A (200,000 IU cap)*
- Ferrous sulphate (200 mg tab) + folic acid (0,25 mg)*
- Folic acid (5 mg tab)*
- Mineral and vitamin <<cocktails>>
- Potassium chloride (powder) (If no mineral mix available.)
- Vitamin C, B. and multivitamins*
- Measles immunization materials: vaccines, cold chain (fridge in hospital and coolboxes)*
- Aspirin* (300 mg or 500 mg)
- Paracetamol* (100 mg)
- Nystatin (250,000 IU)
- Quinine (200 or 300 mg, depending on the national protocol)
- Benzyl Benzoate* (25%)
- Tetracycline eye ointment* (1%)
- Chlorexydine / Cetrimide*
- Zinc Oxide cream

* may also be required for SFPs

Follow-up of defaulters

Through careful registration in the attendance register, and a clear definition of a defaulter (absence during two consecutive days), defaulters can be detected immediately. Home - visits by the nutrition outreach workers should be scheduled to follow up defaulters.

· Do not reprimand mothers: try to find out the reason for drop - out; they may have very good reasons (work, other sick family members). Or mothers may not attend because their children fall sick in which case it is essential to convince the mother of the importance to come to the feeding centre with the child. Sometimes a solution can be found with the help of the community.

· A frequent reason for drop - out is because mothers do not feel comfortable in the feeding centre and lose motivation to attend. Proper accommodation (i.e. shelter from the sun and rain, clean latrines with adequate privacy and adequate food and water), a friendly atmosphere and continuous explanation to the mother on the course of treatment are essential in preventing drop - outs.

· Another reason for drop - out from the programme may be that the mothers do not like the food offered to them in the centre (HEM, porridge). The provision of food, cooking materials and fuel to mothers to prepare their own meals might make daily attendance to the programme more attractive. Moreover, provision of foods can provide an opportunity for nutrition education.

· If the reason for drop - out is the death of the child, it is important to include that child in mortality surveillance figures.

7. Registration and monitoring

Registration

Proper registration should allow close monitoring and management of individual case progress (changes in nutritional and health status, treatment phase and diet, etc.), but should also easily provide information necessary to monitor the functioning of the programme at feeding centre level.

Examples of a registration book and an individual patient chart are given in Annexes 18, 19. Children are weighed and examined daily in TFPs and all this information should be recorded over time. Children are not weighed and measured every day in SFPs, but they do need to attend daily for food distribution (wet SFP) - therefore 2 registration books may be required for attendance and individual monitoring of health status.

ATTENDANCE REGISTER BOOK

Based on the register book, the statistics for overall attendance, admission, discharge and average child performance can be followed. A good registration system can rapidly detect defaulters, who can then be followed up by a home visit. Registration includes:

Identification: Bracelet number, name, age, sex, name of parents, address/section of camp.

Health indicators:

Admission weight, height, W/H%, clinical signs of malnutrition (oedema, vitamin deficiencies, etc.), other medical remarks.

Attendance indicators: Admission, present, absent, defaulter, discharged, death, transfer.

Definitions:

- Admission: all new entries, including children who relapse after being successfully discharged from the programme. It does not include defaulters who were only absent for some days.

- Present:

TFP - physical presence for at least four meals during the day.


SFP - physical attendance for at least one meal during the day.


Dry SFP - physical presence for ration distribution

- Defaulter:

WET - absent for 2 consecutive days; on the third day of absence the defaulter will be visited at home by the outreach worker.


DRY - absent for 2 consecutive distributions, after the second distribution the child will be followed up.


Defaulters readmitted in the month are not included in end of month defaulter statistics.

- Death:

any child who died while participating in the programme. It is important to follow up defaulters to see if the reason for not attending is death and include them in the mortality statistics.

- Transfer:

TFP - to hospital, or intensive care feeding centre.

- Targetted:

SFP - to hospital or TFP Blanket SFP - to hospital, targetted SFP or TFP.

- Discharge:

any child who was discharged from the programme after having reached the official discharge criteria (may have been discharged to another programme i.e. TFP-> SFP).

INDIVIDUAL PATIENT CHART - TFP

The patient chart (Annex 19) gives a clear overview of the changes in nutritional status of each child (weight, height, and clinical signs: oedema, vitamin deficiencies etc.), health status (medical consultations, treatments, immunization), as well as the treatment phase and calculated food requirements.

Weights should be graphed on the chart, enabling regular monitoring of weight gain or loss. Weight gain together with the registered clinical observations (both positive and negative) enables prompt action in case of failure to respond to treatment. The chart also makes it easier to decide when to discharge the child.

INDIVIDUAL PATIENT CHART - SFP

In an SFP, the monitoring data can all be entered in a registration book as there is far less information that needs recording (Annex 18). Individual cards may be used (Annex 19)

Nutritional status monitoring:

- Weight assessment: every 1 - 2 weeks
- Height assessment: every 4 weeks
- W/H% calculation: every 1 - 2 weeks

Remarks: medical treatments, prophylaxis, special circumstances.

· Informations recorded on the individual card:

- Identification:
- Bracelet number, name, address, admission date.
- Health indicators:

Age, sex, weight, height, target weight, Weight - for - Height category, oedema, medical diagnosis & treatment.

- Food distribution:

Date, quantity.

Main Child Surveillance Procedures

There are 3 main procedures:

Correct application of admission and discharge criteria
The different treatment phases and transition criteria
Surveillance of the individual child

For a TFP the surveillance of each individual child is particularly crucial and should include:

* During the First phase, close medical and nutritional surveillance of the child should be daily. Surveillance should consist of:

- daily weight measurement,
- growth curve,
- oedema assessment,
- clinical examination,
- temperature,
-treatment scheme (medical and nutritional).

Food needs and meal frequency have to be calculated individually and marked on the child's individual chart.

* During the Second phase, nutritional and medical surveillance is given every 2 days. A nurse should make daily rounds to identify any children that may be ill. Surveillance should consist of:

- weight measurement every 2 days,
- growth curve,
- monthly height measurement,
- oedema assessment,
- clinical examination,
- treatment scheme (medical and nutritional).

Food needs (minimum requirements) should also be calculated and registered individually, although feeding is ad libitum.

Depending on the child's age and degree of malnutrition, a severely malnourished child should gain 10 - 20g/kg/day during the Second Phase. At this growth rate the discharge criterium of 85% W/H should be achieved after about 1 month. A moderately malnourished child should gain 5 - 10g/kg/day. At this growth rate 85% W/H should be achieved within 4 - 6 weeks, and discharge after 6 - 10 weeks.

Failure of children to gain weight may be attributed to:

- irregular attendance to the feeding programme,
- poor organization and supervision of the feeding programme, leading to inadequate supplementary rations, or incorrect recipes,
- unequal distribution of food within the family (substitution or sharing),
- specific nutrient deficiency,
- acute infection,
- undiagnosed psychological problem,
- TB or AIDS.

Any child who fails to gain weight should be investigated for all possible causes.

· If the child has not gained weight for 3 or more weeks, while receiving correct medical and nutritional care (including 2 full courses of antibiotics),

· If all other causes of failure to gain weight have been excluded, AIDS or TB may be the causes.

These cases should be seen by a medical doctor.

· If AIDS is the suspected diagnosis, this does not alter the treatment strategy: the child should be treated as any other child on the programme.

· If tuberculosis is suspected, the decision to initiate treatment should be taken by a doctor and only if there is a fully functioning and well supervised TB programme. Diagnosis of TB in children is difficult (see Ref. 22).

8. Evaluation of feeding programmes

Feeding centres can be evaluated during their operation to see how efficiently they function and to determine which aspects of the programme require the most attention at any time (PROCESS evaluation).

Monitoring the Functioning of a Feeding Centre

MONTHLY ATTENDANCE REPORT

Monitoring the functioning of the feeding centre is based on the monthly collection of clear data on the activities in the feeding centre, including admission and discharge criteria, kcal/person/day distributed, number of meals per day and the attendance pattern of the children.

The attendance book is the basis for the following attendance report:


FIGURE

Total Last Month (A):

copy Row I of last month

Total Exits (H):

Row D + E + F + G

Total End Month (V:

Row A + B + C - H

INDICATORS AS A PROPORTION OF EXITS

Changes in the functioning of the feeding centre can be quickly detected through monthly calculation of several indicators. Most of these indicators can be obtained directly from the attendance report.

In order to facilitate comparison between months and between feeding centres, indicators should be calculated for children under 5 and above 5 years of age separately (and if other vulnerable groups are includedincluded in the SFP, these should also be graphed separately i.e. pregnant and lactating women).

Function indicators should be expressed as proportions of the total number of children leaving the programme during the reporting month for any reason.

The proportions of the number of exits that each indicator reflects are not real population <<rates>>. For example, the proportion of deaths is not a mortality rate and does not reflect the risk of dying in the population, it indicates the severity of malnutrition in the programme participants and the quality of programme functioning.

- Proportion of Recovered (%): No. of children successfully discharged / No. of exits Row (D) / (H) x 100%
- Proportion of Deaths (%): No. of deaths in the centre / No. of exits Row (E) / (H) x 100%
- Proportion of Defaulters (%): No. of defaulters / No. of exits Row (F) / (H) x 100%
- Proportion of Transferred (%): No. of transferred / No. of exits Row (G) / (H) x 100%

Absolute Figures from the attendance report can be graphed over time, to help interpretation of trends in programme functioning (see the example in Annex 20).

Interpretation

Analysis of the different function indicators should be done in the field, because proper interpretation can only be made within the specific context. Furthermore, the information is vital for programme management, allowing appropriate and prompt adaptations, if necessary.

The main advantage of calculating proportions as a function of the number of exits is that these indicators are independent of the number of new admissions, which may greatly vary over time for different reasons (for example as a result of population movements).

The function indicators, as given above, are highly inter-related and should therefore always be interpreted in relation to each other.

For example: an increase in the number of defaulters during the month will result in a decrease in the proportion of recovered and deaths. This does not mean that the functioning of the programme has improved; on the contrary, the increase in defaulting is worrying, and demands attention.

Another example: a decrease in the number of defaulters will result in a increase in the proportion of recovered and deaths. This should not be interpreted as bad functioning of the centre, but as improved functioning; the proportion of successful recoveries will also have increased. In general it can be said that the proportion of recovered is the most important indicator, as it reflects the ultimate objective of the feeding programme.

The table below provides provisional targets and reference figures are given to provide benchmarks against which to interpret the functioning of individual programmes. The target figures should not be considered as rigid objectives for every programme as the feasibility of reaching targets depends on the local circumstances and the stage in programme development. However, target figures may give an indication of what might be considered <<good>> and <<bad>> functioning under <<average>> conditions.

The proportion of those transferred is usually left out of the analysis as it is usually a minor proportion and only confuses interpretation.


FIGURE

OTHER INDICATORS

· Attendance rate

WET - Average daily attendance over the month/Average No. of children registered over the month = Average daily attendance / Row {[(A)+(I)]/2}

DRY - Average weekly attendance over the month/Average No. of children registered over the month = Average weekly attendance / Row {[(A)+(I)]/2}

Objective: > 80%

It is sufficient to only calculate the average attendance rate for a few randomly chosen days during the month. Make sure that a record of attendance in the attendance book corresponds with actual physical presence of the child during meals - to be checked by physical counting of recipients during the meals.

Example. Average attendance rate:

· There are 90 children registered in a TFP:

Attendance on 6 randomly chosen days during the previous month: day 3: 76; day 9: 83; day 11: 79; day 18: 69; day 25: 74; day 28: 81.

- Average attendance = 77
- Attendance rate = 77/90 x 100 = 86%

· There are 1,600 children registered for dry feeding. Attendance over the last month: week 1: 1,250; week 2: 1,116; week 3: 1,120; week 4: 1,050. - Average monthly attendance = 1,134 - Attendance rate = 1,134/1,600 x 100 = 71% The average child will come 3 out of every 4 distribution days.

· Coverage:

Total No of children < 5 years registered at the end of the month/Total No of malnourished children < 5 years estimated by the last survey. Objective: > 50% in rural populations, > 75% in urban / camp populations

Example of coverage:

· Total population: 20,000 people
· The proportion of children under 5 years is estimated at 20% = 4,000 children
· Nutritional survey: 4% of children under 5 years are severely
· malnourished (c 2 Z-Scores W/H and/or oedema) = 160
· 17% of children 6-59 months are moderately malnourished

(W/H- 3 - <-2 Z-Scores):

680 children

· Registered in the TFP:

90

· Coverage:

90/160 x 100% =56%

· Registered in the SFP:

430

· Coverage:

430 /680 x 100 = 63%

Note: The coverage calculated this way will become less accurate over time since the survey was performed, as the prevalence of malnutrition will change. However, there is no alternative until another survey is conducted.

· Mean length of stay on discharge

To be calculated monthly or every 3 months, from all recovered children or a random sample of 30 recovered children: total number of days of admission of all (30) recovered children added/No of recovered children (30). Objective: < 30 days for TFP and < 60 days for SFP.

· Average weight gain: (every 3 months - OPTIONAL):

The average weight gain of the children in a TFP is a very good indicator of the quality of the programme (it is rarely used for SFPs). It can be calculated every three months on a sample of 30 children, chosen randomly from the record files.

The weight gain is calculated over the entire period for marasmic children after entry into the Phase II. For kwashiorkor cases, the indicator is calculated in Phase II after complete loss of oedema.

Objective: 10 - 20 g/kg/day
Daily Weight Gain = W2 - W1 (g/kg/day)/(Wx(T2 - T1))

W1 =

Weight on entry of Second Phase in grams

W2 =

Weight at day 15 or on exit of Second Phase (in grams)

W =

Weight on entry of Second Phase in kg

(T2 - T1) =

Number of days between W1 and W2

Average Daily Weight Gain = Total of daily weight gains of children (g/kg/day) / Total number of children

· Case Fatality

No. of deaths in the centre/Average No. of children registered during the month.

Objective: < 10%

This rate expresses the risk of death for a child attending the programme.

· Percentage of children vaccinated against measles

Objective: 100%

A brief overview of indicators often used for monthly reporting on SFPs and TFPs is presented below:


FIGURE

(*): No of children expected derived from anthropometric surveys

OBSERVATIONS

· Consumption:

Do the consumption of food, firewood and water correspond with the attendance figures.

· Food quality:

The quality of the food commodities should be checked when received and regularly during storage (expiry date, damaged packing, moisture, mould, vermin). This is especially important for milk - powder. For quality control procedures of dried skim mink see Annex 14.

Hygiene during preparation and distribution of food should be carefully controlled.

· Ration:

Recipe of the HEM/porridge/dry ration:

- Are the quantities of each ingredient correct?
- Is the volume of the rations per child correct?
- Are taste and palatability and consistency of the HEM/porridge correct (the HEM/porridge should be tasted regularly)?

· Staff:

The level of job performance of the staff should match their job descriptions, motivation, loyalty.

Annex 21 is a check list of tasks for the supervision of TFPSs. It should be clear to the supervisor which points from this list should be accomplished in the programme.

Monitoring the Effectiveness (Impact) of the Programme (every 3 - 6 months)

The influence of a particular nutritional programme on the health status of a population is not easy to ascertain as other vital sectors (water, shelter, health care, etc.) contribute to well being. Secondly, one needs fairly accurate knowledge of the <<denominator>> or real population size for an impact indicator based on routinely collected data to be correct.

Mortality figures, malnutrition rates and basic morbidity data (routine and epidemic events) are valuable indicators that need to be monitored in emergency situations in order to appreciate needs and adapt programmes. Information can be collected through cross - sectional surveys, but trends in the data can also be used to help follow the impact of the programme.

By regularly monitoring mortality and prevalence of severe malnutrition, the initial objectives/design of the programme can be evaluated and adapted when necessary.

· Mortality rate among children under five:

Of children in the community: through monthly/weekly (under - five) mortality surveillance (see Annex 1) or a mortality survey.

· Prevalence of severe malnutrition among children under 5 years in the population:

To be measured by regular nutrition surveys and comparison with results from previous surveys.

Trends in health and nutrition indicators can be related to various and multiple factors. Thus, one might be able to demonstrate a positive trend in improved rates of malnutrition and mortality over the programme period, but it is impossible to prove that the selective feeding programme caused this trend.

However, with well collected information from multiple sources, one can show a very strong association and argue for a reasonable interpretation of the impact of the feeding programme.

When to Close Down Feeding Programmes

When the number of patients is too low to make it efficient to run separate feeding centres, feeding centres should be closed down (< 20 for a TFP and < 30 for an SFP). New cases should then be referred to the nearby hospital or health centre (supply these services with the necessary food, equipment, and technical support, if not available).

Low numbers of participants may not reflect an improved situation but poor accessibility or acceptability of the programme. Therefore, the decision to close down selective feeding programmes should only be made after a nutrition survey has clearly shown a significant decrease of global acute malnutrition in the population.

Prevalence of global acute malnutrition (<-2 Z-Scores W/H and/or oedema) among children under - five years old should be below 10%.

The following conditions should also be met:

- General food distributions are reliable and adequate,
- Effective public health and disease control measures are in place,
- No seasonal deterioration of nutritional status is anticipated,
- Mortality Rate is low (see Annex 1),
- The population is stable - no major influx is expected. (See Ref. 12)

Follow-up nutrition surveys must be planned to detect any deterioration of the situation, even after closure of selective feeding programmes. This is especially important if the overall situation remains unstable.

9. Food management

Food needs

The composition of rations and exact make-up of recipes depends on availability (from donors and local markets) and local acceptability (local food habits) of foods. See Annex 14 and 16 for suitable ration sizes, food commodities used and recipes.

Try to obtain the foods from donors with in - country food stocks:

- International organizations
- Bilateral donations
- NGO's (see Annex 4)

If donors are unable to supply adequate quantities of food or supply essential items rapidly enough, essential commodities (cereals, pulses, oil, sugar) may be bought locally/regionally.

In order to prevent serious disruptions in the programme, due to irregular food supply, each feeding centre/programme should always have its own buffer stock, sufficient to cover needs for one to three months, depending on local storage and supply conditions.

Transport capacity is critical in the planning and location of feeding centres - a normal 4x4 pick-up can carry 1,000 kg, if roads are not too bad.

Calculations of monthly food needs for wet feeding centres should be based on the needs of a child with an average weight of 9 kg:

200 kcal/kg/day x 9 = 1.81/child/day - TFP Depends on food used in wet SFP.

Example:

If the initial survey estimated the number of severely malnourished children at 245, the food to be ordered for one month will be:

DSM: 80g x 1.81 x 245 children x 30 = 1058 kg = 1.058 Mt Oil: 60g x 1.81 x 245 x 30 = 794 kg = 0.794 Mt Sugar: 50g x 1.81 x 245 x 30 = 662 kg = 0.662 Mt

Estimates are increased by 10% to allow for losses during transport and preparation, so the total amount to be ordered in this example will be: DSM: 1.164 Mt, Oil: 0.875 Mt. Sugar: 0. 728 Mt, Total: 2. 767 Mt. This amount of food will require at least 3 trips by pick-up.

In addition, local foods need to be purchased for meals for carers.

For calculating food needs for one month for dry ration distribution programmes: average attendance: 150 children per week, dry ration for one child per day:

- 270 gram dry premix containing:
- WSB 140g
- DSM 50g
- 1250Kcal + 46g protein sugar 30g oil 50g food needs for one month for 150 children, including an addition of 10% for losses:

WSB

(140 x 30 x 150) + 10% = 693 kg

DSM

(50 x 30 x 150) + 10% = 248 kg

sugar

(30 x 30 x 150) + 10% = 149 kg

oil

(50 x 30 x 150) + 10% = 248 kg

Total

= 1,338 kg

this amount of food can be transported in 2 pick-up loads.

Actual consumption

The actual consumption of the commodities has to be checked in order to:

- adapt the theoretical calculation of the food needs to the actual needs,
- compare the consumption with the number of beneficiaries to control preparation of meals and unexplained losses of food.

Example of check on the actual consumption:

No. of children registered at the end of the month: 150

Calculated needs for this month (including 10% losses)

WSB

140 x 30 x 150 +10%

= 693 kg

DSM

50 x 30 x 150 +10%

= 248 kg

Sugar

30 x 30 x 150 +10%

= 149 kg

Oil

50x 30x 150+10%

= 248 kg

Actual consumption:

WSB

700 kg

Corresponds

DSM

300 kg

20% Overconsumption

Sugar

200 kg

> 30% Overconsumption

Oil

200 kg

20% Underconsumption

Stock management

Good management of the food stock is essential for the successful performance of a selective feeding programme. The store must be properly locked, foods carefully stacked and good ventilation ensured. Food stock management should be systematized so that there is stock rotation (old foods used before the new) and there are always sufficient quantities of ALL commodities in the buffer stock.

Only one person should be responsible for the store, and only with his approval can commodities be released from the storehouse; all commodities going in and out of the store must be systematically registered.

The supply and use of the different commodities must be summarized in a monthly stock balance.


FIGURE

At the end of each month, a physical count (stockcount) of the stocks should be made to cross - check the stock balance. The stockcount should equal the closing stock of the stock balance. If this is not the case, and differences are unacceptable, try to find out reasons and change the food management system accordingly.

The end - of - the - month stockcount should be taken as the opening stock for the next month.

Food Orders

The required food stock at the beginning of the month will depend on the extent of the predicted consumption as well as the size of the required buffer stock. The frequency and stability of the food supply determines the amount of food needed as a buffer stock. If a stable monthly supply can be guaranteed, a buffer of one month is sufficient (although 2 - 3 may be preferred). Large stocks should be avoided, because the management is more difficult, food has a limited shelf lifen, and for security reasons.

The quantity of food to be ordered each month, allowing for a one month buffer stock, can be calculated as follows:

Monthly Order = (2 x Monthly Consumption) - Stock Count

Example:

A feeding centre consumes 0.625 MT of sugar every month. There are 0.25 MT in stock at the end of the month. The next order will be: (2 x 0.625) - 0.25 = 1 MT.

(All food orders should be made in Metric Tonnes = 1000 kg)