|Nutrition Guidelines (MSF, 1995, 191 p.)|
|Part III 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 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.
- 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
- 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.
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 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.