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).