EHN Capacity Building Training

Nutrition in Emergencies

EHN Capacity Building Training

The Impact of Malnutrition

The Impact of MalnutritionMalnutrition-Infection Cycle

Inadequate dietary intake

Weight loss

Growth faltering

Lowered immunity

Mucosal damageDisease

Appetite loss

Nutrient loss

Mal-absorption

Altered metabolism

The Impact of MalnutritionMalnutrition & Child Mortality

Source: Lancet Child Survival Series

Pneumonia19%

Diarrhea17%

Malaria8%Measles

4%Aids3%

Injuries3%

Other10%

Newborn36%

Malnutrition underlies

35% to 60% of these deaths

Nutrition Causal Framework

Adapted from Unicef

Outcome Under-Nutrition

ImmediateCauses

InadequateDietary Intake Disease

UnderlyingHealth /NutritionCauses

Inadequate Care for Mothers

and Children

InsufficientAccess to Food

Lack of health services & unhealthy environment

Nutrition Indices – A Review

Nutrition Indices - Review

Stunting (Chronic)

Underweight(Both)

Wasting (Acute)

Index Height for Age

Weight for Age

Weight for Height or MUAC

Moderate

< -2 SD < -2 SD < -2 SD

Severe < - 3 SD < - 3SD < - 3SD

Despite new WHO growth standards,

UNSCN recommends continued use

of NCHS

Nutrition Indices - Review Developmental Contexts

Stunting (Chronic)

Underweight Wasting (Acute)

Index Height for Age

Weight for Age

Weight for Height or MUAC

Moderate

< -2 SD < -2 SD < -2 SD

Severe < - 3 SD < - 3SD < - 3SD

Nutrition Indices – ReviewEmergency Contexts

Stunting (Chronic)

Underweight(Both)

Wasting (Acute)

Index H/A W/A W/H or MUAC

Moderate

< -2 SD < -2 SD < -2 SD, 70 - 80% Median, or MUAC 110 – 125*

Severe < - 3 SD < - 3SD < - 3SD, <70% Median, or MUAC <110*, or Oedema*Cut off points for MUAC have differed from agency to

agency – these cut offs are consistent with cluster guidance

Stunting (Chronic)

Underweight(Both)

Wasting (Acute)


Moderate


Severe < - 3 SD < - 3SD < - 3SD, <70% Median, or MUAC <110*, or Oedema

Moderate Acute

Malnutrition


*Cut off points for MUAC have differed from agency to agency – these cut offs are consistent with cluster guidance

Stunting (Chronic)

Underweight(Both)

Wasting (Acute)


Moderate



Severe Acute

Malnutrition (SAM)



Stunting (Chronic)

Underweight(Both)

Wasting (Acute)


Moderate



Global Acute

Malnutrition (GAM)



Nutrition Indices – ReviewSevere Acute Malnutrition

Marasmus (wasting) Kwashiorker (oedema)

Case Fatality: 20 to 30 Percent (Collins, Lancet, 2007)

Case Fatality: 50 to 60 Percent (Collins, Lancet,

2007)

Mara

smic

Kw

as

h

Assessing the Severity of Crisis

Severity of a CrisisThree Criteria

1. Prevalence of malnutrition in relation to internationally defined benchmarks and thresholds

2. Trends in rates of malnutrition over time – pre-crisis including seasonality

3. The relationship between malnutrition and mortality

Adapted from HPN Network Paper 56, Helen Young and Susanne Jaspars, November 2006

Severity of CrisisBenchmarks and Thresholds

WHO, Management of Malnutrition in Major Emergencies, 2000

Severity Prevalence of GAM

Acceptable < 5 %

Poor 5 – 9 %

Serious 10 – 14 %

Critical > = 15 %

WHO, Management of Malnutrition in Major Emergencies, 2000

Severity Prevalence of GAM

Acceptable < 5 %

Poor 5 – 9 %

Serious 10 – 14 %

Critical > = 15 %

Emergency

Threshold



Rainer Gross, Patrick Webb Lancet 2006; 367: 1209–11

Static rates exceed

emergency thresholds

Severity of CrisisMalnutrition Over Time

K. Brown Et al., 1982, The American Journal of Clinical Nutrition 36: pp. 303-313.

Seasonal & annual

Variation in rates

Severity of CrisisMalnutrition and Mortality

High GAM + CMR >1 – Severe

High GAM + CMR >2 – Critical

Source: Emergency Nutrition Assessment, Guidelines for Field Workers, Save the Children

Understand your data source

Screening (rapid assessment)– Often done as part of a rapid assessment using MUAC. Findings should be

used cautiously, but can give an indication of relative severity of a situation.

Population-based Surveys– Provide a “snap shot” of the situation at a given time. Typically used to

establish prevalence of malnutrition, often including data on morbidity and mortality. More intensive and generalizable than screening.

Surveillance– Used to identify trends in nutritional status of a population. Mechanisms

vary but can include a combination of repeated surveys, sentinel site surveillance, or health service statistics, etc.

Responding to Crisis

Food security/General Distribution

Supplementary feeding

Therapeutic

feeding

Early Intervention

Late Intervention

Responding to Crisis Prevention Before Cure

Cost/Benefit

Responding to CrisisPrevention before Cure

Rebel engageme

nt increases

April 07 June 07 September 07

Cattle prices down – food

prices upFood supplies

diminishing

Rates of malnutrition

begin to climb

CRISIS

Rates of acute malnutrition

(<5)

December 07

Cross-border trade

disrupted

Responding to CrisisPrevention Before Cure

Early Warning SystemsAgricultural production such as crop production

and livestock farmingMarkets such as domestic and international trade

(import/export), prices of key staples and livestock

Vulnerable groups such as monitoring povertyNutrition and health status of populations

Responding to Crisis Prevention Before Cure

Ensure the population has adequate access to appropriate quantities of quality food (SPHERE = 2100 kcal/day)

• Market-based interventions

• Cash transfers

• General food distribution or blanket supplementary feeding

• Nutritional SurveillanceFood Security Colleagues

Responding to CrisisPrevention before Cure

ENDF engageme

nt increases

April 07 June 07 September 07

Cattle prices down – food

prices up

Food supplies diminishing

Rates of malnutrition

begin to climb

CRISIS!

Rates of acute malnutrition

(<5)

December 07

Cross-border trade

disrupted

Food security/General Distribution

Supplementary feeding

Therapeutic

feeding

Early Intervention

Late Intervention

Responding to Crisis Selective Feeding

Cost/Benefit

Screening

Responding to CrisisTraditional approach

Responding to Crisis Screening

Stage I: MUAC

Stage II: Weight for Height

Many now advocate for using MUAC

alone, the cluster recommends

continued use of W/H

Screening

Moderate (70 - 80% Median)*

Severe (<70% Median/Oedema

)*

Supplementary Feeding

Therapeutic Care

Recovered

No Malnutrition

Responding to CrisisTraditional approach

Note: Standard screening protocols use percent of the median – not z-scores

*ACF breaks treatment into 3 phases.

**See WHO, Management of Severe Malnutrition, 1999 for further detail.

Responding to CrisisTraditional Approach

Phase I Stabilization

Phase II Rehabilitation

Treatment

Antibiotic, Anti-malarial, Vitamin A, etc.

CareAttend to complications (e.g. shock,

hypoglycemia)

FeedF-75 Therapeutic

MilkF-100 Therapeutic

Milk

Quantity 135ml/kg/day 200ml/kg/day

Time 1-7 Days, 3 to 4 Weeks

Responding to CrisisTraditional Approach

Highly effective in reducing case specific mortality, BUT…

– Extremely labor intensive – Costly

– High potential for cross infection

– Child & caretaker are away from family for 20+ days – high opportunity cost

– Poor Coverage

Responding to CrisisKey Developments – late 90’s

Com

plicate

d

Un

com

plicate

d

Responding to CrisisScreening – New Approach

Acute Malnutrition

With ComplicationsWithout Complications

Oedema (+++) OR Marasmic-

Kwashiorker OR WHM <80% OR MUAC <125mm OR oedema

AND illness*

Inpatient Care

*Anorexia, LRI, High fever, Severe dehydration, anemia, not alert, hypolglycaemia, or hypothermia

70 - 80% WHM, MUAC

<125mm


<70% WHM, MUAC <110mm

OR oedema

Outpatient Therapeutic

Care

Moderates Severes

Severes (and moderates) with

complications

>80% of severes can be treated

as outpatients

Responding to CrisisSupplementary Feeding

Acute Malnutrition


80% WHM, MUAC

<125mm

70% WHM, MUAC <110mm

OR oedema



AND illness*



CareInpatient Care


Moderates Severes


complications

“Blanket” Prevent malnutrition by providing a food supplement to all members of vulnerable groups such as children <5 and pregnant and lactating women (alluded to earlier)

“Targeted” Prevent moderately malnourished women and children from becoming severely malnourished by providing a food supplement to malnourished individuals


“Wet” Rations – Food is prepared and

consumed on-site (ration is determined according to child’s nutritional requirements)

“Dry” Rations– Food is taken home

and consumed with family (ration often increased to account for intra-household allocation)

Responding to Crisis Supplementary Feeding “should be based

on dry take-home rations unless there is a clear rationale for on-site feeding” -

SPHERE

Responding to Crisis Supplementary Feeding

Source: WHO (2000) The Management of Nutrition in Emergencies

Take home rations

On site rations

Item 1 2 3 4 5 6 7

Blend (g) 250 200 100 125 100

Cereal (g) 125

HEB (g) 125

Fortified Oil (g)

25 20 15 20 10 10

Pulses (g) 30 30

Sugar (g) 20 15 10 10

Energy (Kcals)

1250 1000 620 560 700 605 510

Protein (grams)

45 36 25 15 20 23 18

Fat (grams) 30 30 30 30 28 26 29

Responding to Crisis Supplementary Feeding

Source: WHO (2000) The Management of Nutrition in Emergencies

Take home rations

On site rations

Item 1 2 3 4 5 6 7

Blend (g) 250 200 100 125 100

Cereal (g) 125

HEB (g) 125

Fortified Oil (g)

25 20 15 20 10 10

Pulses (g) 30 30

Sugar (g) 20 15 10 10

Energy (Kcals)

1250 1000 620 560 700 605 510

Protein (grams)

45 36 25 15 20 23 18

Fat (grams) 30 30 30 30 28 26 29

Use only when blended foods

are unavailable – early stages


• A Retrospective study of Emergency Supplementary Feeding Programmes notes only 41% achieve objectives. Carlos Navarro-Colarado. June 2007. ENN and SC UK. Available at www.ennonline.net/research

• Fortified blended foods inadequate in both caloric and micronutrient content - Ready to Use foods are far superior

• Potential use of RUFs in supplementary feeding programs – both in prevention of malnutrition, and in treatment of moderate malnutrition

http://www.ennonline.net/research

Responding to CrisisOutpatient Therapeutic Care

Acute Malnutrition


80% WHM, MUAC

<125mm


OR oedema



AND illness*



CareInpatient Care


Moderates Severes


complications

80% of severes can be treated

as outpatients

Uncomplicated

Complicated

Responding to CrisisOTP - Screening

Complications:• anorexia or• severe oedema (3 +) or • marasmus with any level of oedema, or• the presence of associated complications (e.g. extensive infections, severe dehydration, severe anaemia, hypothermia, hypoglycaemia or the patient not being alert).

Uncomplicated

Responding to CrisisOTP – First Contact

• Medical Assessment

• Appetite Assessment

• Presumptive treatment: Antibiotic (amoxicillin), Anti-malarial, and Vitamin A and/or Folic Acid in cases presenting with deficiency symptoms

• Ready to Use Therapeutic Food (RUTF)

Uncomplicated

Complicated

Responding to CrisisOTP - Weekly Follow Up

• Medical exam

• RUTF

• De-worming for children above 1 year of age – Week 2

• Measles immunization for all children above 9 months of age – Week 4

Responding to CrisisInpatient Therapeutic Care

Acute Malnutrition


80% WHM, MUAC

<125mm


OR oedema



AND illness*



CareInpatient Care


Moderates Severes


complications

Responding to CrisisInpatient Care


Phase II Rehabilitation

Treatment Antibiotic, Anti-malarial, Vitamin A, etc.


hypoglycemia)


MilkF-100 Therapeutic

Milk


Time 1-7 Days, 3 to 4 WeeksWHO, Management of Severe Malnutrition, 1999



Phase II Trans/

Rehabilitation

Treatment Antibiotic, Anti-malarial, Vitamin A, etc.


hypoglycemia)


MilkRUTF


Time 1-7 Days, 3 to 4 WeeksWHO, Management of Severe Malnutrition, 1999

Outpatient Care


Responding To CrisisSimplified Decision Tool

Finding Action requiredFood availability at household level < 2100 kcal/person/day

Improve general rations until local food availability and access can be made adequate

Malnutrition rate (GAM) under 10 % with no aggravating factors

- Attention to malnourished individuals through regular community services[2].

Malnutrition rate (GAM) 10 – 14 % or 5 – 9 % plus aggravating factors

- Supplementary feeding targeted to individuals identified as malnourished in vulnerable groups- Therapeutic feeding for SAM individuals

Malnutrition rate (GAM) ≥ 15 % or 10 – 14 % with aggravating factors[1]

- General rations; plus- Supplementary feeding for all members of vulnerable groups.- Therapeutic feeding for SAM individuals

[1] Aggravating factors are: i) General food ration below the mean energy requirement (<2100 kcal/kg/person), ii) Crude Death Rate greater than 1/10 000/day and iii) Epidemic of measles or whooping cough.[2] This may include therapeutic care integrated into primary health system (hospitals and health centres).

MicronutrientsThe Silent Killer

• Over 2 billion people affected

• Increases the general risk of infectious disease and of dying from diarrhea, measles, malaria and pneumonia

• Emergency affected populations are at increased risk of deficiency

MicronutrientsPrevention Before Cure

Ensure the population has access to key micronutrients

– Local foods – Fortified foods– On-site fortification– Supplements– Multiple Micronutrient Powders

Case Study - Questions

Using the information provided, estimate the number of severely malnourished children in the province12 million/4 = 3 million x .20 = 600,000 x .038 = 22,800

Do you hink this situation requires a response? Justify your answer

Is there any other information that would be helpful in assessing the situation?

What do you propose as a response?

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