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Figure
Situation
In emergencies, food and nutritional security is often severely threatened. This causes increased risk of malnutrition, disease and death. Therefore, refugees will need partial or full food support. Some may also need nutritional rehabilitation.
Objective
To provide the refugees with sufficient quantities of appropriate food to maintain their health and nutritional status and, where necessary, to improve the condition of those who are already malnourished.
Principles of Response
· Measures to meet food needs should be appropriate and standardized, with responsibilities clearly defined, and the overall co-ordination ensured by a single organization;
· Whenever possible use familiar foods that meet nutritional requirements and maintain sound traditional food habits;
· The food distribution system should allow families to prepare their own meals;
· Pay particular attention to infant feeding and the needs of children, women and others prone to malnutrition;
· Maintain close co-ordination with the other vital sectors (health, water, environmental sanitation, etc.) and aim for maximum integration in existing services;
· Ensure the active involvement of a nutritionist.
Action
· Assess health and nutritional status and food needs as soon as possible;
· Ensure the availability of appropriate food and the necessary transport, storage, cooking fuel and utensils;
· Organize a general feeding programme for all refugees and, if necessary, selective feeding programmes to meet the additional needs of children, women and others;
· Monitor effectiveness of feeding programmes and make necessary changes.
1. In an emergency, refugees may be completely dependent on external food sources. An initial assessment of their health and nutritional condition and their numbers must be made as soon as possible. The types of programmes needed will be determined by this initial assessment. Continuous monitoring of nutritional status will ensure that the emphasis on different programmes can be adjusted in order to reflect changing conditions.
2. The causes of malnutrition are often complex and multi-sectoral (see Fig 1). Therefore coordinating the food and nutrition programmes with health and other vital sectors is essential.
3. Assistance must be appropriate to the nutritional needs of the refugees and be culturally acceptable. Foods prepared locally with local ingredients are preferable to imported foods. Infant feeding policies require particular attention.
4. Certain groups are more at risk of malnutrition than others. These include infants, children, pregnant women and nursing mothers, the sick and the elderly. Special action is required to identify the malnourished and vulnerable and to meet their additional needs. Where the refugees have already suffered a prolonged food shortage, many will be malnourished by the time of the first assessment.
5. If the refugees are already suffering the effects of severe food shortage, immediate action must be taken to provide food available locally which is acceptable to the refugees.
6. If insufficient acceptable food is available locally, it must be brought in from outside, initially by air if necessary. Flexibility and improvisation will be required, and time may be needed to develop the full response set out in this chapter.
7. This chapter should be read in conjunction with "Nutrition Guidelines" Médecins Sans Frontières (MSF), 1995, and UNHCR/WFP Guidelines for Estimating Food and Nutritional Needs, 1997 and Selective Feeding Programmes, 1999.
· The World Food Programme (WFP), the food aid arm of the United Nations system, shares with UNHCR responsibility for meeting the food and nutritional needs of refugees;
· The Memorandum of Understanding (MOU) signed between WFP and UNHCR establishes the division of responsibilities and coordination mechanisms for refugee, returnee and internally displaced persons feeding operations;
· The aim of the food programme is to ensure the restoration and maintenance of sound nutritional status through a food ration that meets the assessed requirements, is nutritionally balanced, palatable and culturally acceptable;
· In most refugee emergencies a UNHCR food and nutrition co-ordinator should be appointed, who will have overall responsibility for co-ordination of all aspects of the food and nutrition programme;
· The refugees, and in particular refugee women, must be involved in the organization of these programmes;
· Simple nutrition education is an integral part of effective food support.
Figure 1 - The Complex causes of
malnutrition
Adapted form: UNICEF Conceptual Framework of Malnutrition, 1997.
WFP/UNHCR Co-operation
|
The objective of WFP/UNHCR co-operation is the timely provision of the right amount of food, to ensure the restoration and maintenance of sound nutritional status. |
8. The means to achieve this is through a food ration that meets the assessed requirements, is nutritionally balanced, palatable, culturally acceptable, and promotes gradual self-reliance of the beneficiaries. Essential to this objective is joint UNHCR/WFP planning, from the start of the emergency.
9. A Memorandum of Understanding (MOU) (see Appendix 3) exists between UNHCR and WFP covering cooperation in the provision of food aid. Under the terms of the MOU, WFP meets the emergency food needs of refugees, returnees, and, in specific situations, internally displaced persons, and provides associated logistic support. The terms of the MOU only apply when the beneficiaries in the country of asylum number more than 5,000, irrespective of their country of origin or their location within the country of asylum. UNHCR will meet the food needs of persons of its concern who are outside the scope of the MOU.
10. Within the scope of the MOU, WFP has the lead responsibility for mobilizing the following food commodities (whether for general or selective feeding programmes) and the resources to deliver them.
|
WFP resourced commodities include: i. Cereals; ii. Edible oils and fats; iii. Pulses and other sources of protein; iv. Blended food; v. Iodized salt; vi. Sugar; vii. High energy biscuits. |
11. WFP is also responsible for arrangements for milling cereals and transporting WFP commodities to agreed extended delivery points (EDPs), and for the operation and management of the EDPs. UNHCR is responsible for the transportation of all commodities from the EDP to the final destination and for final distribution.
12. Under the MOU, UNHCR is responsible for mobilizing and transporting complementary food commodities and for the provision of the necessary micronutrients (vitamins and minerals) when they cannot be met through the ration.
|
UNHCR resourced commodities include: i. Local fresh foods; ii. Spices and Other condiments; iii. Tea; iv. Dried milk; v. Therapeutic milk. |
13. UNHCR and WFP have developed a common set of guidelines for estimating food and nutritional needs in emergencies and in selective feeding programmes2. These guidelines should be used to assess the food needs for both the general and selective feeding programmes.
|
Extended delivery Points (EDP) An EDP is the location at which WFP hands over a consignment of food to UNHCR or its implementing partner. WFP is responsible for the consignment and all costs incurred in moving and storing it, until UNHCR or its representative collects it from the EDP. In all cases the location of EDPs must be agreed jointly by UNHCR and WFP. EDPs should be positioned to give cost effective and logistically practical delivery, while avoiding the imposition of undue hardships on the beneficiaries because of travel distance and/or difficult access. Whenever possible the EDP should be at the same place as the final distribution point, or, if not, then as near as possible to it. An EDP should be established for approximately every 10,000 beneficiaries. |
1 WFP/UNHCR Guidelines for Estimating Food and Nutritional Needs in Emergencies, UNHCR/WFP, 1997.
2 UNHCR/WFP Guidelines for Selective feeding Programmes in Emergencies, WFP, UNHCR, Geneva, 1999.
Joint Assessment and Planning
14. UNHCR and WFP should carry out a joint assessment of the overall food, nutrition and related requirements in consultation with government authorities, operational partners and experts.
|
The first requirement is a knowledge of the numbers, nutritional status and food habits of the refugees. |
Assessing nutritional status is discussed in detail below. The joint UNHCR/WFP assessment for the food assistance programme should cover the following:
Basic Information
i. Numbers and demography (see chapter 11 on registration);
ii. Current nutritional status;
iii. Milling possibilities;
iv. Food commodity preferences of the beneficiaries;
v. Capacity of the family to prepare, store, and process the food;
vi. Access to cooking fuel, utensils and distribution containers;
vii. Food availability now and over time;
viii. Availability of local food for purchase;
ix. Ease of access to food supplies;
x. Groups at risk - identify who and how many;
xi. Degree of and prospects for self-reliance;
xii. Coping strategies.
Other Important Information
i. Health status and health services;
ii. Environmental health risks;
iii. Community structure;
iv. Food distribution systems;
v. Socio-economic status;
vi. Availability of human resources;
vii. Logistics constraints;
viii. Storage capacity and quality;
ix. Delivery schedule of food and non-food commodities;
x. Other agencies' activities and assistance currently provided: quantity, items and frequency, and selective feeding programmes.
15. WFP and UNHCR should draw up plans covering: the number of beneficiaries, the composition of the food basket, ration size, duration of assistance, and directly related non-food inputs which may have an impact on the nutritional status of the beneficiaries (for example, cooking utensils, cooking fuel and milling equipment).
16. The main considerations to take into account when responding to food and nutritional needs of refugees are set out in figure 1.
17. Special consideration should be given to the needs of women, children and groups-at-risk. The views of the beneficiaries, especially those of women, should be sought. The proposed food assistance programme should also take into account the need to minimize the environmental impact of cooking the food provided.
Coordination
18. A UNHCR coordinator should be appointed as focal point for food and nutritional issues. In smaller operations, either the programme officer or the logistics officer could be appointed as food coordinator. If technical expertize is not available initially within UNHCR then assistance should be sought from government nutritionists, UN agencies or NGOs.
19. The food and nutrition coordinator's responsibilities are to establish standard procedures, including procedures for general food distribution, coordinate feeding programmes, monitor and evaluate the feeding programmes, and ensure close coordination and integration with community services, health and other sectors. The coordinator should art as the focal point within UNHCR for coordination with WFP and NGO's. Where the food coordinator is not her/himself a nutrition specialist, an experienced nutritionist will also be needed to provide the food coordinator with the necessary technical advice.
Role of Refugees and Nutrition Education
20. The refugees must be involved from the start in the organization and management of the feeding programmes. Special training will be necessary for refugees.
21. The provision of simple nutrition education for the refugees is always necessary when unfamiliar foods or new methods of cooking cannot be avoided. This should be organized in conjunction with nutrition education activities and provide guidance on: proper infant feeding, feeding sick children, treating diarrhoea, basic food hygiene and preparing available foods for maximum nutritional benefit.
Cooking Fuel
22. Particular attention must be paid to the provision of cooking fuel and the control and management of the natural resources in the vicinity of the camp. Failure to deal with this can quickly lead to destruction of the vegetation in and around the site causing lasting damage to the environment, with direct effects on the health and well-being of refugees and local people and friction with the local population. Fuel needs and consumption vary considerably3-factors affecting the use of fuel include:
i. food preparation, cooking techniques, fuel type and preparation. Soaking beans prior to cooking, ensuring lids are used on pots, ensuring wood is dry and chopped, and that fires are put out after cooking - all these make considerable fuel savings and can be incorporated into environmental awareness raising and training programmes. Other steps to facilitate efficient fuel use are to ensure that the pots supplied have lids.
ii. type of stove. It may be possible to use local technology to modify existing types of wood or charcoal burning stoves in order to make them more fuel efficient. Simple improvements and local technologies are best. Note that the social and economic implications of a new technology are usually more important in determining whether it will be adopted than the effectiveness of the technology itself. The promotion and use of improved stoves must closely involve the refugees.
iii. type of food. Freshly harvested foods take less cooking time, also using milled rather than whole grain and using pre-cooked food make considerable fuel savings. The environmental implications of the food basket need to be taken into account with WFP.
iv. availability (or "price") of fuel itself. This is often the most significant factor affecting per capita fuel consumption. The provision of fuel wood and managing and controlling the use of natural resources around a refugee camp is discussed further in chapter 12 on site planning.
3 Average fuel-wood consumption per person per day in different refugee camps has varied from 0.9 kg to 4kg.
· The nutrition assessment should be carried out as soon as possible by an experienced nutritionist;
· Nutritional assessment should include anthropometric surveys as well as food security information;
· Regular assessment is necessary both to monitor the nutritional status of the community as a whole and identify individuals and groups who need special care and food assistance;
· Information must be gathered on mortality and morbidity in addition to malnutrition rates, in order to understand the underlying causes of malnutrition and to identify people who are most affected.
Introduction
23. An initial assessment of the nutritional status of the refugees should be made as soon as possible and should be carried out by an experienced nutritionist. The extent of malnutrition has important implications for what form the emergency response will take, and will enable early decisions to be taken on the components of the rations and on the requirement for any additional selective feeding programmes.
24. The nutritional assessment should be followed by regular nutrition surveys under specialist supervision to monitor the condition of the population as a whole.
25. Where conditions and/or results of the initial assessment or later surveys indicate a need for selective feeding programmes, individuals will need to be identified and registered for these programmes. Their individual progress should then be monitored through periodic measurements at the feeding centres.
26. The initial nutrition assessment and the periodic nutrition surveys of the population as a whole should be done by measuring the weight and height of a random sample of the child population (as explained below). Initially such surveys should be carried out every two to three months. When conditions have stabilized, once every six to twelve months is sufficient. Any change or trend in nutritional status can thus be detected and appropriate adjustments made in the assistance programmes.
|
There is a serious nutritional emergency where the malnutrition rate is either over 15%, or over 10% with aggravating factors (e.g. an epidemic). Such a situation requires I urgent action. |
Recognizing and Measuring Malnutrition
27. Malnutrition can be recognized by clinical signs (such as oedema and micronutrient deficiencies) and by anthropometry (body measurements). Measurements such as weight-for-height are used as an objective assessment of nutritional status, which quantifies the nutritional situation at one point in time, and allows comparisons over time.
28. Mortality and morbidity information will assist in understanding the underlying causes of malnutrition and identify people who are most affected. Child mortality rates are particularly important.
|
In an emergency a high child mortality rate is very often associated with high levels of malnutrition. |
Death rates among children who are severely malnourished can be about six to ten times greater than those who are healthy and well nourished in the same population.
29. Weight-for-height in children, is the best indicator to assess and monitor nutritional status of populations. The actual weight of a child is calculated as a percentage of the standard weight for a normal child of that height, or as a Z score. It is the most sensitive indicator of acute malnutrition and is preferred for nutrition surveys and for measuring individual progress in feeding programmes. It is usually young children aged between 6 and 59 months who are measured in nutrition surveys, because young children are the first to show signs of malnutrition in times of food shortage and are the most severely affected. When the ages of children are not known, 65 cm and 110 cm height are used as the cut off points instead of 6 and 59 months.
30. Body mass index (BMI) (Weight in kg)/ (Height in m)2, is used for assessing the nutritional status of adults by assessing the degree of thinness (see table 1).
31. Oedema is an essential nutrition indicator and indicates kwashiorkor (see Annex 3). Oedema is characterized by swelling in both feet due to an abnormal accumulation of fluid in intercellular spaces of the body.
32. Mid-upper-arm-circumference
The mid upper arm circumference (MUAC) is measured on the left arm, at the mid-point between elbow and shoulder. MUAC should only be used as part of a two-step screening exercise. In the first step the MUAC of children is measured. Those falling below a certain cut-off circumference are then channelled to weight-for-height measurement to determine their nutritional status and whether they should be included in selective feeding programmes.
33. Weight-for-age and height-for-age are not such useful assessment indicators in emergencies as age is often difficult to determine. This can be used for growth monitoring of individual children, and in assessing long-term (chronic) malnutrition.
Moderate and Severe Malnutrition
34. The standard cut-off points to describe malnutrition, are between 70% and 80% weight-for-height (or between -3 and -2 Z scores) for moderately malnourished and less than 70% weight-for-height (or < -3 Z scores) for severely malnourished.
|
Children with oedema are always classified as severely malnourished. |
Table 1 summarizes the key malnutrition indicators.
Table 1: Key Nutritional Indicators*
|
Malnutrition |
Children under 5 years |
Adults BMI | ||
| |
Weight-for- |
Weight-for- |
MUAC |
|
|
Moderate |
70% to 79% |
-3 to -2 Z |
110mm to <125mm |
16-17 |
|
Severe |
less than 70% |
less than -3 Z or oedema |
< 110mm, oedema |
less than 16 |
* Results expressed by different methods are not directly comparable
4 Percentage below the median "reference" weight-for-height values.
5 Standard deviations (SDs, or Z score) below the median "reference" weight-for-height values.
· A mean figure of 2,100 kcal per person per day is used as the planning figure for calculating the food energy requirements of refugees in emergencies in developing countries6;
· Everyone in the population, irrespective of age or sex, should receive exactly the same general ration (i.e. same quantity and type of foods);
· The food basket should be nutritionally balanced and suitable for children and other groups at risk;
· Every effort should be made to provide familiar foodstuffs and maintain traditional food habits;
· The level of fat intake should provide at least 17% of the dietary energy of the ration. Protein intake should provide at least 10-12% of the total energy;
· The diet must meet essential vitamin and mineral requirements;
· Particular attention should be paid to locally prevalent nutrient deficiencies.
6 The Management of Nutritional Emergencies in Large Populations, WHO, Geneva, 1978.
General Ration
35. Every effort should be made to provide familiar foodstuffs and maintain sound traditional food habits. Expert advice on the ration size and composition is essential and should take full account of local availability of food commodities. Staple food should not be changed simply because unfamiliar substitutes are readily available. Inappropriate foods often lead to waste and lower the morale of the refugees.
36. The first concern is to ensure that energy and protein requirements are met. The planning figure for the average minimum daily energy requirement per person per day for a developing country population at the beginning of an emergency is 2,100 kcal. See Annex 1 for examples of rations which meet this requirement. This average requirement is calculated on an average population containing men, women and children of different age groups. However, a complete ration should be provided to each refugee without distinction.
|
A minimum requirement of 2,100 kcal per person per day is used as the planning figure for a developing country population at the beginning of an emergency. |
A population which contains mostly active adults may require considerably higher average energy intakes. In addition, a higher ration is vital for survival in a cold climate.
37. The daily energy requirement can be adjusted when the situation has stabilized7 and detailed data is available. Factors to be taken into consideration are:
i. Age and sex composition of the population;
ii. Activity level;
iii. Climatic conditions;
iv. Health, nutritional and physiological status;
v. People's access to other food sources e.g. agriculture, trade, labour.
38. The food basket should comprise: a staple food source (cereals), an energy source (fats and oils), a protein source (legumes, blended foods, meat, fish), salt and possibly condiments (such as spices). Fresh foods should be included in the food basket for essential micronutrients. The level of fat intake should provide at least 17% of the dietary energy of the ration, and protein intake should provide at least 10-12% of the total energy.
39. When certain food commodities are not available, they can be replaced for a maximum of one month by other available food items in order to maintain the adequate energy and protein level. Substitution in energy value, should an item not be available, is:
|
Corn Soy Blend (CSB) for beans |
1:1 |
|
Sugar for oil |
2:1 |
|
Cereal for beans |
2:1 |
|
Cereal for oil8 |
3:1 |
E.g. the energy from 20 g of sugar can substitute for that from 10 g of vegetable oil.
40. Cereal flour, rather than whole grain, should be provided, especially at the beginning of an emergency. Considerable fuel savings are made by using milled rather than whole grain. If whole grains are provided, local milling should be made available and the cost compensated for.
41. Essential vitamin and mineral requirements must also be met. The basic food commodities distributed through the general ration do not normally cover the required amounts of vitamins and minerals. Therefore, deficiencies often arise among populations entirely dependent on external food aid and within a population among vulnerable groups like infants, pregnant women and nursing mothers. Particular attention should also be paid to locally prevalent nutrient deficiencies.
42. The risk of specific nutrient deficiencies can be estimated from the composition of the general ration and access the population has to other food sources in the area. Possible options for providing vitamins and minerals are:
i. Provide fresh food products;
ii. Promote the production of vegetables and fruits;
iii. Add to the ration a food rich in a particular vitamin and micronutrient such as fortified cereals, blended foods, or condiments;
iv. Provide supplements in tablet form, which is the least preferred option.
43. Wherever possible the refugees should be encouraged to grow vegetables themselves: the production of fresh food by refugees not only improves and diversifies the diet but saves fuel and provides an opportunity to generate some income. Larger plot sizes and the provision of appropriate seeds would facilitate this, however, it can be difficult to encourage refugees to produce fresh food because of their uncertainty as to the length of their stay and problems of access to land.
7 See for further information: WFP/UNHCR Guidelines for Estimating Food and Nutritional Needs in Emergencies, 1997.
8 One way only, note that oil cannot be used in place of cereal.
Food Distribution
44. The need for a fair, efficient and regular food distribution cannot be over-emphasized. This is discussed in chapter 13 on commodity distribution. There are two main types of distribution: dry ration and cooked meals.
45. Dry food distribution (which is taken home) has major advantages over cooked food distribution. It allows families to prepare their food and to use their time as they wish, permits them to continue to eat together as a unit and is more culturally and socially acceptable. It also reduces the risk of the spread of infectious diseases.
46. Cooked meal distribution requires centralized kitchens with adequate utensils, water and fuel (the requirement is less than the amount required for family cooking), and trained personnel. The refugees usually sit together in a feeding compound, although in some circumstances families can carry the cooked meal to their accommodation. At least two meals must be served each day.
|
Cooked meals are much more difficult to organize efficiently than dry ration distribution, particularly for large numbers. |
Cooked meal distribution to the whole population is therefore only provided under exceptional circumstances when the refugees do not have access to adequate water and/or cooking fuel and in insecure situations.
47. In addition to cooking pots, fuel and utensils, the refugees must have containers and sacks to protect and store their food rations. Oil tins and grain bags will be useful, and contracts with suppliers, at least for initial deliveries, should not require their return.
Monitoring the General Feeding Programme
48. The general feeding programme can be monitored by:
Food basket monitoring: Comparing the quantity and quality of food collected by the refugees at the distribution site on distribution days compared with the planned ration, Also by monitoring after the distribution at household level through house visits (on distribution day);
For more information on how to monitor the general food programme see UNHCR's Commodity Distribution: A Practical Guide For Field Staff, and MSF's Nutrition Guidelines.
· The objective of a selective feeding programme is to reduce the prevalence of malnutrition and mortality among the groups at risk;
· Selective feeding programmes provide extra food for the malnourished and at-risk groups - this food must be in addition to (not a substitute for) the general feeding programme;
· The programme must actively identify those who are eligible for the selective feeding programmes, using criteria described in this chapter.
Figure 2 - Response to food and
nutritional needs
General Principles of Selective Feeding Programmes
49. Where malnutrition exists or the needs of the groups at risk cannot be met through the general ration, special arrangements are required to provide extra food. This is organized through different types of selective feeding programmes which take into account the degree of malnutrition and associated risks. In the emergency phase of an operation, selective feeding programmes are part of an emergency measure to prevent excess mortality. However, preventing excess mortality should be a combined strategy of selective feeding, public health and emergency health care. Ref. Figure 2.
|
The organization of these programmes should be integrated from the beginning with community and health services and especially with Mother and Child Health Care programmes (MCH). |
50. Malnutrition develops particularly among infants, children, pregnant women, nursing mothers, the elderly and the sick. Their vulnerability stems from the greater nutrient requirements associated with growth, the production of breast milk, repair of tissues and production of antibodies. Malnutrition results in lower resistance to infection, which in turn results in further malnutrition. Small children are particularly susceptible to this cycle of infection and malnutrition. Sick children must eat and drink even if they do not have an appetite, are vomiting, or have diarrhoea. Because children are unable to eat a large volume of food, it is necessary to prepare food in a concentrated form (giving the required nutrients in less volume), and to provide more frequent meals.
51. Certain other groups or individuals may be at risk of malnutrition for social or economic reasons. These include unaccompanied children, the disabled, single-parent families, and the elderly, particularly those without family support. In some communities specific social or cultural practices and taboos may put constraints on meeting the nutritional needs of certain persons, for example pregnant women and nursing mothers or even sick children.
52. Even if the overall quantity of food is sufficient there may be other causes such as:
i. Inequities in the distribution system reducing access to food for certain groups;
ii. Inaccuracies in registration or unfair distribution of ration cards;
iii. Infections;
iv. Faulty feeding or food preparation habits.
|
Selective feeding programmes are not a substitute for an inadequate general ration. |
53. The following types of selective feeding programmes are contemplated:
i. Supplementary Feeding Programmes (SFP)
a) Targeted SFP
b) Blanket SFP;
ii. Therapeutic Feeding Programmes.
|
To be effective, the extra ration provided must be additional to, and not a substitute for, the general ration. |
Supplementary Feeding Programmes (SFP)
54. Targeted and blanket supplementary feeding programmes provide extra food to groups at risk, in addition to the general ration, as dry take-home or wet on-the-spot feeding for a limited period of time.
55. A targeted SFP aims to rehabilitate those who are moderately malnourished. These could be children adults or older persons and/or individuals selected on medical or social grounds, e.g. pregnant and nursing women and the sick. This is the most common type of supplementary feeding programme.
56. A blanket SFP provides a food (and/or micronutrient) supplement to all members of a certain vulnerable group regardless of their individual nutritional status in order to prevent a deterioration in the nutritional status of those groups most at risk (usually children under five, pregnant women and nursing mothers.
57. Supplementary feeding programmes can be implemented either by giving wet or dry rations.
Therapeutic Feeding Programmes (TFP)
58. A TFP aims to reduce deaths among infants and young children with severe protein-energy malnutrition (PEM). The forms of PEM are described in Annex 3. Generally the target group is children under 5 years with severe malnutrition. Therapeutic feeding can either be implemented in special feeding centres or in a hospital or clinic. TFP involves intensive medical and nutritional treatment. Therapeutic milk (TM) is used for treatment of severely malnourished children. However if TM is not available, high protein milk can be used (dried skimmed milk, oil and sugar) mixed with vitamin mineral supplements.
Starting a Selective Feeding Programme
59. The decision to start a selective feeding programme is based on the prevalence of malnutrition and other aggravating factors. Aggravating factors include high mortality (more than 1 person per 10,000 per day), measles epidemic, high prevalence of infectious diarrhoea, general ration below minimum requirements. The prevalence of malnutrition is assessed from the initial and ongoing nutrition assessments and surveys.
|
In all situations, remember that it is more important to address the root causes of malnutrition than to address symptoms through selective feeding programmes. |
60. The effectiveness of these programmes will be severely compromised if an adequate general ration is not provided.
Figure 3 - Selective Feeding
Programmes
61. Figure 3 provides guidance on deciding when to initiate selective feeding programmes. Clear criteria for the termination of these programmes should be defined from the beginning.
Identifying Those Eligible
62. Selective feeding programmes must be based on the active identification and follow up of those considered at risk. Beneficiaries can be identified by:
63. Table 2 below summarizes the main objectives, target groups and criteria for selection of beneficiaries of selective feeding programmes.
Table 2 - Types of Selective Feeding Progammes
|
Programme |
Objectives |
Criteria for selection and target group |
|
Targeted SFP |
· Correct moderate
malnutrition |
· Children under 5 years
moderately malnourished: |
|
Blanket SFP |
· Prevent deterioration
of |
· Children under 3 or under 5
years |
|
TFP |
· Reduce excess mortality
and |
· Children under 5 years
severely malnourished: |
64. The links between different selective feeding programmes and the criteria for entry and discharge from a programme are shown in figure 4 below.
Planning and Organizing a Selective Feeding Programme.
Organizing a Supplementary Feeding Programme
65. Supplementary feeding programmes can be implemented either by providing wet rations or dry rations.
i. Wet rations are prepared in the kitchen of a feeding centre and consumed on-site. The beneficiary, or child and caretaker, have to come for all meals to the feeding centre every day;
ii. Dry rations are distributed to take home for preparation and consumption. Rations are usually distributed once a week.
66. In most situations dry take-home SFP programmes are preferable. The advantages of dry instead of wet rations for SFP include:
Figure 4 - Admission and discharge
Criteria
i. Much easier to organize;
ii. Fewer staff are needed;
iii. Lower risk of transmission of communicable diseases;
iv. Less time-consuming for the mother;
v. The mother's responsibility for feeding the child is preserved.
The ration for dry feeding however has to be higher than for wet feeding in order to compensate for sharing and substitution. Wet rations are typically given in situations where insecurity prevents dry rations from being taken home safely or where access to cooking facilities are limited. See Table 3 below for some of the main considerations when organizing a selective feeding programme.
Organizing a Therapeutic Feeding Programme
67. Therapeutic feeding programmes are either implemented in specially organized feeding centres or in hospitals or clinics. They involve intensive medical and nutritional treatment as well as rehydration. The programme should be easily accessible to the population, near to or integrated into a health facility. The treatment should be carried out in phases (see Table 3), the length of which depend on the severity of malnutrition and/or medical complications. At least during the first week of a TFP, care has to be provided on a 24-hour basis.
Table 3
|
Organization of Selective Feeding Programmes |
|||
| |
Supplementary Feeding Programme |
Therapeutic Feeding Programme | |
|
Organization |
· On site wet feeding On site feeding |
· Take home dry This is the preferred |
· On site wet
feeding |
|
Size of |
· 500-700kcal/ · 15-25 g protein |
·
1,000-1,200 · 35-45 g protein |
· 150 kcal/kg
body-weight/day/ |
|
Frequency |
Minimum 2 |
Ration distributed |
Frequent meals. |
68. One of the main constraints to the implementation of a TFP is the lack of experienced or insufficient staff to manage the programme. Proper training of both medical and non-medical personnel is essential before starting the programme. The refugees, particularly the mothers of patients, must be involved in managing the TFP centres.
Planning the quantity of food needed for selective feeding
69. The amount of food needed for the selective feeding programme will depend on:
i. The type of selective programme;
ii. The type of commodities;
iii. The expected number of beneficiaries.
70. This information should be based on precise demographic information and on the prevalence of malnutrition taken from the results of the nutritional survey. The nutritionist will advise on the appropriate commodities and type of programme.
71. However, in some circumstances, estimates on the prevalence of malnutrition and expected number of beneficiaries may need to be made for planning purposes, when for example a registration and nutrition assessment have not yet been carried out. See table 4 below for a projected demographic breakdown for a typical population.
72. If it is apparent that there is, or is likely to be, a major nutritional emergency, the following assumptions can be made for planning purposes:
i. 15 to 20% may suffer from moderate malnutrition;
ii. 2 to 3% may be severely malnourished;
iii. The breakdown of a typical population, by age, is as follows:
Table 4
|
Projected Breakdown by Age | |
|
age groups |
% total population |
|
0-4 or under 5 |
15-20% |
|
Pregnant |
1.5-3% |
|
Lactating |
3-5% |
73. For example, to estimate the number of beneficiaries for a targeted SFP and TFP, both for children under 5 years:
If the total population = 30,000
Estimated number under 5 yrs = 4,500 -6,000(15-20%)
Estimated prevalence of moderate malnutrition (15%) gives 675-900 children
Estimated prevalence of severe malnutrition (2%) gives 90-120 children
With these numbers the estimated food requirements can be calculated by multiplying the estimated number of beneficiaries for each programme by the ration scale appropriate for each beneficiary, as follows:
Quantity of Commodity req. = Ration / person / day × no. benef. × no. days
Monitoring Selective Feeding Programmes
74. The effectiveness of impact of the selective feeding programme should be monitored at regular intervals.
75. Selective feeding programmes should be monitored and evaluated to assess their performance in relation to the established objectives9. Monitoring and evaluation will involve the regular collection and analysis of:
76. The effectiveness of selective feeding programmes can be measured through nutrition surveys and the regular collection of feeding centre statistics. Specific forms for monthly reporting on supplementary and therapeutic feeding programmes are attached as Annexes 4 and 5. A nutrition survey results form (weight-for-height) is also attached (Annex 6).
77. Trends in health and nutrition indicators can be related to many different factors. Actions in other sectors such as water, shelter, or community services may help explain a positive outcome.
9 For further reference, consult Chapter 8: Evaluation of Feeding Programmes in the MSF Nutrition Guidelines.
Criteria for Closing Programmes
78. Once the number of malnourished is significantly reduced, it may be more efficient to manage the remaining severely malnourished individuals through health facilities and through community based programmes. The specific criteria for closing each selective feeding programme will depend on the degree of success in reducing the main aggravating factors mentioned in Figure 3 and on the degree of integration between these feeding programmes and mother and child health (MCH) activities and other support services offered by the refugee community.
79. After closing selective feeding programmes, any deterioration of the situation should be detected by nutrition surveys undertaken at regular intervals and review of morbidity and mortality data. This is especially important if the overall situation remains unstable.
· Breast-feeding is best for babies and must be promoted and continued for as long as possible;
· Ban baby bottles completely;
· Weaning foods must be appropriate; foreign baby foods and special foods often are not;
· Infant formulae should be avoided and used only under strictly controlled conditions, with a cup and spoon;
· Re-stimulate lactation10 in cases where milk production has been affected by stress and use wet nursing where appropriate;
· Milk products, especially powdered milk, and infant formulae can cause health problems (as described below) and they are often inappropriate.
80. Human milk is the best and safest for infants and children under two years. Breast-feeding provides a secure and hygienic source of food, often initially the only source of food, as well as antibodies giving protection against some infectious diseases. Breast feeding must be encouraged for as long as possible. Every effort must be made to promote or re-stimulate lactation even among sick and malnourished mothers. Experience has shown that this can be done. Mothers may need to receive extra food to encourage breast-feeding and provide the additional calories and nutrients required. This should be done through the feeding programmes.
81. The problems associated with infant formulae, milk products and feeding bottles are exacerbated in a refugee emergency. Clean boiled water is essential but rarely available, careful dilution of the feeds is of critical importance but difficult to control, mothers are unlikely to be familiar with the use of infant formulae, and the instructions are often in a foreign language. Infant formulae, if unavoidable, should be distributed from health or feeding centres under strictly controlled conditions and proper supervision. Infant feeding bottles must never be distributed or used; they are almost impossible to sterilize and keep sterile under emergency conditions and are therefore dangerous. Babies should be fed by clean cup and spoon if necessary. Appropriate weaning foods should be introduced while breast-feeding is continuing. Weaning foods should be locally available foodstuffs and as far as possible be prepared in the traditional manner. Overseas donations of tinned baby foods are rarely appropriate.
10 Re-stimulate lactation refers to the re-establishment of an adequate volume of milk release. This is achieved by increasing suckling and through social peer support.
|
Policy On Use of Milk Powder11 i. Never distribute milk powder, by itself, to take home. It should be mixed with cereal flour, six parts cereal to one part milk powder; ii. Never let liquid milk be carried home; iii. Only use dried milk in supervised wet feeding programmes as a high energy drink mixed with oil and sugar; iv. Dried skimmed milk should always be fortified with Vitamin A and have a Shelf-life Of more than six months. |
11UNHCR IOM 88/89/FOM 76/89 Policy Directive for acceptance, distribution and use of milk products in refugee feeding centres, UNHCR, Geneva.
Calculation of Nutritional value of Food Commodities (NUT-VAL), an EXCEL spreadsheet which can be used to calculate the nutritional value of ration scales, UNHCR, Geneva, 1998.
Commodity Distribution: A Practical Guide For Field Staff, UNHCR, June 1997.
IOM 88/89 - FOM 76/89 Policy for acceptance, distribution and use of milk products in refugee feeding programmes, UNHCR, Geneva, 1989. Also available in French.Memorandum of Understanding (MOU) on the Joint Working Arrangements for Refugee, Returnee and Internally Displaced Persons Feeding Operations, Also available in French. WFP/ UNHCR, 1997.
Nutrition Guidelines, Médecins Sans Frontières (MSF), 1995. Essential Reading.
Nutrition Surveys in Emergency Situations, (Video, PAL, 38 min), UNHCR Geneva.
WFP/UNHCR Guidelines For Estimating Food and Nutritional Needs, Also available in French. WFP/UNHCR, 1997.
WFP/UNHCR Guidelines For Selective Feeding Programmes in Emergency Situations, WFP/ UNHCR, 1999.
Glossary
|
Anthropometric |
Assessment of body size and composition which reflects food intake, physical activity and disease. Most common anthropometric indicators include weight, height and arm circumference. |
|
Baseline data |
Data collected at the beginning of a programme that can be compared with similar data collected later and so used to evaluate the impact of interventions or to monitor trends. |
|
Body Mass Index (BMI) |
(weight in kg)/ (height in m)2 which is used for assessing the nutritional status of adolescents and adults. |
|
Fortified blended food |
A flour composed of pre-cooked cereals and a protein source, mostly legumes, fortified with vitamins and minerals, e.g. corn soya blend (CSB), wheat soya blend (WSB) used for feeding programmes. |
|
Fortification |
Adding micronutrients to foods, e.g. iodized salt and fortified blended food. |
|
Kilocalorie |
Unit of energy used in nutrition, 1 Kcal = 4.17 kilojoules. |
|
Kwashiorkor |
Severe form of malnutrition characterized by oedema (swelling) particularly of the lower parts of the arms and legs. |
|
Marasmus |
Severe form of malnutrition in which the person becomes wasted. |
|
Micronutrients |
Minerals and vitamins. |
|
Mid-upper arm |
Circumference at the mid-point of the left upper arm, which is an indicator of malnutrition and used as a tool for screening. |
|
Nutrients |
Those parts of food that are absorbed and/or used by the body i.e. carbohydrate, protein, fat, alcohol, vitamins and minerals. |
|
Oedema |
An abnormal accumulation of fluid in intercellular spaces of the body. In case of nutritional oedema this is oedema due to a deficiency in the diet. |
|
On-site feeding |
Cooked meal eaten at the feeding centre. |
|
Stunting |
Low height for age. Comparing the height of a child of a certain age with the height of reference (healthy) children of the same age indicates the level of chronic malnutrition. |
|
Take-home rations |
Dry rations that are given to people to take and prepare at home. |
|
Therapeutic milk |
Special milk used for rehabilitation of severely malnourished persons. |
|
Wasting |
Abnormal loss of fat and/or muscle tissue which is indicated by a low weight for height, a low body mass index or observation (thinness). |
|
Xerophthalmia |
Clinical signs in the eye caused by Vitamin A deficiency. |
|
Weight-for-Height |
The weight of a person at a certain height compared with the reference weight for that height. |
Annex 1 - Basic Facts About Food and Nutrition
All foods are made up of five basic types of nutrient in addition to variable amounts of water.
Carbohydrates, the main source of energy, provide 4 kcal/g. They are mostly starches and sugars of vegetable origin, and are a major component of cereals and tubers.
Fats and oils provide the most concentrated source of energy, and have more than twice the energy content per weight of carbohydrates and proteins (9/kcal/g).
Proteins are body-building substances required for growth and tissue repair. Protein is found in foods of animal origin and in cereals and legumes and provide 4 kcal/g.
Vitamins and minerals are needed in small quantities for the adequate functioning of the body and protection against disease. Fresh vegetables and fruits are a good source of vitamins. Water soluble vitamins are fragile and cannot be stored (Vitamins Bs and C), whereas fat soluble vitamins can be stored in the body (Vitamin A and D). Important minerals are iron, sodium, iodine, zinc, magnesium, potassium, etc. Individual vitamins and minerals or combinations are found in all foods in very variable amounts.
Energy and Protein Intakes
If the energy intake is inadequate, some protein will be burnt to provide energy. That is, it will be used in the same ways as carbohydrate or fat. More than 20% of the energy requirement should be supplied from fats and oils which greatly enhance the palatability of the diet and increase energy density (important for younger children). Energy requirements vary widely even in normal individuals. They are also increased by physical activity. Much higher energy and protein intakes are required for the treatment of malnutrition, when the aim is rehabilitation rather than maintenance.
Food and Diets
Most diets in most countries contain adequate amounts of all the nutrients required for good health if enough of the diet is taken to satisfy the individual's energy requirements. Even a growing child, if healthy, requires no more than 10% of total calories to be supplied from protein sources.
Figure
Annex 1 (cont.) - Nutritional Value Of Food Commodities
|
COMMODITY |
Nutritional Value/100 g | | ||
| |
Energy |
Protein |
Fat |
Price per MT |
|
Cereals |
|
| |
|
|
Wheat |
330 |
12.3 |
1.5 |
165 |
|
Rice |
360 |
7.0 |
0.5 |
280 |
|
Sorghum/Millet |
335 |
11.0 |
3.0 |
200 |
|
Maize |
350 |
10.0 |
4.0 |
170 |
|
Processed Cereals |
|
|
|
|
|
Maize meal |
360 |
9.0 |
3.5 |
225 |
|
Wheat flour |
350 |
11.5 |
1.5 |
240 |
|
Bulgur wheat |
350 |
11.0 |
1.5 |
220 |
|
Blended Food |
|
|
|
|
|
Corn Soya Blend |
380 |
18.0 |
6.0 |
320 |
|
Wheat Soya Blend |
370 |
20.0 |
6.0 |
390 |
|
Soya-fortified bulgur wheat |
350 |
17.0 |
1.5 |
240 |
|
Soya-fortified maize meal |
390 |
13.0 |
1.5 |
270 |
|
Soya-fortified wheat flour |
360 |
16.0 |
1.3 |
240 |
|
Soya-fortified sorghum grits |
360 |
16.0 |
1.0 |
190 |
|
Dairy Products |
|
|
|
|
|
Dried Skim Milk (enriched) |
360 |
36.0 |
1.0 |
1,900 |
|
Dried Skim Milk (plain) |
360 |
36.0 |
1.0 |
1,800 |
|
Dried Whole Milk |
500 |
25.0 |
27.0 |
2,200 |
|
Canned cheese |
355 |
22.5 |
28.0 |
1,850 |
|
Therapeutic milk |
540 |
14.7 |
31.5 |
2,200 |
|
Meat and Fish |
|
|
|
|
|
Canned meat |
220 |
21.0 |
15.0 |
1,950 |
|
Dried salted fish |
270 |
47.0 |
7.5 |
1,500 |
|
Canned fish |
305 |
22.0 |
24.0 |
2,000 |
|
Oils and Fats |
|
|
|
|
|
Vegetable oil |
885 |
- |
100.0 |
750 |
|
Butter oil |
860 |
- |
98.0 |
2,300 |
|
Edible fat |
900 |
- |
100.0 |
950 |
|
Pulses |
|
|
|
|
|
Beans |
335 |
20.0 |
1.2 |
440 |
|
Peas |
335 |
22.0 |
1.4 |
375 |
|
Lentils |
340 |
20.0 |
0.6 |
500 |
|
Miscellaneous |
|
|
|
|
|
Sugar |
400 |
- |
- |
350 |
|
High Energy Biscuits |
450 |
12.0 |
15.0 |
1,250 |
|
Tea (black) |
- |
- |
|
1,235 |
|
Iodized salt |
- |
- |
- |
150 |
|
Dates |
245 |
2.0 |
0.5 |
1,900 |
|
Dried fruit |
270 |
4.0 |
0.5 |
1,200 |
Note: The prices quoted are free-on-board (FOB) and therefore do not include transportation costs. The prices shown are as of 1998 and will vary over time. This information is regularly updated and published by WFP and is available from WFP HQ's or from their offices in the field.
Annex 1 (cont.) - Characteristics of Common Foods
|
|
Food type |
Vitamins and minerals |
Comments |
|
1. |
Cereal grains (rice, corn, sorghum, oats, etc.) |
Contain vitamin B and iron. |
The main source of both |
|
2. |
Legumes/oilseeds (beans, peas, soya, groundnuts, etc.) |
B complex vitamins. Most |
Legumes are particularly |
|
3. |
Whole tubers and roots (yams, taro, cassava, sweet potato, potato, etc.) |
Variable but generally low, |
Bulk and low protein content |
|
4. |
Vegetables and fruits |
Important source of vitamins |
|
|
5. |
Meat, milk and dairy products, eggs, etc. |
Good sources of B vitamins. |
Usually consumed in very |
|
6. |
Fish, dried |
Rich source of calcium and |
A concentrated source of |
|
7. |
Fats and oils |
Fats derived from milk are |
Useful way to increase |
Annex 2 - Examples of Food Rations
Examples of adequate full rations for the affected population entirely reliant on food assistance12
Five types of rations are shown to illustrate differences due to such factors as the food habits of the population and the acceptability and availability of the commodities in the region.
|
Items |
Rations | ||||
|
|
Type 1* |
Type2* |
Type 3* |
Type 4** |
Type 5* |
|
Cereal flour/rice/bulgur |
400 |
420 |
350 |
420 |
450 |
|
Pulses |
60 |
50 |
100 |
60 |
50 |
|
Oil (vit. A fortified) |
25 |
25 |
25 |
30 |
25 |
|
Canned fish/meat |
- |
20 | |
30 |
|
|
Fortified blended foods |
50 |
40 |
50 |
- |
- |
|
Sugar |
15 |
20 |
20 | |
20 |
|
Iodized salt |
5 |
5 |
5 |
5 |
5 |
|
Fresh veg./fruits |
- |
- |
| |
100 |
|
Spices |
- |
- |
- |
- |
5 |
|
Energy: kilocalories |
2113 |
2106 |
2087 |
2092 |
2116 |
|
Protein (in g and in % kcal) |
58 g; 11 % |
60 g; 11 % |
72 g; 14% |
45 g; 9% |
51 g; 10% |
|
Fat (in g and in % kcal)* |
43g; 18% |
47 g; 20% |
43 g; 18% |
38 g; 16% |
41 g; 17% |
* For rations 1, 2, 3, & 5 the cereal used for the calculation is maize meal
** This ration has rice as a cereal; the low percentage energy for protein is acceptable due to its high quality; the slightly low fat content is in line with food habits in rice-eating countries
Examples of Typical Daily Rations for SFPs (in grammes per person per day)
|
|
Take-home |
On-site feeding or wet ration | |||||
|
Item |
Ration 1 |
Ration 2 |
Ration 3 |
Ration 4 |
Ration 5 |
Ration 6 |
Ration 7 |
|
Blended food, fortified |
250 |
200 |
100 |
|
|
125 |
100 |
|
Cereal |
|
|
| |
125 |
|
|
|
High Energy Biscuits (HEB) |
|
|
12513 | |
|
|
|
|
Oil, fortified with vitamin A |
25 |
20 |
15 |
20 |
|
10 |
10 |
|
Pulses |
| |
30 |
30 |
|
|
|
|
Sugar |
20 |
15 |
|
| |
10 |
10 |
|
Salt, iodized |
|
|
5 |
| |
|
|
|
Energy (Kcal) |
1250 |
1000 |
620 |
560 |
700 |
605 |
510 |
|
Protein (g) |
45 |
36 25 |
|
15 |
20 |
23 |
18 |
|
Fat % Kcal |
30 |
30 |
30 |
30" |
28 |
26 |
29 |
12 WFP/UNHCR Guidelines for estimating food and nutritional needs. December, 1997.
13 WFP Specification.
14 High Energy biscuits with 15% fat meet the energy density requirement.
Annex 3 - Main Nutritional Deficiency Disorders in Emergencies"
|
Protein-energy malnutrition (PEM) is likely to be the most important health problem and a leading cause of death during an emergency. There are several forms: Marasmus is marked by the severe wasting of fat and muscle, which the body has broken down for energy, leaving "skin and bones". It is the most common form of PEM in nutritional emergencies. Children under 5 years are usually the most affected, but older children and adults are also often at risk or affected. The treatment of severe forms of PEM is presented in the section on selective feeding programmes. Vitamin and mineral deficiencies can cause long-lasting or permanent disabilities and can be fatal. The deficiencies most likely to occur include: Iron deficiency (1) causes anaemia. (signs: pallor of skin and eyelids, fatigue, weakness and shortness of breath); (2) increases the risk of haemorrhage, infection and death associated with childbirth; (3) increases rates of low-birth-weight and (4) impairs the cognitive development of infants and children. Iodine deficiency causes not only goitre but also some impairment of intellectual development of children and of reproductive performance in women. Severe maternal deficiency can cause cretinism in the offspring. Best prevented in emergencies by the use of Iodized salt. Vitamin A deficiency causes Xerophthalmia, blindness and death. Eye signs: poor vision in dim light, dryness of conjunctiva or cornea, foamy material on the conjunctiva or clouding of the cornea itself. These signs may appear after several months of an inadequate diet, or following acute or prolonged infections, particularly measles and diarrhoea. Vitamin B1 (Thiamine) deficiency causes beri-beri. Symptoms and signs: loss of appetite, malaise and severe weakness, especially in the legs; may also lead to paralysis of the limbs or swelling of the body, heart failure and sudden death. Beri-beri occurs when the diet consists almost exclusively of white polished rice or starchy staple such as cassava. Vitamin C deficiency causes scurvy. Signs: swollen gums which bleed easily, swollen painful joints, easy bruising. This occurs due to a lack of fresh vegetables and fruits. Niacin deficiency causes pellagra. Signs: skin rash on parts of body exposed to sunlight; diarrhoea; and mental changes leading to dementia. This occurs especially where maize and sorghum are the staples and there is a lack of other foods. Prevention involves ensuring that people receive or have access to a variety of foods that contain sufficient quantities of essential vitamins and minerals. This also includes fortified food items distributed in food aid, access to local markets, and produce from home gardens. Treatment consists of administering therapeutic doses of the missing nutrients. The distribution of multi-vitamin tablets to the entire refugee population is a waste of time and money, since they contain insufficient quantities of individual vitamins to correct deficiencies. |
15 Adapted from: The Management of Nutritional Emergencies in Large Populations, WHO, Geneva, 1999 (in press).
Annex 4 - Reporting Form: Supplementary Feeding Programme
|
Country: Location: Agency: | | | |
Period: | |
| |
Total population: |
| |
CATEGORIES |
| ||||||
|
|
< 5 years |
³ 5 years |
Pregnant |
Lactating |
TOTAL | |
||
| |
M |
F |
M |
F |
women |
women |
| |
|
Total at end of last |
|
|
|
|
|
|
| |
|
New Admissions: |
|
|
|
|
|
|
| |
|
< 80% WFH or |
|
|
|
|
|
|
| |
|
Others |
|
|
|
|
|
|
| |
|
Total New |
|
|
|
|
|
|
| |
|
Re-admissions |
|
|
|
|
|
|
| |
|
Total Admissions |
|
|
|
|
|
|
| |
|
Discharged |
|
|
|
|
|
|
|
percentage |
|
Discharges (E) |
|
|
|
|
|
| |
E/I*100%= |
|
Deaths (F) |
|
|
|
|
|
|
|
F/l*100%= |
|
Defaulters (G) |
|
|
|
|
|
|
|
G/l*100%= |
|
Referrals (H) |
|
|
|
|
|
|
|
|
|
Total Discharged |
|
|
|
|
|
|
| |
|
New Total at end |
|
|
|
|
|
|
| |
Average length of stay in the programme
(from all or a sample of 30 recovered children) (target <60 days) =
|
Total No of days of admission of all (or 30) recovered children |
|
No of recovered children (or 30) |
Comments:
Annex 5 - Reporting Form: Therapeutic Feeding Programme
|
Country: | | | |
Period: | |
| |
Total population: |
| |
CATEGORIES |
|
|
|
< 5 years |
³ 5 years |
Adults |
TOTAL | |
|||
| |
M |
F |
M |
F |
M |
F |
| |
|
Total at end of last |
|
|
|
|
|
|
| |
|
New Admissions: |
|
|
|
|
|
|
| |
|
< 70% WFH or | |
| | |
| | |
|
|
Kwashiorkor |
|
| | |
|
|
| |
|
Others |
|
|
|
|
|
|
| |
|
Total New |
|
|
|
|
|
|
| |
|
Re-admissions (C) |
|
|
|
|
|
|
| |
|
Total Admissions |
|
|
|
|
|
|
| |
|
Discharged |
|
|
|
|
|
|
|
percentage |
|
Discharged (E) |
| | |
| | |
|
E/l*100%= (>75%) |
|
Deaths (F) |
|
|
|
|
|
|
|
F/l*100%= (<10%) |
|
Defaulters (G) |
|
|
|
|
|
|
|
G/l*100%= (<15%) |
|
Referrals (H) |
|
|
|
|
|
|
|
|
|
Total Discharged (I=E+F+G+H) |
|
|
|
|
|
|
| |
|
New Total at end |
|
|
|
|
|
|
| |
Causes of death:
Average weight gain during last month (from all or a sample of 30 children) (target: >8 g/kg/day) =
|
weight at end of month (or on exit) - lowest weight recorded during month |
|
lowest weight recorded in last month × No of days between lowest weight recorded and end of month (or on exit) |
Average weight gain for marsmus (include only children in phase II) =
Average weight gain for kwashiorkor (include only children in phase II after complete loss of oedema) =
Average length of stay in the programme (from all or a sample of 30 recovered children) (target <30 days) =
|
Total No of days of admission of all (or 30) recovered children |
|
No of recovered children (or 30) |
Annex 6 - Nutrition Survey Reporting Form
Country:
Camp:
Date of reporting:
|
Population |
Male |
Female |
Total | ||
| |
number |
% |
number |
% |
number |
|
total population |
|
|
|
|
|
|
under five population |
|
|
|
|
|
|
Survey |
| ||||||||||
|
date: |
............/............/............/ | ||||||||||
|
method: |
random - systematic - cluster | ||||||||||
|
sample size: |
| ||||||||||
|
under five population |
Male |
Female |
Total | ||||||||
|
(6-59 month or 65-110 cm) |
number |
% | | |
number |
% | | |
number | ||
| |
| | | |
|
| | |
| ||
|
Results |
| ||||||
|
weight-for-height |
weight-for-height | ||||||
|
category |
number |
% |
confidence |
category |
number |
% |
confidence |
|
<70% and/or |
|
|
|
£ 3 and/or |
|
|
|
|
>70 |
|
|
|
³3 and ³2 |
|
|
|
|
total |
|
|
|
total |
|
|
|
Other results:
(mean Z-score, mean SD, family size, % children in each category that is attending feeding center)
Comments/Observations:
Action/Intervention:
 |
 |
