ACC/SCN Working Group on Nutrition in Emergencies

Excerpts from Working Group Report

The ACC/SCN held its 27th Session at the World Bank in Washington DC last April. About 60 participants from NGOs, bilateral and UN agency were present for the afternoon meeting of the Working Group in Emergencies. The agenda included, among other topics, an update on research work among malnourished adults and nutritional problems faced by infants in emergencies.

Update on Adult Malnutrition programmes and research in Brazzaville and Burundi

(Carlos Navarro, ACF-F Action Contre La Faim)

Dr. Navarro presented a broad overview of some of the problems encountered when trying to treat severely malnourished adults in Burundi and Congo-Brazzaville, where ACF is undertaking an analysis of its operational (nutritional) programmes. The project in Burundi has been operating since 1994 and at least 1,000 persons per month (including 700 adults) have been treated in 5 Therapeutic Feeding Centres (TFCs) in two provinces. The programme in Brazzaville began in July 1999, and has treated approximately 600 patients per month, including 400 adults, in 3 TFCs. The objective of the presentation was to present some of the operational dilemmas that arise.

Emergency nutrition interventions aiming to address adult malnutrition, are becoming increasingly common practice in emergencies and there continues to be an enormous demand for information on diagnostic criteria, and protocol specifications.

In summary, the following issues were highlighted as operational problems in ACF programmes:

Criteria for assessment of acute adult malnutrition

• The inappropriateness of Body Mass Index (BMI) for assessing acute malnutrition ("a progressive loss") in emergencies, as opposed to chronic malnutrition (a "steady state" of malnutrition), is increasingly recognised. Despite ongoing ambiguities regarding cut-offs, MUAC and clinical outcomes are used more frequently as assessment tools for admission criteria in current operations.
• The inability to stand has been identified as a very good prognostic tool to predict mortality in malnourished adults. Ways to identify this functional deterioration by measuring strength are currently being explored.
• Preliminary findings have shown severely malnourished individuals recover well in supplementary feeding interventions. Those admitted with BMI<16 have recovery rates of at least 50% and those admitted with BMI between 16 and 17 have recovery rates greater than 90%. Current research is focusing on the followup and outcomes of the remaining 50%.

Medical management of patients in TFCs
The high prevalence of both acute and chronic disease among malnourished adults poses a serious challenge in the management of adult malnutrition. The design of therapeutic feeding for adults must take into consideration some important medical issues. These include:

• In adults, severe malnutrition beyond a certain threshold is almost always accompanied by medical complications;
• Acute diseases such as diarrhoea do not necessarily contribute to malnutrition in adults to the same extent as in children, instead malnutrition is often associated with, or is the consequence of, a chronic and debilitating disease such as chronic hepatic and cardiac complications, which are more prevalent in adults. Case by case diagnosis is essential and either referral services or hospital facilities should be provided. It is important to recognise that medical and nutritional problems both need addressing.
• Staff working in therapeutic nutrition centres may not have sufficient medical skills, or may not be appropriately trained to address severe adult malnutrition.

An agency that wants to assist severely malnourished adults may therefore need to consider a complete revision of the strategy, objectives, training, and other means (including human) it usually puts in place to cope with severe malnutrition in emergencies.

Oedema and refeeding oedema

• The differential diagnosis of famine oedema in adults is complicated by the high prevalence of other diseases (cardiac insufficiency, cirrhosis, etc.). Further training and guidelines, adapted for staff in emergency TFCs need to be developed.
• Large numbers of patients have been identified with re-feeding oedema or have failed to reduce levels of oedema despite appropriate diagnosis and treatment. This is most likely due to inappropriate foods being consumed e.g. those with high salt or low protein content or both.

Treatment considerations

• Treatment with the same protocols proposed for children (with changes in the quantities per kilo) have been found to be very satisfactory. Weight gains, duration of stay and success rates may be as high as those for children.
• Acceptability and adherence to a therapeutic diet is more challenging for adults, in particular the refusal of a pure milk based diet remains a constraint. Alternatives to milk (with the same nutritional properties) are currently being explored.

HIV/AIDs

• In both Brazzaville and Burundi, ACF has reported that a high prevalence of the patients admitted to the TFCs are HIV positive. Despite this, recovery rates and other indicators (weight gain, duration of stay) do not seem to be affected, suggesting that HIV positive malnourished adults do recover as well as HIV negative adults.
• The impact of the high prevalence of HIV related malnutrition in adults and its therapeutic management is not well understood. Research into HIV and malnutrition in emergencies is urgently required, however the complexity of the topic, and the ethical and operational problems presented make it extremely difficult for any agency to conduct such research.

Social considerations

• Adults have a caring role in the family, are the source for food and revenues, and the actors of reconstruction, social representation, etc. Separating them from their social environment may have deleterious consequences for their livelihoods and their ability to cope with, or recover from their current situation. Shorter-term treatment and ambulatory treatment may be appropriate strategies for addressing these issues.
• In locations where malnutrition related mortality is high among adults indirect social problems may also arise. In Burundi, many children have become orphans. ACF and its partners in Burundi are actively involved in taking care of orphans, and also in reuniting them with their surviving relatives.

Nutritional problems faced by infants in emergencies

Prof. Michael Golden, University of Aberdeen

Prof. Golden outlined a number of important problems/issues regarding infant nutrition. Issues about the inclusion of infants in nutritional surveys were covered in an article post-script written by Prof Golden in Field Exchange 9^* and so will only be cursorily dealt with here. The main points about infants in nutritional surveys made in the presentation were that:

• Infants are not systematically surveyed.
• Current selection criteria for surveys often only include children above 6 months and longer than 65 cm so that there is a selection bias.
• There are no established cut-off points or criteria for infants less than six months to define severe malnutrition (and admission into TFCs).
• The weighing scales and length boards currently provided by UNICEF are insufficiently accurate to screen and manage high-risk infants.

Additional points raised by Golden about infant nutrition in emergencies included the following:

• Currently F100, diluted to lower the renal solute load and osmolarity, is used empirically to re-feed infants. There have been no studies on alternative diets for the severely malnourished infant.
• Rehabilitating the severely malnourished infant whilst maintaining lactation raises a number of serious difficulties. Severely malnourished infants:
  • do not cry and, because they do not complain or show hunger, are neglected (this is not abuse),
  • lack strength and therefore are not able to suck effectively or stimulate milk production,
  • have a very high mortality risk.
• A technique to support lactation, known as supplemental suckling, has been developed (see Field Exchange 9).

Mother's diet

• Breastfeeding mothers need a nutrientdense balanced diet. Mothers with type 1 deficiencies (not associated with maternal anthropometric change) can have breast-milk which can lead to death or severe and irreversible defects in their infants.
• Clinical deficiencies of Vitamin K and D, iodine, thiamine, cobalamine, pyridoxine appear in breast-fed infants before their mothers. Deficiencies of selenium, Vitamin E and A and folate can appear in both child and mother at the same time, although data are inconclusive. Type 2 nutrients are preferentially preserved in breastmilk, while Type 1 levels will fluctuate in breastmilk.
• In order to have a healthy infant (and mother) the breastfeeding mother's diet must contain all 40 essential nutrients.

Recommendations of the Working Group to the ACC/SCN for action

Adult malnutrition

Clarify issues relating to adult malnutrition including its definition, and operational intervention guidelines. Disseminate this information as widely as possible to agencies in need of support and guidance.

Infant feeding issues

Liaise with the Breastfeeding and Complementary Feeding Working Group in taking responsibility for further development of the operational guidance, management of the consultative process and coordination of dissemination. Improve the training of humanitarian staff on infant feeding practice. Advocate for the need of experts on infant feeding issues to be present at all emergencies from the outset.

For further information or full report contact the ACC/SCN c/o World Health Organisation, 20 Avenue Appia 1211 Geneva 27 Switzerland. phone: + 41-22-791 04 56 fax: + 41-22-798 88 91 EMail: accscn@who.int http://www.unsystem.org/scn/

^*'Comment on: Including infants in nutrition surveys, experiences in Kabul city', Field Exchange 9, March 2000, pp16-17