Revised MSF Nutrition Guidelines II

By Saskia van der Kam, MSF Holland, Senior Nutritionist

This is the second in a series of pieces published in Field Exchange^* which summarises key sections of the newly revised MSF nutrition guidelines for use in emergencies. The first article highlighted the importance of locating the food security situation on the continuum from food insecurity to famine and the implications for intervention. This second article summarises the section of the guidelines¹ which deals with choice of nutritional interventions and programme design in relation to severity of food crisis and other factors.

Decision tree

An overall contextual analysis is critical for guiding appropriate decisions on intervention type and design. Each situation requires a coherent nutritional strategy as well as ensuring that all target groups are catered for by the different programmes.

Based upon the stage of the food insecurity situation^*, MSF have developed a decision tree which helps to interpret the seriousness of a situation through an analysis of indicators. Quantitative and qualitative information on these indicators can then be used to inform decisions about nutritional strategies.

Although analysis of the indicators is an important component of decision-making there are other considerations as well. The capacities and coping strategies of the community must not be underestimated or undermined by the intervention. Unnecessary feeding programmes can have an adverse impact on the community by creating dependency and disrupting market mechanisms.

Additionally, factors such as population movements, epidemics, poor health care, inadequate water supplies (quantity, quality), extreme temperatures and security problems should all be taken into account when deciding to implement a programme and what form it should take.

An optimal nutritional strategy takes into account constraints in order to arrive at a realistic response. The constraints most commonly encountered are: limited access to the population, lack of skilled personnel, insufficient financial resources and insecurity.

TFP

The primary aim of a Therapeutic Feeding Programme is to treat severely malnourished people.

In principle, each person suffering from severe malnutrition is at extreme risk of mortality and thus, should receive immediate intensive medical and nutritional treatment. A TFC should be implemented when the absolute number is over 30 patients and the prevalence of severe malnutrition is above 3% (provided staff and other resources are available). Where there is only a small number of severely malnourished individuals, it is more appropriate to support existing health structures in the provision of therapeutic feeding care rather than setting up a new programme.

Therapeutic feeding centres should provide a 24 hour care component. However, in times of famine when the numbers to be treated are overwhelming and staff are limited a preferred option may be to implement a simplified protocol of day care. This would include simple standard treatments and meals based on weight groups rather than individual weight criteria. Snacks can be distributed for night consumption at home.

Severely malnourished adults should always be admitted to therapeutic feeding centres. If there are large numbers of severely malnourished adults, it may be appropriate to open a special TFC for adults. Adult TFCs have certain specific design features and requirements.

SFP

The primary objective of a supplementary feeding programme is to treat moderate malnutrition and prevent further deterioration in nutritional or health status.

Supplementary feeding is usually necessary in a food crisis or famine situation where malnutrition rates exceed 15% and there is increased mortality or increased numbers of severely malnourished. The implementation of a SFP is not dependent upon overall food availability, the General Food Distribution (GFD) and/or presence of a blanket feeding programme.

Furthermore, SFCs should be established as a follow up programme for TFC dischargees.

However, other factors can influence decisions about whether to implement a SFC. For example, when food security is expected to improve considerably within two months, it may not be appropriate to implement a SFC, even if there is a high prevalence of moderate malnutrition.

The two main design options for SFPs are daily serving of cooked meals (wet feeding) or weekly/bi-weekly handing out of a fortified food item (dry feeding). As there is no significant difference in outcome dry feeding tends to be preferred as it requires less programme input and also allows more freedom for the beneficiaries. Reasons for implementing an on-site feeding programme are: a high level of insecurity in the area (theft) and lack of water or firewood.

Blanket feeding

The objective of blanket feeding is to act as a temporary means of covering for quantitatively or qualitatively inadequate General Food Distributions thereby preventing immediate deterioration in nutritional status. Advocating for an adequate GFD is therefore an integral part of a blanket feeding programme. Such programmes exist as damage control measures.

A blanket feeding programme can be initiated when there is a severe food crisis or a significant and persistent deterioration in food availability is expected even when nutritional problems have not yet arisen. The precise objective of a blanket feeding programme will determine the target group and the ration.

Target groups might be: vulnerable families, families excluded from a GFD, pregnant and lactating women, under fives and elderly. All members of a specific vulnerable group are included in the blanket feeding programme, regardless of their nutritional status.

Blanket feeding may be appropriate at the start of an emergency as implementation of a full general food distribution programme takes time. A rapid way of giving out blanket feeding programme rations may be to distribute a fixed amount of food to all under fives assuming that all households have at least one under five. The ration is meant for the entire family and it is expected that it will be shared.

Blanket feeding as a supplement for pregnant and lactating mothers to cover their increased nutritional needs may be appropriate in situations where the GFD is structurally inadequate for some people, e.g. partial rations.

When the general ration provides inadequate micro-nutrients for specific groups like pregnant and lactating women they can be supported via a blanket feeding programme. In other situations blanket feeding may provide an infrastructure for providing adequate weaning foods for all small children.

General food distribution

Provision of a satisfactory general food distribution is the key nutritional strategy in every nutritional crisis. Target groups, organisation of the distribution and ration size may alter with the severity of the situation.

In a food insecure situation, economic support for the most socially and economically vulnerable is often a sensible aim of a GFD. This could be provided through food for work. In a developing nutritional crisis targeting becomes less appropriate, while increasing food availability rather than providing economic support becomes more of a priority.

It is essential that there is good monitoring of the entire food distribution chain even though different agencies may be involved at different stages of the process. Ideally, monitoring should be carried out by agencies who are not involved or responsible for the distribution and who have good relations with beneficiaries.

The next issue of Field Exchange highlights technical issues in the treatment of the severely malnourished taken from the new MSF guidelines on nutrition in emergencies.

Authors of the MSF nutritional guidelines: Sophie Baquet, Saskia van der Kam, Jane Little, Veronique Priem, Fabienne Vautier.

*see Field Exchange 10

¹The MSF nutrition guidelines are still in draft; consequently details may differ from the final book