Outil d’aide à la prise de décision en cas de malnutrition aiguë modérée (MAM)

Objectifs de la réunion Réviser l’outil d’aide au processus de prise de décision en cas de malnutrition aiguë modérée (MAM) Travailler sur la situation du pays Fournir un compte rendu sur : Le contenu L’usage La présentation

Malnutrition aiguë modérée (MAM) Historique Révision des programmes d’alimentation complémentaire (2007) Consultations OMS MMI (2008) et MMII (2010) Besoins alimentaires Programme d’approche afin de gérer la MAM Révision NUGAG (OMS) sur la MAM Orientation limitée des programmes Différentes approches Augmentation des produits disponibles pour les programmes The review of supplementary feeding by Save the Children found poor quality data making it difficult to assess the impact of the programs on reaching their objectives. Nutrition Guidance expert Advisory Group -NUGAG (WHO) Food specifications, effectiveness and safety Cash Transfers Population versus Individual There are various guidance documents- from the WHO intervention table from 2000 in the Management of acute malnutrition to individual agency documents- but these may have had differing approaches to programming. Additionally, the proliferation of products increased the confusion on the appropriate use of products for the programme objectives. The MAM taskforce reviewed existing guidance and current research to come up with the basis for this tool. CONFUSION!!!

Malnutrition aiguë modérée (MAM) Chiffres de la MAM Globalement entre 36 et 41 millions d’enfants souffrent de MAM 3 x plus de risque de mort comparé aux enfants bien nourris Risque de malnutrition sévère augmenté dans les situations d’urgence

Groupe de travail MAM Formé à partir du Cluster Global Nutrition UNHCR UNICEF WFP OFDA ACF Save the Children CDC Membres additionnels OMS ECHO The MAM taskforce was formed under the auspices of the Global Nutrition Cluster and tasked with developing interim programmatic guidance. Additional members have been included in the taskforce- namely WHO and ECHO. The tool was reviewed by an external group of experts, before circulating to the field. 6 countries have been selected for piloting and feedback of the tool- Kenya, Somalia, Chad, Mali, Niger, DRC. The tool will be translated into French prior to the piloting in the francophone countries.

Objectifs de l’outil Guider les praticiens afin d’identifier les stratégies les plus adéquates et réalisables pour aborder la MAM Prévention Gestion (traitement) Harmoniser le programme nutrition dans la prise de décision sur la MAM dans les situations d’urgence Introduire les facteurs contexte/situation dans le processus de prise de décision Aller au-delà du statut nutritionnel Prendre part à la discussion The tool aims to use data to inform programme design, however careful consideration and discussion of the contextual factors is needed. The key objectives of the tool are to identify the most appropriate /feasible strategies to address MAM- prevention, treatment, combination of the two or no additional interventions may be needed To unify decision making on MAM. This however does not mean that all progammes will be the same. There may even be variation within an emergency. To incorporate context into the decision-making process. This was done before, but not uniformly. In this tool, it is a specific step taken to inform the decision on the type of programme. Processus de prise de décision fondé sur les données mais subjectif sur certains niveaux

Mise en garde de l’outil Limité aux contextes d’urgence Apparition rapide et soudaine Lente apparition Urgence prolongée Urgence aiguë dans un contexte d’une urgence chronique Urgence locale ou à grande échelle Non applicable dans les contextes de réfugiés UNHCR/WFP Conseils pour l’alimentation sélective : La gestion de la malnutrition dans les urgences 2011 http://www.unhcr.org/4b7421fd20.pdf The use of this tool is limited to emergency contexts and is not meant to be used in regular nutrition programming. Emergencies can range from- Rapid/sudden onset- earthquake, flood Slow onset- drought Protracted emergencies- Somalia Acute emergencies with a chronic setting- high cereal prices in the Sahel; Programming may be different at varying levels across a region or country. The tool can be used for both local and large-scale emergencies. It is important to note that this tool does not apply to refugee contexts where UNHCR is the lead. New guidance for refugee camp settings or refugees where UNHCR is the lead were drafted in 2011. The guidelines are available online at: (see slide). As mentioned previously, UNHCR participated in the drafting of the tool and where feasible there is alignment in the recommendations.

Mise en garde de l’outil Objectif premier: prévenir la morbidité et la mortalité associée à la MAM Liens: la MAM ne peut pas être traitée seule MAS Alimentation pour nourrissons et jeunes enfants en urgence Autres secteurs (WASH, santé, sécurité alimentaire) Réévaluation For the purpose of this tool, the primary objective of MAM programming is to prevent morbidity and mortality associate with MAM. Ultimately, if we want to achieve this, we need to have a multi-sectoral approach- linking MAM with the treatment of SAM, IYCFE, and sectors such as WASH health and food security which have significantly impact the nutritional status of individuals and populations. This list of sectors is not exhaustive and in certain contexts other sectors may need to be involved- for example shelter or protection. Finally, it is critical that the situation be monitored and re-assessed. Programming needs can vary over the course of the emergency.

Etapes de l’outil Prévention/Traitement Prévention Traitement Pas de programme en plus Etape 1: Type de programme/Objectif Etape 2: Méthode Alimentation complémentaire Cash/Bon d’échange Alimentation des nourrissons et jeunes enfants There are 4 steps in the process. Step 1: determine your programme type and objective Step 2: modality- how are you going to achieve your objective Step 3: Operation- which includes target group, product, delivery mechanism and duration. It is crucial to have an exit strategy from the beginning of the program Step 4: review and revise program as the emergency progresses. Programs need to be flexible to meet the needs of the population. We will work through each of these steps and decision making process. Etape 3: Exploitation du programme Groupe cible Produit Durée Distribution Etape 4: Révision Régulièrement tout au long de l’urgence

Besoins en données Fréquence de la malnutrition aiguë globale (MAG) dans la région affectée (actuel ou historique) Information et sévérité de la crise (risque) Base des données de santé dans les régions affectées Impact attendu sur la morbidité Situation de la sécurité de l’alimentation Impact attendu sur la sécurité de l’alimentation Données sur la population Déplacement Densité There are some key pieces of data that will be needed to work through the decision making tool. We will go through each of these points in the next few slides.

Données nutritionnelles MAG scénarios pour l’outil Haut >15% Moyen 8-15% Faible <8% Sources Données des tendances Selon les saisons Données d’admission (la couverture doit être évaluée) Données de dépistage Nutritional data is our starting point. Here we have classified the prevalence of GAM into 3 levels: High >15%. Medium 8-15% and Low <8%. There are various sources of data that can be used to classify the current ( or historical if need be ) nutritional situation. A current survey is probably the easiest and best source. However in the absence of this data, you may use trend data- especially paying attention to any seasonal variation across the year. In the absence of this type of data, admission data could be used or even screening data. Based on this data, classify the nutritional situation.

Risque de détérioration Analyse Score Score total Catégorie de risque Morbidité augmentée (diarrhée aqueuse aiguë, rougeole, infections respiratoires aiguës) Haut 3 Score 6-8: Haut Score 4-5 :Moyen Score <3: Faible Moyen 2 Faible 1 Disponibilité de nourriture et/ou accès interrompu (marché, prix et/ou production) Déplacement significatif de population Oui Non Densité de population In addition to the current nutritional status of the population, we need to consider the risk of deterioration in GAM. You might think of these as what were previously referred to as aggravating factors. These are specific factors which can greatly impact the nutritional status of the population. Four key factors sum to determine the overall risk of deterioration in the situation and a potential increase in GAM. They are: Morbidity Food security Displacement Density Let’s look at each of these risks in more detail.

Morbidité Risque de détérioration Analyse Score Morbidité augmentée Cycle d’infection dû à la malnutrition Probabilité de morbidité et/ou déclenchement et impact (malnutrition aiguë globale) Données de base Couverture de vaccination et de vitamine A, profil de maladie Services WASH Accès aux soins Risque de détérioration Analyse Score Morbidité augmentée diarrhée aqueuse aiguë rougeole infections respiratoires aiguës Haut 3 Epidémie (déclenchement) Moyen 2 Incidence en augmentation Hauts niveaux Faible 1 Incidence stable Faibles niveaux We are all familiar with the malnutrition:infection cycle. Children who are malnourished have increased susceptibility to infection- which has ultimately has a longer duration of illness, which is of greater severity. Children then experience increased metabolism with fever with decreased intake- either due to anorexia or malabsorption- losing weight/growth faltering. The cycle continues. You will need to assess the likelihood of an increase in morbidity or and outbreak which could impact the GAM prevalence. There are some diseases that can significantly influence the nutritional status- diarrhea, measles and ARI. Malaria does not really influence acute malnutrition. An outbreak or an epidemic exists when there are more cases of a particular disease than expected in a given area, or among a specific group of people, over a particular period of time. In an outbreak or epidemic, we usually presume that the cases are related to one another or that they have a common cause. Many epidemiologists use the terms "outbreak" and "epidemic" interchangeably; however, some restrict the use of "epidemic" to situations involving large numbers of people over a wide geographic area. The public is more likely to think that "epidemic" implies a crisis situation.

Sécurité alimentaire Risque de détérioration Analyse Score Magnitude, mesure, sévérité et durée de la crise sur la sécurité alimentaire Consommation ménagère et sources des données du marché Risque de détérioration Analyse Score Disponibilité de nourriture et/ou accès interrompu (marché, prix et/ou production) Haut 3 Manques extrêmes de consommation de nourriture Moyens d’existence épuisés Stratégies de survie iréversibles Moyen 2 Manques significatifs de consommation de nourriture Stratégies de survie irréversibles Diminution initiale des moyens d’existence Faible 1 Consommation de nourriture réduite Pas de consommation déficiente Pas de stratégies de survie The second risk factor to assess is food security. Certain crises like drought or those that damage markets or negatively impact HH income or food prices can significantly impact nutritional status. The magnitude, extent and severity and the impact on food security should be assessed based on data assessing household food consumption and market analysis. As well, the progression of the emergency should be considered- i.e. the proportion of household moving from moderate to severe food insecurity.

Déplacement Type d’influence et fréquence de programme Beaucoup de contextes différents et de types of déplacement Peuplements dispersés, abris de masse dans des centres collectifs, camps d’accueil et de transit, camps indépendents, camps pré-établis (officiels et non officiels), population déplacées intérieurement avec des populations d’accueil Risque of détérioration Analyse Score Déplacement significatif de la population Oui 1 Déplacement augmentant et concentré Non Pas de déplacement Pas d’augmentation de déplacement Région faiblement peuplée Patterns of displacement are diverse and there may be multiple types across a single emergency. Displacement is significant as it relates to issues of access, crowding, WASH, health, shelter- which are all interlinked to nutritional status.

Densité de population Risque de morbidité Considerer le concept du programme de distribution Exemple: faible malnutrition aiguë globale, mais forte densité = nombre élevé d’enfants en besoin Haiti : après tremblement de terre à Port au Prince Kenya : après élection violence dans les centres urbains Population density can greatly impact morbidity and the risk of outbreaks of disease. Additionally, density can influence the delivery design of the programme. For example, in Haiti post earthquake there was a low GAM in in highly densely populated Port-au-Prince. While the GAM was low, the number of children in need was high at the onset of the emergency. Kenya urban areas were similar to this example Risque de détérioration Analyse Score Densité de populati0n Oui 1 Région urbaine Dense concentration de la population Non Toutes les autres régions

Risque de détérioration Analyse Score Score total Catégorie de risque Morbidité augmentée (diarrhée aqueuse aiguë, rougeole, infections respiratoires aiguës) Haut 3 Score 6-8: Haut Score 4-5 :Moyen Score <3: Faible Moyen 2 Faible 1 Disponibilité de nourriture et/ou accès interrompu (marché, prix et/ou production) Déplacement significatif de population Oui Non Densité de population Once you have scored each category of risk- you can sum them to get the overall risk of deterioration for the current situation.

Recommandations de programmes The programme recommendation is based upon the GAM prevalence and the risk level (from tallying the risk for deterioration table). This analysis can be performed for varying levels in an emergency- regional, district. As well, differing vulnerabilities and potential differences in impact on groups should be considered and incorporated into targeting. Examples: women, girls, boys men, ethnic groups, livelihood groups etc.

Etapes de l’outil Prévention/Traitement Prévention Traitement Pas de programme en plus Etape 1: Type de programme/Objectif Etape 2: Méthode Alimentation complémentaire Cash/Bon d’échange Alimentation des nourrissons et jeunes enfants There are 4 steps in the process. Step 1: determine your programme type and objective Step 2: modality- how are you going to achieve your objective Step 3: Operation- which includes target group, product, delivery mechanism and duration. It is crucial to have an exit strategy from the beginning of the program Step 4: review and revise program as the emergency progresses. Programs need to be flexible to meet the needs of the population. We will work through each of these steps and decision making process. Etape 3: Exploitation du programme Groupe cible Produit Durée Distribution Etape 4: Révision Régulièrement tout au long de l’urgence

Alimentation pour nourrissons et jeunes enfants en urgence Prévention : modalité Couverture d’alimentation complémentaire Réserve de nourriture complémentaire Plateforme pour d’autres interventions Dépistages + références Survie de l’enfant (vermifuge, vitamine A, immunisation) Santé/nutrition et éducation Cash ou bon d’échange Cash/bon si la nourriture et les substances nutritives sont bonnes, les marchés fonctionnants, les pratiques de soins maintenues Recherche plus en détails nécessaire Produit spécialisé + cash Cash 4 X la valeur du produit spécialisé Alimentation pour nourrissons et jeunes enfants en urgence IYCF-E support There are 2 main programme choices for the prevention of MAM- Blanket Supplementary Feeding or Cash/vouchers. BSFP is the standard intervention in situations of high GAM, high food insecurity or high chronic malnutrition or micronutrient deficiencies were preexisting. It provides a supplemental food ration. In many situations, BSFP can provide a platform for other interventions- screening and referral, child survival activities and educational outreach. The second option in a cash or voucher system. There is some evidence which suggests that conditional cash transfers show improvement in nutritional status- although further research is needed, particularly as it translates to the emergency context. Two studies have shown that a specialised nutrition product + cash is more effective than cash alone (epicentre, niger) and that a cash transfer equivalent to 4 times the value of special foods had a similar outcome of nutritional status. Cash and vouchers can only be used where the food and nutrient availability is good, markets are functioning and caring practices have been maintained. IYCF-E should be incorporated into any response for MAM. It is rare that in an emergency that IYCF-E would be a stand alone intervention for the prevention on MAM. It would require functioning markets where households have the ability to purchase nutrients and nutrient dense foods required by young children. It is uncommon that an emergency offers the context of stable markets, food diversity and sufficient access for households, therefore the default response should be a supplemental food ration until further research can provide evidence and guidance is produced.

Prévention : groupe cible Les enfants en-dessous de 5 ans sont à risque augmenté de mortalité Les enfants cible sont de 6-59 mois Si les contraintes logistiques réduisent le groupe cible Femmes enceintes et allaitantes Pas de critère standard pour inscription Impact sur le programme d’alimentation complémentaire pour les nourrissons et jeunes enfants en urgence Programme de traitement de la MAM existant Faible poids à la naissance Mettre en priorité Les enfants sur les femmes enceintes et allaitantes Les femmes allaitantes sur les femmes enceintes (protégeant ainsi les nourrissons de 0-6 mois) Children under 5 are at increased risk of mortality associated with acute malnutrition. Emergency situations the risk is often exacerbate. When possible, children 6-59 months should be targeted. It may not always be possible to target all children 6-59 months of age, and so other age groups can be considered,: 6-23, 6-36 months if there are logistic or resource constraints. Deciding whom to target should be based upon several considerations. 1. Children 6-23 months of age should be prioritised if there are logistic/resource constraints- as they often have higher rates of malnutrition and mortality as well as a greater nutrient demand for sustained growth. 2. Children 6-59 months if MAM/SAM treatment is not available or if coverage is <20% 3. There are no current standard criteria or recommendations for the inclusion of PLW into prevention programmes. Issues to be considered include: low birth weight rates, capacity and resources, the impact of the crisis on IYCF-E and if MAM treatment exists for PLW. If LBW programmes are inadequate, include all PLW. Children should be prioritized over PLW and lactating women over pregnant if resources are limited as you are indirectly protecting children 0-6 months by targeting lactating women. BSFP should not be extended beyond 6-59 months or PLW unless there are extraordinary circumstances. The GFD or equivalent HH food security intervention should meet the needs of the household members. Advocacy for improving the GFD should be enacted. Le programme de couverture d’alimentation complémentaire ne devrait pas être étendu au-delà d’enfants de 6-59 mois et aux femmes enceintes et allaitantes excepté selon sérieuses conditions. La distribution générale de nourriture (DGN/GFD) devrait correspondre aux besoins des autres membres du ménage. Un plaidoyer pour améliorer la DGN ou autre sécurité alimentaire devrait être produit.

Prévention : produit Considérations Approbation du gouvernement Objectif de l’intervention et groupe cible Certains produits sont ciblés pour les enfants de 6-23/ 6-36 mois Abilité des membres du ménage à cuisiner Ont-ils les moyens de cuisiner à disposition, ont-ils accès à l’eau et au carburant ? Pratiques culturelles et préférences alimentaires Supercéréales à base de maïs, blé et riz Nourriture prête à consommer à base de cacahuète, pois chiche et lait (quantités limitées) Manque de substance nutritive (énergie et micronutriment) Décider le type de complément selon le niveau d’énergie le plus haut ou le plus bas Sécurité alimentaire, variété d’alimentation, alimentation de base, malnutrition chronique, déficiences de micronutriment Partage des pratiques, utilisation de la nourriture, accès à d’autres produits Selection of product is the next step after you have determined whom to target. Before you start product selection, you must first know what products are approved for use in your context. Not all RUF’s have been approved by countries. There are 4 main considerations in selecting a product(s). The objective of the programme- is it prevention or treatment. What age group are you targeting? Some products are targeted to specific age groups (6-23 or 6-36 months) For example: medium quantity LNS (plumpy’doz) is used for children 6-23 and sometimes up to 36 months of age Supercereal Plus can be used for children 6-59 months The HH ability to cook needs to be assessed The ability to cook is essential for the use of supercereal/plus. If there is no ability to cook, then RUFs are recommended. Cultural practices and food preferences If at all possible, these should be taken into account. New formulations of supercereal are available in wheat and maize and rice based formulations are forthcoming. RUF’s are primarily peanut-based, but there are formulations under development and available in limited quantities (chick-pea based and milk based) Nutrient gap- defined as the energy and micronutrient gaps A judgment on whether to use a high or low energy supplement based on household food security, dietary diversity levels, available information on the baseline diet of children and malnutrition- chronic and micronutrient.

Fiche produit Produits nutritionnels spécialisés At the end of the toolkit is the Product sheet- shown here. It is a reference of products, their intended use, content, packaging, cost per dose and manufacturers. Because new products and manufacturers are regularly coming into production- this list is not exhaustive and will need to be regularly updated.

Fiche produit Produits nutritionnels spécialisés

Produits et alternatives recommandés Groupe cible Recommandation première Provisoire/Alternative Treatment of MAM 6- 59 months RUSF Supercereal Plus Supercereal/oil/sugar premix PLW Supercereal/oil/sugar Older Children RUSF or Supercereal Plus Prévention de la MAM 6-23 ou 6-59 mois Supercéréale Plus LNS en quantité moyenne Complément alimentaire prêt à consommer± Supercéréale/huile/sucre ½ sachet de complément alimentaire prêt à consommer Femme enceinte ou allaitante Within the toolkit- there is a recommended product table which also lists alternative products should the primary product not be available. You can see here for the prevention of MAM among children the primary recommendation is to use supercereal Plus, LNS medium quantity (plumpy’doz) or in rare circumstances RUSF – only where this will be the primary source of food. Alternative are supercereal+oil+sugar or a ½ sachet of RSUF. For PLW- supercereal+oil+sugar is recommended or the alternative would be LNS medium quantity. ± Seulement si le complément est la première source de nourriture disponible

Prévention : durée et stratégie de sortie Durée du programme de couverture d’alimentation complémentaire doit être basée sur l’ampleur et la sévérité de l’urgence MAG + risque de détérioration Généralement 3-6 mois Exemple : commence au moins 1 mois avant la saison de soudure et dure jusqu’à après la récolte Régulière réévaluation Mise à l’échelle de haut en bas Prolongation Admission constante sans renvoi jusqu’à la fin du programme (même si l’enfant est plus âgé que la limite d’âge à la fin du programme) The duration and timing of the BSFP should be based upon the scale and severity of the emergency: prevalence of GAM, food security, seasonality and infectious disease profile. Typically, BSFP operates for 3-6 months. Context will determine the start and end. For example if a BSFP operates in relation to the lean season- it would need to start at least 1 month prior to the onset and run until post harvest. The situation should be re-assessed during implementation and monitored regularly. Programmes can be re-oriented or scaled-up and down. Children should be continually admitted during the programme with no discharge until the end of the programme. Even if the children are older than the age criteria

Prévention : mécanisme de distribution Considérations Accès à la population Sécurité, saisons, physique Ampleur de la crise (nombre total de régions affectées) Capacité de mise en oeuvre Faible ou sécurité - considérer une union avec Distribution Générale de Nourriture (GDF Global Food Distribution) Densité de population Détermine le nombre de lieux Si dense, plusieurs jours/semaines peuvent être nécessaires pour la distribution For any programme- prevention or treatment- there are some key considerations.

Prévention : mécanisme de distribution Programme de couverture d’alimentation complémentaire autonome Ciblé directement sur les ménages avec enfants Programme de couverture d’alimentation complémentaire avec livraison intégrée L’alimentation complémentaire pour les enfants est ajoutée à la nourriture/cash/bon d’échange Contexte de sécurité faible Rapide début, immédiate programmation Erreurs d’intégration et d’exclusion Changer pour un programme parallèle indépendant aussitôt que possible There are 2 potential delivery mechanism for a BSFP. A stand alone programme where the ration is targeted directly to households with children in the target age group. Or you can integrate the delivery of the ration into another programme- such as the GFD or cash/voucher distribution. This is not ideal as targeting is often difficult. It may be the only option at the onset of an emergency or in low security contexts when access to the population is limited or the ability of the population to attend distributions is limited. Ex: In 2004 in North Darfur, attendance at BSFP distributions for IDPs outside of camps was low. Upon further investigation, security on the walk to and from the distribution site was a barrier to attendance. If an integrated delivery is selected, as soon as possible, a parallel distribution system should be set up.

Traitement Programme d’alimentation complémentaire ciblé Traitement de la MAM avec des compléments alimentaires nutritifs et des soins médicaux de routine Critères d’admission/renvoi basés sur des mesures anthropométriques (lignes directrices nationales ou internationales) Communication/éducation sur la nutrition Soutien pour l’alimentation des nourrissons et jeunes enfants en urgence Evidence doit être démontrée quant à l’impact du cash et des bons d’échange If you have selected treatment for your programme, the modality will be targeted supplementary feeding. It provides treatment for MAM through the direct provision of a nutritious food supplement and routine medical care. Admission and discharge criteria are based on anthropometric measures. National or international guidelines (in the absence of national) should be used. Nutrition education and support of IYCF-E should be incorporated into the treatment. More evidence is needed on the impact of cash/vouchers where the treatment of MAM is the objective. As well, only where access and availability area not constrained should IYCF-E be considered as a stand alone option.

Traitement : groupe cible Malnutrition Enfants 6-59 mois Enfants libérés du traitement de la MAS Femmes enceintes et allaitantes (jusqu’à 6 mois postpartum) Maladie chronique (VIH, tuberculose) Exceptions Nourrissons <6 mois non admis, soutien à l’alimentation complémentaire pour les nourrissons et jeunes enfants renforcé Autres populations vulnérables identifiées (enfants handicapés, enfants 5-10 ans, personnes âgées) The standard target group is children 6-59 months of age- including those discharged from treatment for SAM. As well malnourished PLW can be enrolled- up to 6 months postpartum. In some contexts, persons with chronic illness may be enrolled- some examples include those with HIV, TB. There are some key exceptions to remember. Children <6 months of age are not treated in TSFP. IYCF-E would be supported and if the mother was malnourished, they would be enrolled. If a survey or other assessment revealed specific vulnerable groups, they may be considered for treatment: disabled children, older children 5-10 or older people.

Traitement : produit Considérations Approbation du gouvernement Groupe cible Abilité des membres du ménage à cuisiner Ont-ils les moyens de cuisiner à disposition, ont-ils accès à l’eau et au carburant ? Pratiques culturelles et préférences alimentaires Supercéréales à base de maïs, blé et riz Nourriture prête à consommer à base de cacahuète, pois chiche et lait (quantités limitées) Selection of product is the next step after you have determined whom to target. Before you start product selection, you must first know what products are approved for use in your context. Not all RUF’s have been approved by countries. There are 4 main considerations in selecting a product(s). The objective of the programme- is it prevention or treatment. What age group are you targeting? Supercereal Plus can be used for children 6-59 months The HH ability to cook needs to be assessed The ability to cook is essential for the use of supercereal/plus. If there is no ability to cook, then RUFs are recommended. Cultural practices and food preferences If at all possible, these should be taken into account. New formulations of supercereal are available in wheat and maize and rice based formulations are forthcoming. RUF’s are primarily peanut-based, but there are formulations under development and available in limited quantities (chick-pea based and milk based)

Fiche produit Produits nutritionnels spécialisés

Produits et alternatives recommandés Groupe cible Recommandation première Provisoire/Alternative Traitement de la MAM 6- 59 mois Alimentation prête à consommer Supercéréale Plus Supercéréale/huile/sucre prémélange Femmes enceintes et allaitantes Supercéréale/huile/sucre Enfants plus âgés Alimentation prête à consommer ou supercéréale Plus Prevention of MAM 6-23 or 6-59 months Supercereal Plus LNS medium quantity RUSF± Supercereal/oil/sugar ½ sachet RUSF PLW For children RUSF or Supercereal Plus is the recommended food supplement. If these are not available, a premix of supercereal/oil/sugar can be used. For PLW supercereal/oil/sugar For older children: the primary recommendation is supercereal/oil/sugar, but RUSF and supercereal plus could be used as an alternative.

Traitement : Durée et stratégie de sortie Durée du traitement entre 1-4 mois Programme d’alimentation complémentaire ciblé réduit proportiennellement MAG <5% Pas de facteurs aggravants Le faible nombre d’admissions au traitement MAM et MAS peut aussi être pris en compte pour décider une suppression graduelle Etre attentif à la couverture et à la performance du programme Length of treatment can vary from 1-4 months, depending on the level of malnutrition and individual response to treatment. Scale down of programmes should be considered when GAM rates are <5% and no aggravating factors exists (those risk of deterioration). Low numbers of admissions into MAM and SAM treatment may also be used to decide to phase out- but be mindful of the coverage and performance of the programme as this may effect the number of admissions

Prévention : mécanisme de distribution Considérations Accès à la population Sécurité, saisons, physique Ampleur de la crise (nombre total de régions affectées) Capacité de mise en oeuvre Faible ou sécurité - considérer une union avec Distribution Générale de Nourriture (GDF Global Food Distribution) Densité de population Détermine le nombre de lieux Si dense, plusieurs jours/semaines peuvent être nécessaires pour la distribution For any programme- prevention or treatment- there are some key considerations.

Traitement: mécanisme de livraison Lié de près au traitement de la MAS sous le modèle de la communauté de gestion de la malnutrition aiguë (CGMA/CMAM) Les lieux de programme d’alimentation complémentaire ciblé adjacents au programme thérapeutique ambulatoire ou centres de santé ou centres de référence (dans les deux sens) Large région pour distribution/services Si mobile ou loin des centres de santé fournir des interventions de base Considérations Couverture du service de santé, programmes existants MAM/MAS, capacité à intensifier The delivery mechanism should be closely linked to the treatment of SAM as part of CMAM. TSFP sites can be adjacent to the OTP or health centers to facilitate referrals to both programmes. MAM should not burden the existing health care system- as much as possible. A large area will be needed for the delivery of services- waiting, anthropometric assessment, health care, food delivery etc. Mobile programmes can be used to deliver services as well. The existing health system, capacity and national guidelines are all important considerations as well as the existing services available for MAM/SAM.

Prévention et traitement Prévention et traitement peuvent être recommendés pour : Poursuivre l’étape précédente afin de mettre en place chaque programme Penser aux liens entre les programmes Idéalement les enfants ne devraient pas être inscrits dans les deux programmes simultanément En réalité, les risques associés à la non-participation l’emportent sur le coût de la participation double Dans les grandes urgences les enfants devraient être inscrits dans les programmes de prévention car ils peuvent être en traitement ou hors traitement Exemple: Nord Kenya, 2011/12 In many circumstances both prevention and treatment may be called for. In this case, you would just work through the previous steps for each programme component. Where possible, children should not be enrolled simultaneously in both programmes. However, in reality children often are as the risk associated with non-participation outweigh the actual cost of double admission. In some situations, children enrolled in prevention programmes and referred to treatment programmes should not be discharged from the prevention programming as they my come in and out of treatment. For example in Northern Kenya in 2011/12- children enrolled in BSFP but referred to TSFP or CMAM- were not discharged from the BSFP. There was no guarantee that they would seek treatment and therefore they were maintained in the BSFP.

Pas d’intervention supplémentaire Programmes supplémentaires non nécessaires Programmes nutritionnels existants Réévaluer les risques comme un progrès Mettre en place un plan d’intervention nutritionnel Renforcer le soutien pour l’alimentation des nourrissons et jeunes enfants ou les programmes de micronutriments If the combination of low GAM and low risk of deterioration exists- it is essential to continue to monitor the situation for any changes or deterioration in the population. Additionally, current programmes should be strengthen- such as IYCF. Les programmes d’urgence sont en plus des programmes de nutrition existants

Etapes de l’outil Prévention/Traitement Prévention Traitement Pas de programme en plus Etape 1: Type de programme/Objectif Etape 2: Méthode Alimentation complémentaire Cash/Bon d’échange Alimentation des nourrissons et jeunes enfants There are 4 steps in the process. Step 1: determine your programme type and objective Step 2: modality- how are you going to achieve your objective Step 3: Operation- which includes target group, product, delivery mechanism and duration. It is crucial to have an exit strategy from the beginning of the program Step 4: review and revise program as the emergency progresses. Programs need to be flexible to meet the needs of the population. We will work through each of these steps and decision making process. Etape 3: Exploitation du programme Groupe cible Produit Durée Livraison Etape 4: Révision Régulièrement tout au long de l’urgence

Liens avec d’autres programmes Interventions dans les urgences : traiter la malnutrition aiguë Distritution générale de nourriture Programmes d’alimentation sélective Traitement ciblé Malade hospitalisé Prévention Distribution générale Cash/Bon d’échange Traitement ambulatoire Traitement pour la MAS Programmes MAM Alimentation pour les nourrissons et jeunes enfants en urgence Traiter les causes sous-jacentes de sous-nutrition Traiter les déficiences en micronutriments Finally, it is critical that the programme selected be linked to existing programmes as well as programmes in other sectors which influence nutritional status. If we look at the areas of intervention in emergencies, we can see the inter-linkages. CMAM IYCFE Underlying causes: WASH, health (immunizations), food security Micronutrient deficiencies WASH Sécurité de l’alimentation Santé

Informations supplémentaires Josephine Ippe: Global Nutrition Cluster jippe@unicef.org Lynnda Kiess: World Food Programme lynnda.kiess@wfp.org Leisel Talley: Centers for Disease Control and Prevention ltalley@cdc.gov