:: Disaster Risk Management and Mainstreaming :: Disaster Risk Management Commission

Guidelines for the Management of Moderate Acute Malnutrition, in Ethiopia

GUIDELINES

For the

Management of Moderate Acute

Malnutrition, in Ethiopia

Final version

September, 2012

ENCU/EWRD/MOARD

Addis Ababa, Ethiopia

Tel: 0115 52 35 56

e-mail: isaackm@dppc.gov.et

http://www.dppc.gov.et

Acknowledgments

The DRMFSS and Federal Ministry of Health (FMoH) would like to express its appreciation to the Emergency

Nutrition Coordination Unit (ENCU) for leading the process to develop these guidelines. We are also

grateful to the Humanitarian Response Fund (HRF) for providing the financial support required to produce

this document. These guidelines were developed by Ms. Emily Mates, an independent consultant engaged

by UNICEF with funding from the HRF.

We would like to express our appreciation to the very many people who contributed to these guidelines.

Many thanks are due to members of both the MAM Technical Working Group (TWG) and the Multi Agency

Nutrition Task Force (MANTF) in Ethiopia, who provided valuable input, comments and feedback to

improve the document.

Early Warning and Response Directorate (EWRD) of the Disaster Risk Management and Food Security

Sector, of the Ministry of Agriculture and Rural Development, Addis Ababa, Ethiopia. 2012.

Table of Contents

Acknowledgments ..................................................................................................................................................... ii

Table of Contents ...................................................................................................................................................... iii

List of Boxes, Figures and Tables ........................................................................................................................... iv

List of Annexes .......................................................................................................................................................... v

Glossary of Acronyms ............................................................................................................................................... v

Definition of Terms................................................................................................................................................... vii

Introduction ................................................................................................................................................................ 1

Current health and nutrition situation in Ethiopia ...................................................................................................... 1

Current MAM situation in Ethiopia ............................................................................................................................ 2

The aim of these guidelines...................................................................................................................................... 3

Chapter 1. Overview and classification of malnutrition.......................................................................................... 4

1.1 Types of malnutrition...................................................................................................................................... 4

1.2 Causes of malnutrition ................................................................................................................................... 5

1.3 Identification of acute malnutrition using WHO growth standards (2006)....................................................... 7

1.3.1 Identification of Weight for Height Measurement (WFH) ratio using the reference tables ............................. 8

1.3.2 Identification of malnutrition using MUAC...................................................................................................... 9

1.4 Information sources that can provide information on the need to establish MAM treatment emergency

interventions ............................................................................................................................................................. 9

Chapter 2. Supplementary Feeding Interventions................................................................................................. 10

2.1 Description of supplementary feeding.......................................................................................................... 10

2.1.1 Objectives of setting up an SFP .................................................................................................................. 10

2.2 Planning the intervention ............................................................................................................................. 11

2.2.1 Staff ............................................................................................................................................................. 11

2.2.2 Supplies, equipment and transport .............................................................................................................. 11

2.2.3 Storage and Warehousing........................................................................................................................... 12

2.3 Types of Supplementary Feeding Programmes (SFPs)............................................................................... 12

2.3.1 Blanket Supplementary Feeding Programme (BSFP) ................................................................................. 13

2.3.1.1 Objectives of the BSFP ............................................................................................................................... 13

2.3.1.2 General criteria for establishing emergency BSFPs...................................................................................... 13

2.3.1.3 Case load estimation and beneficiary identification for BSFPs...................................................................... 13

2.3.1.4 Admission and discharge criteria for BSFP ................................................................................................. 14

2.3.1.5 When to Close emergency BSFPs ................................................................................................................ 14

2.3.2 Targeted Supplementary Feeding Programme (TSFP) ............................................................................... 14

2.3.2.1 Objective of the TSFP................................................................................................................................. 14

2.3.2.2 When to establish TSFPs............................................................................................................................ 15

2.3.2.3 Determining the case load for a TSFP ......................................................................................................... 15

2.3.2.4 TSFP triage, diagnosis and beneficiary selection ......................................................................................... 16

2.3.2.5 Admission criteria for TSFP ....................................................................................................................... 18

2.3.2.5.1 MAM children 6-59 months.................................................................................................................... 18

2.3.2.5.2 MAM Pregnant and Lactating Women (PLW).......................................................................................... 19

2.3.2.5.3 MAM in other vulnerable groups (admission and discharge criteria)....................................................... 20

2.3.2.6 TSFP distribution procedures at the site for new and registered beneficiaries ............................................... 20

2.3.2.6.1 Beneficiary registration ................................................................................................................... 21

2.3.2.6.2 Routine treatment ........................................................................................................................... 21

2.3.2.6.3 Follow up procedures for those already registered in TSFP .............................................................. 21

2.3.2.6.4 Transfer to OTP or inpatient unit (TFU or SC) .................................................................................. 22

2.3.2.7 Nutrition counselling and education .......................................................................................................... 22

2.3.2.8 Supplementary food ration ........................................................................................................................ 22

2.3.2.8.1 Provision of the dry ration ............................................................................................................... 22

2.3.2.8.2 Premixing the ration........................................................................................................................ 23

2.3.2.8.3 Cooking demonstrations.................................................................................................................. 23

2.3.2.8.4 Newer products for the treatment of MAM ....................................................................................... 24

2.3.2.9 Discharge criteria ..................................................................................................................................... 24

2.3.2.9.1 Discharge recovered cured .............................................................................................................. 24

2.3.2.9.2 Discharges from TSFP other than recovered cured - children 6-59 months ....................................... 25

2.3.2.9.3 Discharges from TSFP other than recovered cured - PLW ................................................................. 26

2.3.2.10 When to close the emergency TSFP ........................................................................................................ 26

iii

Chapter 3. Monitoring, reporting and coverage .................................................................................................... 27

3.1 Monitoring .................................................................................................................................................... 27

3.2 Reporting ..................................................................................................................................................... 28

3.2.1 Completing the monthly report .................................................................................................................... 28

3.2.2 Using the monthly reports to determine programme performance .............................................................. 28

3.3 Coverage ..................................................................................................................................................... 29

Chapter 4. Community mobilisation, nutrition counselling and education ....................................................... 32

4.1 Community mobilisation ............................................................................................................................... 32

4.1.1 Objectives of community mobilisation ......................................................................................................... 32

4.1.2 Information required prior to programming .................................................................................................. 33

4.1.3 Who should be involved in community mobilisation .................................................................................... 33

4.1.4 Supplies and training ................................................................................................................................... 33

4.1.5 Case finding and referral ............................................................................................................................. 34

4.1.6 Follow-up and home visits ........................................................................................................................... 34

4.2 Nutrition counselling and education ............................................................................................................. 35

4.2.1 Promotion of good hygiene at health facilities and distribution sites............................................................ 36

Chapter 5. Management of acute malnutrition in infants under-6 months (MAMI), maternal health, urban and

pastoralist issues ..................................................................................................................................................... 37

5.1 Management of acute malnutrition in infants < 6 months (MAMI) ................................................................ 37

5.1.1 Implications for Ethiopia from the MAMI project findings ............................................................................. 38

5.1.2 Identification and response.......................................................................................................................... 39

5.2 Maternal nutrition health .............................................................................................................................. 40

5.3 Urban and pastoralist issues........................................................................................................................ 41

5.3.1 Urban issues ............................................................................................................................................... 41

5.3.2 Pastoralist issues ........................................................................................................................................ 42

References................................................................................................................................................................ 43

List of Boxes, Figures and Tables

Box 1: The Productive Safety Net Programme (PSNP)....................................................................................................... 2

Box 2: Technical review of the Management of Acute Malnutrition in Infants (MAMI) Project: Current evidence, policies,

practices & programme outcomes ...................................................................................................................................... 38

Box 3: Urban issues .......................................................................................................................................................... 41

Figure 1: Types of Malnutrition............................................................................................................................................ 4

Figure 2: UNICEF conceptual framework for the determinants of nutritional status ............................................................ 6

Figure 3: The important features of warehousing and storing food commodities .............................................................. 12

Figure 4: Triage process for children 6 – 59 months screened or referred to distribution site or health facility for

Management of Acute Malnutrition (for infants 0 - 6 months, refer to SAM guidelines) .................................................. 16

Figure 5: Formulas for calculating period and point coverage........................................................................................... 30

Table 1: Target group and type of measurement .............................................................................................................. 18

Table 2: Summary of Admission Criteria for TSFP............................................................................................................ 19

Table 3: Recommendations for admission and discharge criteria for other vulnerable groups suffering from MAM ......... 20

Table 4: Summary of routine medicines for children ......................................................................................................... 21

Table 5: Summary of routine medicines for pregnant and lactating women ...................................................................... 21

Table 6: Criteria for MAM beneficiaries, discharge ‘recovered/cured’ ............................................................................... 24

Table 7: Calculation of indicators for the monthly report (example given is for Under-5 children)..................................... 29

List of Annexes

Annex 1

Annex 2

Annex 3

Annex 4

Annex 5

Annex 6

Annex 7

Annex 8

Annex 9

Annex 10

Annex 11

Annex 12

Annex 13

Annex 14

Annex 15

Annex 16

Annex 17

Annex 18

Annex 19

Annex 20

Annex 21

Annex 22

Annex 23

WFH Reference Table (WHO GS 2006)

TSFP Ration Card: Children 6-59 months and PLW

Referral Slip from Community to Distribution Site

Registration Book: Children 6-59 months and PLW

TSFP Tally and Compilation Sheets

TSFP Monthly Statistics Report & How To Calculate Average Weight Gain, Length Of Stay

TSFP Supervision Checklist

Suggested Equipment and Supplies for TSFP

Stock Card

Taking Anthropometric Measurements: Oedema, MUAC, height/length and weight

WFH % of Median Reference Table (NCHS 1977) & Admission and Discharge Criteria Table

WFH z-score Reference Table for Adults and Adolescents

Referral Form Between TSFP and OTP

How to Prepare CSB

Decision Tree for Nutritional Products

Discharge Table (13%) Target Weight Gain

Discussion of 13% Weight Gain as MUAC Discharge Criteria

Home Visit Form

Post Distribution Monitoring (PDM) Questionnaire

Planning and Analysing Focus Group Discussions (FGD)

CSAS Picture Guide

Guiding Principles on IYCF in Emergencies

Warehouse Management

Glossary of Acronyms

AIDS

ANC

ASRI

BMI

BSFP

CBN

CDC

CHD

CMAM

CSAS

CSB

CTC

CVHW

DHS

DRMFSS

EHNRI

ENCU

ENA

ENI

ENN

EOS

EPI

FBF

FDA

FFI

FGD

FMHACA

FMoH

Acquired Immune Deficiency Syndrome

Ante Natal Care

Accelerated Stunting Reduction Initiative

Body Mass Index

Blanket Supplementary Feeding Programme

Community Based Nutrition

Centre for Disease Control and Prevention

Child Health Day

Community Management of Acute Malnutrition

Centric Systematic Area Sampling

Corn-Soy Blend

Community-based Therapeutic Care

Community Volunteer Health Worker

Demographic and Health Survey

Disaster Risk Management and Food Security Sector

Ethiopian Health and Nutrition Research Institute

Emergency Nutrition Coordination Unit

Essential Nutrition Actions

Emergency Nutrition Intervention

Emergency Nutrition Network

Enhanced Outreach Strategy

Expanded Programme of Immunisation

Fortified Blended Food

Food Distribution Agent

Food Fortification Initiative

Focus Group Discussion

Food, Medicine and Health Care Administration and Control Authority

Federal Ministry of Health

GAM

GFD

GMP

GoE

HABP

HEP

HEW

HFA

HIV

HTP

IASC

IDP

IEC

IFE

IRT

ITN

IUGR

IYCF

KCAL

LBW

MAM

MAMI

MDG

MoH

MUAC

NCHS

NFI

NGO

NNP

NNS

OTP

PLWHA

PLW

PSNP

RDA

RUF

RUSF

RUTF

S3M

SAM

SFP

SQUEAC

TFP

TFU

TSFP

UNHCR

UNICEF

VAS

WASH

WFA

WFH

WFP

WHO

Global Acute Malnutrition

General Food Distribution

Growth Monitoring and Promotion

Government of Ethiopia

Growth Standards

Household Asset Building Programme

Health Extension Programme

Health Extension Worker

Height-for-Age

Human Immunodeficiency Virus

Harmonised Training Package

Inter-Agency Standing Committee

Internally Displaced Population

Information, Education and Communication

Infant Feeding in Emergencies

Integrated Refresher Training

Insecticide Treated Net

International Units

Intra Uterine Growth Retardation

Infant and Young Child Feeding

Kilocalories

Low Birth Weight

Moderate Acute Malnutrition

Management of Acute Malnutrition in Infants

Millennium Development Goal

Ministry of Health

Mid Upper Arm Circumference

National Centre for Health Statistics

Non Food Item

Non-Governmental Organisation

National Nutrition Programme

National Nutrition Strategy

Outpatient Therapeutic Programme

People Living With HIV/AIDS

Pregnant and Lactating Women

Productive Safety Net Programme

Recommended Daily Allowance

Ready-to-Use Food

Ready-to-Use Supplementary Food

Ready-to Use Therapeutic Food

Simple Spatial Survey Method

Severe Acute Malnutrition

Stabilisation Centre

Standard Deviation

Supplementary Feeding Programme

Semi-Quantitative Evaluation and Assessment of Coverage

Tuberculosis

Therapeutic Feeding Programme

Therapeutic Feeding Unit

Targeted Supplementary Feeding Programme

United Nations High Commission for Refugees

United Nations Children’s Fund

Vitamin A Supplementation

Water Sanitation and Hygiene

Weight-For-Age

Weight-For-Height

World Food Programme

World Health Organisation

Definition of Terms

Acute malnutrition/ wasting - measure of “thinness” due to rapid recent weight loss.

Anthropometry - the study and technique of human body measurement. It is used to measure and monitor

nutritional status in an individual or population group. Body measurements include: age, sex, weight,

height, oedema (fluid retention) and mid upper arm circumference (MUAC).

Blanket Supplementary Feeding (BSF) - feeding of all nutritionally vulnerable population irrespective of

nutritional status.

Body Mass Index (BMI) - a number that indicates a person’s weight in proportion to height/length,

calculated as kg/m².

Caregiver – parent or guardian of the malnourished child.

Community Involvement (sometimes referred to as social or community mobilisation) - term used to

cover a range of activities that, help nutrition programme implementers (i.e. nutritionists, managers and

health workers) build a relationship with the community and encourage programme uptake by community

members.

Community-based Management of Acute Malnutrition (CMAM) - international term for timely detection

of severe acute malnutrition in the community (social mobilisation); provision of treatment for those

without medical complications with ready-to-use therapeutic foods or other nutrient-dense foods at home

(OTP) combined with a facility-based approach for those malnourished children with medical complications

(TFU or SC). In some instances/programmes the CMAM also includes TSFP activities.

Community Sensitization - a way to reach out to people in the community and teach the causes, signs and

symptoms of malnutrition, and how to seek treatment opportunities and prevent healthy children from

becoming malnourished.

Community-based Therapeutic Care (CTC) - international term used prior to the CMAM term.

Complementary Feeding - the process starting when breastmilk alone is no longer sufficient to meet the

nutritional requirements of infants and therefore other food and liquids are needed along with breastmilk.

The target age range for complementary feeding is generally 6-24 months even though breastfeeding can

continue beyond 2 years.

Crude Mortality Rate (CMR) - the rate of death in the entire population, including both sexes and all ages.

The CMR can be expressed with difference standard population denominators and for different time

periods, often commonly described as deaths per 10,000 population per month/year.

Emergency Nutrition Intervention (ENI) - programmes set-up to manage malnutrition and to provide food

to a population that does not have sufficient access to or quality of food. Emergency Nutrition

Interventions can also be started in response to other factors such as disease outbreaks in populations with

sufficient access to food.

Evaluation - a process that objectively determines appropriateness, relevance, effectiveness, efficiency and

impact of activities in light of specified objectives.

vii

Exclusive breastfeeding (EBF) - breastfeeding while giving no other food or liquid, not even water.

Recommended for infants up to the age of 6 months.

Fortified Blended Food (FBF) - a precooked mixture of cereals and other ingredients such as pulses, dried

skim milk and vegetable oil, which is fortified with micronutrients. Commonly marketed as CSB (+ and ++),

Famix or Unimix.

F-75 - Formula 75 (75kcal/100 ml) is the milk based diet recommended by WHO for the stabilisation of

children with SAM with in inpatient care (those with medical complications and/or no appetite).

F-100 - Formula 100 (100kcal/100 ml) is the milk based diet recommended by WHO for the nutrition

rehabilitation of children with SAM after stabilisation in inpatient care, now is generally replaced by RUTF.

Global Acute Malnutrition (GAM) - a population indicator that provides an aggregate of moderate and

severe malnutrition, i.e. ≤-2 Z-scores and oedema. GAM is divided into moderate and severe acute

malnutrition (GAM = MAM+SAM).

Inpatient Therapeutic Care - severely malnourished patients admitted to inpatient facility for treatment

(TFU or SC).

IYCF - describes the feeding of infants and young children (usually 0-24 months).

Kwashiorkor - bilateral pitting oedema (nutritional oedema) that is a clinical indicator for SAM. Oedema is

the excessive accumulation and abnormal infiltration of serous fluid in connective tissue or in a serous

cavity. Classified into 3 grades; + mild (both feet, can include ankles), ++ moderate (both feet, lower legs,

hands or lower arms); +++ severe (generalized oedema over whole body including arms and face).

Malnutrition - a state in which the physical function of an individual is impaired to the point where s/he

can no longer maintain adequate bodily performance processes.

Marasmic-Kwashiorkor – a combination of both maramus and kwashiorkor.

Marasmus - severe weight loss and muscle mass leaving ‘skin and bones’. Appearance can manifest as ‘old

man face’ and ‘baggy pants’.

Moderate Acute Malnutrition - description of malnutrition level; persons with MAM have higher morbidity

and mortality risks. In Ethiopia the definition encompasses children 6-59 months with < -2 to ≥-3 z-scores

and/or MUAC ≥ 11.0 to < 12.0 cm; and PLW with MUAC < 23.0 cm. For MAM classifications for infants,

older children and adults in Ethiopia, please refer to Table 3 on page 19.

Monitoring - periodic oversight of the implementation of an activity which seeks to establish the extent to

which input deliveries, work schedules and targeted outputs are proceeding according to plan.

MUAC – Low MUAC is an indicator for wasting. For a child 6-59 months, MUAC < 11.0 cm indicates severe

wasting or SAM, MUAC ≥ 11.0 to < 12.0 cm indicates moderate wasting or MAM. For PLW, MUAC < 23.0 cm

indicates MAM. For adults with HIV/AIDS (or other chronic diseases), MUAC ≥ 18.0 to < 23.0 cm indicates

MAM. MUAC is a better indicator of mortality risk associated with acute malnutrition than WFH.

NCHS/WHO Reference - the 1977 NCHS/WHO growth reference, which is based on the weights and heights

of a statistically valid population of healthy infants and children in the United States, was previously widely

used to assess, monitor and evaluate the nutritional status of individual children or groups of children.

Many countries have now moved to the use of the new WHO Growth Standards (2006), see below.

viii

Nutrition - study of food and its nutrients; its functions, actions, interactions and balance in relation to

health and disease.

Nutrition Education – process of imparting knowledge, designed to improve people’s attitude, habits,

behaviour, customs and beliefs that are related to food consumption

Outpatient Therapeutic Programme (OTP) - programme run from a health centre or health post offering

outpatient care to severely malnourished cases who have appetite and who do not have any medical

complications (this group usually represents > 90% of all the SAM cases). At admission, children receive a

medical check to determine if they warrant direct referral to the nearest inpatient TFU. If they are well

enough to be treated as an outpatient they receive systematic treatment and a ration of RUTF. Patients are

seen on a weekly or fortnightly basis, but carers are encouraged to return to the OTP if the child’s condition

deteriorates during that time. The average length of stay in OTP is 4-8 weeks.

Prevalence Rate - the proportion of the population that has the health problem under study (e.g. the

prevalence of GAM).

Ready-to Use Foods (RUFs); Ready-to use Supplementary Food (RUSF) and Ready-to Use Therapeutic

Food (RUTF) - energy dense, mineral and vitamin enriched food that does not require cooking or

preparation or dilution with water and can be eaten directly from the packet. RUTF has been specifically

developed for the recovery of severe acute malnutrition at home, while RUSF is for the recovery of

moderate acute malnutrition.

Recommended nutrient intake (RNI) - the daily intake which meets the nutrient requirements of almost all

(97.5%) apparently healthy individuals in an age- and sex-specific population.

Selective Feeding Programmes – therapeutic (for severely malnourished) and supplementary (for

moderately malnourished).

Severe Acute Malnutrition (SAM) - description of malnutrition level encompassing children 6-59 months

with < -3 z-scores, and/or MUAC < 11.0 cm, and/or bilateral pitting nutritional oedema. Persons with SAM

have higher morbidity and mortality risks.

Sphere Project - was launched in 1997 by a group of humanitarian NGOs, the Red Cross and Red Crescent

movement. The Sphere humanitarian charter and minimum standards in disaster response, 3rd edition

(2011) has just been released; providing a set of recommendations that humanitarian projects should aim

to meet.

Standard Deviation (SD) or z-score - the deviation of the anthropometric value (weight, height etc.) for an

individual from the median value of the reference population.

Stunting - or chronic undernutrition, is a form of undernutrition that is defined by a height-for-age (HFA) z-

score below two SDs of the median WHO standards. Stunting is a result of prolonged or repeated episodes

of undernutrition often starting before birth. This type of undernutrition is best addressed through

preventative maternal health programmes aimed at pregnant women, infants, and children under age 2.

Programme responses to stunting require longer-term planning and policy development.

Supplementary Feeding Programme (SFP) - provision of an additional food ration for moderately

malnourished individuals through a ‘targeted SF’; or to the most nutritionally vulnerable groups (regardless

of nutritional status) through ‘blanket SF’.

Targeting - a method of delivering goods (such as food assistance) and/or services to a selected group of

individuals or households, rather than to every individual or household in the population.

Therapeutic Feeding Programme (TFP) - combination of inpatient (TFU) and outpatient (OTP) therapeutic

feeding for the treatment of severe acute malnutrition.

Therapeutic Feeding Unit (TFU) - units in hospitals and health centres offering inpatient care to the

severely malnourished cases with complications and/or lack of appetite. If OTP is not available in the

catchment area, TFU offers full inpatient care with Phase 1, Transition Phase and Phase 2 with an average

length of stay of 2-3 weeks. When OTP is available in the catchments area, only the complicated severe

cases as defined by a lack of appetite and the presence of medical complications are admitted in TFU.

Usually, patients would only stay as long as they required Phase 1 treatment (2-7 days) and then would

progress to outpatient care.

Triage of Acute Malnutrition - Refers to the selection/ sorting/classification of cases of acute malnutrition

presented to fast track treatment and increase survival rates.

Undernutrition - Is a consequence of a deficiency in nutrient intake and/or absorption in the body. The

different forms of undernutrition that can appear isolated or in combination are acute malnutrition

(bilateral pitting oedema and/or wasting), stunting, underweight (combined form of wasting and stunting),

and micronutrient deficiencies.

Underweight - Underweight is a composite form of undernutrition including elements of both stunting and

wasting and is defined by a weight-for-age (WFA) z-score below 2 SDs of the median (WHO standards). This

indicator is commonly used in growth monitoring and promotion (GMP) and child health and nutrition

programmes aimed at the prevention and treatment of undernutrition.

Vulnerable Groups – Groups of people who are ‘at risk’ of malnutrition, which vary in characteristic but are

often defined by age, sex, ethnicity and location; can also include those with disabilities and stigmatised

illnesses, such as mental ill-health and displaced persons such as refugees or migrant workers

WHO Growth Standards (WHO GS 2006) - Developed using data collected in the WHO Multicentre Growth

Reference Study in Brazil, Ghana, India, Norway, Oman, and the United States between 1997 and 2003 to

generate new curves for assessing the growth and development of children from birth to five years of age

under optimal environmental conditions. They are intended to be used to assess children everywhere,

regardless of ethnicity, socioeconomic status and type of feeding.

Z-score - Indicates how far a measurement is from the median – also known as the standard deviation (SD)

score. The reference lines on the growth charts (labelled 1, 2, 3, -1, -2, -3) are called z-score lines; they

indicate how far the measurement is above or below the median (= z-score of 0).

Introduction

Current health and nutrition situation in Ethiopia

Ethiopia is the third most populous country in Africa with an estimated population of 79.5 million, of which

approximately 11 million are children under-5.1 The health situation in Ethiopia is generally poor; a

reflection of widespread poverty, limited employment opportunities, low income levels, high population

pressure, low education levels (especially among women), inadequate access to clean water and sanitation,

high rates of migration and poor access to health services. The recent National Nutrition Survey (2010)

confirmed that maternal and child feeding practices and knowledge of ‘healthy behaviours’ remain at sub-

optimal levels.2

Ethiopia’s long and continuing history of food insecurity is attributed to erratic rainfall and/or the complete

failure of rains, degraded land, archaic and inefficient farming practices and regular pest infestations,

among other factors. As a result, every year millions of people in rural Ethiopia are in need of support in the

form of food aid, nutrition support, health, water supply and sanitation, shelter and other emergency

inputs. With more than 80% of the population relying on subsistence agriculture as their primary livelihood,

they are dependent on the success of two annual rainy seasons to secure nearly all their food needs for the

year. As such, they are particularly vulnerable to climatic shocks and their ability to recover from those

shocks is limited. Over the past few years some communities have faced considerable hardships, as one or

other, or both of the two annual rains have failed and pest infestation has been high, causing crop failures

across many areas of the country and intensifying the cumulative vulnerability of communities

The consequence of Ethiopia’s poor health situation, sub optimal caring practices and continuing food

insecurity (which can regularly develop into more severe food crises), is that malnutrition rates among

children remain at unacceptably high levels; the prevalence of Global Acute Malnutrition (GAM) at the

national level is estimated to be 11% (moderate and severe), with 47% of children suffering from chronic

malnutrition. By now it is very well understood that much of childhood morbidity and mortality is rooted in

malnutrition. While it is encouraging that Ethiopia’s under-5 mortality rate has decreased in recent years

from 169/1,000 to 123/1,000 live births, this figure still represents 389,000 under-5 deaths annually.3

The importance of achieving good nutritional status for vulnerable groups is fundamental, not only to avoid

the short-term consequences of increased morbidity and mortality, but also to avoid potential longer-term

economic consequences that have been identified. Undernourished infants and children, who manage to

survive may be subject to longer-term impairment. Furthermore, they are more likely to grow into shorter

adults, to have lower educational achievements and, for women, more likely to subsequently give birth to

smaller infants themselves, thus perpetuating an intergenerational cycle of undernutrition. Prevention of

maternal and child undernutrition is therefore of critical importance that will benefit not only the present

generation, but also their children.4

1 Population Projection (2010) according to the Ethiopia Census 2007. Central Statistics Agency.

2 The National Nutrition Survey, 2010. Ethiopian Health and Nutrition Research Institute.

3 Ethiopia Demographic and Health Survey, 2005. Central Statistics Agency. Preliminary results from the EDHS 2011 suggest that

the U5 mortality rate has reduced to 88/1,000 live births

4 Black, R., Allen, L. H., Bhutta, Z. A., Caulfield, L. E., De Onis, M., Ezzati, M., Mathers, C., and Rivera, J. For the Maternal and

Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. The

Lancet. Published online Jan 17 2008. DOI:10.1016/S0140-6736(07)61690-0

In response to the continuing high levels of malnutrition, the Government of Ethiopia (GoE) developed the

National Nutrition Strategy during 2008, to be implemented through the National Nutrition Programme

(NNP). The objective is better harmonization and coordination of the various approaches to manage and

prevent malnutrition. The NNP is currently a 10 year initiative, aiming to reduce the levels of stunting,

wasting, underweight and Low Birth Weight (LBW) infants, thus contributing to Ethiopia’s efforts to reach

the relevant Millennium Development Goals (MDGs) by 2015. Its first phase spans five years (2008-2013)

and consists of two main components: a) ‘Supporting Service Delivery’ which includes ‘increased access for

the management of Severe Acute Malnutrition (SAM)’, and b) ‘Institutional Strengthening and Capacity

Building’.

In efforts to further expedite improvements in nutrition indicators, the GoE has recently developed a

number of initiatives to combat malnutrition and work toward reaching the MDGs, which include the

Accelerated Stunting Reduction Initiative (ASRI), Food Fortification Initiative (FFI) and enhancing linkages

between the NNP and the Productive Safety Net Programme (PSNP).

Box 1: The Productive Safety Net Programme (PSNP)

The PSNP focuses support continuously on selected households over several years and has an

explicit objective of beneficiaries eventually graduating. The PSNP is the largest social safety

net programme in Sub-Saharan Africa with plans for it to be complemented by the Household

Asset Building Programme (HABP)

The PSNP is currently reaching 7.57 million chronically food insecure people through two

components: public works (80%) and direct support (20%). This remuneration enables

households to meet their food gaps (through provision of food or cash), in order that they are

not forced to sell productive assets, when faced with periodic food shortages or other shocks.

Current MAM situation in Ethiopia

The 2005 Demographic and Health Survey (DHS) identified that 11% of children 6-59 months in Ethiopia

were wasted; a situation that has remained unchanged since the first DHS conducted in 2000. A number of

approaches have been employed over recent years to address MAM, summarised below.

MAM in Ethiopia is currently detected and treated via three food-based programmes:

1. The Ethiopian government has been implementing the Enhanced Outreach Strategy Targeted

Supplementary Feeding (EOS/TSF) programme or Child Health Days (CHD), which conducts

screening exercises (6-monthly and 3-monthly, respectively) in 168 chronically food insecure

woredas and includes provision of TSF rations for identified MAM individuals. Selected beneficiaries

[drawn from under-5 children and Pregnant and Lactating Women (PLW)] are issued with a ration

card that is presented to receive 3-monthly TSFP rations. In addition to screening, additional

promotive/preventative services are provided every 6 months, of vitamin A supplementation (VAS)

and de-worming. The EOS is in the process of transitioning into the activities of the routine CHDs

that are managed by the Health Extension Workers (HEWs) every 3 months; as such MAM

treatment will be provided as part of routine health services in food insecure areas of the country.

2. During times of deteriorating and/or acute nutritional situations (as defined and guided by the

DRMFSS 'hot-spot' classification of woredas as food insecure, with raised malnutrition rates), a

smaller MAM caseload is detected and treated, usually through Non-Governmental Organisations

(NGOs) Targeted Supplementary Feeding Programmes (TSFPs), set up in selected woredas. These

programmes act as a complement to on-going Therapeutic Feeding Programmes (TFPs). The TSFPs

are characterised by rigorous nutritional monitoring, active case finding and usually bi-weekly

distributions. However, it is important to note that these NGO TSFPs are generally short-term

operations and have limited coverage across this vast country.

3. While not identified by their nutritional status, young children and pregnant women are included in

beneficiary lists of communities receiving relief food to benefit from an extra ration of highly

fortified Corn Soya Blend (CSB)5. This intervention is embedded in the DRMFSS sector of the

Ministry of Agriculture and is also addressing MAM to some extent.6

While we know that MAM treatment programmes work, there is considerable interest to move away from

the ‘food bias’ when treating MAM and the international community has been raising questions about the

effectiveness of traditional SFPs.7 However, as yet there is limited evidence available for what type of non-

food interventions might be most appropriate to both prevent and treat MAM in the Ethiopian context. In

some countries, cash transfers are being targeted to malnourished populations, although it is recognised

that this alternative might need to be piloted in the Ethiopian context alongside the ongoing

implementation of the PSNP, which already provides cash transfers to large sections of the population.

Additionally, cash transfers intended to treat MAM could face some challenges in areas of Ethiopia, where

there might be limited purchasing availability in the markets for sufficiently nutritious food.

Due to the interest in other (and potentially more effective) approaches, some organisations are currently

reviewing traditional SFP programming e.g. the Centre for Disease Control (CDC) ‘grey literature’ review

and the University of Westminster and Emergency Nutrition Network (ENN) review of evidence for the

effectiveness of interventions during emergencies. It is possible that ‘new and improved’ thinking or

alternative methods of programming might be proposed in the near future. It is therefore recommended

that these guidelines are viewed as ‘living document’, subject to revision as new evidence and best

practices emerge.

The aim of these guidelines

These guidelines are intended for use by all health and nutrition staff from government, agencies and

organisations involved in nutrition related activities in Ethiopia. The purpose of the guideline is to define

basic concepts and criteria related to the planning, implementation, monitoring and evaluation of

nutritional interventions aimed at treating and/or preventing Moderate Acute Malnutrition (MAM) and to

describe locally appropriate and internationally acceptable standards for MAM treatment programmes, as

well as overall intervention management.

These guidelines focus on the implementation of Supplementary Feeding Programmes (SFPs) in emergency

contexts, to complement the programme implementation manual of the EOS/TSF that guides the ongoing

programmes to identify and treat MAM. They also highlight the importance of increased awareness of

infant and Young Child Feeding (IYCF) and maternal nutrition; in order to reduce the incidence of MAM in

Ethiopia through comprehensive programming, as outlined in Ethiopia’s National Nutrition Programme

(NNP). In response to requests from the MAM TWG to provide the latest international information, at times

these guidelines veer from technical guidance on known interventions, to discussion of some of the

outstanding questions that are arising during the implementation of programmes to address MAM.

These guidelines should be used in conjunction with the Emergency Nutrition Intervention (ENI) Guideline,

2011, and the Guidelines for the Treatment of Severe Acute Malnutrition (SAM) in Ethiopia, 2007, endorsed

by the Ministry of Health.8

5 The more enriched product of CSB+ is known as ‘super cereal’. CSB++ is now known as ‘super cereal plus’

6 Concept note for the Management of MAM. Ethiopian Federal Ministry of Health, 2010.

7 Navarro-Colorado, C., Shoham, J., Mason, F. Measuring the effectiveness of Supplementary Feeding Programmes in Emergencies.

Working Paper HPN Network Papers 63, August 2008.

8 Protocol for the Management of Severe Acute Malnutrition, Ethiopia, Federal Ministry of Health (FMoH), March 2007.

Chapter 1. Overview and classification of malnutrition

1.1 Types of malnutrition

The nutritional requirements of individuals vary at different stages of life and depend on a number of

factors including age, sex and current health status of the individual. Nutritional requirements will also

depend on:

differing physiological conditions, such as pregnancy and breastfeeding

environmental conditions, such as temperature

varying levels of physical activity

There are two categories of nutrients needed by the body:

1. Macronutrients - that provide the energy required for growth and replacement of cells, which are

required in large amounts and include protein, carbohydrate and fat

2. Micronutrients - which ensure the healthy functioning of organs and body processes. These are

required in much smaller amounts and include vitamins and minerals

Malnutrition can exist in two forms as outlined in Figure 1 below; overnutrition and undernutrition.9 In

Ethiopia the most common form of malnutrition is undernutrition, which can manifest as wasting, stunting

and/or deficiencies of essential vitamins and minerals (collectively referred to as micronutrients).

Undernutrition generally results from a complex web of interactions, from the molecular and

microbiological level of the individual, to the cultural and socioeconomic features of societies.10

Figure 1: Types of Malnutrition

9 In this guideline unless otherwise indicated, the term ‘malnutrition’ refers to undernutrition in the form of wasting.

10 Heikens, G. T., Amadi, B. C., Manary, M., Tollins, N., and Tomkins, A. Nutrition interventions need improved operational

capacity. The Lancet. Published online Jan 17 2008. DOI:10.1016/S0140-6736(07)61690-0

The three main types of undernutrition are known as acute malnutrition (wasting), chronic malnutrition

(stunting) and micronutrient deficiency.

1. Chronic malnutrition or ‘stunting’ (individuals whose height is below the average expected height

for their age) - is generally a result of prolonged or repeated episodes of undernutrition that often

starts before birth. Stunting is strongly associated with poverty, poor health and impaired physical

and mental development. Stunting can be reversed through ‘catch up growth’ until 2 years of age;

after which it is irreversible.

2. Acute malnutrition or ‘wasting’ [a measure of thinness defined by Weight-For-Height (WFH) or Mid

Upper Arm Circumference (MUAC) measurements] - is characterized by rapid weight loss usually

due to illness and/or reduced food intake. Wasting can be reversed, however it is of particular

concern during emergency situations because it can quickly lead to excess morbidity and mortality.

Acute malnutrition leads to changes in the body related to cellular composition, tissue and organ

functions. Acute malnutrition can either present itself as severe or moderate and can result from

type II nutrient deficiencies (see below)

3. Micronutrient deficiencies - individuals can have a deficiency of either Type I or type II nutrients.

a. Type I nutrients are those required for adequate functioning of the body, such as iron,

vitamin A, iodine, etc. These nutrients regulate hormonal, immunological, biochemical and

other bodily processes. While these deficiencies can cause major illness and increased risk

of mortality, anthropometric measurements (e.g. height and weight) can be normal,

although it is common for stunted or wasted individuals to also have some degree of

micronutrient deficiency.

b. Type II nutrients are the growth nutrients required to build new tissue e.g. nitrogen,

essential amino-acids, potassium, magnesium, sulphur, phosphorus, zinc, sodium, etc.

Deficiencies will result in the failure to grow, to repair tissue that is damaged, to replace

cells that rapidly turn-over (e.g. intestine and immune cells) or to gain weight after an

illness, which can lead to an increase in the risk of stunting and/or wasting.

1.2 Causes of malnutrition

Figure 2 below describes the three layers of the determinants of nutritional status;

1. Immediate - which act on the individual

2. Underlying - which influence households and communities

3. Basic - which act on entire societies

Figure 2: UNICEF conceptual framework for the determinants of nutritional status

1. Immediate Causes

These include inadequate dietary intake and infection or disease. Malnutrition is often exacerbated by

a vicious cycle between these two factors. Inadequate food intake can lead to a higher risk of infection

or disease, and conversely disease can lead to inadequate food intake. In the Lancet series (2008) Black

et al, summarised the effects of the deadly relationship between infection and undernutrition by

stating that:

“substantially more children die as a result of the synergy between infectious diseases and

undernutrition than from the direct sequelae of the nutritional conditions themselves.” 11

Nine out of ten child deaths in Ethiopia are due to only five conditions: pneumonia, malaria, diarrhoea,

neonatal problems and measles. Approximately 57% of these deaths are related to a weak physical

state due to malnutrition (three-quarters of these deaths result from mild to moderate malnutrition).12

2. Underlying Causes

The main underlying causes of malnutrition include shocks, such as drought, flooding, etc.; household

food insecurity, inadequate social and care environment, inadequate access to health services and

environmental factors, such as poor water and sanitation facilities.

3. Basic Causes

The basic causes of malnutrition include the country’s social, economic and political situation, for

example, the formulation and implementation of policies to address issues such as lack of capital

(financial, human, physical, social, agro-ecological, technical).

1.3 Identification of acute malnutrition using WHO growth

standards (2006)

The World Health Organisation (WHO) undertook a comprehensive survey in the early 1990’s to review the

existing National Centre for Health Statistics (NCHS) 1977 reference values and develop more appropriate

standards for use with a wider range of children from a variety of ethnic backgrounds, in developing and

developed countries. The outcome of this survey was the development of new growth standards that

describe how children should grow when their nutritional needs are fully met. These child growth standards

support the notion that given the same environmental conditions, growth potential is independent of

ethnic origin; therefore these standards can apply in any country.

The new growth standards use the same cut-off points for weight-for-height, weight-for-age, and height-

for-age z-scores, although the international recommendations for cut-off points for mid-upper arm

circumference (MUAC) measurement was increased from a MUAC <11cm to <11.5cm for SAM diagnosis.

The MUAC cut-off for MAM diagnosis remained the same at <12.5 cm.13

11 Black, R., Allen, L. H., Bhutta, Z. A., Caulfield, L. E., De Onis, M., Ezzati, M., Mathers, C., and Rivera, J. For the Maternal and

Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. The

Lancet. Published online Jan 17 2008. DOI:10.1016/S0140-6736(07)61690-0

12 UNICEF and IFPRI coordinated effort, 2005. An Assessment of the causes of Malnutrition in Ethiopia: A contribution to the

formulation of a National Nutrition Strategy for Ethiopia (Background Papers)

13The FMoH has endorsed the MUAC cut-offs for children 6-59 months in Ethiopia as follows: SAM < 11.0 cm;

MAM ≥11.0 to < 12.0 cm. See section 2.3.2.5 for further details of admission criteria

Studies have shown that the changes in growth standards and cut-off points have potential implications on

the numbers of children eligible for admission to selective feeding programmes (especially for SAM, to a

lesser degree for MAM).14 15 16 It is therefore advisable to introduce them systematically so as not to

overload the system. With the introduction of the new growth standards, intense nation-wide training

should be conducted for all staff involved in the treatment of acute malnutrition.

When adopting the new growth standards, selective feeding programmes must be prepared for an increase

in case load by ensuring:

• Staff numbers in health facilities are adequate

• Facility staff are trained on MAM procedures, reporting, stock management, etc.

• Stock capacity at federal, regional, zonal and woreda levels are secured to prevent pipeline

ruptures

1.3.1 Identification of Weight for Height Measurement (WFH) ratio using

the reference tables

When a child's WFH is assessed, the child's weight is being compared to a reference weight for a child of

the same height. The reference weights for each height are known as the WHO reference values. The

reference values are used to assess or compare individual or population nutritional status.

The method by which a child or group of children is compared to the reference is known as "standard

deviation (SD)" or more commonly, "z-score". The z-score or SD describes how far a child's weight is from

the median weight of a child at the same height in the reference population.

The z-score is a more sensitive descriptor than either "percentiles" or "percentage of the median" so its use

implies that more children who are actually malnourished are identified. In addition to MUAC

measurements, to assess malnutrition, z-score or SD is used.17

For assessment of malnutrition in adolescents or adults, see section 2.3.2.5.3.

Health workers should use the WFH Reference Tables

for Girls and Boys in annex 1 to quickly identify if a child

is acutely malnourished or not.

14 Myatt, M., and Duffield, A. (2007) Assessing the impact of the introduction of the World Health Organisation (WHO) growth

standards on the measured prevalence of acute malnutrition and the number of children eligible for admission to emergency feeding

programmes. Background paper

15 de Onis, M., Onyango, A. W., Borghi, E., Garza, C., Yang, H. (2006) Comparison of the World Health Organisation (WHO) child

growth standards and the National Centre for Health Statistics/WHO international growth reference: implications for child health

programmes. Public Health Nutrition 9: 942-947

16 Seal, A., and Kerac, M. (2007) Operational implications of using the 2006 World Health Organisation growth standards in

nutrition programmes: secondary data analysis. British Medical Journal. DOI:10.1136

17 For programmes that are not yet implementing the WHO GS (2006), instead are using NCHS (1977) ‘percentage of the median’

reference values, the WFH reference tables are provided in annex 11.

1.3.2 Identification of malnutrition using MUAC

MAM in children 6-59 months (girls and boys) is

classified as a MUAC measurement of

≥ 11.0 to < 12.0 cm

MUAC tapes are portable, simple to use with minimal training and the colour coding ensures that

beneficiaries (or their caregivers) can easily understand why they have been included in a programme, or

not. MUAC is also the best predictor of mortality, an important fact for any child survival programme.18

However, the accuracy of MUAC measurements [especially those taken during the Enhanced Outreach

Strategy (EOS) nutrition screening] has frequently been questioned. Poor measurements can result in poor

targeting of the nutrition intervention, that is, inclusion of children in the TSFP who may not need nutrition

support and/or exclusion of children who do need nutrition support.

Problems generally arise with insufficient monitoring of programmes; food is a valuable commodity, and it

is all too easy to pull the MUAC tape a ‘bit tight’ to ensure the individual is included in the programme,

particularly if the measurer is under some pressure to include them (e.g. they are known personally to the

worker conducting the screening). It is therefore extremely important to ensure that the measurements are

taken accurately at health facilities or distribution sites, to ensure that only those individuals who fit the

admission criteria and can be admitted to the programme.

1.4 Information sources that can provide information on the need

to establish MAM treatment emergency interventions

MAM is treated in food insecure areas of Ethiopia through routine ongoing activities, such as the TSF/EOS

(as part of the quarterly CHD activities, refer to EOS/TSF implementation manual). However, in times of

heightened food insecurity emergency nutrition interventions might be required. For further information

on sources that can provide evidence on the need to establish emergency nutrition interventions, please

refer to the Ethiopia Emergency Nutrition Intervention (ENI) guideline, 2011.

18 Myatt, M., Khara, T., and Collins, S. A review of methods to detect cases of severely malnourished children in the community for

admission into community-based therapeutic programmes. Food and Nutrition Bulletin. Vol 27. No 3 (Suppl). 2006:S7-23.

Chapter 2. Supplementary Feeding Interventions

2.1 Description of supplementary feeding

At present the most common interventions for the management of MAM are Supplementary Feeding

Programmes (SFP). Supplementary feeding is the provision of nutritious rations to vulnerable children

(usually classified at < 5 years) or those with special dietary needs (e.g. pregnant and lactating women,

individuals with HIV/AIDS, etc.). SFPs also provide vital links to ongoing SAM treatment programmes. In

most situations, SFPs are implemented in order to prevent excess mortality among vulnerable groups. SFPs

can either be blanket or targeted and aim to supplement the energy and nutrients missing from the diet

due to various reasons.

During emergency situations, SFPs should be a short-term measure and not necessarily be seen as a means

of compensating for inadequate household food security.19 A significant and continued reduction in the

prevalence of malnutrition is likely only if an SFP is implemented alongside adequate General Food

Distributions (GFD), and/or is well aligned with the PSNP. The recently endorsed National Guidelines on

Targeting Relief Food Assistance (2011) states:

“In areas where nutritionally-targeted interventions such as TSF or CMAM are in operation, the

households of individuals who are registered for such nutritional support should automatically be

included in the registration for GFD. That is, current acute malnutrition should be an inclusion criterion

for general rations. All international experience shows that supplementary feeding is only effective

when the household has adequate access to basic foods.

In PSNP woredas, similarly, no household should be excluded from nutritional programmes (e.g. TSF,

CMAM or BSFP) on the grounds that they are already receiving support from the PSNP. Overlaps

between these programmes at the household level are desirable and represent effective targeting of

complementary assistance types.”20

2.1.1 Objectives of setting up an SFP

It is vital that the objectives of commencing and setting up the programme are well defined at the start of

the programme and are understood by all partners.

1. To reduce the risk of mortality and morbidity associated with MAM

2. To rehabilitate at-risk individuals to prevent deterioration into MAM (blanket SFP) and moderately

malnourished individuals to prevent deterioration into SAM (targeted SFP)

3. To provide a ‘protection ration’ for individuals discharged from therapeutic feeding programmes

and thus prevent relapse into SAM

4. To rehabilitate PLW who are at-risk or moderately malnourished to improve maternal nutritional

status and minimise the risk of infants born with low birth weight

5. To provide nutritional/health education messages for beneficiaries or caregivers and hence

increase awareness on optimal child feeding practices and appropriate health seeking behaviours

19 A toolkit for addressing nutrition in emergency situations. IASC Global Nutrition Cluster, UNICEF, New York, NY, 2008

20 National Guidelines on Targeting Relief Food Assistance. Ministry of Agriculture (Disaster Risk Management and Food Security

Sector), Addis Ababa, Ethiopia, 2011

2.2 Planning the intervention

MAM is treated in food insecure areas of Ethiopia through routine ongoing activities, such as the TSF/EOS

(as part of the quarterly CHD activities). However, in times of heightened food insecurity emergency

nutrition interventions might be required.

Prior to any emergency intervention, discussion must be held with local authorities to discuss and

determine the methodology, size, location and other important features of the proposed programme.

Wherever possible, programmes must be run within existing health structures/facilities. SFPs are usually

implemented through a large number of decentralised sites, the number of which will depend on the area,

terrain, density of population, expected number of beneficiaries, etc. The exit strategy of any programme

must be clearly identified and communicated prior to implementation.

2.2.1 Staff

The routine treatment of MAM through the EOS/TSF is currently managed at community level during the

quarterly CHDs by the HEWs, with support from the Food Distribution Agents (FDAs).

During times of heightened food insecurity, emergency SFPs might be needed. When these programmes

are required, it is vital to discuss the aims and objectives of the programme with local officials from the

start, such as woreda Administrators. It is also essential to have local authority representatives, e.g. kebele

Chairpersons, attending distribution activities in order to ensure that the operation runs smoothly and to

facilitate liaison with the community. Local government personnel are essential for good communication

between programme implementers and the community, for example, clarity regarding which vulnerable

groups the programme is targeting, passing messages for which days distributions will be held, any changes

to the schedule, etc.

Emergency SFPs are encouraged to use whatever capacity is already present in the community e.g. existing

FDAs, who will have prior knowledge and experience with screening, health education, etc. Additional

numbers and types of programme staff will depend on the size of the planned programme and projected

case-loads.

For emergency SFPs, key positions may include;

1. Overall Programme Manager

2. Health workers available to conduct triage and provide medical checks for beneficiaries

3. Supervisor

4. Distribution staff; registrar, measurers, food mixers, health educators and demonstrators, guards

5. Store keeper

6. Outreach workers/community mobilisers for screening, mobilisation and follow-up activities (see

section 3.1)

2.2.2 Supplies, equipment and transport

The size of the area and number of beneficiaries expected for the SFP will determine the amount of

materials, equipment, food and other items that are required.

The minimum supply requirements for an emergency SFP may include:

1. Food commodities; Fortified Blended Food (FBF), oil, sugar and/or other products to treat MAM

(see section 2.3.2.8)

2. Routine and other common drugs and vitamin supplements (see section 2.3.2.6.2)

3. Monitoring materials; ration cards, bracelets, referral slips, registration books, reporting formats,

supervision formats (see annex 2, 3, 4, 5, 6, 7)

4. Anthropometric equipment; salter scale or electronic scales, height/length boards, MUAC tapes,

WFH reference tables in z-scores (see annex 1, 8)

5. Non-Food Items (NFIs); shelter, soap for washing hands and utensils, clean water, cups, spoons,

cooking demonstration equipment, tables, chairs/benches (see annex 8)

6. Documentation; Information, Education and Communication (IEC) materials, training materials,

National Guidelines, job aids, field guides (e.g. CSB+, RUSF usage), pictorial information for

beneficiaries outlining what they can expect at the site, such as ration entitlements, etc.

7. Sufficient transport must be available to effectively implement the programme; to ensure

uninterrupted product supply chains and to move staff around, as necessary

2.2.3 Storage and Warehousing

Figure 3: The important features of warehousing and storing food commodities

(Source - adapted from the Somalia MAM guidelines, 2009)

• Products should be stored 40 cm off the wall and 10 cm off

the floor. Food commodities like CSB should be stored on

pallets to prevent weevil infestation/ contamination. Food

commodities should be protected from rodent infestation

• Food products should be stored separately from other

commodities, e.g. medicines or stationary

• Bags must not lie directly on the floor. Stacks of bags should

be no more than 2 m high

• Separate damaged bags/boxes. Record and report any

damage that occurs

• Keep an inventory of all the items in the store; a record list

should indicate name of item, quantity, date received, date

dispatched, from whom, by whom, balance and expiring

dates. It is helpful to have a Stock Control System, using the

‘first in, first out’ storage strategy (but also considering the

expiry date; goods with earlier expiry dates should be used

first). See annex 9 for sample stock card and annex 23 for

tips on good warehouse management (supplied by WFP)

2.3 Types of Supplementary Feeding Programmes (SFPs)

There are two types of SFPs: Blanket or Targeted.

(Source – adapted from UNHCR/WFP Selective Feeding Guidelines, 2009)

The key difference between the two types of SFP is that:

• Targeted SFP target and treat moderately malnourished individuals;

while

• Blanket SFP has a more preventative role, targeting all those in ‘at risk

groups’ irrespective of nutritional status

2.3.1 Blanket Supplementary Feeding Programme (BSFP)

A BSFP is a temporary distribution of a supplementary ration to all members of a specified at-risk group

(e.g. all children <5 years, or all PLW, or people with chronic diseases), whether they are suffering from

MAM, or not. BSFPs are generally implemented in a specified geographical area e.g. a camp or woreda.

2.3.1.1 Objectives of the BSFP

BSFPs are implemented at population level, therefore their objectives are primarily preventative. BSFPs aim

to prevent deterioration in the nutritional status of a population, to reduce the potential prevalence of

acute malnutrition and micronutrient deficiency in order to reduce excess morbidity and mortality among

those at-risk, through the provision of a food/micronutrient supplement.

BSFPs can act as a very effective measure to stabilise rapidly deteriorating situations (e.g. very high GAM

levels, during outbreaks or epidemics of infectious diseases, etc.), or they may act as a short term measure

during a seasonal hunger gap. BSFPs are usually implemented alongside a GFD, or can be implemented as a

‘stop-gap’ measure until sufficient GFD can be established.

BSFPs provide a fortified food supplement for all members of the identified vulnerable group. The

availability of resources will dictate the scope of the target group, for example, under-24 months, under-36

months, under-60 months, PLW, etc. Where resources are limited, the priority is usually to ensure full

coverage of children 6-23 months in a defined geographical area.

While anthropometric status is not measured or monitored during BSFPs, staff are encouraged to conduct

anthropometric screening wherever possible, in order to facilitate the correct referrals of persons with

MAM and SAM. As targeted supplementary feeding programmes and BSFPs are not implemented

concurrently, emphasis must be placed on the referral of identified SAM children for further assessments of

complications and appropriate treatment.

All registered beneficiaries receive the same nutritional support over a fixed period of time (e.g. 2 months).

Individual measurements are not usually recorded; therefore it is not possible for BSFPs to quantify

individual outcomes.21

2.3.1.2 General criteria for establishing emergency BSFPs

Refer to the Ethiopia ENI guideline, 2011.

2.3.1.3 Case load estimation and beneficiary identification for BSFPs

Where no definitive population data exists, programme staff should discuss with relevant authorities

(woreda offices, health facilities and local leaders) to establish the population size for the area. Numbers of

potential beneficiaries within the defined groups (e.g. children < 2 years) can then be estimated. Where

population data cannot be obtained from local authorities, other information should be sourced that can

provide the ‘best guess’, for example, use of recent DHS or any other surveys/campaigns conducted in the

area.

21 Harmonised Training Package. Module 12: Management of MAM, technical notes, version 2: 2011.

http://www.ennonline.net/pool/files/ife/management-of-moderate-acute-malnutrition-technical-notes.pdf

At community level, beneficiaries that fall within the defined group must then be identified, for example,

children 6 - 23 months or 6 - 59 months (less than 87 cm or 110 cm in height, respectively). This can be

done through the passing of information via local sources, for example, calling the population to come to a

certain area on a certain day to be registered for the programme.

Depending on the seriousness of the situation and in discussion with local and regional authorities, it may

be decided to include other vulnerable groups in a BSFP,22 for example;

All PLW

All adults showing signs of malnutrition

Older persons

Those with a disability

Where possible, effort should be made to provide Vitamin A supplements and deworming tablets during

contact points with the children on distribution days. Where appropriate and resources allow, other

interventions could also complement the BSFP distribution mechanism, such as distribution of Insecticide

Treated Nets (ITNs), water purification tablets, etc. It is important to focus on nutrition, health and hygiene

sensitisation during any contact points with beneficiaries. Appropriate IEC material should be

disseminated/broadcasted.

2.3.1.4 Admission and discharge criteria for BSFP

Admission and discharge criteria for BSFPs do not rely on anthropometric indicators. Once the targeted

groups have been defined, those that meet the criteria are admitted (e.g. children aged 6 - 23 months).

After a specific time period or when the BSFP is closed, they are ‘discharged’.

2.3.1.5 When to Close emergency BSFPs

Refer to the Ethiopia ENI guideline, 2011.

2.3.2 Targeted Supplementary Feeding Programme (TSFP)

2.3.2.1 Objective of the TSFP

The Targeted Supplementary Feeding Programme (TSFP) aims to rehabilitate moderately malnourished

individuals (most commonly children 6 - 59 months and Pregnant and Lactating Women, PLW) through the

provision of nutritional support,

• To prevent deterioration into Severe Acute Malnutrition (SAM)

• To reduce the risk of morbidity and mortality associated with MAM

• To provide nutrition/health education and opportunities for counselling

Where required and resources allow, other nutritionally vulnerable groups can also be targeted, e.g.

adolescents, people living with HIV/AIDS (PLWHA) or other chronic disease, older people, etc.

22 Refer also to the 2011 National Guidelines on Targeting Relief Food Assistance. Ministry of Agriculture (Disaster Risk

Management and Food Security Sector), Addis Ababa, Ethiopia.

2.3.2.2 When to establish TSFPs

During times of heightened food insecurity, emergency nutrition interventions such as TSFPs may be

required to complement routine MAM treatment and prevention programmes. For further information

regarding criteria for starting emergency TSFPs, please refer to the Ethiopia ENI guideline, 2011.

2.3.2.3 Determining the case load for a TSFP

For new programmes, the number of beneficiaries can be estimated based on the findings of the most

recent nutritional assessment. Examples are given below for how to calculate the expected case-loads:

Total number of malnourished group =

Total population of vulnerable group X Prevalence rate of Moderate Acute Malnutrition23

For planning purposes, it is common to estimate that between 70-80% coverage of the population will be

reached by the TSFP.

Example 1:

A standard nutrition survey conducted in Borena Zone indicated a GAM level of 14.6% and a SAM of 1.6%.

The estimated total population of the survey area was 50,000. Based on the nutrition survey results, the

estimated number of children to be enrolled in the programme is calculated as follows:

• Total population of the area = 50,000

• Under 5 population (for example, 18% of total population) = 50,000 x 18/100 = 9,000

• Prevalence of MAM = GAM- SAM = MAM level (14.6% - 1.6%)= 13%

• Number of MAM children in the area = 9,000 x 13/100 = 1,170

• 75% of MAM children expected to be reached by TSFP = 1,170 x 75/100 = 878

It can be more difficult to estimate the expected case load of pregnant and lactating women for the TSFP

because the exact percentage of the women of childbearing age in the population that is pregnant or

lactating is generally unknown (if the figure is known, then it can be used for the calculation). However, a

rough measure can be used, estimating that approximately 5% of the total population will be women of

childbearing age, who are likely to be pregnant or lactating at any one time.

Example 2:

The same standard nutrition survey in Borena Zone also measured the MUAC of all PLW included in the

survey. This indicated that 10% of PLW were moderately malnourished.

• Total population in the area = 50,000

• Estimated population of PLW in the area (5% of total population) = 50,000 x 5/100 = 2,500

• Estimated number of PLW who are MAM (10%) = 2,500 x 10/100 = 250

• 75% of PLW with MAM expected to be reached by TSFP = 250 x 75/100 = 188

For ongoing programmes (and where it is not possible to conduct a nutrition assessment), trends of

admissions can be used, to forecast expected case-loads for the next phase of the programme.

23 The incidence rate should also be accounted for as new cases will arise during programme implementation. However, as yet there

is no international consensus about what number to use as the incidence multiplier, although at global level, WFP is currently using

prevalence multiplied by 2.

2.3.2.4 TSFP triage, diagnosis and beneficiary selection

Screening conducted at the community level is done through MUAC measurement (see community

mobilisation section 3.1). When individuals arrive at the distribution site (referred or otherwise),

programme staff (ideally in conjunction with an HEW or other suitably qualified health worker) should

assess each individual for malnutrition; this includes taking anthropometric measurements, recent history,

and a medical examination. Based on this information, the health worker can determine the appropriate

course of treatment depending on whether the individual is moderately or severely malnourished. Figure 4

below summarises the triage process for acute malnutrition:

Figure 4: Triage process for children 6 – 59 months screened or referred to distribution site or health

facility for Management of Acute Malnutrition (for infants 0 - 6 months, refer to SAM guidelines)

Step 1: Check for visible signs of malnutrition and medical complications

Does the child have any of the following? (Refer to IMCI treatment booklet

for advice and guidance on assessing the sick child)

hypoglycaemia, fever, hypothermia, vomiting, dehydration, severe

anaemia, very weak, lethargic, unconscious, convulsions, skin lesions,

difficult or fast breathing, bilateral pitting oedema +++

Step 2: Check oedema and anthropometric measurements; record

on the child growth card

YES

And the child

has:

MUAC <11.0

WFH < -3 Z-

score

And the child

has:

MUAC ≥11.0

to < 12.0 cm

WFH < -2 to

≥-3 Z-score

AND

No oedema

If the child has:

MUAC >12.0 cm

WFH > -2 Z-score

AND

No oedema

CHILD IS HEALTHY

Step 3: Praise the

mother, provide

counselling on child

nutrition (including the

use of milk products,

where possible) and

send child home

If the child has:

MUAC ≥11.0 – < 12.0 cm

WFH < -2 to ≥-3 Z-score

AND

No oedema

CHILD IS MAM

without complications

Step 3: Admit to

Targeted SFP following

procedures outlined

below

If the child has:

MUAC < 11.0cm OR WFH

< -3 Z-score

+, ++ Bilateral oedema

CHILD IS SAM

without complications

Step 3: Refer to

Outpatient Therapeutic

Programme (OTP)

YES

CHILD

IS SAM

with

compli-

cations

CHILD

IS MAM

with

compli-

cations

Fast

Track to

TFU (for

in-patient

care)

Follow IMCI

algorithm for

appropriate

treatment of

complications.

Refer to higher

level facility as

necessary.

Provide

treatment for

MAM

according to

the protocol.

The triage diagram in figure 4, outlines steps to identify individuals with acute malnutrition (see annex 10

for how to check for oedema and measure MUAC, weight and height/length):

Step 1:

Check for visible signs of malnutrition and any medical complications (e.g. signs of common infections). If

the individual is medically unwell or severely malnourished, they should be referred to the nearest health

facility for further assessment and appropriate treatment.

Step 2:

Check for oedema and measure anthropometry (see table 1 below); for those with acute malnutrition

(without additional medical complications) refer to the appropriate nutritional treatment centre and record

on the child growth card.

If bilateral pitting oedema is present, the individual is suffering from SAM and should be referred to the

nearest health facility (or mobile health clinic) providing OTP (+ or ++ oedema) or TFU (+++ oedema). See

annex 10 for a description of how to test for oedema.

Bilateral pitting oedema (kwashiorkor) is always considered as severe

malnutrition (SAM), due to its complex causes and high mortality risk if

left untreated (or poorly treated). Successful treatment requires the child

to receive additional medical care and therapeutic products; RUTF and

specialised milks.

Immediately refer any child identified with oedema to the nearest health

facility.

Step 3:

Take appropriate action. Use the WHO reference tables to determine z-scores and MUAC measurements.

• For healthy children (green) praise the caregiver, provide nutrition counselling including the use of

milk products, where possible and send the child home.

• For MAM children (yellow), admit to TSFP. For MAM children (yellow) with complications, follow

IMCI algorithm for appropriate treatment of complications. Refer to higher level facility as

necessary. Provide treatment for MAM according to the protocol.

• For SAM children (red) with appetite and without complications (see national protocol for SAM

management), refer to OTP. For SAM children with complications (red), refer to nearest TFU.

Table 1: Target group and type of measurement

Target group

Type of measurement

Children 6 to 59 months

•

(establish the age of the younger child from

discussion with the mother. 110 cm in height •

can be used as a proxy for children up to 5

years)

•

Take MUAC measurement for children 6 – 59

months using MUAC tape

Take Weight and length, if child is less than 24

months or less than 87 cm

Take height if child is 24 months and above or more

than 87 cm

Pregnant and lactating women (PLW)

Take and record MUAC measurement using MUAC tape

2.3.2.5 Admission criteria for TSFP

Admission to TSFPs for children 6-59 months rely on two types of anthropometric indicators of acute

malnutrition; MUAC and WFH z-score based on the 2006 WHO GS (as summarised in table 2 below). As the

transition to the use of WHO GS might take some time to implement, the NCHS 1977 reference tables and

table for admission/discharge criteria are provided in annex 11.

In Ethiopia, emergency TSFPs have traditionally used WFH percentage of the median, and MUAC for

admission and discharge, with the Enhanced Outreach Strategy (EOS) programme using MUAC ≥11.0 to <

12.0 cm as the sole admission criterion. Since 2009, global recommendations for admission to programmes

that treat acute malnutrition have recommended the use of WFH z-scores instead of percentage of the

median (see section 1.3 the identification of acute malnutrition for more detail).

If programmes are using a ‘two-stage’ screening and admission process, i.e. screening conducted in the

community using MUAC and subsequent admission to the programme using only WFH criteria, then it is

likely that the programme will suffer from negative feedback in the community due to the number of

‘rejected referrals’. WFH and MUAC are two different indicators, which identify two different populations;

while there is some overlap of cases that will be identified as MAM using both indicators, inevitably some

cases of MAM identified through MUAC will not subsequently be admitted to the programme on the WFH

criteria. Problems arise when caregivers have attended the site with the expectation that they will receive

food for their child (the referral slip is often viewed as a ‘promise’ of food). If their child is then not

admitted to the programme, meaning they go away empty handed, caregivers often will not return to the

site, even if their child’s condition deteriorates. Furthermore, they might discourage family, friends and

neighbours from attending the programme following referral.

2.3.2.5.1 MAM children 6-59 months

MUAC is an internationally accepted independent criterion for admission for children 6-59 months of age,

although exact age may be difficult to obtain. Where this is so, the caregiver should be asked to estimate

the age of the child (or use the family health card, where available). The mother is likely to be able to recall

the time of birth of a young child and it is essential to obtain this information. 24 Local events calendars can

help this process. Children should not only be selected on the basis of height as a proxy for age, as in

24 A guide for selective feeding programmes, UNHCR/WFP. Geneva, May 2009.

populations with high stunting rates (such as Ethiopia), there will be many children older than 6 months but

shorter than 65 cm. Such children would therefore be excluded from the programme if a proxy height was

used.

Infants under-6 months must never be included in the TSFP, but referred to the nearest TFU for treatment

when identified as malnourished [see section 4.1 for the Management of Acute Malnutrition in Infants

(MAMI)].

2.3.2.5.2 MAM Pregnant and Lactating Women (PLW)

During pregnancy and lactation, women’s nutritional needs are greatly increased, largely due to the

demands for net tissue deposit or milk formation. According to the recommendations from 2003, pregnant

women with a normal weight before pregnancy require an additional 285 kcal/day and lactating women

require an additional 500 kcal/day. 25 Both pregnant and lactating women also have increased needs for

micronutrients. Iron, folate, vitamin A and iodine are especially important for the health of women and

their infants.26

In Ethiopia, the current MUAC cut-off for classification of MAM in pregnant women in their third trimester

of pregnancy and lactating women with an infant < 6 months, is recommended to be < 23.0 cm

Table 2: Summary of Admission Criteria for TSFP

Target group

Indicator

Oedema

Children:

6-59 months

Women:

Pregnant (3rd trimester)

Lactating (infant < 6 months)

Anthropometric

Measurements

Follow-up of SAM

patients

Anthropometric

Measurement

Criteria

None

MUAC: ≥11.0 cm to < 12.0 cm

AND/OR

Weight-for-height (WFH) z-

score: < -2 to ≥ -3

Discharged cured from OTP

(automatic admission TSFP for

2 months to prevent relapse)

MUAC: < 23.0 cm

25 Well-nourished women with adequate gestational weight gain should increase their food intake by 505 kcal/day for the first 6

months of lactation, while undernourished women and those with insufficient gestational weight gain should add to their personal

energy demands 675 kcal/day during the first semester of lactation. Energy requirements for milk production in the second 6 months

are dependent on rates of milk production, which are highly variable among women and populations. Food and Nutrition Needs in

Emergencies. UNHCR/UNICEF/WFP/WHO. Geneva, 2003. http://www.unhcr.org/publ/PUBL/45fa745b2.pdf

26 A guide for selective feeding programmes, UNHCR/WFP. Geneva, May 2009.

2.3.2.5.3 MAM in other vulnerable groups (admission and discharge criteria)

Table 3: Recommendations for admission and discharge criteria for other vulnerable groups

suffering from MAM

(Source – adapted from the HTP MODULE 12: Management of MAM, technical notes, version 2: 2011 and

the Ethiopia HIV and Nutrition guideline, revised 2011)

Vulnerable

group

Infants < 6

months

Children 5 to

<10 years

Admission

Discharge

WFH z-score ≤ -2. Infants with MAM should immediately be referred to in-patient care

where appropriate support for breastfeeding can be given, where possible.

MUAC ≥ 13 to < 14 cm

MUAC ≥ 14.0 cm for two

consecutive distributions

Adolescents

with MAM

Weight-for-height (WFH) z-score: < -2 to ≥ -3.

MUAC for age >10 to ≤ 15 years old; ≥ 16 to < 18

WFH ≥ -2 z-score for two

consecutive distributions

MUAC ≥ 18.0 cm for two

consecutive distributions

Adults with

HIV/AIDS

and/or TB and

MAM

Body Mass Index (BMI)27 –for-age, with results

presented based on

Weight-for-height (WFH) z-score: < -2 to ≥ -3

according to the WHO growth Reference for

children and adolescents (see annex 12)

MUAC ≥ 18.0 to < 23.0 cm

For non-pregnant or lactating

BMI < 18.5

For PLW with HIV/AIDS and/or TB

MUAC ≥ 18.0 to < 23.0 cm

WFH ≥ -2 z-score for two

consecutive distributions

MUAC ≥ 23.0 cm for two

consecutive distributions

UNHCR/WFP recommend

discharge for adults as

BMI ≥ 18.5

2.3.2.6 TSFP distribution procedures at the site for new and registered

beneficiaries

Once the decision has been made to admit a beneficiary to the TSFP, the following steps should be

completed as follows;

1. Beneficiary registration

2. Administration of routine treatment

3. Follow-up procedures for those already registered in TSFP and referrals to OTP/TFU

4. Nutritional counselling and education

5. Distribution of the supplementary food ration

6. Discharge criteria and procedures

27 Body Mass Index defined as the (weight in Kg)/(height in m)² for assessing the nutritional status of adults

2.3.2.6.1 Beneficiary registration

a) Provide the beneficiary or caregiver with a ration card (see annex 2)

b) Ensure that the registration book is filled in with all essential information, e.g. name, age, sex,

home address, anthropometric details on admission, etc. (see annex 4 for example of registration

book)

c) Explain the process of the TSFP to the beneficiary or caregiver, including how the programme

works, reasons for admission to the programme, the ration given and expected length of stay.

Posters at the site (in local language and/or descriptions through pictures) can help the

beneficiaries understand what to expect at the site, and what they are entitled to

2.3.2.6.2 Routine treatment

The TSFP should always provide routine medicines, such as, antihelminthics, vitamin A supplementation

and routine immunizations. The tables below (4 and 5) detail each medicine, with specifications of when to

give and the dose. Pregnant women must be referred to the nearest health facility for Ante-Natal Care

(ANC) to receive additional services, such as iron/folate supplementation and tetanus vaccination.

Table 4: Summary of routine medicines for children 6-59 months

Name of Medicine

Vitamin A28

When

On admission

Antihelminithic

Albendazole

On admission

Mebendazole

Measles vaccination

On admission

Age

Dose

6 to 11 months 100,000 IU

≥ 12 months

< 12 months

12 to 23 months

≥ 24 months

< 12 months

12 to 23 months

≥ 24 months

9 months or older

200,000 IU

Do not give

200mg

400mg

Do not give

500 mg

Prescription

Single dose on

admission

None

Single dose on

admission

None

Single dose on

admission

One dose

Table 5: Summary of routine medicines for pregnant and lactating women

Name of Product When

Albendazole or

Mebendazole

Vitamin A

Third trimester

Within first 6

weeks after

delivery

Physiological

Status

Pregnancy

Post-partum

Dose

Albendazole 400mg OR

Mebendazole 500 mg

200,000 IU

Prescription

Single dose

on admission

2.3.2.6.3 Follow up procedures for those already registered in TSFP

The beneficiary’s progress should be monitored at every visit; assess for oedema, weight and MUAC every 2

weeks and height every month (where a height board is available). Record the measurements in the

28 Do not give vitamin A supplement (VAS) if child has received within the last one month. It is vital to check with local health

officials whether there have been any VAS campaigns in the area during the previous month.

deterioration is noted, alert the TSF supervisor and refer to the nearest health facility for further follow up.

Each beneficiary should receive nutrition counselling and education sessions (including the importance of

using milk-based products for children < 2 years) prior to receipt of the next ration.

During each follow up at the TSFP site, the following actions are encouraged:

• If the child is gaining weight, congratulate the caregiver and explain that the child is improving

• If the child has lost weight since the last visit, or has not gained weight in 3 consecutive

distributions, conduct a thorough medical examination to ensure there are no concurrent medical

problems. Explain the situation to the caregiver with a reminder of the importance of not sharing

the food rations; reinforce nutritious food preparation with the caregiver

• If the child or PLW fails to reach the target weight within four months, or loses weight on 3

consecutive distributions, refer him/her to the outpatient department for a medical check-up (see

section 2.3.2.9.2 for discharge criteria)

2.3.2.6.4 Transfer to OTP or inpatient unit (TFU or SC)

Even while registered in the TSFP, MAM children can be at risk of becoming severely malnourished if they

suffer from an episode of illness or other problem. Their health and growth must be monitored at each SFP

visit to ensure that they are improving as expected and also to identify those whose condition has

deteriorated.

Children should be referred to the nearest OTP for further assessment if any of the following occurs (see

annex 13 for example of referral form):

Bilateral pitting oedema develops

MUAC drops below 11.0 cm

WFH z-score decreases to less than -3

Development of any medical complications

The health worker at the OTP can then determine if the child should be admitted to OTP or referred to the

nearest TFU (using the triage diagram outlined in figure 3, page 16).

2.3.2.7 Nutrition counselling and education

A vital part of MAM programming; for further information refer to chapter 4.

2.3.2.8 Supplementary food ration

2.3.2.8.1 Provision of the dry ration

The regular distribution of fortified blended food (FBF) or other nutritional rehabilitation products (e.g.

RUF) to assist in home treatment is given. FBF is a pre-mixed, fortified food which contains the necessary

nutrients to treat MAM. It is strongly advised to provide dry rations to beneficiaries rather than implement

‘wet feeding’ programmes for the following reasons:

Advantages of the dry ration

• Less risk of cross-infection as large numbers of malnourished and sick children do not have to sit in

close proximity while feeding

• Fewer resources and organisation than wet feeding; staff time taken to establish and implement

the programme. Programmes can therefore be established in a more timely fashion

• Less opportunity costs for caregivers who only have to attend once every two weeks, which

generally leads to better coverage of the population and a lower default rate

• Encourages the responsibility for rehabilitation of malnourished individuals within the family

• Improved access which is more appropriate for widely dispersed populations (as in much of

Ethiopia), many of whom would have to travel long distances to attend daily

Quantity and quality of the ration

The dry ration supplement should consist of approximately 1124 kcal per day.

This can be achieved by the provision of 6.25 kg FBF and 1 litre of oil29 per beneficiary/per month.

The food provided should have the following characteristics using NutVal 2006 version:

37.4 % of the energy as protein

45.5 % of the energy as fat

An adequate nutrient content (concentration) for all the essential micronutrients according to

Recommended Dietary Allowances (RDAs)

The shelf-life of the supplementary food should be known; the product adequately labelled and must be

free from infestation and spoilage. Supplementary food must be correctly stored (see section 2.2.3 for

more detail).

2.3.2.8.2 Premixing the ration

When oil and sugar are given alongside the FBF, it is essential to mix it into the FBF before distribution. This

is to ensure that the oil and sugar are not used for the family cooking or sold, as they can otherwise be

viewed as valuable cash opportunities for the caregivers. If rations are premixed at the distribution site, the

beneficiaries will be more likely to reap the full benefit of the ration, resulting in TSFPs being more able to

reach the objectives of successful treatment of MAM in the community.

However, premix must be used within a 2 week period before any rancidity develops; if the distributions

are being conducted less frequently e.g. monthly, then FBF and oil should not be premixed at the site.

2.3.2.8.3 Cooking demonstrations

Fortified Blended Food (FBF) can be ‘spoiled’ if it the porridge is cooked either for too little, or too much

time. The ideal cooking time to maximise the nutrients available in FBF is 10 minutes. In order that the

beneficiaries well understand how best to cook the ration, cooking demonstrations conducted on-site can

be very helpful. If at all possible, caregivers should be asked to assist with the cooking, as the learning will

likely be more effective if they are included in the practical aspects of cooking. It is also important to

indicate how much and how often the porridge should be given to the children. The correct measurements

for cooking either thick or thin porridge are included as annex 14.

Sometimes beneficiaries prefer to cook bread with the flour. This should be strongly discouraged, as bread

more often tends to be shared around the family, meaning the malnourished individual will not be

receiving the correct amount of calories/nutrients for recovery.

29 One litre of oil weighs 0.9 kg

Where possible and resources allow, demonstrations should also be conducted to show how to prepare

nutrient-rich meals which are appropriate for infants and young children using locally available foods. This

can help to reinforce the nutrition and health education messaging on how to prevent healthy children

deteriorating into sick children.

2.3.2.8.4 Newer products for the treatment of MAM

A host of new products are now available for the treatment of MAM. However, as yet no conclusive

evidence is available to identify which product is superior to the others in any given situation. A decision

tree has been developed to assist with the selection of nutritional products for particular MAM

interventions and is included as annex 15.

It is however important to note that no definitive evidence is yet available for which of these products

might be most appropriate and in which context. Organisations need to weigh up the advantages and

disadvantages of each product (including cost of treatment) before deciding what is best to use. Any

products used in Ethiopia must be registered and approved for use by the Food, Medicine and Health Care

Administration and Control Authority (FMHACA). It is also vital that agencies discuss and secure agreement

with local, regional and federal MoH staff, prior to implementing programmes using any of these ‘new’

products. It is also very important that organisations ensure they have sufficient stocks of the product for

the entire programme. Beneficiaries might become confused and/or discouraged if they are receiving

different products at different times.

2.3.2.9 Discharge criteria

2.3.2.9.1 Discharge recovered cured

There is currently no internationally recognised consensus on the discharge criteria for TSFP using the

recommended admission criterion, MUAC.30 It is therefore recommended that a target weight gain of 13%

increase in weight from admission weight is used for MUAC admissions (see annex 16 for 13% target weight

gain table and annex 17 for discussion of the 13% target weight gain criterion). For admissions on WFH z-

scores, discharge is recommended as ≥ -2 scores for two consecutive distributions. Table 6 below

elaborates the discharge criteria for recovery of children 6-59 months and PLW suffering from MAM:

Table 6: Criteria for MAM beneficiaries, discharge ‘recovered/cured’

Admission criteria:

Children with MUAC ≥11.0 to < 12.0 cm

Children with WFH < -2 to ≥-3 z-score without

complications

Pregnant and lactating women with a MUAC

< 23.0 cm

Corresponding discharge criteria:

Reach the target weight gain of 13% from admission

weight AND

MUAC ≥ 12.0 cm for two consecutive distributions

≥ -2 z-score for a period of two consecutive

distributions

MUAC > 23.0 cm for two consecutive distributions

30 The EOS programme does not need to use a discharge criteria; as the screening is done every 6 months (child health days screen

every 3 months), the child has a MUAC < 12.0 cm so is admitted/remains in the programme, or the MUAC is ≥ 12.0 cm and is not

registered for the next distribution.

The discharge criteria must match the admission criteria. For example, children admitted on WFH z-scores

should be discharged using WFH Z-score ≥ -2 for 2 consecutive distributions.

If a child was admitted based on MUAC, they should be discharged based on a target weight gain of 13%

AND MUAC ≥ 12.0 cm for 2 consecutive distributions. If the child reaches 13% target weight gain, but the

MUAC measurement remains less than 12.0 cm, the child should continue attending TSFP distributions until

the MUAC reaches ≥ 12.0 cm.

2.3.2.9.2 Discharges from TSFP other than recovered cured - children 6-59 months

Programme discharges in categories other than those who ‘recover’ are described below:

• Died: Child died after admission to the programme (this should be confirmed by a home visit or by

information provided by neighbours/relatives)

• Defaulter: Child is absent from the programme for three consecutive distributions

• Transfer: Either the child’s condition deteriorated requiring transfer to the TFP (OTP or TFU) or the

family moved and the child was transferred to another SFP site (transfers are not included in

calculations of programme performance). Numbers of transfers to in-patient care should be closely

monitored, as high numbers could indicate a worsening food security situation in the area

• Non-response (failure to respond to treatment): Where a child fails to reach the discharge criteria

over a period of four months, they should be discharged as a non-responder. Investigations must

be conducted prior to discharge, as outlined below

Criteria for investigating failure to respond to treatment:

1. No weight gain after 6 weeks in the programme

2. Weight loss during 4 consecutive weeks in the programme

3. Weight loss exceeding 5% of body weight at any time

4. Failure to reach discharge criteria after 4 months in the programme

Possible reasons for failure to respond:

1. Problems with the application of the protocol

2. An underlying physical condition/illness, such as HIV/AIDS, TB

3. Nutritional deficiencies that are not being corrected by the diet supplied in the TSFP

4. Home/social circumstances of the individual

5. Excessive sharing of the ration

6. Other causes

Steps to take for failure to respond to treatment:

Step 1: Review the patient’s register card and confirm that the protocol for TSFP has been adhered to

correctly (ensure that the details on the child’s card are correct)

Step 2: Conduct a full medical examination and nutrition assessment. If the patient presents with any signs

of medical complications or nutrition deficiencies, refer immediately to the nearest health facility or TFU

for further investigation and/or treatment

Step 3: Request a home visit by community mobilisers to assess the home/social situation of the child.

Assess whether the caregiver is preparing the porridge correctly, whether it is acceptable/tolerated by the

child and whether the supplementary food is being given exclusively to the child or excessive sharing is

occurring (see annex 18 for home visit form)

2.3.2.9.3 Discharges from TSFP other than recovered cured - PLW

Programme discharges in categories other than those who ‘recover’ are described below:

• Died: PLW died after admission to the programme (this should be confirmed by a home visit or by

information provided by neighbours/relatives)

• Defaulter: PLW is absent from the programme for three consecutive distributions

• Transfer: If the family has moved and the PLW was transferred to another SFP site (transfers are

not included in calculations of programme performance)

• Other discharges/non-response

o For pregnant women - child is born. The woman should be encouraged to return to the TSFP

once the confinement period is over (usually 40 days), to check whether she is still MAM and

is entitled to receive TSF rations

o For lactating women - Infant reaches 6 months of age. Infant’s anthropometric status should

then be checked, if the infant is MAM, it should be admitted to the TSFP

2.3.2.10 When to close the emergency TSFP

Repeat anthropometric nutrition surveys should be conducted to inform programme effectiveness and

assess whether the programme should continue or phase-out. Refer to the Ethiopia ENI, 2011 for more

details.

Chapter 3. Monitoring, reporting and coverage

3.1 Monitoring

It is important to know whether the intervention is making progress towards its objectives. Monitoring

helps implementers to understand what is working well and what is sub-optimal, and where gaps may be.

If management and information systems are simple the burden on programme staff will be produced, but

sufficient and useful information to ensure programme effectiveness can be provided. Robust and regular

monitoring information can also facilitate programme managers in decision making and whether any

adjustments are required.

For effective TSF programming three kinds of monitoring are required: 31

a) individual beneficiaries

Four tools are available:

i) Individual ration/record cards

ii) Registration books

iii) Referral slips

iv) Records of home visit/post distribution monitoring forms

Beneficiaries are anthropometrically monitored at each visit with details recorded in the registration book

and on their ration cards. Numbering systems should be developed to enable tracking of individual

beneficiaries, especially for those transferring between SFP and OTP.

Home visits using post-distribution monitoring questionnaires (see annex 19) should be conducted when

indicated and wherever possible.

b) Programme performance and effectiveness

Several tools are available for use:

Monthly reports with data on admissions and discharges (statistical data) are compiled for TSFP.

See below, reporting.

Supervision checklists and/or reports - supportive supervision of TSFP sites should be conducted

regularly by programme managers and federal/regional MoH counterparts (see annex 7). Joint

supervision between partners is more likely to result in successful outcomes

Collection of additional information – readmissions, cause of death, reasons for default and non-

recovery. Collected by community outreach workers, mobilisers or other programme staff

Mapping – simple mapping can also be done. This will help identify where most of the admissions

are coming from and can help determine if more sites should be opened. This can also help

programme implementers better understand possible issues in the programme such as high default

or low coverage

Focus group discussions (FGD) with community members - discussions with affected communities

by the MoH and programme staff can also provide useful insights into programme perceptions, and

identify any barriers to uptake. FGDs are useful tools to initiate and direct discussion around how

programmes can improve the delivery of services (see annex 20).

Coverage monitoring surveys (see below)

31 Following the individual beneficiary is only possible in TSFPs, not BSFPs.

c) Commodity distribution monitoring and reporting

Stock reports are required to provide a breakdown of stock movement and to facilitate uninterrupted

supplies (see annex 9). It is recommended that programmes keep a buffer stock of supplies and pre-

position food during expected rainy seasons when transport of commodities are likely to become more

challenging. The provision of clear instructions regarding minimum re-order levels of commodities can

assist with ensuring an uninterrupted supply chain.

3.2 Reporting

3.2.1 Completing the monthly report

• Programme data can be compiled at each distribution site (usually 2-weekly) on tally sheets. The

compilation sheets can be used for combining information from various sites and also for collating

2 weekly information into monthly data (see annex 5 for example of tally and compilation sheets)

• Programme data must be extrapolated according to admission group e.g. 6-59 months, PLW, other

vulnerable groups

• Data should be disaggregated by gender e.g. no of boys/girls recovered cured, died, etc.

• Programme data should then be compiled every month from the tally and compilation sheets and

collated into one monthly report per woreda (see annex 6 for example of monthly report)

• To facilitate calculations and speed up data processing, the monthly reports may be collated into a

simple excel spreadsheet or access database, to facilitate programme implementers in monitoring

progress and performance

• Reports must be filled in accurately. Cases should not be double counted. Particular attention

should be given to accurately recording returning defaulters and/or readmissions. In areas where

there is considerable movement of the population (e.g. pastoralist livelihood zones), care should be

given to track ‘moved’ cases, where possible

3.2.2 Using the monthly reports to determine programme performance

• Programme outcomes (numbers of beneficiaries who have recovered, died, defaulted and non-

recovered) can be compared to international minimum standards in order to provide information

on how well the programme is performing. Outcomes can be illustrated in graph form

• Following analysis at facility level with health staff, the reports should be passed to the woreda

health information system and then to zonal, regional and federal level

Table 7: Calculation of indicators for the monthly report (example given is for Under-5 children)

Indicator32

Recovery rate

Death rate

Default rate

Non-responder

rate

Mean length of

stay (see annex

6 for how to

calculate)

Average weight

gain (see annex

6 for how to

calculate)

Description

Proportion of U5

discharges due to

recovery

Proportion of U5

discharges due to death

Proportion of U5

discharges due to default

Proportion of U5

discharges due to non-

response

Average length of stay for

recovered children

Average number of grams

that 6-59 m recovered

children gained per kg per

day since admission to

TSFP

Formula

No. 6-59 m recovered/total no.

of 6-59 m discharges

(recovered, died, default and

non-response) X 100

No. 6-59 m died/total no. of 6-

59 m discharges (recovered,

died, default and non-response)

X 100

No. 6-59 m defaulted/total no.

of 6-59 m discharges

(recovered, died, default and

non-response) X 100

No. 6-59 m non-response/total

no. of 6-59 m discharges

(recovered, died, default and

non-response) X 100

Sum no. of weeks admissions of

recovered children 6-59 m/No.

6-59 m discharges due to

recovery

Sum [(weight on discharge (g) –

weight on admission

(g))/(weight on admission (kg))

X duration of treatment (days)]

Unit

weeks

g/kg/day

Sphere

recommendation

for TSFP33

>75%

<3%

<15%

recommendation

Depends on

country context

Depends on

country context

3.3 Coverage

Estimating coverage of selective feeding programmes

Coverage is an extremely valuable indicator to monitor the quality and impact of selective feeding

programmes.34 Assessments of programme coverage are vital, as while the TSFP services might be in place,

it does not necessarily follow that the population are fully utilising these services. It is important to

measure and quantify levels of service uptake by the target population, to understand the reasons why

some areas may have high uptake and others low, as lessons can be learned from both scenarios.

Previous methods to assess coverage were based on two stage cluster sampling methodology using

population proportional sampling (PPS) which were only able to produce fairly unreliable estimates of

coverage.

32 Transfers in/out of the programme are not included in the calculation of programme performance

33 The Sphere Project. Humanitarian Charter and Minimum Standards in Disaster Response. Geneva. 2011 Edition. Sphere Project.

Hobbs Publishing, UK. www.sphereproject.org

34 Coverage refers to the degree of exclusion error- i.e. the omission of eligible children (e.g. with WFH <-2 to ≥-3 z-score and/or

MUAC ≥11.0 and < 12.0 cm) into the programme. ‘Acceptable’ standard for coverage refers to the Sphere Project Guidelines (2011)

recommending >50% coverage as acceptable for selective feeding programmes in rural communities, >70% in urban populations and

>90% in a camp situation.

Methods of measuring coverage:

1. Centric Systematic Area Sampling (CSAS)

In 2003, a new methodology for the measurement of coverage was developed that has been widely

used in Ethiopia; the Centric Systematic Area Sampling (CSAS) survey.35 These surveys are based on

small eligible populations assuming simple random samples. CSAS is based on spatial geographic

sampling, using many clusters randomly selected from quadrats allocated to a map of the study area.

Survey teams are assigned to use active case finding techniques to identify all cases in the sampled

community and calculate the number of cases that are currently enrolled in the programme. CSAS

surveys provide two estimates of coverage; period and point, described below in Figure 5:

Figure 5: Formulas for calculating period and point coverage

Formula 1: Period coverage

Children enrolled in the programme, malnourished or not malnourished

Children enrolled in the programme, malnourished or not malnourished + children

malnourished but not enrolled

X 100

Formula 2: Point coverage

Malnourished children admitted in the programme

Total malnourished children

X 100

Period coverage estimates show the proportion of respondents in the programme, whilst point

coverage gives the ratio of cases in the programme as compared to the total number of cases

identified by the assessment.

Period coverage is designed to take into account the number of children treated by the programme

over its recent duration, including those who are no longer cases, i.e. children from 6-59 months who

were admitted as MAM cases but are currently recovering and no longer MAM on the day of the

assessment. Period coverage can therefore provide a good reflection of programme performance over

recent months.

Point coverage shows the ratio of MAM cases in the programme compared to the total number of

MAM cases identified by the assessment. Point coverage does not include children registered in the

programme who are partially recovered and no longer MAM (e.g. MUAC ≥ 12.0 cm on the day of

assessment). Point coverage estimates, with the stricter definitions, provide a reflection of

programme performance ‘right now’.

Estimates of period coverage will therefore always be higher than point coverage. While both are

useful measures, period coverage estimates are more commonly quoted, as they can provide a

broader picture of programme coverage, especially over its recent duration.

In addition to the quantitative information presented above, CSAS will also enable a wealth of

qualitative information to be collected to better understand the barriers to service uptake, or

35 New Method for Estimating Programme Coverage. Mark Myatt presentation at an interagency workshop on Community-based

Approaches to Managing Severe Malnutrition. Dublin 8-10th October 2003. http://fex.ennonline.net/21/coverage.aspx

misperceptions of the various selective feeding programmes that may co-exist in a community for

example. This information, if acted on, can help programme implementers to strengthen programme

performance and impact. It is therefore strongly recommended that agencies implementing selective

feeding programmes conduct a coverage survey using CSAS (or other methodology as it becomes

available) in order to effectively monitor their programmes. Annex 21 provides a simple picture guide

for conducting CSAS surveys.

At present, the current CSAS methodology is suitable only for measuring small intervention areas (i.e.

individual woredas); however new methodology for assessing wider area coverage surveys [Simple

Spatial Survey Method, (S3M)] is under development, with a plan to pilot it in Ethiopia during 2011.

2. Semi Quantitative Evaluation and Assessment of Coverage (SQUEAC)

The use of standardised and validated tools such as Semi-Quantitative Evaluation of Access and

Coverage (SQUEAC) surveys is encouraged, where resources are available. SQUEAC surveys also report

point and period coverage. These surveys are particularly useful for exploring the causes of high and

low coverage that are identified. SQUEAC surveys are usually used for measuring coverage of SAM

programmes, although it would be possible to adapt them for assessment of MAM coverage.36

3. Simple Spatial Survey Method (S3M)

The Simple Spatial Survey Method (S3M)37 is currently under development and will be piloted during

2011 in partnership with EHNRI. It has the potential to offer a platform that can accept a wide range of

indicators, is most appropriate for large area-based sampling, and produces great efficiency over

previous area-based methods (a 5-fold increase in precision over CSAS).

The potential application of this method in conducting surveys for major national level nutrition

interventions should be explored.

36 A system for providing support with coverage related queries is currently under development. It will likely be hosted on the en-net

discussion forum at http://www.en-net.org.uk/

37 To date, there is no published literature available for S3M

Chapter 4. Community mobilisation, nutrition counselling

and education

4.1 Community mobilisation

The term ‘community mobilisation’ refers to a range of activities designed to help implementers

understand affected communities, build a relationship with them and foster participation in the

programme.38 The high levels of MAM seen in many areas of Ethiopia ensures that it is essential that

individuals seek treatment for malnutrition as soon after onset as possible. It is also imperative that

communities understand the principles underlying malnutrition and services provided to treat it, in order to

be able to access care appropriately, obtain the maximum benefits and prevent future episodes of

malnutrition. Early and comprehensive case-finding is a key component of MAM prevention and treatment,

through a well-informed and responsive community.

A strong community volunteer network can have a considerable impact on MAM programming by

supporting and sustaining services and feeding into longer-term strategies, such as those outlined under

the National Nutrition Programme (NNP). The Health Service Extension Programme, a community based

health care delivery system that provides essential health interventions at village/kebele and household

level is the ideal vehicle for effective mobilisation; its health extension workers (HEWs) providing the bridge

between health services and the community in the facilitation of case finding, follow up and sustaining

community-based programmes to prevent and treat malnutrition.

Due to the wide variety of individuals and organisations that undertake nutrition and/or health mobilisation

activities in Ethiopia, the general term ‘community mobiliser’ is used throughout this document. Mobilisers

may be the HEWs, Community Health Volunteers, members of the Health Development Army, other

members of the community, etc.

4.1.1 Objectives of community mobilisation

The purpose of community mobilisation is to:

• Promote understanding of available services and the target groups

• Increase programme coverage

• Conduct active case finding and make appropriate referrals

• Follow-up absentees and defaulters and understand the reasons for it so that programme

implementers can address them

• Increase understanding of any barriers to access (why people might not be accessing services)

• Link prevention and treatment services at community level wherever possible, in order to address

the underlying causes of malnutrition

38 Community-Based Therapeutic Care (CTC); A Field Manual. Valid International. First Edition, 2006.

4.1.2 Information required prior to programming

It is important for programme implementers to gain a good understanding of community structures and

perceptions, through engaging in dialogue with key community members to determine the following

information:

• What the problems with malnutrition in the area are, what the local terms for malnutrition are, the

perceived causes and common solutions

• What the formal (e.g. village meetings) and informal (e.g. discussions at water points) channels of

communication are in the area, especially to identify those that are known to be most effective for

disseminating information

• The local schedules of events that the programme can work with and around, for example, market

days

• Local attitudes and beliefs towards health and health seeking behaviours

• Any existing interventions in the area that the programme can link with, including health, nutrition,

agriculture, water, etc. It is useful to determine interventions that already use community

volunteers to prevent duplication. Standardisation of any messages to be given to community

members is also vital, to minimise possible confusion

4.1.3 Who should be involved in community mobilisation

Community screening and mobilisation is an ongoing process and is best conducted by a range of key

figures, both to help in gaining the population’s acceptance and trust and also for communicating and

disseminating messages. In discussion with the HEWs, potentially important individuals might include;

social or political leaders (traditional and modern), religious leaders (priests, imams), traditional health

practitioners (healers, birth attendants), teachers and elders. Members of key community organisations can

also be a useful resource, for example, women’s associations, funeral associations (idirs), youth

associations, etc. Once programmes have been operational for a while, caregivers of children who have

already recovered from an episode of malnutrition can act as powerful motivators to encourage other

caregivers to seek treatment for their child (sometimes referred to as ‘positive deviants’).

4.1.4 Supplies and training

Mobilisers will need the following supplies (where resources allow) to conduct screening and follow-up

activities

• MUAC tapes

• Referral slips (see annex 3)

• Home visit forms (see annex 18)

• Post distribution monitoring forms (see annex 19)

Community mobilisers should be trained to identify, refer and follow-up malnourished individuals. Training

is usually conducted during one or two days, depending on available time, resources and levels of

understanding. Refresher training sessions should also be regularly conducted, especially if there is high

turnover of mobilisers. Training sessions should include:

• Programme aims, objectives and the target population

• Basic information on the causes, identification and treatment of malnutrition

• Practical sessions in identification of oedema (for referral to SAM treatment programmes) and

wasting, using the MUAC tape

• Case finding and referral

• Follow-up and home visits

• Health and nutrition education topics based on the Essential Nutrition Action (ENA) framework

• Appropriate counselling techniques

Regular meetings can also help to identify and discuss any challenges that mobilisers might be facing, and

to devise appropriate solutions.

4.1.5 Case finding and referral

In order to reach as many malnourished individuals as possible, community mobilisers must actively

identify children who require treatment. Screening can be conducted via a number of opportunities,

including:

• House to house visits

• At health facilities, community and outreach programmes (e.g. EPI, CHDs)

• At community or religious meetings, health campaigns (e.g. polio eradication campaigns) or other

opportunities

• At growth monitoring sessions (e.g. during the CBN programme), general food distributions, PSNP

gatherings, etc.

Individuals are identified with MAM in the community through the use of MUAC tapes (see section

2.3.2.5.3 for MUAC cut offs for vulnerable groups) and should be referred to the nearest distribution site

for treatment. Individuals identified as suffering from SAM [presence of bilateral pitting oedema or (for

children 6-59 months) MUAC < 11.0 cm] should be immediately referred to the nearest health facility

offering TFP services.

If programmes are using a ‘two stage’ screening and admission process, i.e. screening in the community

using MUAC and admission using WFH, as outlined in section 2.3.2.5; mobilisers should be aware that there

might be some negative feedback in the community from those they have referred, but who were

subsequently not admitted at the site.

4.1.6 Follow-up and home visits

Community mobilisers have an important role in the tracing of beneficiaries who have been absent or have

defaulted from the programme; identifying the cause of absence or default and encouraging them to

return, where possible. Individuals who are failing to gain sufficient weight also require home visits, to

establish and correct the causes of static or loss of weight.

4.2 Nutrition counselling and education

During emergency situations it is vitally important that IYCF practices are strengthened, wherever possible.

International guiding principles on IYCF in Emergencies is included as annex 22.

Ideal opportunities exist when addressing MAM (either during routine activities or emergency situations),

to provide nutrition and health education to beneficiaries and the wider community; at screening sites,

during home visits and SFP sites. While it must be noted that messages given at sites in ‘campaign style’ are

much less likely to be effective than those given on a one-to-one basis, education sessions given at the SFP

sites can be reinforced later by home visits or through other sessions given by HEWs or other key

community members. Community mobilisers should be encouraged to pass key health and nutrition

messages each time they come into contact with community members.

It is vitally important to ensure that any health or nutrition education

information sessions are given in the local language that the

community can understand. If the health and or distribution staff do

not speak the local language, then a person must be trained who can

speak the language in nutrition education techniques. Where this is

not possible, a translator can be used.

Simple and contextually specific flip charts written in the local

language can also help to relay important information

Areas to be addressed during nutrition education and behavioural change sessions should place particular

emphasis on the promotion of breastfeeding, discouragement of early weaning, improved feeding practices

and other measures to prevent malnutrition. The key to effective education messaging is to keep the

messages simple. In this way, caregivers and the wider community can easily understand and absorb the

most important information. The Essential Nutrition Action (ENA) framework provides an excellent base to

model education sessions on. The ENA list of seven nutrition actions is based on a lifecycle approach, as

follows:39

1. Promotion of optimal nutrition for women

2. Promotion of adequate intake of iron and folic acid and prevention and control of anaemia for

women and children

3. Promotion of adequate intake of iodine by all members of the household

4. Promotion of optimal breastfeeding during the first six months

5. Promotion of optimal complementary feeding starting at six months with continued breastfeeding

to 2 years of age and beyond

6. Promotion of optimal nutritional care of sick and severely malnourished children

7. Prevention of vitamin A deficiency in women and children

The ENA booklet that nutrition messages must be modelled on has been translated into Amharic, Tigrinya

and Oromifya and widely disseminated within the MoH system. It should therefore be available in most

health facilities. ENA information has also been included in many other materials developed by the MoH,

for example, information for the CBN programme, the Integrated Refresher Training (IRT) package, etc.

39 Guyon, AB and Quinn, VJ. Booklet on Key Essential Nutrition Actions Messages. Core Group, Washington, D.C., January 2011

The web link for full ENA information is:

http://www.coregroup.org/storage/Nutrition/ENA/Booklet_of_Key_ENA_Messages_complete_for_web.pdf

Nutrition surveys can provide information regarding what topics might be the most urgent to address (e.g.

low rates of breastfeeding or sub-optimal complementary feeding practices). However, four key messages

should always be provided at the TSF site or during home visits:

1. Handwashing with soap (or ash if soap is unavailable) before eating and after defecation

2. Exclusive breastfeeding (for the first 6 months)

3. Timely introduction and use of appropriate complementary foods using locally available foods

4. Continued feeding during illness

4.2.1 Promotion of good hygiene at health facilities and distribution

sites

The linkages between malnutrition and unsafe water sources/poor hygiene practices are by now extremely

well understood. It is difficult for distribution staff and/or health workers to demonstrate good hygiene and

sanitation practices (e.g. hand washing techniques) if there is an inadequate water supply at the site or

health facility. Where the health facilities lack appropriate water supply, short term measures need to be

implemented; for example sufficient jerry cans of water and supplies of soap need to be brought to the site

to provide a practical illustration for the caregivers the importance about of hand washing prior to food

preparation. It can often be useful to provide enhanced training to at least one of the distribution staff in

hygiene practices, so they can share this knowledge with other members of the team and provide on-site

training in the case of high staff turnover.

UNICEF standards generally suggest that between 3 - 7 hand-washing stations are required per health post,

with one allocated for drinking and the rest for hand washing. If health posts lack sufficient hand washing

stations, they should immediately inform UNICEF via the Zonal and Regional MoH authorities, as it may well

be possible to supply more hand-washing stations to make up the shortfall.

Chapter 5. Management of acute malnutrition in infants

under-6 months (MAMI), maternal health, urban and

pastoralist issues

5.1 Management of acute malnutrition in infants < 6 months

(MAMI)

Treatment for acute malnutrition in infants has been largely neglected during emergency programming and

measurement of their nutritional status is almost never included in nutrition surveys or rapid assessments.

Focus is placed instead on children 6-59 months and malnourished pregnant and lactating women, with the

burden of malnutrition in infants remaining largely hidden.

During 2009, the Management of Acute Malnutrition in Infants (MAMI) project40 undertook an important

retrospective meta-review. The review utilised data from DHS national datasets of 21 nutritionally

vulnerable countries, drawn from the 2008 Lancet ‘Maternal and Child Undernutrition’ series of countries

(those that account for >90% of global malnutrition). Current national and international guidelines for

treatment of acute malnutrition were also assessed from 37 different countries.41

The aim of the MAMI Project was to investigate the management of acutely malnourished infants under six

months of age (infants <6m) in emergency programmes, in order to improve practice by contributing to

evidence-based, best practice and development of guidelines. Main findings are summarised below in box

40 Kerac, M. et al, 2009. Prevalence of wasting among under 6-month-old infants in developing countries and implications of new

case definitions using WHO growth standards: a secondary data analysis. Summarised in a Technical Review; Field Exchange, No

39, pg 19. 2010.

41 The MAMI Project was a collaborative effort between ENN, University College London Centre for International Health and

Development (CIHD) London, and Action Contre la Faim, funded by the UNICEF-led IASC Nutrition Cluster.

Box 2: Technical review of the Management of Acute Malnutrition in Infants (MAMI) Project: Current

evidence, policies, practices & programme outcomes

MAMI - A retrospective review of the current field management of moderately and severely

malnourished infants under six months of age

What was already known on this topic:

• Infants aged under 6 months are often excluded from nutrition surveys and marginalised in

malnutrition treatment programmes

• In May 2009, a joint statement from WHO and UNICEF recommended a transition to WHO

growth standards to identify wasting but only reviewed the implications for children aged

from 6 - 59 months

What this study added:

• In developing countries, large numbers of infants under 6 months are wasted; it was

estimated that 0.8 million are severely wasted worldwide and 2.2 million moderately

wasted (diagnosed using NCHS growth references)

• Using WHO standards to diagnose wasting results in a large prevalence increase: an extra 3

million infants under 6 months severely wasted and an extra 2.5 million moderately wasted

worldwide

Principal findings: The data suggested that large numbers of infants under 6 months in developing

countries are wasted. Prevalence is greatest when using WHO growth standards to define cases;

severe infant wasting prevalence is 3.5 times greater than when using NCHS references. By

comparison, severe child wasting is 1.7 times greater using WHO standards. Moderate wasting of

infants under 6-months is 1.4 times greater, whereas moderate child wasting decreases.

Conclusions: Whether defined by NCHS references or WHO standards, wasting among infants

under-6 months is prevalent in many of the developing countries examined in this study. Use of

WHO standards to define wasting results in a greater disease burden, particularly for severe

wasting. Policy makers, programme managers and clinicians in child health and nutrition

programmes should consider resource and risk/benefit implications of changing case definitions.

5.1.1 Implications for Ethiopia from the MAMI project findings

Results from the MAMI project suggest that there may be a considerable (and currently undetected) case-

load of acutely malnourished infants in Ethiopia, and the move to the WHO GS will ensure that this case-

load more than doubles. Most selective feeding interventions implemented to date in Ethiopia have not

focussed on this group, more often targeting lactating women who are themselves MAM (according to

MUAC), but not those infants of women who have difficulty breast-feeding, or those infants who have

started a period of acute malnutrition; which not only raises the immediate risk of mortality, but is also

likely to rapidly lead to growth faltering.

It is important for programmes to identify this highly vulnerable group and refer for appropriate counselling

and treatment, in order to have additional impact on the infant mortality rate in Ethiopia. The vicious cycle

of infection and undernutrition is especially powerful for infants; a sick baby can rapidly deteriorate into a

malnourished baby, with a greatly increased chance of death.

The role of the Community Based Nutrition (CBN) programme42 is to capture and help prevent growth

faltering, but as height is not taken, infants starting an acute period of malnutrition could be missed.

Additionally, it is often preferred to keep sick infants within the house, so their presence at CBN gatherings

might not be guaranteed and the CBN programme is currently operational only in the most food insecure

woredas of Ethiopia.

5.1.2 Identification and response

It can be difficult to measure acute malnutrition in infants under-6 months of age, with no internationally

agreed MUAC cut-off to identify malnutrition in this age group. MAM in infants can only therefore be

identified through the use of WHO GS, using z-scores. In terms of accuracy, where staff have not had

sufficient training in anthropometric measurements and because the legs of infants may not straighten as

well as older children, it can be difficult to measure length; small errors might considerably alter the WFH z-

scores of the infant. 43

The HEWs and community health workers are therefore the essential community tool for identifying this

(currently hidden) case-load; through identifying and encouraging the caregivers to urgently attend the

health post for nutritional screening and counselling:

Women who are experiencing difficulty breast-feeding

Those infants where there are no opportunities for breast-feeding (e.g. mother has died and no

‘wet nurse’ available)

Infants having acute periods of infectious disease such as, diarrhoea respiratory infections, malaria,

etc.

Interventions need to be carefully planned in advance. Wherever possible, awareness and expertise in

infant feeding and the provision of breast-feeding support is essential. Where there is limited capacity

amongst the health workers in maternal and infant nutritional requirements (including breastfeeding

assessment, management and support), training sessions should urgently be facilitated by suitably qualified

personnel. The current Sphere recommendations (2011) for the malnutrition treatment programmes do

not provide specific indicators regarding infants under 6 months; however in recognition of the importance

of implementing these ‘life-saving IYCF interventions’ during emergency and non-emergency situations,

two new standards have been introduced.44

IYCF standard 1: Policy guidance and coordination

Safe and appropriate infant and young child feeding for the

population is protected through implementation of key policy

guidance and strong coordination.

IYCF standard 2: Basic and skilled support

Mothers and caregivers of infants and young children have

access to timely and appropriate feeding support that minimises

risks and optimises nutrition, health and survival outcomes.

42 The CBN is currently operational in more than 200 woredas and provides preventative nutritional support including growth

monitoring and promotion (GMP) for children under-2, followed by community conversations with women and other key village

members.

43 En-net discussion: http://fex.ennonline.net/36/prevalence.aspx. - date accessed - June 2011.

44 The Sphere Project. Humanitarian Charter and Minimum Standards in Disaster Response. Geneva, 2011 Edition. Sphere Project.

Hobbs Publishing, UK. www.sphereproject.org

Sphere also recommended that breast-feeding mothers of infants with acute malnutrition should be

admitted to MAM treatment programmes, regardless of their nutritional status.

Appropriate responses for interventions that identify and target women and malnourished infants

emphasise intensively supporting or re-establishing appropriate and successful breast-feeding, wherever

possible. Where breast-feeding is not possible, support for artificial feeding should be given. MAM

programme implementers must recognise that that this process will take considerable time on the part of

the health/community worker, and also require sufficient expertise. Enough time must be provided for

training and supervision at community level, where most of the counselling needs to take place.

Infants with MAM should receive similar support as those with SAM, including extensive support for

mothers with breastfeeding and optimal health and hygiene behaviours. Detailed information regarding

these practices is provided in the National Protocol for the Management of SAM (FMoH 2007), including

supplementary suckling techniques, so is not repeated here.

For full information regarding guidance for IYCF programming, refer to the Ethiopian F-MoH National

Strategy for IYCF (April 2004).

Further information can also be sourced from the ‘Infant feeding in Emergencies (IFE) module 2, follow this

link:

http://www.who.int/nutrition/publications/emergencies/ife_module2/en/index.html

For operational guidance on IFE, follow this link:

www.ennonline.net/ife

Part 4 of the IYCF module in the HTP, lists key resources and sources for IYCF in emergency situations,

follow this link:

http://www.unscn.org/en/gnc_htp/howto-htp.php#howtousehtp

5.2 Maternal nutrition health

Maternal undernutrition rates in Ethiopia are also amongst the highest in the world, with one in three

suffering from undernutrition. Maternal mortality rates are particularly high. It is well known by now

amongst the international community that much of the stunting that occurs in children is predetermined at

birth; low birth weight (LBW) infants, defined as those that weigh < 2.5 kg at birth. They are described in

terms of being ‘undernourished’ because they were deprived of essential energy and nutrients before they

were born. While in developed countries, Intra Uterine Growth Retardation (IUGR) may be more associated

with risk factors such as maternal smoking, in less developed countries, it is maternal undernutrition that

most often leads to the birth of small infants; undernourished infants are then at risk for a host of potential

illnesses, many of which may be fatal.

Any newborn infant is highly vulnerable; for the LBW infant, this vulnerability is magnified. Healthy, well-

nourished women do not generally give birth to LBW infants. It is evident therefore that poor foetal

growth results from undernutrition in women. Maternal macro- and micronutrient deficiencies can be

particularly damaging to the functioning both to her child’s present, and future, cognitive, developmental

and immune systems.45

45 Black, R., Allen, L. H., Bhutta, Z. A., Caulfield, L. E., De Onis, M., Ezzati, M., Mathers, C., and Rivera, J. For the Maternal and

Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. The

Lancet. Published online Jan 17 2008.

SFPs do target undernourished PLW and must continue to do so. But a stronger focus is also needed to

develop understanding through enhanced education of the importance of the woman consuming (at least

most of) the ration allocated for her.

Recommendations for strengthening maternal nutrition health programming include:

Linkages with CBN, PSNP and other major bilateral projects need to be urgently strengthened. The

catchment population of these programmes is likely to not only include beneficiaries who are

pregnant and/or breast-feeding women, but also their husbands (who are often in charge of

household expenditure), leaders and other community members. Strengthened linkages with these

programmes therefore present an unique opportunity to reach wider and more diverse audiences

than SFP alone

Even if the women are not currently undernourished, encouragement for ‘healthy pregnancies’ can

be provided. Ante-Natal Care (ANC) is a vital part of ensuring healthy foetal growth, which results in

stronger infants better able to withstand the rigors of being born into poor households with limited

dietary diversity, education, resources and optimal WASH practices

Deeper analysis of the prevailing gender issues in Ethiopia is suggested, as enduring gender

inequalities are likely to be one of the major underlying causes of undernutrition across the country

5.3 Urban and pastoralist issues

5.3.1 Urban issues

Ethiopia’s population is undergoing steadily increasing urbanisation.46 Nutrition services in most large cities

and towns are poorly developed at present, see box 3 below:

Box 3: Urban issues

(Source – Harmonised Training Package. Module 12: Management of MAM, technical notes, version 2:

2011)

There are several issues related to addressing MAM in urban contexts. The scale of the problem of

malnutrition in urban contexts is largely hidden, given that very few anthropometric surveys have

been undertaken in this context in Ethiopia. Disparities in economic status between groups can also

be obscured through anthropometric surveys with only a single estimate of GAM for the population,

while sampling to obtain estimates of GAM for separate groups can be resource intensive. Population

density, issues of overcrowding and disease transmission, along with higher HIV and TB levels, poor

sanitation and limited capacity for household level agricultural production exacerbate the underlying

causes of malnutrition. For example, food access is often more of an issue than food availability. A

more appropriate response to MAM in this instance could be cash or voucher transfers rather than

traditional blanket or targeted SFPs.1 In cities where household registration is required, this and other

socio-cultural issues of urban living can be important. Security issues are also often different in urban

settings than in rural or camp settings.

These issues underline how anthropometric survey results need to be complemented by other

available information during the assessment and design phase of programmes to address MAM.

Given increasing urbanisation globally, further clarity on best practice for addressing MAM in urban

populations is needed.

46 Ethiopian DHS, 2005. Central Statistics Agency

5.3.2 Pastoralist issues

A number of issues are relevant when identifying and treating MAM in pastoralist populations, briefly

described below:

• The mobile nature of the population; static distribution sites are not usually sufficient for mobile

populations. Organisations/agencies will be likely to have more effective programmes if mobile

distribution sites are organised, according to where the population is likely to be heading. As much

information as possible should be sourced from local officials and community leaders, both prior to

setting up a new programme and on an ongoing basis, as situations may change according to

rainfall patterns or available pasture

• Pastoralist populations often face considerable difficulties with water supply, which should be

taken into consideration during the planning phase of the programme. Water trucking might be an

appropriate adjunct to a MAM treatment programme. Distribution teams must ensure that they

bring enough water to the sites (in jerry cans or other suitable containers) to ensure that

beneficiaries and staff are sufficiently hydrated

• Milk is an integral part of the pastoralist diet, providing a vital contribution to the improvement of

dietary quality for women and young children. During times of drought, milk access is considerably

reduced due to the weak state and/or death of their livestock.47 To improve the nutritional status

of these vulnerable groups and where resources allow, treatment programmes should strive to

include some form of milk or milk protein in the ration; for example through the mixing of milk

powder into the dry ration, or using one of the lipid based products that contains milk protein

• Questions have been raised about suitable indicators and criteria for evaluating levels of wasting

that constitute an ‘emergency’ in pastoralist livelihood zones.48 Differences in growth or body

shape may have the effect of overestimating the prevalence of wasting measured by WFH in

pastoralist children aged 2 years and above, in both emergency and non-emergency situations.

While investigations into the most suitable indicators and criteria for pastoralist populations are

still in the early stages and WFH remains an indicator recommended by WHO, the use of MUAC to

define wasting in these populations will be particularly useful to contribute to both the national

and international national learning agenda

47 Sadler, K. Kerven, C. Calo, M. Manske, M. and Catley, A. (2009). Milk Matters: A literature review of pastoralist nutrition and

programming responses. Feinstein International Centre, Tufts University and Save the Children, Addis Ababa.

48 Chotard, S. Mason, J.B. Oliphant, N.P. Mebrahtu, S. and Hailey, P. Fluctuations in wasting in vulnerable child populations in the

Greater Horn of Africa. Child nutrition in vulnerable populations in Eastern and Southern Africa, 2000–2006. Food and Nutrition

Bulletin. Volume 31, Number 3, September 2010

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consequences. The Lancet. Published online Jan 17 2008. DOI:10.1016/S0140-6736(07)61690-0

Chotard, S. Mason, J.B. Oliphant, N.P. Mebrahtu, S. and Hailey, P. Fluctuations in wasting in vulnerable child

populations in the Greater Horn of Africa. Child nutrition in vulnerable populations in Eastern and Southern Africa,

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Statistics Agency.

CSA. Ethiopia Demographic and Health Survey, 2005. Central Statistics Agency.

DRMFSS (MOARD). National Guidelines on Targeting Relief Food Assistance. Ministry of Agriculture (Disaster Risk

Management and Food Security Sector), Addis Ababa, Ethiopia.2011

EHNRI. The National Nutrition Survey, 2010. Ethiopian Health and Nutrition Research Institute.

ENN. Harmonised Training Package (HTP) Module 12: Management of MAM, technical notes, version 2: 2011.

http://www.ennonline.net/pool/files/ife/management-of-moderate-acute-malnutrition-technical-notes.pdf

FMoH. Concept note for the Management of MAM. Ethiopian Federal Ministry of Health, 2010.

FMoH. Protocol for the Management of Severe Acute Malnutrition, Ethiopia, Federal Ministry of Health (FMoH),

March 2007.

Guyon, AB and Quinn, VJ. Booklet on Key Essential Nutrition Actions Messages. Core Group, Washington, D.C., January

2011

Heikens, G. T., Amadi, B. C., Manary, M., Tollins, N., and Tomkins, A. Nutrition interventions need improved

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Kerac, M. et al, 2009. Prevalence of wasting among under 6-month-old infants in developing countries and

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Myatt, M., and Duffield, A. (2007) Assessing the impact of the introduction of the World Health Organisation (WHO)

growth standards on the measured prevalence of acute malnutrition and the number of children eligible for

admission to emergency feeding programmes. Background paper

Myatt, M., Khara, T., and Collins, S. A review of methods to detect cases of severely malnourished children in the

community for admission into community-based therapeutic programmes. Food and Nutrition Bulletin. Vol 27. No 3

(Suppl). 2006:S7-23.

Myatt, M. New Method for Estimating Programme Coverage. Mark Myatt presentation at an interagency workshop on

Community-based Approaches to Managing Severe Malnutrition. Dublin 8-10th October 2003.

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Navarro-Colorado, C., Shoham, J., Mason, F. Measuring the effectiveness of Supplementary Feeding Programmes in

Emergencies. Working Paper HPN Network Papers 63, August 2008.

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(WHO) child growth standards and the National Centre for Health Statistics/WHO international growth reference:

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Sadler, K. Kerven, C. Calo, M. Manske, M. and Catley, A. (2009). Milk Matters: A literature review of pastoralist

nutrition and programming responses. Feinstein International Centre, Tufts University and Save the Children, Addis

Ababa.

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in nutrition programmes: secondary data analysis. British Medical Journal. DOI:10.1136

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Project. Hobbs Publishing, UK. www.sphereproject.org

UNICEF. A toolkit for addressing nutrition in emergency situations. IASC Global Nutrition Cluster, New York, NY, 2008

UNICEF and IFPRI coordinated effort, 2005. An Assessment of the causes of Malnutrition in Ethiopia: A contribution to

the formulation of a National Nutrition Strategy for Ethiopia (Background Papers)

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http://www.unhcr.org/publ/PUBL/45fa745b2.pdf

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Annex 1: Weight-for -height reference tables, girls and boys, World Health Organisation

Growth Standards (WHO-GS), 2006

-4SD

1,7

1,8

1,9

2,0

2,1

2,2

2,3

2,4

2,5

2,6

2,7

2,8

2,9

3,0

3,1

3,2

3,3

3,4

3,5

3,6

3,7

3,8

3,9

4,0

4,1

4,2

4,3

4,4

4,5

4,6

4,7

4,8

4,9

5,0

5,1

5,2

5,3

5,4

5,5

5,6

5,7

5,8

5,9

6,0

6,1

6,2

6,3

6,4

6,5

6,6

6,7

6,8

6,9

7,0

7,1

7,2

7,3

7,4

7,5

7,6

7,7

7,8

7,9

8,0

8,1

8,2

8,3

Boys weight (kg)

-3SD

1,9

2,0

2,1

2,2

2,3

2,4

2,5

2,6

2,7

2,8

2,9

3,0

3,1

3,2

3,3

3,4

3,6

3,7

3,8

3,9

4,0

4,1

4,3

4,4

4,5

4,6

4,7

4,8

4,9

5,0

5,1

5,2

5,3

5,4

5,5

5,6

5,7

5,8

5,9

6,0

6,1

6,2

6,3

6,4

6,5

6,6

6,7

6,8

6,9

7,0

7,1

7,2

7,3

7,4

7,5

7,6

7,7

7,8

7,9

8,0

8,1

8,2

8,3

8,4

8,5

8,6

8,7

8,8

8,9

9,0

-2SD

2,0

2,1

2,2

2,3

2,4

2,5

2,6

2,7

2,8

2,9

3,0

3,1

3,2

3,3

3,4

3,5

3,6

3,7

3,8

4,0

4,1

4,2

4,3

4,5

4,6

4,7

4,8

5,0

5,1

5,2

5,3

5,4

5,6

5,7

5,8

5,9

6,0

6,1

6,2

6,3

6,4

6,5

6,6

6,7

6,8

6,9

7,0

7,1

7,2

7,3

7,4

7,5

7,6

7,7

7,8

7,9

8,0

8,1

8,2

8,3

8,4

8,5

8,6

8,7

8,8

8,9

9,0

9,1

9,2

9,3

9,4

9,5

9,6

9,7

-1SD

2,2

2,3

2,4

2,5

2,6

2,7

2,8

2,9

3,0

3,1

3,2

3,3

3,5

3,6

3,7

3,8

3,9

4,0

4,2

4,3

4,4

4,6

4,7

4,9

5,0

5,1

5,3

5,4

5,5

5,6

5,8

5,9

6,0

6,1

6,2

6,4

6,5

6,6

6,7

6,8

6,9

7,0

7,1

7,2

7,3

7,5

7,6

7,7

7,8

7,9

8,0

8,1

8,2

8,3

8,4

8,5

8,6

8,7

8,8

8,9

9,0

9,1

9,2

9,3

9,4

9,5

9,6

9,7

9,8

9,9

10,0

10,1

10,2

10,3

10,4

10,5

Median

2,4

2,5

2,6

2,7

2,8

2,9

3,0

3,1

3,2

3,3

3,4

3,5

3,6

3,8

3,9

4,0

4,1

4,3

4,4

4,5

4,7

4,8

5,0

5,1

5,3

5,4

5,6

5,7

5,9

6,0

6,1

6,3

6,4

6,5

6,7

6,8

6,9

7,0

7,1

7,3

7,4

7,5

7,6

7,7

7,9

8,0

8,1

8,2

8,3

8,4

8,5

8,6

8,8

8,9

9,0

9,1

9,2

9,3

9,4

9,5

9,6

9,7

9,8

9,9

10,0

10,1

10,2

10,3

10,4

10,5

10,6

10,7

10,8

10,9

11,0

11,2

11,3

11,4

Length (cm)a

45,0

45,5

46,0

46,5

47,0

47,5

48,0

48,5

49,0

49,5

50,0

50,5

51,0

51,5

52,0

52,5

53,0

53,5

54,0

54,5

55,0

55,5

56,0

56,5

57,0

57,5

58,0

58,5

59,0

59,5

60,0

60,5

61,0

61,5

62,0

62,5

63,0

63,5

64,0

64,5

65,0

65,5

66,0

66,5

67,0

67,5

68,0

68,5

69,0

69,5

70,0

70,5

71,0

71,5

72,0

72,5

73,0

73,5

74,0

74,5

75,0

75,5

76,0

76,5

77,0

77,5

78,0

78,5

79,0

79,5

80,0

80,5

81,0

81,5

82,0

82,5

83,0

83,5

84,0

84,5

Median

2,5

2,6

2,7

2,8

2,9

3,0

3,1

3,2

3,3

3,4

3,5

3,6

3,7

3,8

3,9

4,0

4,2

4,3

4,4

4,6

4,7

4,8

5,0

5,1

5,2

5,4

5,5

5,6

5,7

5,9

6,0

6,1

6,3

6,4

6,5

6,6

6,7

6,9

7,0

7,1

7,2

7,3

7,4

7,5

7,6

7,7

7,9

8,0

8,1

8,2

8,3

8,4

8,5

8,6

8,7

8,8

8,9

9,0

9,1

9,2

9,3

9,4

9,5

9,6

9,7

9,8

9,9

10,0

10,1

10,2

10,3

10,4

10,5

10,6

10,7

10,9

11,0

11,1

Girls weight (kg)

-1SD

2,3

2,4

2,5

2,6

2,7

2,8

2,9

3,0

3,1

3,2

3,3

3,4

3,5

3,6

3,7

3,8

3,9

4,0

4,2

4,3

4,4

4,5

4,6

4,8

4,9

5,0

5,1

5,3

5,4

5,5

5,6

5,7

5,8

5,9

6,0

6,2

6,3

6,4

6,5

6,6

6,7

6,8

6,9

7,0

7,1

7,2

7,3

7,4

7,5

7,6

7,7

7,8

7,9

8,0

8,1

8,2

8,3

8,4

8,5

8,6

8,7

8,8

8,9

9,0

9,1

9,2

9,3

9,4

9,5

9,6

9,7

9,8

9,9

10,1

10,2

-2SD

2,1

2,2

2,3

2,4

2,5

2,6

2,7

2,8

2,9

3,0

3,1

3,2

3,3

3,4

3,5

3,6

3,7

3,8

3,9

4,0

4,2

4,3

4,4

4,5

4,6

4,7

4,8

4,9

5,0

5,1

5,2

5,3

5,4

5,5

5,6

5,7

5,8

5,9

6,0

6,1

6,2

6,3

6,4

6,5

6,6

6,7

6,8

6,9

7,0

7,1

7,2

7,3

7,4

7,5

7,6

7,7

7,8

7,9

8,0

8,1

8,2

8,3

8,4

8,5

8,6

8,7

8,8

8,9

9,0

9,1

9,2

9,3

-3SD

1,9

2,0

2,1

2,2

2,3

2,4

2,5

2,6

2,7

2,8

2,9

3,0

3,1

3,2

3,3

3,4

3,5

3,6

3,7

3,8

3,9

4,0

4,1

4,2

4,3

4,4

4,5

4,6

4,7

4,8

4,9

5,0

5,1

5,2

5,3

5,4

5,5

5,6

5,7

5,8

5,9

6,0

6,1

6,2

6,3

6,4

6,5

6,6

6,7

6,8

6,9

7,0

7,1

7,2

7,3

7,4

7,5

7,6

7,7

7,8

7,9

8,0

8,1

8,2

8,3

8,4

8,5

8,6

-4SD

1,7

1,8

1,9

2,0

2,1

2,2

2,3

2,4

2,5

2,6

2,7

2,8

2,9

3,0

3,1

3,2

3,3

3,4

3,5

3,6

3,7

3,8

3,9

4,0

4,1

4,2

4,3

4,4

4,5

4,6

4,7

4,8

4,9

5,0

5,1

5,2

5,3

5,4

5,5

5,6

5,7

5,8

5,9

6,0

6,1

6,2

6,3

6,4

6,5

6,6

6,7

6,8

6,9

7,0

7,1

7,2

7,3

7,4

7,5

7,6

7,7

7,8

7,9

Boys weight (kg)

Girls weight (kg)

-4SD

-3SD

-2SD

-1SD

Median Height (cm)a Median

-1SD

8,4

9,1

9,8

10,6

11,5

85,0

11,2

10,3

8,5

9,2

9,9

10,7

11,6

85,5

11,3

10,4

8,6

9,3

10,0

10,8

11,7

86,0

11,5

10,5

8,7

9,4

10,1

11,0

11,9

86,5

11,6

10,6

8,9

9,6

10,4

11,2

12,2

87,0

11,9

10,9

9,0

9,7

10,5

11,3

12,3

87,5

12,0

11,0

9,1

9,8

10,6

11,5

12,4

88,0

12,1

11,1

9,2

9,9

10,7

11,6

12,5

88,5

12,3

11,2

9,3

10,0

10,8

11,7

12,7

89,0

12,4

11,4

9,3

10,1

10,9

11,8

12,8

89,5

12,5

11,5

9,4

10,2

11,0

11,9

12,9

90,0

12,6

11,6

9,5

10,3

11,1

12,0

13,0

90,5

12,8

11,7

9,6

10,4

11,2

12,1

13,1

91,0

12,9

11,8

9,7

10,5

11,3

12,2

13,2

91,5

13,0

11,9

9,8

10,6

11,4

12,3

13,4

92,0

13,1

12,0

9,9

10,7

11,5

12,4

13,5

92,5

13,3

12,1

9,9

10,8

11,6

12,6

13,6

93,0

13,4

12,3

10,0

10,9

11,7

12,7

13,7

93,5

13,5

12,4

10,1

11,0

11,8

12,8

13,8

94,0

13,6

12,5

10,2

11,1

11,9

12,9

13,9

94,5

13,8

12,6

10,3

11,1

12,0

13,0

14,1

95,0

13,9

12,7

10,4

11,2

12,1

13,1

14,2

95,5

14,0

12,8

10,4

11,3

12,2

13,2

14,3

96,0

14,1

12,9

10,5

11,4

12,3

13,3

14,4

96,5

14,3

13,1

10,6

11,5

12,4

13,4

14,6

97,0

14,4

13,2

10,7

11,6

12,5

13,6

14,7

97,5

14,5

13,3

10,8

11,7

12,6

13,7

14,8

98,0

14,7

13,4

10,9

11,8

12,8

13,8

14,9

98,5

14,8

13,5

11,0

11,9

12,9

13,9

15,1

99,0

14,9

13,7

11,1

12,0

13,0

14,0

15,2

99,5

15,1

13,8

11,2

12,1

13,1

14,2

15,4

100,0

15,2

13,9

11,2

12,2

13,2

14,3

15,5

100,5

15,4

14,1

11,3

12,3

13,3

14,4

15,6

101,0

15,5

14,2

11,4

12,4

13,4

14,5

15,8

101,5

15,7

14,3

11,5

12,5

13,6

14,7

15,9

102,0

15,8

14,5

11,6

12,6

13,7

14,8

16,1

102,5

16,0

14,6

11,7

12,8

13,8

14,9

16,2

103,0

16,1

14,7

11,8

12,9

13,9

15,1

16,4

103,5

16,3

14,9

11,9

13,0

14,0

15,2

16,5

104,0

16,4

15,0

12,0

13,1

14,2

15,4

16,7

104,5

16,6

15,2

12,1

13,2

14,3

15,5

16,8

105,0

16,8

15,3

12,2

13,3

14,4

15,6

17,0

105,5

17,0

15,5

12,3

13,4

14,5

15,8

17,2

106,0

17,1

15,6

12,4

13,5

14,7

15,9

17,3

106,5

17,3

15,8

12,5

13,7

14,8

16,1

17,5

107,0

17,5

15,9

12,6

13,8

14,9

16,2

17,7

107,5

17,7

16,1

12,7

13,9

15,1

16,4

17,8

108,0

17,8

16,3

12,8

14,0

15,2

16,5

18,0

108,5

18,0

16,4

12,9

14,1

15,3

16,7

18,2

109,0

18,2

16,6

13,1

14,3

15,5

16,8

18,3

109,5

18,4

16,8

13,2

14,4

15,6

17,0

18,5

110,0

18,6

17,0

13,3

14,5

15,8

17,1

18,7

110,5

18,8

17,1

13,4

14,6

15,9

17,3

18,9

111,0

19,0

17,3

13,5

14,8

16,0

17,5

19,1

111,5

19,2

17,5

13,6

14,9

16,2

17,6

19,2

112,0

19,4

17,7

13,7

15,0

16,3

17,8

19,4

112,5

19,6

17,9

13,8

15,2

16,5

18,0

19,6

113,0

19,8

18,0

14,0

15,3

16,6

18,1

19,8

113,5

20,0

18,2

14,1

15,4

16,8

18,3

20,0

114,0

20,2

18,4

14,2

15,6

16,9

18,5

20,2

114,5

20,5

18,6

14,3

15,7

17,1

18,6

20,4

115,0

20,7

18,8

14,4

15,8

17,2

18,8

20,6

115,5

20,9

19,0

14,6

16,0

17,4

19,0

20,8

116,0

21,1

19,2

14,7

16,1

17,5

19,2

21,0

116,5

21,3

19,4

14,8

16,2

17,7

19,3

21,2

117,0

21,5

19,6

14,9

16,4

17,9

19,5

21,4

117,5

21,7

19,8

15,0

16,5

18,0

19,7

21,6

118,0

22,0

20,0

15,2

16,7

18,2

19,9

21,8

118,5

22,2

20,1

15,3

16,8

18,3

20,0

22,0

119,0

22,4

20,3

15,4

16,9

18,5

20,2

22,2

119,5

22,6

20,5

15,5

17,1

18,6

20,4

22,4

120,0

22,8

20,7

a Using this table, length should be measured from 45 to 86,9 cm and height should be measured from 87 to 120 cm.

-2SD

9,4

9,6

9,7

9,8

10,0

10,1

10,2

10,3

10,4

10,5

10,6

10,7

10,9

11,0

11,1

11,2

11,3

11,4

11,5

11,6

11,7

11,8

11,9

12,0

12,1

12,2

12,3

12,4

12,5

12,7

12,8

12,9

13,0

13,1

13,3

13,4

13,5

13,6

13,8

13,9

14,0

14,2

14,3

14,5

14,6

14,7

14,9

15,0

15,2

15,4

15,5

15,7

15,8

16,0

16,2

16,3

16,5

16,7

16,8

17,0

17,2

17,3

17,5

17,7

17,8

18,0

18,2

18,4

18,5

18,7

18,9

-3SD

8,7

8,8

8,9

9,0

9,2

9,3

9,4

9,5

9,6

9,7

9,8

9,9

10,0

10,1

10,2

10,3

10,4

10,5

10,6

10,7

10,8

10,9

11,0

11,1

11,2

11,3

11,4

11,5

11,6

11,7

11,9

12,0

12,1

12,2

12,3

12,4

12,5

12,7

12,8

12,9

13,0

13,1

13,3

13,4

13,5

13,7

13,8

13,9

14,1

14,2

14,4

14,5

14,7

14,8

15,0

15,1

15,3

15,4

15,6

15,7

15,9

16,0

16,2

16,3

16,5

16,6

16,8

16,9

17,1

17,3

-4SD

8,0

8,1

8,2

8,4

8,5

8,6

8,7

8,8

8,9

9,0

9,1

9,2

9,3

9,4

9,5

9,6

9,7

9,8

9,9

10,0

10,1

10,2

10,3

10,4

10,5

10,6

10,7

10,8

10,9

11,0

11,1

11,2

11,3

11,4

11,5

11,6

11,8

11,9

12,0

12,1

12,2

12,3

12,4

12,6

12,7

12,8

12,9

13,1

13,2

13,3

13,5

13,6

13,7

13,9

14,0

14,1

14,3

14,4

14,5

14,7

14,8

15,0

15,1

15,2

15,4

15,5

15,6

Annex 2 - Ration card; Children 6-59 months, PLW

Source: Adapted from Community-based Therapeutic Care (CTC): A field Manual. VALID International. First Edition, 2006

Childs Name

(include Grandfather's

name)

Gott/Kebele

TSFP RATION CARD; CHILDREN 6-59 MONTHS

Registration Number

Facility/ Distribution

Site

Admission date

W/H z-score

Age (months)

MUAC (cm)

sex M

Admission weight

TARGET WEIGHT

Distribution/Week

Date

Weight (kg)

Height (cm)

W/H z-score

MUAC (cm)

Type and amount of food

(kg)

Medication

Vitamin A (IU)

De-worming (mg)

Date

Visit date

Visit signature

Comment

Routine Admission Medication

Dosage

Medication

Measles

Anti malarial

Other

Additional Information

Date

Dosage

TSFP RATION CARD; PREGNANT or LACTATING WOMEN

Mother's Name

Admission MUAC (cm)

Admission Date

Preg expected delivery

date

Gott

Baby reach 6

month date

Registration Number

Kebele

Facility/

Distribution

Site

Distribution/Week

Date

MUAC (cm)

Type and amount of food

(Kg)

Medication

Vitamin A (IU)

Date

Dosage

Notes:

Medication

De-worming

Date

Dosage

ADMISSION

EXIT

Annex 7: Supervision checklist TSFP

TSFP Facility/Distribution Site:

Kebele:

_____________

Woreda:

Date:

Zone:

Region:

Activity

Quality

(Poor, Average,

Good)

Discussed with

supervisor

(Y/N)

Registration numbers allocated

correctly

Weight measured accurately

Height measured accurately

Weight-for-Height calculated correctly

MUAC measured accurately

Oedema measured accurately

Information recorded on card and in

registration book

Beneficiary correctly referred to either

TSFP, OTP, TFU, hospital or home

Admission medication given according

to protocol and recorded

Children with no measles vaccination

referred to nearest health facility

Correct amount of food distributed

Follow up weight, MUAC and height

recorded correctly

Appropriate education given to

caretakers and TSFP beneficiaries

Cooking demonstrations conducted

Beneficiaries discharged according to

protocol.

Absentee and defaulter beneficiaries

being followed up in the community

Home visit and post-distribution

monitoring being conducted by

community workers

TSFP tally and compilation sheets

correctly completed (spot check with

cards)

TSFP monthly reports accurately

completed

Sufficient stocks of supplementary

food and other supplies available to

implement the programme

Food commodities and other stock

stored correctly

Comment

Annex 8: Suggested equipment and supplies required for TSFP

(per Health Facility/distribution site)

Item

1 TSFP file for admission cards

2 Pens

3 Calculator

4 Water jug (with lid)

5 Plastic cups

6 Teaspoons or medicine cups

7 Thermometer

Salter scale (25kg) and pants; ‘Mother and Child’

Weighing scale

9 Height board

10 MUAC tapes

National Protocol for the management of MAM;

11 admission and discharge criteria, Weight for Height z-

score reference tables

Scale/balance to measure food ration or

12 calibrated container that holds known weight

of food ration

Minimum stock to keep topped up

1 TSFP ration cards for new admissions

2 ID bracelets (optional)

3 Clear plastic envelopes for filing cards (optional)

4 Drinking water

5 Food: e.g. FBF

6 Routine medicines - Vitamin A and de-worming

Amount per Health Facility/ distribution site

1-2 depending on caseload at each site

Amount per Health facility/distribution site

100

1-4 jerry cans or at hand-washing station

Depends on expected case-load

Annex 8: Suggested equipment and supplies required for TSFP

(per Health Facility/distribution site)

Item

1 TSFP file for admission cards

2 Pens

3 Calculator

4 Water jug (with lid)

5 Plastic cups

6 Teaspoons or medicine cups

7 Thermometer

Salter scale (25kg) and pants; ‘Mother and Child’

Weighing scale

9 Height board

10 MUAC tapes

National Protocol for the management of MAM;

11 admission and discharge criteria, Weight for Height z-

score reference tables

Scale/balance to measure food ration or

12 calibrated container that holds known weight

of food ration

Minimum stock to keep topped up

1 TSFP ration cards for new admissions

2 ID bracelets (optional)

3 Clear plastic envelopes for filing cards (optional)

4 Drinking water

5 Food: e.g. FBF

6 Routine medicines - Vitamin A and de-worming

Amount per Health Facility/ distribution site

1-2 depending on caseload at each site

Amount per Health facility/distribution site

100

1-4 jerry cans or at hand-washing station

Depends on expected case-load

Annex 10: Anthropometric measurement techniques:

10.1 Checking for bilateral pitting oedema

10.2 Measuring the MUAC

10.3 Taking the height/length

10.4 Weighing using a standing scale

10.5 Weighing using Salter scales

10.1 Checking for bilateral oedema

Bilateral oedema is the sign of Kwashiorkor. Kwashiorkor is always a severe form of malnutrition.

Children with bilateral oedema are directly identified to be acutely malnourished. These children are

at high risk of mortality and need to be treated in a therapeutic feeding programme urgently.

In order to determine the presence of oedema, normal thumb pressure is applied to both feet for three

seconds. If a shallow print persists on both feet, then the child presents with oedema. Only children with

bilateral oedema are recorded as having nutritional oedema.

You must formally test for oedema with finger pressure

you cannot tell by just looking

Mild oedema: usually confined to feet or pre-tibial area

Moderate oedema on feet and legs: Intermediate between mild and severe

Severe oedema generalised over the whole body: deep lasting pit formed

+++

10.2 Taking the Mid-upper Arm Circumference (MUAC) measurement

MUAC is used in children from 6-59 months. It is also used for adolescents, adults and pregnant and

lactating women.

For MUAC measurement in children, follow the steps below and the corresponding picture:

1. Ask the mother to remove clothing that may cover the child’s left arm.

2. Calculate the midpoint of the child’s left upper arm by first locating the tip of the child’s

shoulder (arrows 1 and 2) with your finger tips. Bend the child’s elbow to make a right angle

(arrow 3). Place the tape at zero, which is indicated by two arrows, on the tip of the shoulder

(arrow 4) and pull the tape straight down past the tip of the elbow (arrow 5). Read the number

at the tip of the elbow to the nearest centimetre. Divide this number by two to estimate the

midpoint. As an alternative, bend the tape up to the middle length to estimate the midpoint. A

piece of string can also be used for this purpose; it is more convenient and avoids damage to the

tape. Mark the midpoint with a pen on the arm (arrow 6).

3. Straighten the child’s arm and

wrap the tape around the

arm at the midpoint. Make

sure the numbers are right

side up. Make sure the tape is

flat around the skin (arrow 7).

4. Inspect the tension of the

tape on the child’s arm.

Make sure the tape has the

proper tension (arrow 7) and

is not too tight or too loose

(arrows 8 and 9). Repeat any

step as necessary.

5. When the tape is in the

correct position on the arm

with correct tension, read out

the measurement to the

nearest 0.1cm (arrow 10).

6. Immediately record the

measurement.

10.3 Measuring the length/height

For children less than 87 cm, the measuring board is placed on the ground. The child is placed, lying

along the middle of the board. The assistant holds the sides of the child’s head and positions the head

until it firmly touches the fixed headboard with the hair compressed. The measurer places her hands on

the child’s legs, gently stretches the child and then keeps one hand on the thighs to prevent flexion.

While positioning the child’s legs, the sliding foot-plate is pushed firmly against the bottom of the child’s

feet. To read the measure, the foot-plate must be perpendicular to the axis of the board and vertical.

The height is read to the nearest 0.1 centimetre.

For children more than 87 cm, the measuring board is fixed upright where the ground is level. The child

stands, upright in the middle, against the measuring board. The child’s head, shoulders, buttocks,

knees, heels are held against the board by the assistant, while the measurer positions the head and the

cursor. The height is read to the nearest 0.1 centimetre.

10.4 Weighing a child using a standing scale (or adult scale)1

Where this scale is available, it can be used to accurately measure the child’s weight. Be sure that the

scale is placed on a flat, hard, even surface. There must be enough light to operate the solar-powered

scale.

Explain all procedures to the mother and enlist her help. Babies should be weighed naked; wrap them in

a blanket or other covering until weighing. Older children should be weighed with minimal clothing.

If the child is less than 2 years old, do “mother and child” weighing.

1. To turn on the scale, cover the solar panel for a second. When the number

0.0 appears, the scale is ready.

2. The mother will remove her shoes and step on the scale to be weighed first

alone.

3. Have someone else hold the undressed baby wrapped in a blanket.

4. Ask the mother to stand in the middle of the scale, feet slightly apart (on

the footprints, if marked), and to remain still. The mother’s clothing

must not cover the display or the solar panel. Remind her to stay on the

scale even after her weight appears, until the baby has been weighed in

her arms.

5. With the mother still on the scale and her weight displayed, reboot the

scale by covering the solar panel for a second. The scale is ready when it

displays a figure of a mother and baby, with the number “0.0”.

6. Hand the undressed baby to the mother and ask her to remain still.

7. The baby’s weight will appear on the display (shown to the nearest 0.1

kg). Record this weight.

Note: If a mother is very heavy (e.g. more than 100 kg) and the baby’s weight is

relatively low (e.g. less than 2.5 kg), the baby’s weight may not register on the

scale. In such cases, have a lighter person hold the baby on the scale.

If the child is 2 years or older and will stand still, weigh the child alone. If the child jumps on the scale or

will not stand still, use the “mother and child” weighing procedure instead.

1. Ask the mother to help the child remove shoes and outer clothing. Talk with the child about the

need to stand still.

2. To turn on the scale, cover the solar panel for a second. When the number “0.0” appears, the

scale is ready.

3. Ask the child to stand in the middle of the scale, feet slightly apart (on the footprints, if

marked), and to remain still until the weight appears on the display.

4. Record the child’s weight to the nearest 0.1 kg

1 World Health Organisation - Training Course on Child Growth Assessment.WHO Child Growth Standards.

10.5 Weighing a child using a 25kg Salter Scale

Children are weighed by using a 25 kg hanging sprint scale graduated to 0.100 kg. Do not forget to re-

adjust the scale to zero before each weighing

A plastic washing-basin should be attached by 4 ropes that go underneath the basin. The basin needs to

be close to the ground in case the child falls out, and to make the child feel secure during weighing. If

the basin is dirtied then it should be cleaned with disinfectant. This is much more comfortable and

familiar for the child, can be used for ill children and is easily cleaned. Weighing pants that are used

during surveys should not be used; they are uncomfortable, difficult to use, inappropriate for sick

children and quickly get soiled to pass an infection to the next patient.

When the child is steady, record the measurement to the nearest 100 grams, the frame of the scale

being at eye level. Each day, the scales must be checked by using a known weight.

Annex 11:

Table of Weight-for-height Index, percentage of the median; National Centre for

Health Statistics (NCHS) 1977

Malnutrition

Moderate Severe

Height 100% 85% 80% 75% 70% 60%

in cm in kg in kg in kg in kg in kg in kg

49,0 3,2 2,7 2,6 2,4 2,2 1,9

49,5 3,3 2,8 2,6 2,5 2,3 2,0

50,0 3,4 2,9 2,7 2,6 2,4 2,0

50,5 3,4 2,9 2,7 2,6 2,4 2,0

51,0 3,5 3,0 2,8 2,6 2,5 2,1

51,5 3,6 3,1 2,9 2,7 2,5 2,2

52,0 3,7 3,1 3,0 2,8 2,6 2,2

52,5 3,8 3,2 3,0 2,9 2,7 2,3

53,0 3,9 3,3 3,1 2,9 2,7 2,3

53,5 4,0 3,4 3,2 3,0 2,8 2,4

54,0 4,1 3,5 3,3 3,1 2,9 2,5

54,5 4,2 3,6 3,4 3,2 2,9 2,5

55,0 4,3 3,7 3,5 3,2 3,0 2,6

55,5 4,4 3,8 3,5 3,3 3,1 2,6

56,0 4,6 3,9 3,6 3,5 3,2 2,8

56,5 4,7 4,0 3,7 3,5 3,3 2,8

57,0 4,8 4,1 3,8 3,6 3,4 2,9

57,5 4,9 4,2 3,9 3,7 3,4 2,9

58,0 5,1 4,3 4,0 3,8 3,6 3,1

58,5 5,2 4,4 4,2 3,9 3,6 3,1

59,0 5,3 4,5 4,3 4,0 3,7 3,2

59,5 5,5 4,6 4,4 4,1 3,9 3,3

60,0 5,6 4,8 4,5 4,2 3,9 3,4

60,5 5,7 4,9 4,6 4,3 4,0 3,4

61,0 5,9 5,0 4,7 4,4 4,1 3,5

61,5 6,0 5,1 4,8 4,5 4,2 3,6

62,0 6,2 5,2 4,9 4,7 4,3 3,7

62,5 6,3 5,4 5,0 4,7 4,4 3,8

63,0 6,5 5,5 5,2 4,9 4,6 3,9

63,5 6,6 5,6 5,3 5,0 4,6 4,0

64,0 6,7 5,7 5,4 5,0 4,7 4,0

64,5 6,9 5,9 5,5 5,2 4,8 4,1

65,0 7,0 6,0 5,6 5,3 4,9 4,2

65,5 7,2 6,1 5,7 5,4 5,0 4,3

66,0 7,3 6,2 5,9 5,5 5,1 4,4

66,5 7,5 6,4 6,0 5,6 5,3 4,5

Malnutrition

Moderate Severe

Height 100% 85% 80% 75% 70% 60%

in cm in kg in kg in kg in kg in kg in kg

67,0 7,6 6,5 6,1 5,7 5,3 4,6

67,5 7,8 6,6 6,2 5,9 5,5 4,7

68,0 7,9 6,7 6,3 5,9 5,5 4,7

68,5 8,0 6,8 6,4 6,0 5,6 4,8

69,0 8,2 7,0 6,6 6,2 5,7 4,9

69,5 8,3 7,1 6,6 6,2 5,8 5,0

70,0 8,5 7,2 6,8 6,4 6,0 5,1

70,5 8,6 7,3 6,9 6,5 6,0 5,2

71,0 8,7 7,4 7,0 6,5 6,1 5,2

71,5 8,9 7,6 7,1 6,7 6,2 5,3

72,0 9,0 7,7 7,2 6,8 6,3 5,4

72,5 9,1 7,7 7,3 6,8 6,4 5,5

73,0 9,2 7,8 7,4 6,9 6,4 5,5

73,5 9,4 8,0 7,5 7,1 6,6 5,6

74,0 9,5 8,1 7,6 7,1 6,7 5,7

74,5 9,6 8,2 7,7 7,2 6,7 5,8

75,0 9,7 8,2 7,8 7,3 6,8 5,8

75,5 9,8 8,3 7,8 7,4 6,9 5,9

76,0 9,9 8,4 7,9 7,4 6,9 5,9

76,5 10,0 8,5 8,0 7,5 7,0 6,0

77,0 10,1 8,6 8,1 7,6 7,1 6,1

77,5 10,2 8,7 8,2 7,7 7,1 6,1

78,0 10,4 8,8 8,3 7,8 7,3 6,2

78,5 10,5 8,9 8,4 7,9 7,4 6,3

79,0 10,6 9,0 8,5 8,0 7,4 6,4

79,5 10,7 9,1 8,6 8,0 7,5 6,4

80,0 10,8 9,2 8,6 8,1 7,6 6,5

80,5 10,9 9,3 8,7 8,2 7,6 6,5

81,0 11,0 9,4 8,8 8,3 7,7 6,6

81,5 11,1 9,4 8,9 8,3 7,8 6,7

82,0 11,2 9,5 9,0 8,4 7,8 6,7

82,5 11,3 9,6 9,0 8,5 7,9 6,8

83,0 11,4 9,7 9,1 8,6 8,0 6,8

83,5 11,5 9,8 9,2 8,6 8,1 6,9

84,0 11,5 9,8 9,2 8,6 8,1 6,9

84,5 11,6 9,9 9,3 8,7 8,1 7,0

Malnutrition

Moderate Severe

Malnutrition

Moderate Severe

Height 100% 85% 80% 75% 70% 60%

in cm in kg in kg in kg in kg in kg in kg

Height 100% 85% 80% 75% 70% 60%

in cm in kg in kg in kg in kg in kg in kg

85,0 12,0 10,2 9,6 9,0 8,4 7,2

85,5 12,1 10,3 9,7 9,1 8,5 7,3

86,0 12,2 10,4 9,8 9,2 8,5 7,3

86,5 12,3 10,5 9,8 9,2 8,6 7,4

87,0 12,4 10,5 9,9 9,3 8,7 7,4

87,5 12,5 10,6 10,0 9,4 8,8 7,5

88,0 12,6 10,7 10,1 9,5 8,8 7,6

88,5 12,8 10,9 10,2 9,6 9,0 7,7

89,0 12,9 11,0 10,3 9,7 9,0 7,7

89,5 13,0 11,1 10,4 9,8 9,1 7,8

107,5 17,7 15,0 14,2 13,3 12,4 10,6

108,0 17,8 15,1 14,2 13,4 12,5 10,7

108,5 18,0 15,3 14,4 13,5 12,6 10,8

109,0 18,1 15,4 14,5 13,6 12,7 10,9

109,5 18,3 15,6 14,6 13,7 12,8 11,0

110,0 18,4 15,6 14,7 13,8 12,9 11,0

110,5 18,6 15,8 14,9 14,0 13,0 11,2

111,0 18,8 16,0 15,0 14,1 13,2 11,3

111,5 18,9 16,1 15,1 14,2 13,2 11,3

112,0 19,1 16,2 15,3 14,3 13,4 11,5

90,0 13,1 11,1 10,5 9,8 9,2 7,9

90,5 13,2 11,2 10,6 9,9 9,2 7,9

91,0 13,3 11,3 10,6 10,0 9,3 8,0

91,5 13,4 11,4 10,7 10,1 9,4 8,0

92,0 13,6 11,6 10,9 10,2 9,5 8,2

92,5 13,7 11,6 11,0 10,3 9,6 8,2

93,0 13,8 11,7 11,0 10,4 9,7 8,3

93,5 13,9 11,8 11,1 10,4 9,7 8,3

94,0 14,0 11,9 11,2 10,5 9,8 8,4

94,5 14,2 12,1 11,4 10,7 9,9 8,5

95,0 14,3 12,2 11,4 10,7 10,0 8,6

95,5 14,4 12,2 11,5 10,8 10,1 8,6

96,0 14,5 12,3 11,6 10,9 10,2 8,7

96,5 14,7 12,5 11,8 11,0 10,3 8,8

97,0 14,8 12,6 11,8 11,1 10,4 8,9

97,5 14,9 12,7 11,9 11,2 10,4 8,9

98,0 15,0 12,8 12,0 11,3 10,5 9,0

98,5 15,2 12,9 12,2 11,4 10,6 9,1

99,0 15,3 13,0 12,2 11,5 10,7 9,2

99,5 15,4 13,1 12,3 11,6 10,8 9,2

112,5 19,3 16,4 15,4 14,5 13,5 11,6

113,0 19,4 16,5 15,5 14,6 13,6 11,6

113,5 19,6 16,7 15,7 14,7 13,7 11,8

114,0 19,8 16,8 15,8 14,9 13,9 11,9

114,5 19,9 16,9 15,9 14,9 13,9 11,9

115,0 20,1 17,1 16,1 15,1 14,1 12,1

115,5 20,3 17,3 16,2 15,2 14,2 12,2

116,0 20,5 17,4 16,4 15,4 14,4 12,3

116,5 20,7 17,6 16,6 15,5 14,5 12,4

117,0 20,8 17,7 16,6 15,6 14,6 12,5

117,5 21,0 17,9 16,8 15,8 14,7 12,6

118,0 21,2 18,0 17,0 15,9 14,8 12,7

118,5 21,4 18,2 17,1 16,1 15,0 12,8

119,0 21,6 18,4 17,3 16,2 15,1 13,0

119,5 21,8 18,5 17,4 16,4 15,3 13,1

120,0 22,0 18,7 17,6 16,5 15,4 13,2

120,5 22,2 18,9 17,8 16,7 15,5 13,3

121,0 22,4 19,0 17,9 16,8 15,7 13,4

121,5 22,6 19,2 18,1 17,0 15,8 13,6

122,0 22,8 19,4 18,2 17,1 16,0 13,7

100,0 15,6 13,3 12,5 11,7 10,9 9,4

100,5 15,7 13,3 12,6 11,8 11,0 9,4

101,0 15,8 13,4 12,6 11,9 11,1 9,5

101,5 16,0 13,6 12,8 12,0 11,2 9,6

102,0 16,1 13,7 12,9 12,1 11,3 9,7

102,5 16,2 13,8 13,0 12,2 11,3 9,7

103,0 16,4 13,9 13,1 12,3 11,5 9,8

103,5 16,5 14,0 13,2 12,4 11,6 9,9

104,0 16,7 14,2 13,4 12,5 11,7 10,0

104,5 16,8 14,3 13,4 12,6 11,8 10,1

122,5 23,1 19,6 18,5 17,3 16,2 13,9

123,0 23,3 19,8 18,6 17,5 16,3 14,0

123,5 23,5 20,0 18,8 17,6 16,5 14,1

124,0 23,7 20,1 19,0 17,8 16,6 14,2

124,5 24,0 20,4 19,2 18,0 16,8 14,4

125,0 24,2 20,6 19,4 18,2 16,9 14,5

125,5 24,4 20,7 19,5 18,3 17,1 14,6

126,0 24,7 21,0 19,8 18,5 17,3 14,8

126,5 24,9 21,2 19,9 18,7 17,4 14,9

127,0 25,2 21,4 20,2 18,9 17,6 15,1

105,0 16,9 14,4 13,5 12,7 11,8 10,1

105,5 17,1 14,5 13,7 12,8 12,0 10,3

106,0 17,2 14,6 13,8 12,9 12,0 10,3

106,5 17,4 14,8 13,9 13,1 12,2 10,4

107,0 17,5 14,9 14,0 13,1 12,3 10,5

127,5 25,4 21,6 20,3 19,1 17,8 15,2

128,0 25,7 21,8 20,6 19,3 18,0 15,4

128,5 26,0 22,1 20,8 19,5 18,2 15,6

129,0 26,2 22,3 21,0 19,7 18,3 15,7

129,5 26,5 22,5 21,2 19,9 18,6 15,9

130,0 26,8 22,8 21,4 20,1 18,8 16,1

Index weight for height, for children <85cm, length should be measured lying down, , children > 85 cm should be

measured standing up according to the reference data

Admission and discharge criteria for children 6-59 months to TSFP using NCHS (1977)

reference values

TSFP admission criteria

Children 6-59 months

MUAC ≥ 11.0 cm to < 12.0 cm

TSFP discharge criteria

Children 6-59 months

Target weight gain of 13% from admission

weight AND

MUAC ≥ 12.0 for 2 consecutive distributions

WFH ≥ 70% and < 80% of reference median

WFH ≥ 85% of median for two consecutive

distributions

Other discharges (default, died, non-

responder)

The same criteria as for admissions using WHO

Growth Standards (2006) – see page 26 in main

document.

Annex 12: WFH charts for adolescents and adults

Weight-for-height charts for adolescents and adults

Height 100% <-1 SD <-2SD <-3SD

(cm) Median (target) mod Severe

sex

120.5

22.1

18.8

17.7

15.5

121

22.3

17.8

15.6

121.5

22.5

19.1

15.8

122

22.7

19.3

18.2

15.9

122.5

19.5

18.4

16.1

123

23.2

19.7

18.6

16.2

123.5

23.5

19.9

18.8

16.4

124

23.7

20.1

16.6

124.5

20.4

19.2

16.8

125

24.2

20.6

19.4

16.9

125.5

24.5

20.8

19.6

17.1

126

24.7

19.8

17.3

126.5

21.2

17.5

127

25.3

21.5

20.2

17.7

127.5

25.5

21.7

20.4

17.9

128

25.8

21.9

20.7

18.1

128.5

26.1

22.2

20.9

18.3

129

26.4

22.4

21.1

18.5

129.5

26.7

22.7

21.3

18.7

130

22.9

21.6

18.9

130.5

27.3

23.2

21.8

19.1

131

27.6

23.4

22.1

19.3

131.5

27.9

23.7

22.3

19.5

132

28.2

22.5

19.7

132.5

28.5

24.2

22.8

19.9

133

28.8

24.5

20.2

133.5

29.1

24.7

23.3

20.4

134

29.4

23.5

20.6

134.5

29.7

25.3

23.8

20.8

135

30.1

25.6

24.1

21.1

135.5

30.4

25.8

24.3

21.3

136

30.7

26.1

24.6

21.5

136.5

26.4

24.8

21.7

137

31.4

26.7

25.1

137.5

31.7

25.4

22.2

138

32.1

27.2

25.6

22.4

138.5

32.4

27.5

25.9

22.7

139

32.7

27.8

26.2

22.9

139.5

33.1

28.1

26.4

23.1

140

33.4

28.4

26.7

23.4

140.5

33.7

28.7

23.6

Height 100% < -1SD <-2SD <-3SD

(cm) Median (target) mod Severe

sex

151.5

41.3

35.1

33.1

28.9

152

41.7

35.4

33.4

29.2

152.5

42.1

35.8

33.7

29.4

153

42.4

36.1

29.7

153.5

42.8

36.4

34.3

154

43.2

36.7

34.6

30.2

154.5

43.6

37.1

34.9

30.5

155

37.4

35.2

30.8

155.5

44.2

37.6

35.4

30.9

156

44.6

37.9

35.7

31.2

156.5

38.2

31.5

157

45.4

38.6

36.3

31.8

157.5

45.8

38.9

36.7

32.1

158

46.2

39.3

32.4

158.5

46.6

39.6

37.3

32.7

159

47.1

37.7

159.5

47.5

40.4

33.3

160

40.8

38.4

33.6

160.5

48.4

41.1

38.7

33.9

161

48.8

41.5

39.1

34.2

161.5

49.3

41.9

39.4

34.5

162

49.8

42.3

39.8

34.8

162.5

50.2

42.7

40.2

35.1

163

50.7

43.1

40.5

35.5

163.5

51.1

43.5

40.9

35.8

164

51.6

43.9

41.3

36.1

164.5

52.1

44.3

41.7

36.5

165

52.6

44.7

42.1

36.8

165.5

53.1

45.1

42.5

37.2

166

53.6

45.6

42.9

37.5

166.5

54.1

43.3

37.9

167

54.6

46.4

43.7

38.2

167.5

55.1

46.9

44.1

38.6

168

55.6

47.3

44.5

38.9

168.5

56.2

47.7

44.9

39.3

169

56.7

48.2

45.4

39.7

169.5

57.3

48.7

45.8

40.1

170

57.8

49.2

46.3

40.5

170.5

58.4

49.6

46.7

40.9

171

50.1

47.2

41.3

171.5

59.6

50.6

47.6

41.7

Annex 13

Referral Form: OTP to TSFP or TSFP to OTP

Referral: Health Facility/distribution site

DATE:

CHILD'S NAME: ________________________

CARER'S NAME: ________________________

AGE (months): ________________________

KEBELE:

________________________

GOTT:

________________________

REFERRED BY: ________________________

From

MUAC

OEDEMA

WEIGHT

____________________ To__________________

__________ cm________

YES

__________ kg

HEIGHT

__________ cm

W/H Z-score __________

COMMENT: _________________________________

SIGNATURE __________________________________

Referral: Health Facility/distribution site

DATE:

CHILD'S NAME: ________________________

CARER'S NAME:

AGE (months):

KEBELE:

________________________

GOTT:

________________________

REFERRED BY: ________________________

From

MUAC

OEDEMA

WEIGHT

HEIGHT

____________________ To__________________

__________ cm________

YES

__________ kg

__________ cm

W/H Z-score __________

COMMENT: _________________________________

SIGNATURE __________________________________

Referral: Health Facility/distribution site

DATE:

CHILD'S NAME: ________________________

CARER'S NAME: ________________________

AGE (months): ________________________

KEBELE:

________________________

GOTT:

________________________

REFERRED BY: ________________________

From

MUAC

OEDEMA

WEIGHT

____________________ To__________________

__________ cm________

YES

__________ kg

HEIGHT

__________ cm

W/H Z-score __________

COMMENT: _________________________________

SIGNATURE __________________________________

Annex 14: How to prepare premixed CSB+ or other Fortified Blended Food (FBF)

• Ensure that the water being used for cooking is safe before starting to cook

• Wash your hands with soap before you start to prepare the porridge

• Mix the premixed CSB+ (Famix, UNIMIX, Faffa) with part of the cold water to make a paste

• Add the rest of the water and bring to boil – ensure that it is not boiled for any longer than 10

minutes

• Where possible and resources allow, add additional oil, sugar, milk products, seasonal fruits

and/or local nuts to increase the energy density and improve the taste

• Serve on a clean plate or bowl

• Wash the child’s face and hands with water and soap before eating

• Use a separate plate for the child

Annex 16: Target weight for

discharge

This table gives the target weight for discharge for MAM children 6-59 months admitted to TSFPs

using MUAC admission criteria (≥ 11.0 cm - < 12.0 cm)

The target weight is calculated as 13% increase in body weight from admission weight

Admission Discharge

Admission

Weight

(kgs)

Discharge

Weight

(kgs)

3.4

7.1

8.0

11.2

12.7

3.1

3.5

7.2

8.1

11.3

12.8

3.2

3.6

7.3

8.2

11.4

12.9

3.3

3.7

7.4

8.4

11.5

13.0

3.4

3.8

7.5

8.5

11.6

13.1

3.5

4.0

7.6

8.6

11.7

13.2

3.6

4.1

7.7

8.7

11.8

13.3

3.7

4.2

7.8

8.8

11.9

13.4

3.8

4.3

7.9

8.9

13.6

3.9

4.4

9.0

12.1

13.7

4.5

8.1

9.2

12.2

13.8

4.1

4.6

8.2

9.3

12.3

13.9

4.2

4.7

8.3

9.4

12.4

14.0

4.3

4.9

8.4

9.5

12.5

14.1

4.4

5.0

8.5

9.6

12.6

14.2

4.5

5.1

8.6

9.7

12.7

14.4

4.6

5.2

8.7

9.8

12.8

14.5

4.7

5.3

8.8

9.9

12.9

14.6

4.8

5.4

8.9

10.1

14.7

4.9

5.5

10.2

13.1

14.8

5.7

9.1

10.3

13.2

14.9

5.1

5.8

9.2

10.4

13.3

15.0

5.2

5.9

9.3

10.5

13.4

15.1

5.3

6.0

9.4

10.6

13.5

15.3

5.4

6.1

9.5

10.7

13.6

15.4

5.5

6.2

9.6

10.8

13.7

15.5

5.6

6.3

9.7

11.0

13.8

15.6

5.7

6.4

9.8

11.1

13.9

15.7

5.8

6.6

9.9

11.2

15.8

5.9

6.7

11.3

14.1

15.9

6.8

10.1

11.4

14.2

16.0

6.1

6.9

10.2

11.5

14.3

16.2

6.2

7.0

10.3

11.6

14.4

16.3

6.3

7.1

10.4

11.8

14.5

16.4

6.4

7.2

10.5

11.9

14.6

16.5

6.5

7.3

10.6

12.0

14.7

16.6

6.6

7.5

10.7

12.1

14.8

16.7

6.7

7.6

10.8

12.2

14.9

16.8

6.8

7.7

10.9

12.3

17.0

6.9

7.8

12.4

15.1

17.1

7.9

11.1

12.5

15.2

17.2

Admission

Weight

(kgs)

15.3

15.4

15.5

15.6

15.7

15.8

15.9

16.1

16.2

16.3

16.4

16.5

16.6

16.7

16.8

16.9

17.1

17.2

17.3

17.4

17.5

17.6

17.7

17.8

17.9

18.1

18.2

18.3

18.4

18.5

18.6

18.7

18.8

18.9

19.1

19.2

19.3

Discharge

Weight

(kgs)

17.3

17.4

17.5

17.6

17.7

17.9

18.0

18.1

18.2

18.3

18.4

18.5

18.6

18.8

18.9

19.0

19.1

19.2

19.3

19.4

19.5

19.7

19.8

19.9

20.0

20.1

20.2

20.3

20.5

20.6

20.7

20.8

20.9

21.0

21.1

21.2

21.4

21.5

21.6

21.7

21.8

Annex 17

Discussion of target weight gain as the discharge criteria for MUAC admissions

When considering the ‘best’ criteria to use for the discharge of MAM children, a number of

questions usually arise. The recommendations for discharge using a target weight gain of 13% have

been based on the following reasons:

1) When admitting using MUAC it is not advisable to discharge on WFH z-scores

This is because WFH and MUAC are 2 different tools, which have the potential to identify 2 different

groups of children. While there is some overlap, MUAC preferentially selects younger children and

those who are at a higher risk of mortality. Because these tools have some, but limited correlation,

some of the children with a MUAC <12.0 cm, are likely to be ≥ -2 z-scores on admission. This could

result in a child being admitted one week, discharged the next, and so on.

2) If MUAC is good to use for admission, then it should be used for discharge also

As yet, there is insufficient evidence available that suggests MUAC responds quickly and accurately

enough to treatment. So if a child has a MUAC of e.g. 11.6 cm on admission, does reaching 12.0 cm,

12.2cm or 12.5 cm constitute recovery? How long will this take? Do children respond in a similar

enough way to define cut-offs for recovery? The current thinking (internationally) is that more

evidence is required on how MUAC responds to treatment before it can be adopted as a discharge

criterion in its own right. This is the reason why target percentage weight gain was introduced for

SAM cases identified through MUAC. It is a logical process therefore, to apply similar reasoning to

the recovery of MAM cases.

3) Is 13% weight gain a reasonable target weight gain to define ‘recovery’ for MAM children

The target weight gain for recovery of SAM children in OTP was classified as 15% through

international recommendations from WHO and UNICEF during 2008. It is logical therefore to

recommend that MAM children should have a lower target weight gain, as the children were less

malnourished to begin with. It is therefore recommended that 13% target weight gain should be

used as the discharge criteria for all MUAC admissionsto TSFP for children 6-59 months. As this

discharge criterion has not yet been thoroughly tested in Ethiopia, it is also recommended that

research is conducted to assess whether target weight gain is appropriate, and whether 13% is the

ideal weight gain to define recovery of MAMthat was identified by MUAC.

Annex 18: Home Visit Form

Volunteer / Community Worker’s Name: ________________

Date of Visit: ______________

Beneficiary name:_______________Kebele:__________________Gott:____________________

Feeding Practices

Is the supplementary food ration present in the home

If not, where is the ration?

Is the available ration enough to last until the next SFP

distribution?

Is the food ration being shared or eaten only by the beneficiary?

Yes

Shared

Beneficiary only

Is the child/beneficiary given other foods in addition to the ration? Yes

If yes, what type of food?

How many times per day is the child given food to eat?

Does someone help/encourage the child to eat?

Yes

What does the caregiver do if the child does not want to eat?

Is the child currently breastfeeding? (for children < 2yrs)

Yes

Is clean water available?

Yes

Caring Practices

Are both parents alive and healthy?

Who cares for the child during the day?

Is the child clean?

Yes

Health

What is the household’s main source of water?

Is there soap for washing in the house?

Yes

Does the caregiver wash the child’s hands and face before

feeding?

Yes

Is food covered and protected from flies?

Yes

What action does the caregiver take when the child has diarrhoea?

Food Security

Does the household currently have food available?

Yes

What is the most important source of income for the household?

Is the household registered for PSNP?

Does the household receive any other form of external support?

Annex 19: Post Distribution Monitoring (PDM) questionnaire for TSFP beneficiaries.

Kebele: ________________ Gott: ___________________

Date: ______________

PSNP: yes:

no:

1. What do you understand as the reason for receiving your/your child’s supplementary food?

2. What are the advantages of receiving this supplementary food?

3. How was the supplementary food that you received last distribution used?

Use proportional piling techniques to assess

Use of food

Eaten within

household

Shared outside Sold

household

Other

(explain)

4. If any supplementary food was sold or exchanged what was bought/received in return?

5. How was the supplementary food that you received last distribution prepared?

Porridge

(thick)

Gruel

(thin)

Bread

Other: _____________

6. Who consumed the supplementary food you received last distribution?

Only the beneficiary registered in the SFP

The beneficiary registered in the SFP and other children in the family

The beneficiary registered in the SFP and other adults in the family

All the children and the adults in the family

Other: _________________________________

7. For how long does the supplementary food ration last? _______________________________

8. Do you have any comments on the quality of the supplementary food?___________________

Annex 20: Planning and Analysing Focus Group Discussions

Source: Community-based Therapeutic Care (CTC): A field Manual. VALID International. First Edition,

2006

Focus group discussions (FGDs) are a valuable tool for assessing community perceptions and different

aspects of the TSFP. There is a growing body of data and publications on how to conduct FGDs. Some of

the key issues are covered below:

Planning a Focus Group Discussion (FGD)

The effectiveness of FGDs, as well as the quality of their results, depends partly on the preparation

beforehand.

Prepare a script:

Have a mix of general and specific questions. Make sure that each question has a number of ‘probe’

questions to follow up with, as they may help clarify responses. Consider asking participants for

definitions (e.g. what is malnutrition?), impressions (e.g. are the children in the programme improving?)

and their idea of other people’s perceptions (e.g. what does the rest of the community think about the

TSFP?). Ask a broad range of questions so that related issues can be explored if they arise.

Develop a ‘questioning route’:

When drafting a questioning route, consider the type of information you want, and who can provide the

information.

Know your setting:

Who are the participants? How will you recruit them?

What questions will you ask? How will you moderate the groups and collect the data?

Conducting a FGD

Keep in mind how the findings will be used:

Avoid asking questions that you will not be able to act on or incorporate into your report. Similarly, be

cautious of raising participants’ expectations with the questions e.g. (what does the community need?)

Ask questions that draw people out:

Follow up questions can be used such e.g. can you give an example? Where do you think this

impression comes from? Encourage participants to voice their opinions, while using questions to

prevent individual members from dominating the discussions (e.g. do the rest of you agree with x’s

opinion? Does anyone have a different experience or opinion?).

Put a time limit on the FGD session:

Setting a time limit helps the moderator to cover the planned topic areas. Remember that it will take

about three times longer to transcribe the session.

Notice non-verbal interactions:

Body language, reluctance or eagerness to speak, dynamics between group members and their effect on

opening or shutting down conversations.

Keep the conversation flowing:

Encourage all participants to say whatever is on their minds. If they stray off the subject for too long, or

get ahead of the issues being discussed, the moderator must re-focus the discussion.

Try to be neutral:

Some of the participants may not like the topic being discussed. They should be actively encouraged to

voice their opinions. In such instances, ask what it is that participants like and do not like about the

subject and where solutions may lie.

Analysing the Results

• Interpret how participants talk about certain issues, as well as the information they give.

• Interpret non-verbal communication and reactions as well as the verbal interaction.

• Bear in mind that information from FGDs is group information and is not necessarily the same as

information obtained in individual interviews. It reflects collective ideas shared and negotiated

by the group. Caution is needed when making general claims extrapolated from FGD data.

Annex 21: Pictorial Guide for conducting CSAS coverage surveys1

Step 1: Find a Map

The first step in the new coverage estimation method is to find a map of the program area. Try to find a

map showing the location of town and villages. A map of 1:50,000 scale is ideal.

Step 2: Draw a grid

The next step is to draw a grid over the map. The size of each square should be small enough for it to be

reasonable to assume that coverage will be similar throughout the square. A square of 10km by 10km

will probably be small enough in most circumstances.

Step 3: Select the squares to sample

Select the squares with about 50% or more of their area inside the program area.

Step 4: Select the communities to sample

Select the community closest to the centre of each square. If prevalence is low then you might need to

select more than one community from each square. Select the communities closest to the centre of

each square. Select the communities to be sampled and the order in which they should be sampled in

advance of visiting the square.

Step 5: Case-finding

When you visit a community find cases using an active case-finding method. It is usually sufficient to ask

community health workers, traditional birth attendants, traditional healers or other key informants to

take you to see "children who are sick, thin, or have swollen legs or feet" and then ask mothers of

confirmed cases to help you find more cases. You could also use door-to-door screening. It is important

that the case-finding method that you use finds all, or nearly all, cases in the sampled communities.

Each case is confirmed by applying the program's entry criteria (e.g. < 70% of the median weight-for-

height from the NCHS reference population and /or bilateral pitting oedema). When you find a

confirmed case you should then find out whether that child is in the programme. Remember to follow-

up on children reported to be in a therapeutic feeding centre or at a distribution point on the day of the

survey

Step 6: Record the data

You need only record the number of cases found and the number of those that are in the program for

each sampled square.

Step 7: Calculate coverage

Coverage is calculated as the number of cases that you found that are in the program divided by the

number of cases that you found. You should calculate this separately for each square as well as for all of

the squares together. You could use a weighted method to calculate the coverage for all of the squares

combined but this is not essential.

Step 8: Plot the data

Coverage data is plotted as a mesh map and as a histogram. The length of the

sides of the filled squares on the mesh map reflects the level of coverage found in

each square (calculated in step 7). The small open squares indicate quadrats

(squares of approximately equal area) with zero coverage. You might find it

helpful to mark the location of feeding centres, distribution points, health posts,

and roads on the map. This will help you interpret the results of the coverage

survey.

1 Myatt M, New Method for Estimating Programme Coverage, Field Exchange, Emergency Nutrition Network, 2004;21:11

Annex 22: Guiding Principles on IYCF in Emergencies

Source: A guide for Selective Feeding Programmes, UNHCR/WFP. Geneva, May, 2009.

Breastfeeding

Breastmilk

substitutes

Complementary

feeding

Caring for

caregivers

Protecting children

Malnutrition

The acute phase of

emergencies

Assessment,

intervention and

monitoring

Principle 1: Infants born into populations affected by emergencies

should normally be exclusively breastfed from birth to 6 months of age.

Principle 2: The aim should be to create and sustain an environment

that encourages frequent breastfeeding for children up to two years or

beyond.

Principle 3: The quantity, distribution and use of breastmilk substitutes

at emergency sites should be strictly controlled.

Principle 4: To sustain growth, development and health, infants from 6

months onwards and older children need hygienically prepared and

easy-to-eat, digestable foods that nutritionally complement breastmilk.

Principle 5: Caregivers need secure uninterrupted access to appropriate

ingredients with which to prepare and feed nutrient-dense foods to

older infants and young children.

Principle 6: Because the number of caregivers is often reduced during

emergencies as stress levels increase, promoting caregivers’ coping

capacity is an essential part of fostering good feeding practices for

infants and young children.

Principle 7: The health and vigour of infants and children should be

protected so they are able to suckle frequently and well and maintain

their appetite for complementary foods.

Principle 8: Nutritional status should be continually monitored to

identify malnourished children so that their condition can be assessed

and treated, and prevented from deteriorating further. The underlying

causes of malnutrition should be investigated and corrected.

Principle 9: To minimise an emergency’s negative impact on feeding

practices, interventions should begin immediately. The focus should be

on supporting caregivers and channeling scarce resources to meet the

nutritional needs of the infants and young children in their charge.

Principle 10: Promoting optimal feeding for infants and young children

in emergencies requires a flexible approach based on continual careful

monitoring.

Annex 23

Warehouse Management: General Store Keeping

Objective:

• accounting of what has been received, stored and issued

• maintaining the quality of the food and minimizing looses

Standard Practices:

1. Receiving, storing and dispatching of food and Non Food Items

• Counting when receiving and issuing

• Checking, conditions of what is received, stored & issued

• Keeping records(remarks)

2. Store and store premises:Checking any damages of sections of store, repair, ensure adequate lighting, arrange security guarding,

and ensure padlocking.

3. Standard food handling and stacking(depending store size ,keep 40-100 cm space, distance from wall & in between

stacks)

• Counting

• Careful unloading

• Inspect for damages, record remarks

• Proper stacking

1. Cleaning and ventilating the store(s):cleaning and ventilating the store, daily, weekly and periodical thorough store

cleaning is mandatory

3. Inspection of stocks and store: periodically make inspection, look for physical damages(insect damage), staining caused

by leakages ,water and evidence of theft and report findings,

4. Stock rotations: oldest stock should be issued first - First in, first out (FIFO).

5. Waste disposal: spillage and sweeping,

• Grain and pulses spilled onto a clean floor are usually not waste – they may be re-bagged, after cleaning by

sieving if necessary - but small quantities of dirty spilt grain should be destroyed.

• Spilled flour and blended food are normally waste.

Note: that spoiled commodities are still the responsibility of the storekeeper until properly disposed of, and must be

accounted for in the records.

6. Pest Control:

• Insecticides and fumigants to control insects, and rodenticides to control rats and mice are dangerous to

human health and should only be used by trained staff.

• Regular inspections of the stock will give early warning of attack by these pests and of the need for control.

7. Temporary Outdoor Storage (outdoor stacks):Only whole-grain cereals and pulses, and for vegetable oil can be temporarily stored in

outside store,

N.B. Should never be used to store flour, blended food, milk powder or canned food.

Effective outside storage needs: a prepared stacking platform; should have dunnage and a waterproof groundsheet;_ waterproof covers

(tarpaulins);ropes for tying down tarpaulins.

8. Documentation and Record keeping: overall objectiveis to provide a commodity tracking system from

first receipt to final discharge. Main documents includes,

• Waybills, sometimes known as delivery notes: Signing a waybill is a formal acceptance of the consignment; therefore, it

is important to check that the consignment matches exactly the description on the waybill.

• Stack cards - record any movement into or out of the stack and display the current stock level,

• Warehouse ledgers (or stock cards) provide an overview of the total stock position in the warehouse.

• Stock-taking or physical audit forms record the result ofindependent physical checks on stock levels.

• Loss or damaged cargo reports - provide full details of the problem and any action taken to repackage or reconstitute.

• Inspection reports provide full details of the condition of the warehouse or the commodity.

• Certificate of destruction describes authorised action taken to destroy or dispose of unfit commodities.

• When a final distribution report is made to the donor it will be supported by copies of many of the above documents.

BASIC WAREHOUSE EQUIPMENT THAT HELPS TO KEEP IT CLEAN AND TO THE STANDARD

• Brooms

• Ladders

• Repackaging equipment e.g. sack needles and twine (orstitching machine), empty sacks, cartons, oil containers,

• adhesive tape

• Sampling spears

• Shovels

• Sieves

• Torch

• Weighing scales

N.B. Fire extinguishers and First aid box if available