mam decision-making tool

MAM Decision-making Tool

Review the MAM decision-making tool Work through country situation Provide feedback on

Content Usability Layout

Meeting Objectives

Background Review of supplementary feeding programs (2007) WHO consultations MMI (2008) and MMII (2010)

Dietary needs Programme approaches to manage MAM

NUGAG review on MAM Limited guidance on programming Differing approaches Increase in products available for programming

Moderate Acute Malnutrition (MAM)

CONFUSION!!!

Burden of MAM 11 million children affected globally 41 million children 3 x risk of death compared to well-nourished

Increased risk of acute malnutrition in emergencies

Moderate Acute Malnutrition (MAM)

Formed by the Global Nutrition Cluster UNHCR UNICEF WFP OFDA ACF Save the Children CDC

MAM Taskforce

Additional MembersWHOECHO

Guide practitioners to identify most appropriate and feasible strategies to address MAM Prevention Management (treatment)

Harmonize nutrition programme decision-making on MAM in emergency situations

Incorporate contextual situational factors into the decision making process Beyond nutritional status Engage in discussion

Tool Objectives

Decision making process grounded by data, but is subjective on some levels

Limited to emergency contexts Rapid/sudden onset Slow onset Protracted emergencies Acute emergency within a chronic emergency setting

Local or large-scale emergencies

Not for refugee contexts UNHCR/WFP Guidelines for Selective Feeding: The

Management of Malnutrition in Emergencies 2011 http://www.unhcr.org/4b7421fd20.pdf

Caveats of Tool

Primary objective: prevent morbidity and mortality associated with MAM

Linkages: MAM cannot be addressed in isolation SAM IYCF-E Other sectors (WASH, health, food security)

Re-assessment

Caveats of Tool

MAM decision tool steps

Step 1:Programme Type/Objective

Step 2:Modality

Step 3:Programme Operation

Step 4:Review and Revise

Prevention/treatmentPreventionTreatmentNo additional programme

Supplementary feedingCash/voucherInfant and Young Child Feeding

Target groupProductDurationDelivery

Regularly throughout the emergency

Prevalence of GAM in the affected area (current or historical)

Information nature and severity of the crisis (risk) Baseline health data in affected areas

Expected impact on morbidity Food security situation

Expected impact on food security Population data

Displacement Density

Data Needs

MAG scenarios for the tool High >15% Medium 8-15% Low <8%

Sources Trend data

Seasonality Admission data (coverage should be assessed) Screening data

Nutritional Data

Risk of Deterioration Analysis

Score Sum Score

Risk Category

Increased morbidity (acute watery diarrhea, measles, acute respiratory infections)

High 3

Score 6-8: HighScore 4-5 :MediumScore <3: Low

Medium

2

Low 1Food availability and/or access disrupted (markets, prices and/or production)

High 3Medium

2

Low 1Significant population displacement

Yes 1No 0

Populati0n density Yes 1No 0

Risk of Deterioration

Malnutrition Infection Cycle Likelihood of morbidity and/or outbreak to impact GAM Baseline data

Vaccination coverage, vitamin A coverage, disease profile WASH services Access to care

Morbidity


Analysis

Score

Increased morbidity • acute watery

diarrhea • measles• acute respiratory

infections

High 3 • Epidemic (outbreak)

Medium

2 • Increasing incidence• High levels

Low 1 • Stable incidence• Low levels

Magnitude, extent, severity and duration of the crisis on food security Household consumption and market data sources

Food Security


Score

Food availability and/or access disrupted (markets, prices and/or production)

High 3 • Extreme food consumption gaps

• Livelihood assets being depleted

• Irreversible coping strategiesMedium

2 • Significant food consumption gaps

• Irreversible coping strategies• Initial depletion of livelihood

assetsLow 1 • Food consumption reduced

• No deficient intakes• No negative coping

strategies

Influences type and frequency of programme Many different contexts and types of displacement

Dispersed settlements, mass shelter in collective centers, reception and transit camps, self settled camps, planned camps (official and unofficial), IDPs with host populations

Displacement


Analysis

Score

Significant population displacement

Yes 1 Displacement increasing and concentrated

No 0 • No displacement• No increase in displacement• Sparsely populated area

Risk of morbidity

Consider in programme delivery design Example: low GAM, but high density= large number of children

in need Haiti, post earthquake in Port au Prince Kenya, post election violence in urban centers

Population Density


Analysis

Score

Populati0n density Yes 1 • Urban area• Dense population

concentrationNo 0 All other areas


Score Sum Score

Risk Category

Increased morbidity (acute watery diarrhea, measles, acute respiratory infections)

High 3

Score 6-8: HighScore 4-5 :MediumScore <3: Low

Medium

2

Low 1Food availability and/or access disrupted (markets, prices and/or production)

High 3Medium

2

Low 1Significant population displacement

Yes 1No 0

Populati0n density Yes 1No 0


Programme Recommendations



Step 2:Modality







Blanket Supplementary Feeding Provision of supplementary food Platform for other interventions

Screenings + referrals Child survival (deworming, vit A, immunisation) Health/nutrition education

Cash or Voucher Cash/voucher if food and nutrient availability is good,

markets functioning, caring practices maintained Further research needed

Specialised product + cash Cash 4X value of specialised product

Prevention: Modality

IYCF-E support

Infant & Young Child

Feeding in Emergenci

esComponen

t

Children under 5 at increased risk mortality Target children 6-59 months

If logistical constraints consider reducing target group PLW

No standard criteria for enrollment Impact on IYCF-E MAM treatment programming exist Low birth weight Prioritise

children over PLW lactating over pregnant women (protecting 0-6 month old infants)

Prevention: Target Group

BSFP should not be expanded to beyond 6-59 months and PLW except under serious conditions The general food distribution (GFD) should meet the needs of other household members.

Advocacy for improving the GFD or other food security measures.

Considerations Government approval Objective of the intervention & target group

Some products are targeted for 6-23/36 months Household’s ability to cook

Are there cooking facilities, easy access to fuel and water? Cultural practices and food preferences

Corn, wheat & rice based supercereals RUFs- peanut, chickpea and milk based (limited quantities)

Nutrient gap (energy & micronutrient) Decide upon higher or lower level energy

HH food security, diet diversity, baseline diets, chronic malnutrition, micronutrient deficiencies

Sharing practices, household use of foods, access to other foods

Prevention: Product

Product SheetNutrition Specialised Products

Target group Primary Recommendation

Interim/Alternative

Treatment of MAM6- 59 months RUSF

Supercereal PlusSupercereal/oil/sugar premix

PLW Supercereal/oil/sugarOlder Children Supercereal/oil/sugar RUSF or Supercereal

PlusPrevention of MAM6-23 or 6-59 months Supercereal Plus

LNS medium quantityRUSF±

Supercereal/oil/sugar½ sachet RUSF

PLW Supercereal/oil/sugar LNS medium quantity

Recommended Products and Alternatives

± Only where supplement is the primary source of available food

Duration of BSFP based on scale & severity of emergency GAM + Risk of deterioration

Generally 3-6 months Example start at least 1 month prior to leans season and run

until post-harvest Regular re-assessment

Scaling up or down Extension Rolling admission and no discharge (exiting) until end of

programme (even if child is older than upper limit at the close of programme)

Prevention: Duration and Exit Strategy

Considerations Access to the population

Security, seasonal, physical Scale of crisis (total area affected) Implementation capacity

Low or security- consider combining with GFD Population density

Determine number of sites If dense, may need multiple days/week for

distribution

Prevention: Delivery Mechanism

BSFP stand alone programme Targeted directly to households with children

BSFP Integrated delivery Child’s supplementary food is added to

food/cash/voucher distribution Low security context Rapid onset immediate programming Exclusion and inclusion errors Shift to parallel independent programme as soon

as feasible

Prevention: Delivery Mechanism

Targeted Supplementary Feeding (TSFP) Treatment for MAM with nutritious food supplement

and routine medical care Admission/discharge criteria based on anthropometric

measures (national or international guidelines) Nutrition communication Support for IYCF-E

Cash/vouchers need more evidence

Treatment

Malnourished children 6-59 months Discharges from SAM Pregnant and lactating (up to 6 months postpartum) women Chronic illness (HIV, TB)Exceptions Infants <6 months not admitted, support IYCF strengthened Other vulnerable populations identified (disabled children , 5-

10 years olds, older people)

Treatment: Target Group

Considerations Government approval Target group Household’s ability to cook

Are there cooking facilities, easy access to fuel and water?

Cultural practices and food preferences Corn, wheat & rice based supercereals RUFs- peanut, chickpea and milk based

(limited quantities)

Treatment: Product

Product SheetNutrition Specialised Products

Target group Primary Recommendation

Interim/Alternative

Treatment of MAM6- 59 months RUSF

Supercereal PlusSupercereal/oil/sugar premix

PLW Supercereal/oil/sugarOlder Children Supercereal/oil/sugar RUSF or Supercereal

PlusPrevention of MAM6-23 or 6-59 months Supercereal Plus

LNS medium quantityRUSF±

Supercereal/oil/sugar½ sachet RUSF

PLW Supercereal/oil/sugar LNS medium quantity

Recommended Products and Alternatives

± Only where supplement is the primary source of available food

Treatment range 1-4 months Scale down of TSFP considered when:

GAM <5% No aggravating factors Low numbers of admissions in MAM and SAM

treatment may also be used to decide to phase out Be mindful of programme coverage and

performance

Treatment: Duration and Exit Strategy

Considerations Access to the population

Security, seasonal, physical Scale of crisis (total area affected) Implementation capacity

Low or security- consider combining with GFD Population density

Determine number of sites If dense, may need multiple days/week for distribution

Treatment: Delivery Mechanism

Linked closely to treatment of SAM under CMAM model TSFP sites adjacent to OTP or health centres

support referrals (both directions) Large area for distribution/services If mobile or away from health centres provide

basic health interventions Considerations

Health service coverage, existing MAM/SAM programmes, capacity to scale-up

Treatment: Delivery Mechanism

Both prevention and treatment may be recommended Follow the previous steps to design each programme Think through linkages between programmes

Ideally, children should not be simultaneously enrolled in both programmes In reality, the risks associated with non-participation

outweigh the cost of dual participation In some large emergencies children should be enrolled in

prevention programmes as they may come in and out of treatment

Example: Northern Kenya, 2011/12

Prevention &Treatment

Additional programs not needed Existing nutritional programs

Re-evaluate risk as emergency progresses Build into nutrition response plan

Strengthen support for IYCF or micronutrient programmes

No Additional Intervention

Emergency programming is in addition to existing nutrition programmes



Step 2:Modality







Programme LinkagesInterventions in emergencies:Addressing acute malnutrition

General Food

Distribution

Selective feeding

programmes

TreatmentTargeted

Inpatient treatment

PreventionBlanket feedingCash/voucher

Outpatient treatment

Treatment for SAM

MAM Programmes

IYCF-E

Addressing underlying causes of

undernutrition

Addressing micronutrient deficiencies

WASH

HealthFood

security

Josephine Ippe: Global Nutrition [email protected]

Lynnda Kiess: World Food [email protected]

My contact: Leisel Talley, Centers for Disease Control and Prevention:[email protected]

Additional Feedback

mailto:[email protected]



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