D. Food and Nutrition

When malnutrition exists or the needs of vulnerable groups of infants, children, pregnant and lactating women, the sick, and the elderly cannot be met from the general ration, special arrangements are required to provide extra food. The vulnerability of these groups stems from the increased nutrient requirements associated with such factors as growth, production of breast milk, repair of tissues, and production of antibodies. Selective feeding programs fall into three categories: SFPs, designed to meet the extra nutritional requirement of vulnerable groups; CTCs, which treat most severely malnourished people at home; and TFPs, lifesaving feeding programs designed to treat severe malnutrition.

Planning and implementation of SFPs, CTCs, and TFPs is a step-by-step process. Given the circumstances of each emergency, being flexible is important. Clear criteria and cutoff points for admission to SFPs, CTCs, and TFPs should be set up in agreement with all the local and humanitarian assistance organizations carrying out these programs.

a. Supplementary Feeding Programs

Small children are particularly susceptible to the cycle of infections and malnutrition. Sick children must eat and drink, even if they have no appetite, are vomiting, or have diarrhea. They must receive additional "supplementary" food whenever possible.

A SFP requires strong advocacy among the population. Its purpose must be clearly understood, otherwise some will question why the weak and sick are being fed when healthy children need food.

Consider the following factors when determining the need for an SFP:

• General rations average less than 1,500 kcal/person/day.
• 10 to 20 percent of the children are malnourished (children under 5 years old exhibit under 80 percent WFH or less than - 2 standard deviation Z-Score).
• Severe public health hazards exist.
• Significant diseases, especially measles, are prevalent or imminent.

The aim of an SFP is to provide high-energy, high-protein, low-bulk meals once or twice a day to those who need it. The number of meals depends on the nutritional status of the population, the nutritional value of the general ration, and the age of the beneficiaries. The size of the supplement also depends on the nutritional status of the beneficiaries. At least 400 kcal and 15 g protein per day, however, should be provided.

These programs usually take two forms: wet or dry rations. In addition to the criteria listed above for wet and dry general rations, supplemental dry rations should always be given priority in emergencies. Dry rations are easier to organize, less costly, lower the risk of communicable diseases, decrease the time mothers have to spend in centers, improve accessibility, and support local customs and household structures.

Wet rations should be considered if households face a lack of fuel or cooking facilities, if women are put at risk from carrying and storing a supplementary ration, or if a strong indication is apparent that children will not receive a ration in the household.

Supplementary meals should be prepared as porridge or soup, which are easily digestible and can be eaten by people of all ages. The food is generally based on cereal and legume blends with edible oil added to increase the energy content. Other ingredients (e.g., sugar, vegetables, fish, and milk) can be added to provide additional nutrients and a variety of flavors. Some prepackaged cereal/legume blended meals are available through UN agencies (e.g., corn-soya blend, wheat-soya blend) that may be useful at the start of an emergency feeding program if ingredients are familiar to the population. Local foods, however, should be substituted as quickly as possible and prepared in a more traditional and appropriate way. High-energy, high-protein biscuits are also sometimes early in the program. These biscuits are specially blended to be a high-protein and high-energy food supplement in a dry, easy-to-distribute form. Their use, however, is not encouraged for supplementary feeding because they serve a special niche, where cooking facilities are unavailable for an emergency feeding program or for distribution as a supplementary food source for a displaced population on the move.

Supplementary feeding programs are usually implemented either as targeted or blanket programs, depending on the objectives and available resources for the program.

(1) Blanket SFPs

Blanket SFP distributions are implemented to reduce or prevent the deterioration of a precarious nutritional situation. Blanket SFPs are those in which all vulnerable groups receive a supplementary ration (usually a dry ration of a blended food). In addition to pregnant and lactating women and sick and elderly persons, blanket SFP programs usually include all children under 5 years of age and do not use anthropometric measurements (weight and height) to define vulnerability.

(2) Targeted SFPs

If food resources are limited, then a more restricted (targeted) program is most likely to be appropriate. Targeted SFPs establish anthropometric criteria for those "targeted" to receive a supplementary ration. Targeted SFPs must be based on the active identification of, and follow up on, those considered vulnerable. This requires a regular house-by-house or family-by-family assessment, usually made by public health workers operating through a referral system. In addition to encouraging those in need to participate in the SFP and ascertaining the reasons for nonparticipation, continued home visiting is required to monitor the progress of infants and children. Those identified for the program should be registered and issued a numbered identity bracelet or card to facilitate followup. An SFP that does not actively identify those in need, but operates on an open "come-if-you-wish" basis, is unlikely to benefit those in greatest need and often results in poor use of food and organizational resources.

Families of children enrolled in the SFP should be provided a general food ration. This action will decrease the sharing of supplementary food that usually happens in families and will expedite the rehabilitation of the malnourished child.

The criteria for admission to a targeted SFP will depend on the condition of displaced people and resources available. The order of priority for is as follows:

• 1. Any malnourished child (less than 80 percent WFH or a Z-Score of less than - 2).
• 2. Women during the last 3 months of pregnancy and the first 12 months of lactation.
• 3. Medical referrals and the socially vulnerable, such as the elderly.

Children should not be discharged from the SFP until they have maintained more than 85 percent WFH for at least 1 month. They should be discharged into a general food distribution system for at least 3 months to solidify nutritional gains made while in the SFP.

b. Exit Criteria

Once begun, SFPs must be considered necessary until an appropriate general ration is provided that meets the needs of the vulnerable population. SFPs should be phased out if surveillance results reflect sustained improvement and global malnutrition prevalence is less than 10 percent among children less than 5 years of age, the mortality rate is low, and seasonal deterioration of the nutritional status is not anticipated (e.g., a rainy season). As children improve, they should be graduated from the program. Otherwise, the SFP becomes too large and unmanageable.

c. Supplementary Food Quantities

The typical daily supplementary ration is illustrated below along with the amount of food required (approximately 3.6 metric tons) for supplementary feeding of 1,000 beneficiaries over a 1-month period.

Table III-10. Typical Daily Ration With Monthly Totals (in metric tons)

*Meets minimum levels of 350 kcal of energy and 15 g of protein/ person/day.

**Wheat-soya blend.

d. Organization and Management of an SFP

Any SFP must be closely integrated with a community health care program, because the SFP will identify and refer health problems. Certain daily medications (e.g., iron, folate) may best be given in the course of the supplementary feeding.

Feeding centers and kitchens must be well organized and kept clean. Long waiting periods must be avoided and the schedule must not clash with family mealtimes or other essential community activities. Mothers may have to be fed with children to ensure that vulnerable children receive special feeding. Parents must understand that the SFP is given in addition to, not in lieu of, the normal meal. Otherwise, parents will think that young children are fed at the center while older children must eat at home. Utensils, bowls, scales, fuel, water, storage facilities, and other equipment will be required. These materials can generally be obtained locally. Some of these supplies are available with an Oxfam Feeding Kit.

One SFP center can usually handle up to 500 beneficiaries. The centers should be run by DPs who have received training. An experienced nurse should be able to supervise four to five centers. If different organizations establish separate SFP centers, central coordination and standardized procedures for all centers are very important. Programs must not be overly dependent on outside assistance to help ensure that they are sustainable when individuals or organizations leave.

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