Lecture 10
Management of Moderate Acute Malnutrition
Introduction
Emergency supplementary feeding programmes (SFPs) aim to rehabilitate individuals with
MAM or to prevent individuals with MAM from developing severe acute malnutrition
(SAM) by meeting their additional needs, focusing particularly (but not exclusively) on
children 6-59 months, pregnant women and breastfeeding mothers. Recently, greater
emphasis has been placed on prevention of MAM as well as refinement of current approaches
for treatment of MAM.
There are two types of SFPs. Blanket SFPs target a food supplement to all members of a
specified at risk group, regardless of whether they have MAM. Targeted SFPs provide
nutritional support to individuals with MAM. To be effective, targeted SFPs should always
be implemented when there is sufficient food supply or an adequate general ration, while
blanket SFPs are often implemented when general food distribution (GFD) for the household
has yet to be established or is inadequate for the level of food security in the population. The
supplementary ration is meant to be additional to, and not a substitute for, the general ration.
The objectives of blanket SFPs are primarily preventative, aiming:
To prevent deterioration in the nutritional status of at risk groups in a population.
To reduce the prevalence of MAM in children under five thereby reducing the
mortality and morbidity (illness) risk.
The objectives of targeted SFPs are primarily curative aiming:
To rehabilitate children, adolescents, adults and older people with MAM.
To prevent individuals with MAM from developing SAM by providing a food
supplement to the general ration.
To reduce mortality and morbidity risk in children under five years.
To prevent malnutrition in selected pregnant and breastfeeding mothers and other
individuals at risk.
To provide follow-up/rehabilitate referrals from treatment of SAM.
When to start programmes
The decision to open a blanket or targeted SFP should be based on a thorough analysis of the
situation, including past and current rates of malnutrition, underlying causes of malnutrition,
public health priorities, and available human, material and financial resources. Current
recommendations are to consider overall trends in global acute malnutrition (GAM) and
SAM and context rather than waiting until a certain threshold has been reached, by which it
could be too late to implement an effective response.
Blanket SFPs are often set up at the onset of an emergency when the GFD systems is
being established and/or rates of acute malnutrition are high (e.g., more than 15 per
cent), or an increase in rates of malnutrition is anticipated due to seasonally induced
epidemics, or in case of micronutrient deficiency disease outbreaks.
Targeted SFPs should be implemented when there are large numbers of malnourished
individuals (e.g., prevalence of GAM 10 to 14 per cent and/or when GAM is between
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5 to 9 per cent with aggravating factors such as high rates of disease). Targeted SFPs
should ideally be run in conjunction with a GFD.
Who are the target groups?
There must be flexibility in defining and prioritizing groups depending on the context,
however generally:
Blanket SFPs target all children aged 6-59 months (or 6-24 months if resources are
constrained), pregnant and lactating women, adults showing signs of malnutrition and
other at-risk groups (e.g., sick and older people).
Targeted SFPs target children 6-60 months with MAM, children 6-60 months
discharged from therapeutic feeding programmes, older children with MAM, then
selected pregnant and breastfeeding women, and, finally, individuals with social and
medical problems such as twins, orphans, the disabled and elderly people.
Infants under 6 months may be part of the SFP but it is the mother who receives the
food ration and exclusive breastfeeding is encouraged.
When to admit and discharge from SFPs?
Admission and discharge criteria for blanket SFPs do not rely on anthropometric indicators.
Once the targeted groups have been defined, individuals who meet those criteria are admitted
and after a specific time period or when the blanket SFP is closed all individuals are
effectively “discharged”.
Admission and discharge criteria for targeted SFPs rely on anthropometric definition of
MAM and/or indicators of vulnerability. Cut-off points used to define MAM should be in
agreement with national policies and guidelines, taking into consideration capacity and
resources for running the programme.
When to close programmes
Blanket SFPs are closed when the GFD is adequate and prevalence of GAM is below
15 per cent without aggravating factors. Duration depends on the scale and severity of
the disaster, as well as the effectiveness of the initial response.
For targeted SFPs, it is a typical practice to close down a programme when there are
less than 30 patients. New cases should then be referred to health centres or hospitals.
Food commodities for SFPs
Supplementary food can be distributed as on-site feeding (wet rations) through daily
distribution of cooked food at feeding centres or as take-home (dry rations) through the
regular (weekly or fortnightly) distribution of food.
Take-home rations should always be considered first as these programmes require
fewer resources and there is no evidence to demonstrate that on-site SFPs are more
effective. Dry ration feeding carries less risk of cross-infection in overcrowded
feeding centres and lower demands on mothers and caregiver time.
On-site feeding may be justified when food supply in the household is extremely
limited, firewood and cooking utensils are in short supply, and when carrying the take
home ration might put beneficiaries at risk due to insecurity.
Take-home rations should be provided in the form of a pre-mix which provides from 1000 to
1200 kcals per person per day, and 35 to 45 grams of protein in order to account for sharing
at home. Women need an additional 350 kcals/day from the third month of pregnancy and
550 kcals per day for breastfeeding.
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On-site feeding should provide from 500 to 700 kcals (500 kcals recommended but up to 700
kcals to account for sharing with siblings at the centre) of energy per person per day,
including 15 to 25 grams of protein. Two meals are needed for children given their small
stomach size. Food is also needed for caregivers.
Rations for blanket SFPs are more variable compared to the standardized ration for targeted
SFPs. A number of factors are reviewed in setting the ration for the blanket SFP, namely
level of household food insecurity and availability of the GFD, as well as availability of
cooking facilities.
Supplementary foods must be energy-dense and rich in micronutrients, culturally appropriate,
easily digestible and palatable. There are a wide range of commodities currently in use to
treat MAM. They generally fall into two categories: dry rations/premixes (such as fortified
blended foods (FBF) or ready to use foods (RUF). Dry rations/premixes require some
additional preparation in the home, while RUFs can be eaten directly from the package.
Currently, there is no clear evidence whether RUFs have more impact than FBFs or are more
cost effective. Shortfalls in FBF in terms of nutrient content are being addressed through new
formulations. RUFs are increasingly being used in the field to treat MAM.
Medical treatment
Routine medical care is generally not provided through blanket SFPs. In cases where the
context requires and resources are available, blanket SFP distributions can be used for
screening/referral for malnutrition and medical issues, and micronutrient supplementation.
Targeted SFPs, in contrast, provide routine treatment. Most beneficiaries referred from a
therapeutic feeding programme will already have received routine treatment.
Recommendations should be reviewed in light of national guidelines for which drugs and
dosages to use. Routine treatment includes:
Medical assessment and referral as needed
Supplementation with vitamin A on admission for children 6-60 months, and 6 weeks
postpartum for women
Treatment of all children for worm infections
Measles vaccination for all children between 9 months and 15 years of age
Supplementation of iron and folic acid on admission and then administered weekly
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Monitoring and evaluation
Programme effectiveness can be assessed in two main ways:
1. Periodic nutrition surveys of the population, although an improvement in nutritional
status may not necessarily be due to the SFP.
2. Monitoring of programme performance statistics, e.g. the percentage of children
recovered, deaths and defaulters expressed in relation to total number of children
leaving the programme each month (applicable to targeted SFPs only). Target levels
for these indicators are outlined in Sphere, although in some circumstances
programme objectives may need to be redefined and targets adjusted accordingly.
Coverage is a critical indicator that is often overlooked. If programme performance in terms
of recovery, mortality (death) and default rates are good, but coverage is low then there will
be little programme impact at the population level. Sphere recommends coverage targets of
greater than 50 per cent coverage in rural areas, greater than 70 per cent in urban areas and
greater than 90 per cent in a camp situation. Coverage can be assessed through nutrition
surveys, though other methods are being explored.
SFP as a component of CMAM
Where community-based management treatment of acute malnutrition (CMAM) is
established, SFPs have a slightly modified role and approach. The supplementary feeding
component of a CMAM programme aims to support moderately or acutely malnourished
children without complications and others with special nutrient requirements.
Challenging areas
Flexible programming
There are many situations where targeted SFPs are implemented in the absence of an
adequate GFD. When this happens the effectiveness of the SFP is bound to decrease as
rations will probably be shared with other family members and the programme may be
overwhelmed with a combination of re-admissions and new cases. In this context the
objective of the programme is about preventing large-scale loss of life and getting as much
food out into the community as possible. Every emergency presents a unique combination of
factors and circumstances and, at times, decisions may conflict with current guidelines.
Need to combine SFPs with other interventions
In chronic emergencies, levels of acute malnutrition may remain unacceptably high for long
periods of time. When this occurs, SFPs may remain open without any obvious exit strategy.
Unless other programmes that address the underlying causes of malnutrition are implemented
as well as the SFP, the SFP effectively becomes a form of welfare. Alternative approaches,
including expanded GFDs or cash transfers with wider coverage may be more effective.
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Conflict situations
In conflict situations, beneficiaries may periodically be prevented from attending feeding
centres while implementing agencies may be unable to deliver food stocks. Staff may also be
unable to attend on some days, which leads to weak programme management and monitoring.
Agencies may be forced to make a number of adaptations, e.g., decentralized feeding centres
so beneficiaries have better access, employing defaulter tracers, and strengthening
communication with communities, local leaders and authorities who in turn take greater
responsibility for screening and sensitization. In these contexts it is possible that Sphere
performance targets cannot be met.
Key messages
1. In emergencies, moderate malnutrition can be addressed through blanket or targeted
supplementary feeding programmes.
2. Blanket supplementary feeding is generally used as a preventive measure among a
specific target group for a specific period of time in order to prevent moderate
malnutrition in the population.
3. Targeted SFPs are generally used for treatment of MAM within individuals based on
anthropometric admission criteria.
4. Programmes involving take home supplementary rations (dry feeding) are preferable in
most situations to on-site (wet feeding) SFPs.
5. Although children under five and pregnant and breastfeeding women are the usual priority
target groups, targets groups should be based on nutritional vulnerability.
6. SFP rations are meant to be additional to regular intake. Where household food insecurity
and/or general food distributions (GFDs) are inadequate, programme objectives may need
to be modified and implementing agencies must advocate for improved GFDs.
7. Rations should always be energy dense, micronutrient rich and culturally appropriate.
8. Targeted SFPs should always include a set of routine medical treatments. Blanket SFPs
are an opportunity for nutrition screening and referral, and where needed additional
medical care/supplementation, but this is not standard practice.
9. A number of programme indicators should always be monitored and analysed in relation
to Sphere standards. Meeting these standards may be challenging in some circumstances
due to constraints outside the control of implementing agencies.
10. SFP programming should be done in as integrated manner as possible, with linkages to
infant and young child feeding support, livelihoods and health programming where
feasible and appropriate.
11. Methods to manage MAM continue to evolve. Key areas include the types of food
commodity used, and methods to improve overall performance and impact at individual
and population level.
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