United Nations System
Standing Committee on Nutrition

Report on the Meeting of the Working Group on Nutrition in Emergencies

Wednesday, 12 April 2000, World Bank, Washington DC

Chairs: Yvonne Grellety (formerly UNICEF) and Sultana Khanum (WHO)
Rapporteurs: Anne Sophie Fournier (ACF-USA) and Annalies Borrel (Independent)

Participants

Among the participants were NGOs, bilateral and UN agency members, approximately 60 people in total.

Agenda

(i) A brief historical perspective of inter-agency collaboration,
(ii) update on research work among adults;
(iii) recent research and findings from Kosovo on infant feeding issues and distribution of infant foods during the emergency,
(iv) nutritional problems faced by infants in emergencies,
(v) agency reports, and
(vi) the working group's terms of reference.

A brief historical perspective of inter-agency activities, and outcomes since the 26th Session

Rita Bhatia, UNHCR

A presentation of the alarming excess mortality among refugees and Internally Displaced Populations (IDPs) at the Symposium on Nutritional Issues in Food Aid in Emergencies in 1992 prompted the formation of the SCN Working Group for Refugees and IDPs. In 1993, the RNIS reports (Reports on the Nutritional Situations of Refugees and Displaced Populations) were launched, with the aim of raising awareness about the nutritional situation of IDPs and refugees.

During the 90s, a series of other important workshops and meetings took place including those in Machakos, Kenya in 1994 (Workshop on the Improvement of the Nutrition of Refugees and Displaced People in Africa)) and in Addis Abba, Ethiopia in 1995 (Tools and Strategies in the Management of Nutritional Emergencies). These meetings led to the establishment, following UNHCR's initiative, of the Interagency Group on Nutrition in Emergencies and also the Field Exchange, a tool for sharing and exchanging information. The main purpose of the Group, consisting of operational NGOs, UNHCR and WFP, is to share lessons learned in operational issues, highlight and advocate for best practice and assist in developing training materials and guidelines. The group met in Dublin, Ireland in 1997 (Emergency Selective Feeding Programmes) and in Amsterdam, Holland in 1998 (Food Security Assessments in Emergencies).

Since the 26th SCN session at least three Interagency workshops focusing on specific operational priorities identified by the group have been held. In Washington DC in April 1999, Improving the quality of relief diets (report of the meeting available from Food Aid Management, 300 I Street, NE, Suite 212, Washington DC 20003); in Boston in June 1999, Public nutrition in Emergencies (report of the meeting available in a special issue of Disasters volume 25:4, from Blackwell Publishers Limited, 108 Cowley Road, Oxford OX4 1JF, UK); in Rome in October 1999, Assessment and Targeting in Emergencies (report available from the ENN, Department of Community Health and Practice, Trinity College, 199 Pearse Street, Dublin 2, Ireland).

Update on Adult Malnutrition programs and research in Brazzaville and Burundi

Carlos Navarro, ACF-F Action Contre La Faim)

Dr. Navarro presented a broad overview of some of the problems encountered when trying to treat severely malnourished adults in Burundi and Congo-Brazzaville, where ACF is undertaking an analysis of its operational (nutritional) programmes. The project in Burundi has been operating since 1994 and at least 1,000 persons per month (including 700 adults) have been treated in 5 Therapeutic Feeding Centres (TFCs) in two provinces. The programme in Brazzaville began in July 1999, and has treated approximately 600 patients per month, including 400 adults, in 3 TFCs. The objective of the presentation was not to provide recommendations on cut-offs for defining adult malnutrition as the data has not yet been fully analysed, but rather to present some of the operational dilemmas that arise.

Emergency nutrition interventions aiming to address adult malnutrition, are becoming increasingly common practice in emergencies, for example in South Sudan and Congo-Brazzaville. However, there continues to be an enormous demand for information on diagnostic criteria, and protocol specifications. Consequently, some agencies (e.g. ACF and Medecins Sans Frontières) have begun to adapt nutritional protocols for adult malnutrition based on review and analysis of their own agency's experiences. ACF's recent work undoubtedly reinforces the two conclusions presented in this Working Group last year:

• Adult malnutrition is a significant public health problem in emergencies, even in the early stages, e.g. in Brazzaville adult admissions represented at least 40-60% of total admissions in the TFCs.
• With correct treatment and management, many of even the most emaciated adults can survive and achieve similar recovery rates and weight gains to those of children (>10g/kg/day and length of stays less than 30 days).

In summary, the following issues were highlighted as operational problems:

• The inappropriateness of BMI for assessing acute malnutrition ("a progressive loss") in emergencies, as opposed to chronic malnutrition (a "steady state" of malnutrition), is increasingly recognised. Despite ongoing ambiguities regarding cut-offs, MUAC and clinical outcomes are used more frequently as assessment tools for admission criteria in current operations. Current recommendations continue to be based mainly on operational and practical challenges rather than scientific evidence of the link between anthropometric cut-offs and functional outcome.
• The inability to stand has been identified as a very good prognostic tool to predict mortality in malnourished adults. Ways to identify this functional deterioration by measuring strength are currently being explored.
• Preliminary findings have shown severely malnourished individuals recover well in supplementary feeding interventions. Those admitted with BMI<16 have recovery rates of at least 50% and those admitted with BMI between 16 and 17 have recovery rates greater than 90%. Current research is focusing on the follow-up and outcomes of the remaining 50%.

Medical management of patients in TFCs:

The high prevalence of both acute and chronic disease among malnourished adults poses a serious challenge in the management of adult malnutrition. The design of therapeutic feeding for adults must take into consideration some important medical issues. These include:

• In adults, severe malnutrition beyond a certain threshold is almost always accompanied by medical complications;
• Acute diseases such as diarrhoea do not necessarily contribute to malnutrition in adults to the same extent in children, instead malnutrition is often associated with, or is the consequence of, a chronic and debilitating disease such as chronic hepatic and cardiac complications, which are more prevalent in adults. Case by case diagnosis is essential and either referral services or hospital facilities should be provided. It is important to recognise that medical and nutritional problems both need addressing.
• Staff working in therapeutic nutrition centres may not have sufficient medical skills, or may not be appropriately trained to address severe adult malnutrition.

An agency that wants to assist severely malnourished adults may therefore need to consider a complete revision of the strategy, objectives, training, and other means (including human) that it usually puts in place to cope with severe malnutrition in emergencies.

• The differential diagnosis of famine oedema in adults is complicated by the high prevalence of other diseases producing it (cardiac insufficiency, cirrhosis, etc.). Further training and guidelines, adapted for staff in emergency TFCs need to be developed.
• Large numbers of patients have been identified with refeeding oedema or have failed to reduce levels of oedema despite appropriate diagnosis and treatment. This is most likely due to inappropriate foods being consumed e.g. those with high salt or low protein content or both.

• Treatment with the same protocols proposed for children (with changes in the quantities per kilo) have been found to be very satisfactory. Weight gains, duration of stay and success rates may be as high as those for children.
• Acceptability and adherence to a therapeutic diet is more challenging for adults, in particular the refusal of a pure milk based diet remains a constraint. Alternatives to milk (with the same nutritional properties) are currently being explored.

• In Both Brazzaville and Burundi, ACF has reported that a high prevalence of the patients admitted to the TFCs are HIV positive. Despite this, recovery rates and other indicators (weight gain, duration of stay) do not seem to be affected, suggesting that HIV positive malnourished adults do recover as well as HIV negative adults.
• The impact of the high prevalence of HIV related malnutrition in adults and its therapeutic management is not well understood. Research into HIV and malnutrition in emergencies is urgently required, however the complexity of the topic, and the ethical and operational problems presented make it extremely difficult for any agency to conduct such research.

• Adults have a caring role in the family, are the source for food and revenues, and are the actors of reconstruction, social representation, etc. Separating them from their social environment may have deleterious consequences for their livelihoods and their ability to cope with, or recover from their current situation. Shorter-term treatment and ambulatory treatment may be appropriate strategies for addressing these issues.
• In locations where malnutrition related mortality is high among adults indirect social problems may also arise. In Burundi, many children have become orphans. Special services should be provided for orphans from an early stage. ACF ands its partners in Burundi are actively involved in taking care of orphans, and also in reuniting them with their surviving relatives.

Infant Feeding Research during the Kosovo crisis and follow-up action

Anna Taylor, SCF-UK (Save the Children) and Andy Seal, Institute of Child Health

The aims of the presentation were to report key findings relating to policy and practice issues from recent research conducted by SCF (UK) and ICH on infant feeding practices. The research was conducted during the Kosovo crisis in 1999 and assessed the availability and use of guidelines on infant feeding, documented the flow of infant relief items, and described infant feeding interventions and infant feeding practices of the refugee population.

The study findings highlighted issues in two broad categories of policy and practice:

• The practical gaps and ambiguities in currently available policy instruments (for example Memorandum of Understandings) as well as the poor institutionalisation and use of these policies. The obvious lack of donor enforcement of current guidelines.
• The complexity of aid flows, and the difficulties encountered when trying to monitor and control supplies. Poor coordination and low levels of compliance with policy instruments were also highlighted as key challenges. The study also showed the inconsistent and generally poor quality of infant feeding interventions. Further, the indicators used to assess infant feeding practices were diverse and therefore were not suitable for comparing data findings.

The findings were presented to an Interagency Group on Infant Feeding in Emergencies in a workshop held in London in 1999 (this report is available from SCF-UK, 17 Grove Lane, London, SE5 8RD, UK). A number of follow-up actions were agreed in this meeting including; (i) feed back to staff and agencies in the Balkan region, (ii) the development and effective dissemination of operational guidance for emergency personnel, and (iii) the review of policy instruments and further research.

Since the meeting, a draft of operational guidance aiming to provide essential information for managers, logisticians and health workers on infant feeding issues at the population level as well as basic guidance for decision makers on infant feeding interventions, has been prepared. This draft will be further refined and reviewed by the Interagency Group.

The following research needs in Infant Feeding in Emergencies were identified by the Group:

• The optimal timing and duration of breastmilk substitute during relactation/lactation support.
• Refinement of assessment tools for infants 0-<6 months: anthropometry, morbidity, feeding practices.
• Evaluation of the effectiveness of non-formal types of support for breastfeeding women in emergencies such as from family, social or community groups.
• Pilot testing of combined approaches to meet infant feeding needs, with development and refinement of the mother and baby tent model seen during the Kosovo crisis.
• Investigation of the effects of stress on lactation so as to better understand how its effects may be mitigated. Which women and infants are most affected by stress and are most likely to benefit from a stress reduction program?
• Evaluation of the effectiveness on feeding practices and health outcomes, and also cost-effectiveness of stress counselling as an intervention.
• Development of outreach mechanisms to optimise the effectiveness of interventions in reaching the most vulnerable.
• Investigation of optimal ways to create supportive environments for infant feeding in stressful situations.
• Development of mechanisms to ensure appropriate infant feeding policies are adopted during post conflict rehabilitation.
• Development of effective media and marketing approaches to reduce public donations of breastmilk substitutes during emergencies.
• Measurement of the cost effectiveness of breastfeeding support and other infant feeding interventions.

Of these research needs, the following priorities were identified:

• Refinement of assessment tools for infants 0-<6 months: anthropometry, morbidity, feeding practices.
• Pilot testing of combined approaches to meet infant feeding needs, with development and refinement of the mother and baby tent model seen during the Kosovo crisis.

For effective research in this area, as for most research in emergencies, prior funding arrangements are required to ensure that applied field research can be quickly instigated when opportunities present themselves.

Nutritional problems faced by infants in emergencies

Prof. Michael Golden, University of Aberdeen

Prof. Golden outlined a number of important problems/issues regarding infants nutrition.

• Infants are not systematically surveyed: Infants have been systematically ignored in emergencies, because it has been assumed that their mothers will breast-feed and that breastmilk is always a perfect feed. Thus there is insufficient data on the nutritional status of infants in emergency situations - they should be included in every nutritional survey when a household is visited, and then desegregated at the time of analysis.
• Selection criteria bias: Current selection criteria for surveys often only include children above 6 months and longer than 65 cm. The results can be biased as the 6 month old infants appear to be normal (selection bias) - and those younger are assumed to be normal too. The issue is of critical importance when one looks at the case fatality rate in TFCs. Data show a large mortality rise for younger / smaller infants e.g. 28.5% mortality in the 50-54 cm category vs. 9% for the 105-109 height range.
• Screening criteria: There are no established cut-off points or criteria for infants less than six months to define severe malnutrition (and admission into TFCs). The new WHO reference will not address this problem, as breast-fed children in general have a lower weight-for-height than the present reference population it is probable that the children that are now admitted into feeding programmes will be excluded when the new reference population are adopted. Existing data on the outcome of severely malnourished infants should be examined using the new reference population cut-off points when they become available to ensure that highly vulnerable infants are not excluded from programs.
• Inappropriate equipment and training: The weighing scales and length boards currently provided by UNICEF are insufficiently accurate to screen and manage high-risk infants. The normal level of accuracy of the instruments may lead to large errors. More accurate equipment is required. In addition, further training of personnel may be necessary.
• Demographic changes: In emergency situations, data on demographic changes should be collected to indicate the relative mortality rates. In some situations almost all infants have "disappeared" from the populations.

• Currently F100, diluted to lower the renal solute load and osmolarity, is used empirically to re-feed infants. There have been no studies on alternative diets for the severely malnourished infant.

Lactation Support

How to rehabilitate the severely malnourished infant whilst maintaining lactation is a serious dilemma. Critical points to be taken into account include the fact that severely malnourished infants:

• Do not cry and, because they do not complain or show hunger, are neglected (this is not abuse),
• Lack strength and therefore are not able to suck effectively or stimulate milk production,
• Have a very high mortality risk.

A technique to support lactation, known as supplemental suckling, has been developed. The technique, which is simple, involves a catheter attached to the nipple at one end and the other in a cup full of appropriate rehabilitation diet. As the child is fed, milk production is stimulated. The cumulative weight gain increases dramatically (270 g/Kg at 21 days) whilst the infant regains strength. When the supplementation is stopped growth continues at an accelerated rate with exclusive breastfeeding. This technique is now used in all ACF programs worldwide and could be extended further.

• Breastfeeding mothers need a nutrient-dense balanced diet. Mothers with type 1 deficiencies (not associated with maternal anthropometric change) can have breast-milk which can lead to death or severe and irreversible defects in their infants.
• Clinical deficiencies of Vitamin K and D, iodine, thiamine, cobalamine, pyridoxine appear in breast-fed infants before their mothers. Deficiencies of selenium, Vitamin E and A and folate can appear in both child and mother at the same time, although data are inconclusive. Type 2 nutrients are preferentially preserved in breastmilk, while Type 1 levels will fluctuate in breastmilk.
• In order to have a healthy infant (and mother) the breastfeeding mother's diet must contain all 40 essential nutrients.

• Historical data show that bottle fed infants had about 150/1000 more deaths than breast-fed infants in Europe and North America between 1880 and 1920, and similar data are found in the developing world today. The situation in an emergency is likely to be as bad or worse. There is no place for any type of diet except for breastmilk in such situations, unless it can be shown that by avoiding breastmilk there will not be an overall increase in mortality.
• HIV testing and counseling have a very low priority in any emergency situation and all mothers should be encouraged to breast-feed. There should be no mixed messages.
• Breastfeeding must therefore to be encouraged. The UN agencies must agree rapidly on a coherent strategy especially as the cost of the logistics for supplying breast milk substitute is rarely taken into account.
• Wet nursing should be encouraged. The use of complex home-modified milks should be never be contemplated as a stopgap measure.
• Orphans: 80% of infants of HIV positive mothers are HIV negative. They will become orphans, many of them during their infancy. This is the major nutritional challenge for the coming decade.

• Prof. Golden presented data on 8,000 children and the risk of death, z-scores, and % median weight-for-height curves. He proposed that nutritionists should use "risk of death" cut-off points rather than either Z-scores, % median or new population based anthropometric references in order to assess the nutritional status of children.

Agency Reports

UNHCR/CDC

UNHCR and CDC are assessing the utility of the WHO guidelines for the assessment of adolescent malnutrition (BMI for age / 5th centile of NHANES I reference). The agencies have conducted 3 nutritional surveys, 2 in Kenya (Kakuma and Dadaab) and the other in Nepal. When the WHO reference was used the prevalence of low BMI among adolescents in Kakuma and the Dadaab camps was estimated at about 60% and at about 30% in the Nepalese camps. However, the prevalence of malnutrition among children aged 6-59 months, morbidity, mortality and general food distribution records did not indicate a large-scale nutritional problem in the camps. The conclusion of these studies is that the surveys overestimated malnutrition among adolescents for three main reasons, (i) the reference population used may not be appropriate for other populations, (ii) knowledge of age for adolescents is largely uncertain in refugee situations and as thinness indices are highly correlated with age this makes interpretation difficult, and (iii) the use of puberty standards is difficult in most populations.

WHO

WHO presented their new guidelines on "The Management of Nutrition in Major Emergencies". Thiamine deficiency and scurvy modules are also newly available; guidelines on pellagra will be available shortly. WHO also announced that they are working towards establishing new growth curves for adolescents.

Working Group participants suggested that WHO's new guidelines should be made available on the WHO Web site. These documents are currently very expensive and difficult to obtain, especially from the developing world.

FAO

FAO's focus in emergencies is mainly on assisting communities becoming re-established. The use of the agricultural potential is the key in achieving this goal. Emphasis will therefore be placed on the agricultural sector via seeds and tools distribution, livestock, etc. FAO is also involved in preparedness planning especially in Early Warning systems and food needs assessments.

UNICEF

UNICEF is mainstreaming its capability for emergency response within the country programming process, in line with the activities envisaged in the MOU with WFP. This will require building the capacity of the agency's staff who will need to monitor the distribution of therapeutic feeding products.

USAID

USAID have adopted Crude Mortality Rate, for children aged 6-59 months, as well as weight-for-height indices as indicators in nutritional emergencies. The agency would like the group to investigate the issue of the harmonisation of the micronutrient content of fortified foods further.

Prof. Mike Golden

Reported that a Computer Auto Learning system (CAL) has been created and is available on CD-ROM from him. This includes information on the basics of marasmus and its treatment. Feed back is requested.

RNIS

Dr A. Duffield (SCN) gave a short presentation outlining the RNIS's plan to enlarge its scope to include information on situations caused by natural disasters (at WFP's request). Issues discussed included differences in the nutritional situation of populations displaced for political reasons (i.e.: those involved in complex emergencies) and those displaced by natural disasters. The RNIS will extend its coverage to include the nutritional situation of certain displaced populations of more 100,000 who are believed to have a heightened risk of malnutrition. The usefulness and feasibility of this work will be reviewed at the next Working Group meeting.

Terms Of Reference Of The Working Group For Nutrition In Emergencies

From the early 90's, two parallel groups have been addressing issues and problems of nutrition in emergencies; the SCN Working Group and the Interagency Group.

It is proposed to integrate and strengthen these existing groups and build on their earlier work. Participation of all UN agencies involved in emergency nutrition, inter-governmental bodies, operational NGOs, bilateral and civil society will be encouraged. It is anticipated that most of the detailed discussion of issues relevant to the Working Group will take place in meetings and workshops of the Interagency group, and then synopses of the conclusions of these meetings and other ongoing work will be presented to the annual SCN for further discussion and ratification.

The meetings will continue to focus on gaps and priorities in operational needs and sharing of information on current practices. The priorities will be addressed on the basis Who? How?Why? When? Where?

It is intended that the identification of gaps in knowledge will be defined using a 2X2 matrix of:

• age groups in the life cycle (e.g. infants, pregnancy lactating women, older children, adolescents etc.);
• aspects of program intervention such as assessment, surveillance, general food distribution, targeted food distribution, type I deficiencies (prevention and treatment), normal nutritional status, moderate malnourished and severe malnourished.

Gaps in methodology, guidelines, training, research and evaluation, intervention will be identified and prioritised for action.

The Working Group will nominate a steering committee from which the members will select proposals for the future chairs and rapporteurs. This process will take place by email and will involve members of both the Working Group and the Interagency group. The Emergency Nutrition Network (ENN) will provide a secretariat for the Working Group.

Recommendations of the Working Group to the ACC/SCN for action:

Adult malnutrition

Clarify issues relating to adult malnutrition including its definition, and operational intervention guidelines. Disseminate this information as widely as possible to agencies in need of support and guidance.

Infant feeding issues

Liase with the Breastfeeding and Complementary Feeding Working Group in taking responsibility for further development of the operational guidance, managing the consultative process and coordination of dissemination. Improve the training of humanitarian staff on infant feeding practice. Advocate for the need of experts on infant feeding issues to be present at all emergencies from the outset.

WHO manuals

Ask WHO to make their nutritional manuals available on their web site for global, low cost dissemination.

RNIS

Expand the coverage of the RNIS to include the nutritional situation of groups (of more than 100,000 people who are potentially at risk of malnutrition) displaced by natural emergencies for one year. Review this work at the next SCN meeting.

Functioning and mechanism of the Working Group

Nominate a steering committee from which the future chairs and rapporteurs can be chosen. This process will take place by email and will involve members of both the Working Group and the Interagency group. The ENN will provide a secretariat for the Working Group.