NUTRITION

- SITUATION WITH DISPLACEMENT OF POPULATION -

Draft version 2011

Editor
Brengre Leurquin Sonia Peyrassol

In collaboration with
Pascale Delchevalerie Marie-Christine Ferir Yannick Garbusinski Peter Maes Jean-Pierre Mustin Michel Van Herp

O.C. Brussels Operations Department / C.O. Bruxelles Dpartement des Oprations

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Pocket Guide Nutrition

INTRO
This pocket guide, conceived on the model of a "quick start manual '" is part of a series dedicated to the activities to implement in the first phase of an emergency (0 to 3 months) with displacement of population. It has the advantage of being short, simple and light (in your pocket)... and thus does not contain all the details.... which you will find in the different guidelines quoted in the pocket guide. You consulted the guidelines and still do not have the information you are looking for ? Do not hesitate to ask advise to your field coordinator and/or medical or technical coordinator. There are technical sheets linked to this pocket guide. These technical sheets will facilitate you the implementation of the various activities. They are available on the CD-Emergency

Your Comments
are more then welcome. You do not see how to use one or the other sheet... perhaps because the sheet is badly designed or the insufficient explanations... your comments will help us to improve the tool. You were confronted with particular situations which led you to adapt the strategy, you have tricks and easy ways, documents or comments which could enrich the next version of this CD? Do not hesitate to contact us so that we can share your experience with everybody.

THIS IS A DRAFT VERSION, MADE AVAILABLE FOR THE NUTRITION E-LEARNING SESSION OF MAY 2011. ADAPTED ANNEXES WILL BE SOON AVAILABLE AND SEND TO THE FIELD.

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Pocket Guide Nutrition

TABLE OF CONTENTS
Nutrition is one of the 10 priorities in the emergency phase......................................................5
General Objective Specific Objective MSF Policy Acute Malnutrition/Chronic Malnutrition

Evaluation of the nutritional situation...........................................................................................6

Rapid MUAC Assessment Nutritional Survey Nutritional surveillance and systematic screening

Calculation and interpretation of the results...............................................................................8

Calculate the estimation of the prevalence of global, moderate and severe acute malnutrition Interpret the results in their context

What action ?..................................................................................................................................9

To treat the cause To treat the cases of malnutrition

Installation of a nutritional programme......................................................................................11

Calculate the number of beneficiaries expected in the programme Decide the type of approach (care and organization) for each programme Calculate the number of centres needed Order the food, the material and the drugs Recruit and train the staff Construction and location of the structure Water, hygiene and sanitation Inform the population

Organization of a TFC..................................................................................................................17
Waiting area Admission Medical treatment Nutritional treatment Registration Psycho-social follow-up Medical and nutritional follow-up Discharge

Organization of a SFC.................................................................................................................19
Waiting area Admission Registration Medical treatment Nutritional treatment Medical and nutritional follow-up Discharge

Evaluation of the nutritional programmes...............................................................................21 References..................................................................................................................................23 List of the technical sheets on the CD.....................................................................................25
4 MSF/B Draftversion2011 Pocket Guide Nutrition

Nutrition is one of the 10 priorities in the emergency phase.

The risk of malnutrition is higher in a displaced population because: - the causes of their flight and their flight in itself are hardships which have weakened them - on arrival, their living conditions are very precarious: drastic reduction in food availability and/or access, deterioration of their environment (lack of water, poor hygiene, lack of healthcare, no shelters to protect them against the bad weather...). Malnutrition is a major cause of mortality in itself (e.g. famine) but also because it increases the vulnerability to other diseases (thus severity).

General Objective
To reduce mortality and morbidity resulting from acute malnutrition by preventive and curative actions.

Specific Objective
To treat people suffering from severe and moderate acute malnutrition To prevent a deterioration of the nutritional situation in the vulnerable groups (children, pregnant and lactating women, elderly, handicapped) To promote the distribution of a minimal1 quality food ration of 2,100 kcal/person/day

MSF Policy
The responsibility for food assistance to refugee/displaced is divided between the HCR (High Commissioner for Refugees) and WFP (World Food Program). In general MSF will not be involved in a general food distribution and will prefer to concentrate on targeted nutritional programmes. However, MSF has the responsibility to ensure the follow-up of the quality, the quantity and the equity of the distributions. If there are no other organizations present and ready to deal with this priority, MSF will make an emergency general food distribution while lobbying at the HCR and WFP to take the necessary measures.

Acute malnutrition/Chronic Malnutrition

Malnutrition is a group of clinical disorders due mainly to a deficiency in energy and protein but also in vitamins and minerals. It is attributed to insufficient or unsuitable food supply. There are 2 types of malnutrition: chronic malnutrition and acute malnutrition.

The factors which impose an increase in the ration are the age and the sex, the medical and nutritional status of the population, period of strong activity and the outside temperature (it is necessary to add 100 kcal/person/day for each 5C below 20 C) 5 MSF/B Draftversion2011 Pocket Guide Nutrition

In emergency, we are interested in ACUTE malnutrition; its indicators are Weight/Height

(W/H), the presence of bilateral oedema and the mid-upper arm circumference (MUAC).
Sheet n1 : Theoretical concepts on malnutrition

EVALUATION OF THE NUTRITIONAL SITUATION

This evaluation is an essential part of the initial assessment and includes 2 parts:
-

The evaluation of the food resources of the population (see: Pocket Guide "Initial
assessment")

The evaluation of the nutritional status of the children less than 5 years2

1. Rapid MUAC Assessment

It is a first estimation3 of the nutritional status of the population by the checking of the possible presence of bilateral oedema and by the measurement of the mid-upper arm circumference (MUAC) in the children from 65 to 110 cm4. The main objective of this rough estimation is to detect the children with a high-risk of mortality in order to take immediate life-saving action. This method has the advantage of being easy to implement, as it does not require complex technical skills, nor specialized staff It can easily be coupled with a measles vaccination campaign

Moderate acute malnutrition + Severe acute malnutrition = Global acute malnutrition

MUAC between 115 and 125 mm (= Orange) with no oedema + MUAC < 115 mm (= Red) OR oedema = MUAC < 125 mm OR oedema

Sheets n Rapid MUAC assessment in practice 2 n Job Descriptions 3 n Measurement of the MUAC 4 n Oedema Assessment 5 n Tally sheet 6

2. Nutritional Survey
As soon as possible, plan a nutritional survey coupled with a retrospective mortality survey with the aim of : refining the analysis of the situation
This group of children less than 5 years is representative of the population because it is particularly sensitive to the changes of the nutritional situation and international reference values can be used. 3 Estimation: because it is the indicator W/H which is most reliable to measure the nutritional status of a population (the risk of measurement error is high with the MUAC) ; Only with a nutritional survey conducted according to the rules can one state the prevalence of malnutrition in a given population at a given period of time. 4 What corresponds to the children from 6 months to 5 years. Children < 2 years (65 to 84,9 cm) are registered separately (see tally sheet) because the results are interpreted differently. 6 MSF/B Draftversion2011 Pocket Guide Nutrition
2

evaluating the coverage of the nutritional programmes already set up. To do so, it is essential to call in a person specially trained in this kind of survey. If this person is not available on the field, ask the HQ to send somebody. (Be aware that, even if it is somebody
external to the field team who comes to make the survey, he/she will need resources (material and human) available on the field to be able to conduct it.) See on this CD : - Nutrition Guidelines MSF - Rapid Nutritional and Mortality Surveys. Step by Step - Kit of folders Nut Survey

3. Nutritional surveillance and systematic screening

Whatever the result of the evaluation of the nutritional situation, set up : A nutritional surveillance system Objective : To follow the evolution of the nutritional situation Systematic measurement of the MUAC in children less than 5 years old in your routine activities will enable you to follow the trends of the nutritional situation and to be alerted in time. Indeed, a situation is never unchanging and can always develop very quickly in one direction as in an other. (Examples: the trucks of WFP do not arrive, change of climatic conditions
(passage of the dry season to the wet season, dryness, flood...) or of security... )

Do not get caught out! A systematic screening of acute malnutrition in children less than 5 years old Objective : To treat all cases of acute malnutrition One generally uses the MUAC (fast tool for initial screening), but the admission in a nutritional programme must rely on the Weight/Height index. The children presenting with a MUAC < 135 mm or oedema will be referred to the points of W/H measurement. These 2 activities take place: At home by the home visitors ; In the health structures ; In the reception centres of the camp or site if they exist.

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Pocket Guide Nutrition

CALCULATION AND INTERPRETATION OF THE RESULTS

1. Calculate the estimation of the prevalence of global, moderate and severe acute malnutrition.
Prevalence of moderate acute malnutrition (%) =
Number of children with a MUAC between 115 mm and < 125 mm with no oedema Total number of children investigated Or more accurately : Number of children with Weight/Height - 3 Z-score or < - 2 Z-score X 100 Total number of children investigated X 100

Prevalence of severe acute malnutrition (%) =

Number of children with a MUAC < 115 mm OR oedema Total number of children investigated Or more accurately : Number of children with Weight/Height < - 3 Z-score OR oedema OR X 100 Total number of children investigated X 100

Attention: the presence of bilateral oedema always indicates severe acute malnutrition!!!

Prevalence of global acute malnutrition (%) = 1 + 2 =

Number of children with a MUAC < 125 mm OR oedema Total number of children investigated Or more accurately : Number of children with Weight/Height < - 2 Z-score OR oedema X 100 Total number of children investigated X 100

Example : In the displaced camp of Sar-e-Pol (Afghanistan) where the total population is estimated to 25,000 person, MSF made a rapid MUAC assessment and measured 3,000 children from 65 up to 110 cm and found : - 2,333 children with a MUAC green ; - 112 children with a MUAC yellow ; - 459 children with a MUAC orange ;
8 MSF/B Draftversion2011 Pocket Guide Nutrition

82 children with a MUAC red ; 14 children with oedemas

The calculation of the estimation of the prevalence of the acute malnutrition is thus : Prevalence of moderate acute malnutrition = 459 / 3,000 * 100 = 15.3 % Prevalence of severe acute malnutrition = (82 + 14) / 3,000 * 100 = 3.2 % Prevalence of global acute malnutrition = (459+ 82 + 14) / 3,000 * 100 = 18.5 %

2. Interpret the results in their context

Contextual information is essential for this interpretation. Most significant are: Crude mortality rate (CMR) and under 5 mortality rate (U5MR) General food rations and accessibility of food Diseases with epidemic potential present Precariousness of the living conditions (climate, shelters, access to drinking water...). Time and season of year (end or beginning of hungergap) Other actors working in the area on nut side (WFP, UNDP,MoH,NGOs)

Guide Initial Assessment),

This information, which normally has been collected during the initial assessment (see: Pocket will help you to understand the causes as well as the severity of a possible nutritional problem.
Note: If you face cases of malnutrition in adults, you have to investigate to know the cause of it: if this malnutrition is not caused by a chronic disease like tuberculosis or AIDS but by a lack of food, it is a sign of severity of the nutritional situation and thus a signal of alarm to which you must react as soon as possible!!!

The calculation and the interpretation of the results will be used to set up an adapted answer.5

WHAT ACTION
The choice of the strategy will depend mainly on: Availability of the food ration Prevalence of malnutrition "Worsening factors"6 which influence the nutritional situation

Human, material or financial resources cannot be a barrier to the interventions of MSF; if the needs are real, move heaven and earth to obtain what is necessary for the activities to be set up!

If you have doubts about the strategy to set up, you will find support and advice from your medical coordinator, the medical person in charge for your cell and nutrition advisor of the medical department CMR > 1/10,000/day or U5MR > 2; General food ration insufficient (< 2100 kcal/person/day); Epidemics of measles, shigellosis and other transmissible diseases; Intense cold and unsuitable shelters; An unstable situation, e.g. caused by an influx of refugees. 9 MSF/B Draftversion2011 Pocket Guide Nutrition

Sheet n Decision-making flow chart for the nu tritional interventions 7

.

If there is a real nutritional problem, it will be necessary simultaneously :

1. To treat the cause

if problem linked to food (availability, access) :
In case of massive nutritional emergency, in the first phase : distribute BP5 (energy biscuits): Complete ration for an adult = 1 box (= 9 bars) of BP5 per day is 2,275 kcal/person/day Complete ration for a child = box

This solution "Quick and dirty" will unfortunately not enable you to save the severely malnourished children but will avoid as much as possible a degradation of the general nutritional situation. Lobby the HCR and WFP for a general food distribution (GFD) of minimum 2,100 kcal/person/day. The calorie level of the total ration is not the only significant criterion. A balanced composition7 (proteins, fats, minerals and vitamins) and a regular distribution must also be guaranteed.

Sheet n8 Automatic calculation Worksheet of the nutritional value of a ration (COMPONUT)

Inform the organizations concerned8 that certain people or groups of people do not have access to these distributions. When the access to food is such that a fast deterioration of the nutritional situation is to be feared, organize a targeted food distribution (TFD) for the vulnerable groups or a . Selective Food Distribution (SeFD) covering specific nutritional and micronutrient needs but only a part of the overall energy needs of groups with particular physiologic vulnerability (e.g. young children, pregnant and lactating women, people with chronic illness) can also be organised.

Sheets n Targeted Food Distribution 9 n Diagram and practical organization of a dist ribution 10

if problem linked to health :

Control the epidemics, treat the diseases.

Reminder : malnutrition involves a weakening of the defence mechanisms, responsible for serious infections, while the viral infection of measles is in itself responsible for a reduction in the immunizing capacities with its serious consequences for the malnourished children
Examples : measles epidemic launch a measles vaccination campaign for all the children from 6 months to 15 years and treat the cases (Seer : Pocket Guide Measles Vaccination) epidemic of malaria inform the population, spray the shelters, distribute mosquito nets and treat the cases

A minimal ration of 2,100 kcal/person/day, with at least 10 % of energy coming from protein and 20 % coming from fat is recommended. 8 Donors such as WFP, USAID or distributors ("implementing agency") such as The Red Cross, Care, Emergency Committees 10 MSF/B Draftversion2011 Pocket Guide Nutrition

case of diarrhoea treat water, communicate the importance of the washing of the hands and the use of the latrines, detect actively and treat the cases (if necessary, install ORS corners)

if problem linked to water (availability, access, quality) :

-

Control the effectiveness (*) of the WHS programme (water, hygiene and sanitation) which must provide as soon as possible 15 to 20 litres of drinking water/person/day.
(N.B. In the very first days of the emergency a minimum of 5 litres of water/person/day is acceptable but this quantity will have to be increased asap).

See : Pocket Guide Water, Hygiene and Sanitation

(*) Is water of good quality ? Is transportation of water (if water-trucking) assured and regular? Does all of the population of the camp have access to it ?

and

2. To treat the cases of malnutrition

ATTENTION : ALL CASES OF MALNUTRITION MUST BE TREATED even if there is no nutritional programme set up!9 Vulnerability of the children of less than 5 years old10, and their high risk of mortality make them the priority targets of the specific nutritional programmes: Therapeutic Feeding Programme (TFP) for the treatment of the severely malnourished children Supplementary Feeding Programme (SFP) for the treatment of the moderately malnourished children

Sheet n - Malnutrition in infants 11

Note : Older children (from 5 to 10 years), pregnant or lactating women, teenagers, adults or malnourished elderly can also be admitted on a case by case basis in these programmes. If you face a famine i.e. with a significant number of teenagers and/or malnourished adults, they will have to benefit from a specific treatment in a structure specially intended for them.
Sheet n12 - Malnutrition in teenagers and adults

INSTALLATION OF A NUTRITIONAL PROGRAMME

1. Calculate the number of beneficiaries expected in the programme
9

Taking care of the malnourished patients, if they are not enough to open a specific structure, should be done on a case by case basis in the health structures (health centres, services of paediatric or medicine of the reference hospital).

Infants (from 0 to 6 months), in theory, are protected by breast-feeding; however, problems of breast feeding linked to the mother (insufficient milk, stress) or to the child (disease...) can lead to malnutrition in infant. See sheet n for the 11 management of these specific cases. MSF/B Draftversion2011 Pocket Guide Nutrition 11

10

The number of malnourished children can be estimated starting from the results of a rapid MUAC assessment or a Nutritional Survey: Total population of less than 5 years old = total population X 17 %11 Total population of less than 5 years old X prevalence of severe acute malnutrition = total number of severely malnourished children that will have to be admitted in the TFP. Total population of less than 5 years old X prevalence of moderate acute malnutrition = total number of moderately malnourished children that will have to be admitted in the SFP.

See example below (point 3)

2. Decide the type of approach (care and organization) for each programme

TFP ITFC (TFC 24/24h) TFC Day Care ATFC (Ambulatory) -

SFP SFC Dry Ration

The choice will depend on: The size of the target population The constraints (geographical, cultural, HR, logistics and financial, security...)

Various approaches can be combined.

Sheet n13 - Definitions, advantages and disadvant ages of the various types of approach for the nutritional programmes

In the first phase of an emergency, the extent of the emergency and/or the means available generally lead us to privilege the following solutions : ITFC or paediatric unit for the malnourished children (severe and moderate) with medical complications Day Care or ambulatory for the severely malnourished children with no medical complication SFC dry ration for the moderately malnourished children with no medical complication The type of approach must be evaluated continuously and adapted according to the nutritional situation and the acceptability of the local population. Thus, be flexible!!!

3. Calculate the number of centres needed

TFP : - TFC 24/24h - TFC day care - TFC ambulatory = 1 for 60 to 100 malnourished children (maximum 150 children) = maximum 250 children = 100 to 150 per day of distribution and per team

11

Attention: the composition of the population can deviate from the "standard repartition" according to the context. Adapt the % of children under 5 years following the results of the initial assessment, the nutritional survey or the mapping if available (see Pocket Guide "Initial Assessment"). 12 MSF/B Draftversion2011 Pocket Guide Nutrition

SFP : - SFC (dry ration)

= 150 to 200 beneficiaries per day of distribution and per team

Example (continuation): In the displaced camp of Sar-E-pol. (Afghanistan) where the total population is estimated at 25,000 people, the rapid MUAC assessment gave high prevalence rates of severe and moderate acute malnutrition. A general distribution of food (2,400 kcal/person/day for one month) was made in emergency by the ICRC and lobby is made at WFP so that it takes over. Consequently, it is decided to open a therapeutic nutritional programme as well as a supplementary nutritional programme containing dry rations targeted on the malnourished children under 5 years. Total population in the camp Population of children < 5 year (17 %) Prevalence of acute severe malnutrition Number of children severely malnourished expected (TFP) Prevalence of acute moderate malnutrition Number of children moderately malnourished expected (SFP) 136 children should be admitted in a TFC 650 children should be admitted in a SFC 25,000 4,250 3.2 % 4,250 x 3.2 % = 136 15.3 % 4,250 x 15.3 % = 650 1 centre (*) 1 centre (dry ration) open 3 to 4 days per week

(*) In Afghanistan, women cannot sleep outside their house ; it was necessary to choose to open day care feeding centre for the children of the camp combined with ambulatory feeding centre for the children of the distant villages. The real number of children admitted in the various programmes will depend on accessibility to the centres (see Chap. 7 Evaluation).

4. Order the food, the material and the drugs

The food
Calculate the needs in food according to: Dietary protocols: the choice of food and thus of the protocol will also depend on the local resources, then national and finally international12. (Attention: the choice of the
protocol will influence the whole logistic chain! Think it over when you make changes...) Sheets n Specialized Food 14 n Dietary Protocols TFC 15 n Dietary Protocols SFC 16

Number of expected beneficiaries The required period of time (Attention: to avoid stock shortage, foresee a buffer stock according to the delivery time (often one month minimum) and add 10 % for the possible losses!)

Note: If you chose a TFC 24/24h or a day care TFC, do not forget to also foresee the meals for accompanying care givers (the mother,).
Sheet n - Meals for accompanying care givers 17 Example: Our SFC admits 650 beneficiaries who receive a weekly dry ration of porridge (Premix) made up of 1.8 kg CSB, 200 g of sugar and 300 g of oil. The quantity of CSB necessary to nourish these beneficiaries for a 3 month period is:

Before making an international order, find out if there is any possibility of getting specialized food from other organizations (other MSF sections included!) present on the ground or in capital such as WFP, UNHCR, UNICEF or the ICRC for example.. 13 MSF/B Draftversion2011 Pocket Guide Nutrition

12

1. 2. 3. 4. 5.

Daily ration of CSB per child: 1,800 g / 7 days = 257 g Daily ration of CSB for 650 children: 0.257 kg X 650 = 167 kg Quantity of CSB for 120 days (3 months + 1 month of buffer stock): 167 kg X 120 = 20,040 kg Add 10% of losses: 20,040 kg + 2,004 kg (10%) = 22,044 kg The total in Tons: 22,044 kg/1000 = 22,044 Tons, rounded with 22 Tons

Sheets n Automatic calculation Worksheet of food order (SIMUFOOD) 18 n Standard Order Sheet WFP 19

Once the order is made, it will be very important to check each week the real consumption of each food: To adapt theoretical calculations to the effective needs To compare consumption with the number of beneficiaries to control the preparation and the unexplained losses of food.

Ensure the transportation, the reception and the storage of food : Foresee an appropriate place (clean, sufficiently large, protected from the bad weather, rodents...) Train a storekeeper in the good management of food

Sheets n Management and quality control of food 20 n How to store food 21 n Stock Card 22

The logistic material

If the nutritional kits are not available quickly, order the kitchen utensils locally. Try also to get furniture locally (made by the local carpenter or improvise with what you find on the spot!).
Sheets n Kits Nutrition 23 n Logistic Material needed to open a TFC 24 n Logistic Material needed to open a SFC 25

The drugs and the medical material

It is strictly prohibited, on the other hand, to buy drugs on the local market: even if you have good intentions, some of these drugs, whose quality is not controlled, can do more harm than good to your patients! Make your order and ask the capital or the HQ to send the necessary drugs ASAP! (Attention:
inform yourself about the national protocol for malaria and/or what will be necessary for you to set up before ordering the drugs against malaria). Dont forget the vaccines. Sheets n - TFC : Needs in drugs and medical m aterial 26 n - SFC : Needs in drugs and medical material 27

It will be then essential to put tools in places to follow the consumption of the drugs and to adapt the next orders to the real needs for the various centres.

5. Recruit and train the staff

The emergency should not make you forget that the recruitment, the organization of work and the training of the staff are essential steps in the opening of a nutritional centre and do not happen on their own! (Attention: to skip one of these steps in order to take care of the malnourished
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children more quickly (but not as well !) is not a good calculation; you will have to pay the piper sooner or later...)

The first step is to determine the number of staff necessary, by category, by basing yourself on the activities to be carried out.
Sheets n Needs in staff by type of nutrition al centre 28

Then, it will be necessary to prepare a job description for each category of staff, and to establish a flow chart for each programme. These two tools will remain essential during the duration of the programme.
Sheets n Job Description ITFC 29 n Job Description ATFC/SFC 30 n Flow chart ITFC 31 n Flow chart ATFC/SFC 32

A standard policy for the staff must be laid down and aligned to the labour regulations of the host country. Several administrative aspects should be tackled rather early in the emergency phase: salary scale, what is the most suitable type of contract, what is the legal status of refugee/displaced workers, etc. These aspects will be handled by the administrator of the mission while the person in charge of the programme will deal with the selection and the recruitment of the workers.
Sheets n Example of work schedules 33 n Job Interview 34

Several types of training will be necessary (theoretical courses, practical exercises...) and in the emergency phase, it is clear that the staff will have to be trained quickly; this means that it will be necessary to limit, to the basic, the number of tasks to be taught and simplify to the maximum
Example: Calibrate the balance with the standard weight is useful but not essential in the emergency phase. Sheet n35 Plan of training

Evaluating and following the training curriculum is part of the process of supervision which must be on a regular basis, with the aim of identifying new needs in training, for which it will be necessary to answer through continuous on-the-job training.

6. Construction and location of the structure

While the medical expatriates trains the staff, the logistician will prepare the structure which will accommodate the malnourished patients. Location The feeding structure must be located in a safe and accessible place for the beneficiaries; a TFC must be accessible within 30 to 45 minutes walk for the target population while a SFC (dry ration) must be able to be reached in less than 2 hours walk. Foresee a sufficiently large location to be able to increase the capacity of your structure.
(You have perhaps only 50 children today, but what will you do if in one week you have 300 of them?) -

Dont forget the water supply, feeding structures should be, if possible, close to a water source Feeding structures should be close to a health facility (hospitals, clinics, health centres) to facilitate patient care and transfer. When several centres are necessary, their geographical distribution should allow a good coverage of the population.
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Construction In the first phase of emergency, -

Either you find buildings available and adapt them into a nutritional centre Or you use tents (82 m for 20 beds) If these two options are not possible, it remains the possibility of quickly building a light structure (in bamboo, stems of millet...) while waiting to have time and materials necessary to build semi-permanent structures.

INSULATE your structure against the cold. One of the frequent causes of mortality in malnourished children is hypothermia.
N.B. It is advised, for the severely malnourished children, and more particularly for the smallest ones (premature, small weights of birth...), the construction of a hot room, i.e. a room particularly well insulated against the cold (it should be noted that even in the very hot countries the nights can be very cold and the differences in temperature day/night are always very significant... if we appreciate this freshness after one day under a blazing sun, the severely malnourished children, whose metabolism is disturbed, will have difficulties of adapting to such variation of t ). Unfortunately the tents are particularly unsuited to protect from the cold. You will thus have, as soon as possible, to built a semi-permanent structure. While waiting, you can: Priority Cover the children with bonnet, clothing, covers ; Provide mattresses ; Protect against the wind : Avoid orienting the entry of the tent facing the dominant winds ; Place the TFC tent so that it is protected by other tents ; Double the interior of the tent with natural fibre mats ; Put wind screens in front of the entry ; Insulate the floor (groundsheet)and isolate from the ground (bed or bench) Insulate the roof (for example by tightening a double roof or mats above the top of the tent... do not forget to leave a space between the two roofs).

During the construction of your semi-permanent structure, in order to insulate it as well as possible, do not hesitate to ask advise at your CoTL and the Expert Construction of the Logistic Department See on this CD Temporary & Semi-Permanent Buildings for Health Structures in Refugees Camps

. Waiting Area You will have many children and accompanying care givers who will sometime have to wait for long periods: Foresee sufficient waiting areas shaded and protected from the bad weather Foresee also points of distribution of drinking water (It would be a pity that children arrive at
the centre completely dehydrated because they had to wait under the sun and without water in front of this same nutritional centre !) Sheets n - Plan TFC and TFC Ambulatory and sta ndards to follow 36 n - Plan SFC dry rations and standards to follow 37

7. Water, Hygiene and Sanitation

Nutritional centres should open only when: 16

Supply of drinking water Elimination of the excreta Drainage and treatment of waste water Waste collection and disposal
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Means of vector control

are set up ; all these measures will contribute to improve the conditions of hygiene of the patients and of the nutritional centre(s) and are essential to reduce the propagation of the transmissible diseases. Inform yourself about the local practices and the practices of hygiene of the population before launching in the construction of perhaps perfect installations at the technical level but which will remain unutilised because socially unaccepted! (It is sometimes better to have an improved trench
latrines correctly located, planned and used than latrines badly located, badly maintained and misused, by, for example, a nomadic population accidentally settled!)

Moreover, if it is important to get adapted installations, it will also be essential to associate it with a programme of hygiene promotion of the population and training of the local technicians.
Sheet n Water, hygiene and sanitation in a n utritional centre 38

8. Inform the population

It is important to inform the population about the objectives of the programme but especially about the localisation of the nutritional centres and their methods during meetings with the representatives of the community (heads of the camp), and during the mass screening of the malnourished children. The existence of a good network of home visitors will also promote the collaboration of the population.

ORGANIZATION OF A TFC
1. Waiting Area
-

Pass regularly in the lines and make a regular triage of the patients who wait in order to detect the most serious cases and to treat them in priority (Attention with dehydration in the
queue : foresee a place protected from the bad weather and drinking water! ) Sheet n - The triage 39

2. Admission
Take the anthropometric measurements : MUAC, oedema, weight and height. Calculate the W/H index in Z-scores and note the target weight13 Admit the new patients according to the admission criteria ; refer those which do not meet the criteria to the appropriate place (SFC, health structure)
Sheets n Measurement of the weight 40 n Measurement of the height 41 n Reference Tables Weight/Height 42 n Admission Criteria TFC 43

13

The target weight is the weight that the child must reach at his exit: it depends on the discharge criteria of the TFC and generally corresponds to 80% of the index W/H (85% if no SFC) MSF/B Draftversion2011 Pocket Guide Nutrition 17

3. Medical Treatment
Make a complete clinical examination: medical history + physical examination In the areas where malaria is endemic, systematically do a rapid test malaria (Paracheck) Vaccinate the child against measles (non discriminating approach), check other necessary vaccinations (see vaccination calendar for severely malnourished) Prescribe the systematic treatment and give it without delay If the child suffers from medical complications (severe malaria, pneumonia, severe dehydration,...), prescribe a specific treatment accordingly (see Clinical and Therapeutic Guide, MSF) and take him in charge immediately in hospitalisation (ITFC) If the child has a good clinical status, assess his appetite by keeping him in observation the time he eats (or not!) the RUTF14. If his appetite is ok, he can be treated in ambulatory (ATFC), if not he has to stay in the ITFC.
Sheets n How to do a complete clinical examin ation in a malnourished child 44 n Systematic Treatment TFC 45 n Oral Rehydration for severely malnourished c hildren 46

4. Nutritional Treatment
Prescribe the dietary protocol to be followed by the child according to his/her weight and give it without delay Phase 1 (Attention : maximum 7 days !) / phase 2 Fill in the individual milk card (ITFC, Day Care) For ATFC, at the end of the day, identify the defaulters and organize visits at home
Sheets n Dietary Protocol TFC 15 n Individual Milk Card 47 n - Hygiene in the meals preparation and distrib ution 48

5. Registration
Register the patients and fill in their individual monitoring card (n of identification, date of entry, first name, name of the parents, full address15, age, sex, nationality and date of arrival on the camp/site + anthropometrics measurements). Put an identification bracelet for each new patient: note his identification n and the name (or symbol) of the centre Give mosquito net, blanket, soap, cup and spoon to the in-patients Explain to the accompanying care givers the operation of the centre, the medical and nutritional taking care in detail but also for which tasks their participation is requested (assign a member of the staff specifically for this task!) It is essential that s/he understands and agrees on the importance of the treatment adherence until it is completed.
Sheets n Standard Register TFC 49 n Individual monitoring card ITFC and ATFC 50

6. Psycho-Social Follow-Up
As soon as possible, it will be necessary to associate the medical and nutritional treatment to session of psychosocial stimulation, which supports the recovery of the child. Thus recruit an animator who will be responsible for organizing these sessions of animation (games in group, songs, music, stories...) to which the mothers will be encouraged to take part.

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Ready to Use Therapeutic Food (Plumpynut, BP100) Note at which place of the camp (or site) the patient lives (section, n of the shelter) and this, in order to be able to easily find the defaulters 18 MSF/B Draftversion2011 Pocket Guide Nutrition
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7. Medical and Nutritional Follow-Up

Phase 1 Each day Weight measurement Oedema assessment Clinical examination Diet control T twice

Phase 2 Weight measurement 1day/2 or 2x/week if workload +++ Clinical examination 1day/2 or 3 days Height 1/month T if necessary

ATFC 1x/week (see point 6 SFC)

8. Discharge
-

Measure the MUAC, the height, the weight, calculation of index W/H and check that the child fits the discharge criteria. Fill in the individual monitoring card of the patient and the register (N.B. The individual card
remains in the TFC).

Fill the health book and check that the vaccine against measles (and eventually others) was made and correctly noted in the health book and give instructions to mother for completion of EPI calendar if not completed yet.
Sheets n Discharge criteria TFC 51

ORGANIZATION OF A SFC
1. Waiting Area
-

Pass regularly in the lines and make a regular triage of the patients who wait in order to detect the most serious cases and to treat them in priority (Be careful for dehydration in the
queue : foresee a place protected from the bad weather and drinking water!) Sheet n - The triage 39

2. Admission
Take the anthropometric measurements : MUAC, oedema16, weight and height Calculate the W/H index in Zscores and note the target weight17 Admit the new patients according to the admission criteria ; refer those who do not meet the criteria to the appropriate place (TFC, health structure) Regularly verify that the admission criteria are strictly respected and that the anthropometric measurements noted on the card correspond well to the patient (Indeed,
some cheating can happen: exchange of bracelets, falsification of anthropometric measurements... be thus vigilant!) Sheets n Measurement of the weight 40 n Measurement of the height 41 n Reference Tables Weight/Height 42 n Admission criteria SFC 53
16 17

Attention, if the child has oedema, you have to refer him immediately to the TFC The target weight is the weight that the child must reach at his discharge: it corresponds to W/H> -2 z-score. MSF/B Draftversion2011 Pocket Guide Nutrition

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3. Registration
Register the patients and fill in their individual monitoring card (n of identification, date of entry, first names, name of the parents, full address18, age, sex, nationality and date of arrival on the camp/site + anthropometric measurements). Put an identification bracelet on each new patient: note his identification n and the name (or symbol) of the centre and the day of distribution Explain to the accompanying care givers the operation of the centre and the medical and nutritional follow-up in detail
Sheets n Standard Register SFC 54 n Individual monitoring card SFC Dry Ration 55

4. Medical Treatment
Make a complete clinical examination: medical history + physical examination In the areas where malaria is endemic, systematically do a rapid test malaria (Paracheck) Vaccinate the child against measles (non discriminating approach) Prescribe the systematic treatment and give it without delay If the patient has medical condition that cant be treated in ambulatory, refer him/her to the ITFC; if no ITFC, to a doctor or an appropriate health structure If possible, refer the pregnant women to an ante-natal consultation
Sheets n How to do a complete clinical examin ation in a malnourished child 46 n Systematic Treatment SFC 56

5. Nutritional Treatment
Distribute the weekly ration to the child and explain well to the mother how to prepare it and give it The patient then returns home; if your circuit is well organized, the patient will not have remained more than 2 hours in the centre The individual monitoring card of each patient must remain in the centre and be brought back to the person of the registration for the following week After each distribution, identify the defaulters and organize the visits at home
Sheets n Dietary Protocol SFC 16

6. Medical and Nutritional Follow-Up

-

A regular monitoring of the patient and a rigorous follow-up of the medical and nutritional treatment are essential Ensure that all information, including the prescriptions, is each time recorded on the individual monitoring card of the patient. To ensure the best follow-up, staff must know the expected progress for the patient (weight gain, improvement of the general state...) If the health of the child is degrading, a transfer to the ITFC or in a hospital must be organized

Weight 18

Take the weight of the patient each visit If the patient does not gain weight, it is necessary to try to understand what is the problem (disease, insufficient food, etc.) and to take the appropriate measures

Note at which place of the camp (or site) the patient lives (section, n of the shelter) and this, in order to be able to easily find the defaulters 20 MSF/B Draftversion2011 Pocket Guide Nutrition

Indicate the target weight on the individual monitoring card and recalculate it each month at the time of the update of the height

Height Measure the height of the patient once per month

Bilateral Oedema Check the possible presence of oedema at each visit. If +, transfer the child to the TFC

MUAC Check MUAC at each visit. If < 115 mm, transfer the child to the TFC Medical Follow-up Do a complete clinical examination each week and give a weekly dose of iron + folic acid (not when RUTF is used)

7. Discharge
Measure the MUAC, the height, the weight, calculation of index W/H and check that the child fulfils well the exit criteria Fill in the individual monitoring card of the patient and the register Fill in the health book and check that the vaccine against measles (and eventually others) was done and correctly noted in the health book and give instructions to mother for completion of EPI calendar if not completed yet.
Sheets n Discharge Criteria SFC 58 n Referral Card 59

EVALUATION OF THE NUTRITIONAL PROGRAMMES

1. Objectives
To evaluate the functioning, quality, coverage, acceptability, accessibility and effectiveness of the programmes to make fast improvements if necessary To follow the trends of the nutritional situation and to adapt the activities of the programmes accordingly To provide data for testimony, lobbying and public information

2. Means
The data collection will relate mainly to :
The number of admissions (type & age groups) and discharges (discharge, death, default, transfer, non respondent) of the programmes Causes of the deaths Average weight gain & length of stay The vaccine coverage
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The follow-up of the diseases with epidemic potential

Analysis of these data and the report :

Without the analysis (which must be done in the field) and especially without the implementation of the actions which result from this, to collect data is useless! Standard forms of evaluation were worked out for an easy and practical use in the field but also to facilitate the comparison of the nutritional programmes in time... use them instead of re-inventing the wheel...!

Sheets n Principal indicators of the nutritio nal programmes 60 n Data Collection Form Feeding Centres 61 61 a How to fill selective feeding centres data reporting forms 61 b Printable data collection forms 61 c- Therapeutic feeding program summary sheet 61 d Supplementary feeding program summary sheet

Observation and supervision :

To supervise in an effective way, it will be necessary for you to ensure an almost permanent presence in your structures and to acquire a global vision of the functioning of the programme and the nutritional situation in general. (Attention: to supervise does not
mean to say "To do all, all alone", nor "to cross the arms by looking at the others working! "but" To work well shoulder to shoulder with the staff")

Discuss the result of your observations (negative AND positive) and the analysis of the data with the staff during regular meetings is essential to involve them more in the improvement of the quality of the taking care of your patients

Sheet n62 Grid of evaluation of a nutritional centre

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REFERENCES
General NUTRITION GUIDELINES MSF 2007 Draft MSFOCB NUTRITION E-LEARNING MSF 2011 MSFOCB Standard_Nut_Protocol_ITFC_2010_final MSF 2010 MSFOCB_ATFC Protocol V3_Jan 2011 MSF 2011 REFUGEE HEALTH An approach to emergency situations MSF - 1997 LA MALNUTRITION EN SITUATION DE CRISE Manuel de prise en charge thrapeutique et de planification dun programme nutritionnel ACF 2001 Evaluation of the nutritional situation RAPID HEALTH ASSESSMENT OF REFUGEE OR DISPLACED POPULATIONS MSF 1999 EMERGENCY NUTRITION ASSESSMENT Guidelines for field workers SAVE THE CHILDREN 2004 ASSESSMENT AND TREATMENT OF MALNUTRITION IN EMERGENCY SITUATIONS ACF 2002 RAPID NUTRITIONAL AND MORTALITY SURVEYS. STEP BY STEP MSF 2002 revised 2011 Food Logistic GUIDELINE LOGISTIQUE ALIMENTAIRE MSF 2010 GUIDE OF KITS Medical and logistic I. KMED p. 115 to 125 : Kits nutrition MSF 2010 MEDICAL CATALOGUE Volume 1 XI. SFOS Specialized food MSF 2010 Installation of a nutritional centre AIDE A LA MISE EN PLACE DE CENTRES NUTRITIONNELS THERAPEUTIQUES ET SUPPLEMENTAIRES. En situation dUrgence. MSFF Document interne 2001-rvision 2010
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MISE EN PLACE DUN CENTRE NUTRITIONNEL THERAPEUTIQUE EN URGENCE : COMMENT ABORDER LE RECRUTEMENT, LORGANISATION PRATIQUE DU TRAVAIL ET LA FORMATION ? MSFF Draft 2001

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Construction LOGISTIC CATALOGUE V. CBUI Construction VI. CSEM Semi-permanent structures VII. Shelter CSHETENH82- Tent 82 m MSF 2006 TEMPORARY & SEMI-PERMANENT BUILDINGS FOR HEALTH STRUCTURES IN REFUGEES CAMPS MSF 1998 Water, Hygiene, Sanitation PUBLIC HEALTH TECHNICIAN IN PRECARIOUS SITUATION MSF 1994 New version to be published in 2007 !? ESSENTIAL WATER AND SANITATION REQUIREMENTS IN HEALTH STRUCTURES WHS Unit, Medical department, MSFB - 2006 Medical CLINICAL GUIDELINES DIAGNOSIS AND TREATMENT MANUAL MSF 2010

MEDICAL CATALOGUE Volume 1 Drugs and Medical Material MSF 2010

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LIST OF THE TECHNICAL SHEETS ON THE CD

Generalities 1. Theoretical concepts on malnutrition Evaluation of the nutritional situation 2. Rapid MUAC assessment in practice 3. Job descriptions 4. Measurement of the MUAC 5. Bilateral oedema assessment 6. Tally sheet Strategies and specifics approaches 7. Decision-making flow chart for the nutritional interventions 8. Automatic calculation worksheet of the nutritional value of a ration (COMPONUT) 9. targeted Food Distribution 10. Diagram and practical organization of a distribution 11. Malnutrition in infants 12. Malnutrition in teenagers and adults 13. Definitions, advantages and disadvantages of the various types of approach for the nutritional programmes Food 14. Specialized food 15. Dietary protocols TFC 16. Dietary protocols SFC 17. Meals for accompanying care givers 18. Automatic calculation Worksheet for food order (SIMUFOOD) 19. Standard Order Sheet WFP 20. Management and Quality Control of Food 21. How to store Food ? 22. Stock Card Material 23. Kits Nutrition 24. Logistic Material needed to open an ITFC 25. Logistic Material needed to open a ATFC/SFC 26. TFC : Needs in Drugs and Medical Material 27. SFC : Needs in Drugs and Medical Material Human Resources 28. Needs in staff by type of nutritional centre 29. Job Description ITFC 30. Job Description ATFC/SFC 31. Flow chart ITFC 32. Flow chart ATFC/SFC 33. Example of work schedule 34. Job interview 35. Plan of training Logistic and WHS 36. Plan ITFC and ATFC and standards to follow 37. Plan SFC and standards to follow 38. Water, Hygiene and Sanitation in a nutritional centre

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TFC 39. The triage 40. Measurement of the weight 41. Measurement of the height 42. Reference Tables Weight/Height 43. Admission criteria TFC 44. How to do a complete clinical examination in a malnourished child ? 45. Systematic Treatment TFC 46. Oral Re-hydration for severely malnourished children 47. Milk Card 48. Hygiene in the meals preparation and distribution 49. Standard register TFC 50. Individual monitoring card ITFC and ATFC 51. Discharge criteria TFC SFC 53. Admission criteria SFC 54. Standard register SFC 55. Individual monitoring card SFC Dry ration 56. Systematic Treatment SFC 58. Discharge criteria SFC 59. Referral card Evaluation of the nutritional programmes 60. Principal indicators of the nutritional programmes 61. Data collection forms feeding centres
61 a How to fill selective feeding centres data reporting forms 61 b Printable data collection forms 61 c - Therapeutic feeding program - summary sheet 61 d Supplementary feeding program - summary sheet

62. Evaluation scale of a nutritional centre

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