Nutrition in camps

Protection objectives

• To ensure that refugees in refugee camps have access at all times to safe and nutritious food, sufficient to maintain a healthy and active life.
• To respect the right to food and the right to health.
• To ensure that refugees in camps receive appropriate treatment for moderate acute malnutrition (MAM) and severe acute malnutrition (SAM).
• To ensure adequate protection, promotion and support for breastfeeding of infants and young children are available, that infants and young children have access to adequate complementary feeding and that infants younger than 6 months who are not breastfed have access to alternative food that is appropriate and adequate.

Underlying principles and standards

Sphere, Food security and nutrition assessments standard 1.2: Nutrition assessment. Nutrition assessments use accepted methods to identify the type, degree and extent of undernutrition, those most at risk and the appropriate response.

Sphere, Management of malnutrition standard 2.1: Moderate acute malnutrition. Moderate acute malnutrition is prevented and managed.

Sphere, Management of malnutrition standard 2.2: Severe acute malnutrition. Severe acute malnutrition is treated.

Sphere, Micronutrient deficiencies standard 3: Micronutrient deficiencies. Micronutrient deficiencies are corrected.

Sphere, Infant and young child feeding standard 4.1: Policy guidance and coordination. Policy guidance and coordination ensure safe, timely and appropriate infant and young child feeding.

Sphere, Infant and young child feeding standard 4.2: Basic and skilled support. Multi-sectoral support to infant and young child feeding in emergencies. Mothers and caregivers of infants and young children have access to timely and appropriate feeding support that minimises risks, is culturally sensitive and optimises nutrition, health and survival outcomes.

UNHCR, Global Strategy for Public Health 2014-2018: Food security and nutrition objective 1. Addresses the prevention of undernutrition and micronutrient deficiencies through the provision of access to food, cash and/or vouchers to the general population, and special nutritional products for vulnerable groups, as well as promotion of and support to adequate infant and young child feeding and care practices.

UNHCR, Global Strategy for Public Health 2014-2018: Food security and nutrition objective 2. Sets standards for treating acute malnutrition that ensure quality treatment and adequate coverage.

UNHCR, Global Strategy for Public Health 2014-2018: Food security and nutrition objective 4. Guides an effective food security and nutrition response in emergencies.

UNHCR and Save the Children, Infant and Young Child Feeding in Refugee Situations: A Multi-Sectoral Framework for Action. 2018. Provides guidance on how to consider the particular vulnerabilities of children under 2 and pregnant and nursing mothers in a multitude of sectors.

Protection Risks

In emergency refugee response operations, protection, food security and nutrition are closely linked.

• If refugees cannot obtain food in camps, they are likely to become food insecure and malnourished and may adopt unsafe coping mechanisms that endanger their security.
• If refugees in camps are not screened (where applicable), for acute malnutrition, or malnutrition programmes are not available, individuals with acute malnutrition will not be identified or treated, making it more likely that they will die or that their nutritional status will deteriorate.
• If infants and mothers who have difficulty breastfeeding are not assisted, those infants are at greater risk of serious malnutrition and death.
• If infants younger than 6 months, who are not breastfed are not identified and supported, such infants face a higher risk of serious malnutrition and death, as a result of eating inappropriate or contaminated food.
• If programmes do not promote and support good feeding and caring practices for infants and children younger than 24 months, infants and young children are at greater risk to be malnourished and to die.

Other risks

Failure to provide adequate food or nutritional rehabilitation may generate indirect or longer term risks.

• The security of camps may be compromised, by riots, demonstrations, or violent behaviour.
• Refugees may take risks to acquire food, or adopt unsafe coping strategies. These may adversely affect feeding and care (including breastfeeding) of infants and young children.
• Malnourished individuals may suffer long-term effects, such as impeded growth or development.

Key decision points

Wherever required, UNHCR and WFP should provide appropriate food assistance, including fortified foods, to refugees in camps.

UNHCR and partners must ensure that appropriate treatment programmes for acutely malnourished camp-based refugees are available, by establishing new facilities or making facilities in the host community accessible to them.

Public health and nutrition services and infrastructures in camps should also be accessible to the host community to ensure peaceful coexistence and inclusion in services.

Support services and facilities for infant and young child feeding should always be available to refugees living in refugee camps (facilities based in the camp or by making facilities in the host community available to them). Skilled support and counselling should be on hand, as well as safe, baby-friendly spaces in which mothers can feed and interact comfortably with their infants.

UNHCR and partners must ensure that services and support are available for individuals who require help to breastfeed and infants younger than six months who need alternatives to breastmilk.

Public health and nutrition interventions must always be:

• Evidence-based. Activities should be planned and implemented, based on the findings of the initial assessment.
• Needs-based. Interventions should be scaled and resources should be allocated to meet the needs of the population.
• Technically sound. Services should be based on current scientific evidence and operational guidance, and implemented by skilled staff.
• Impact oriented. UNHCR promotes the primary health care approach, which ensures that essential health services address the health and nutrition needs of the entire population.
• Priority-based. Emergency nutrition interventions and services should be prioritised to achieve maximum impact across the population. Interventions to address immediate health risks, such as disease outbreaks and malnutrition, must be priorities.
• Integrated. Avoid setting up costly parallel services. Assist the national health system to extend its services to refugees.

Key steps

1. Establish strong co-ordination with all relevant partners of public health and nutrition programmes in camps to ensure they cover all needs and that referrals across services as well as individual follow-up are assured.
2. Ensure refugees have access to information and know where services are available and are able to voice their opinions.
3. Make sure that all refugees in a camp have adequate access to food. To prevent their nutritional status from deteriorating, help them become self-sufficient or provide food assistance.
4. As refugees are arriving in camps, ensure that initial rapid nutrition (MUAC) screenings are conducted, where applicable, in order to determine the extent of the malnutrition situation.
5. Conduct regular nutrition surveys, following UNHCR's most up to date Standardised Expanded Nutrition Survey (SENS) guidelines, to monitor the nutrition situation in camps. During an emergency, nutrition surveys should be conducted bi-annually or annually, depending on the level of malnutrition, the risk of deterioration, and available resources.
6. Continue to screen for acute malnutrition in the community, both to monitor levels of nutrition and identify individuals who need treatment. Community outreach workers should integrate screening in their regular routines.
7. All refugees residing in camps should be able to access programmes for treating moderate and severe acute malnutrition, and individuals who are undernourished should be referred to them.
8. Treatment programmes should follow the principles of community-based management of acute malnutrition (CMAM), according to national treatment guidelines or WHO/UNICEF protocols. Strong links should be established between the different components of CMAM programmes, as well as with health and prevention services.
9. To treat severe acute malnutrition (SAM), inpatient and outpatient services should be made available, wherever possible in collaboration with UNICEF, to secure the supply of products and training. Wherever possible, programmes should support and build on existing health system capacity.
10. To treat moderate acute malnutrition (MAM), outpatient services should be provided; WFP normally provides the food products required. Supplementary feeding programmes may provide wet or dry rations. To tackle malnutrition effectively and identify individuals who are malnourished, it is crucial to inform the community about malnutrition and engage the population in efforts to improve nutrition.
11. During emergencies, infant and young child feeding in Emergencies (IYCF-E) programmes help to save the lives of numerous vulnerable infants and young children, and play a key role in preventing malnutrition and micronutrient deficiencies, even when acute malnutrition is not a general concern. Camp managers should adopt a comprehensive approach to IYCF assistance that protects, promotes and supports exclusive breastfeeding for infants younger than 6 months, and combines appropriate complementary feeding for older infants and children with continued breastfeeding. Community outreach workers and staff in health and nutrition centres should respond quickly to reports that infants younger than 6 months are having difficulty breastfeeding or eating substitute foods. Infants of the same age who are not breastfeeding should be identified and urgently referred to skilled personnel for assessment and action. Set up information and demonstration programmes on child nutrition, and establish baby friendly spaces and community-based support networks in camps.
12. Where the diet of pregnant and lactating women (PLW) lacks nutrients, it may lead to pregnancy complications, maternal mortality, low birth weight infants and lower concentrations of certain nutrients in the breastmilk. PLW should receive complementary food and micronutrient supplements in line with international recommendations. Mothers should be encouraged to exclusively breastfeed their new-born infants, and skilled breastfeeding counselling should be integrated in PLW programmes.
13. Micronutrient deficiencies are mainly prevented through food security programmes. Where a population receives food assistance, a suitable micronutrient-fortified food should be included in the general ration; blanket provision of complementary food for children or other vulnerable groups may be needed. It is also vital to control diseases, notably respiratory infections, measles and parasitic infections like malaria and diarrhoea that deplete micronutrient stores. The provision of water and appropriate sanitation and shelter facilities is essential.
14. Refugees with specific needs who require assistance to access or use nutrition services should be supported and prioritised.
15. Apply an age-gender-diversity perspective and use community based approaches in assessments, response analysis and programme implementation.

Key management considerations

UNHCR must ensure that adequate food assistance, programmes to treat acute malnutrition, and infant feeding support are provided to refugees residing in camps. These services are normally provided by NGO partners in collaboration with WFP and UNICEF and the Ministry of Health.

UNHCR should also ensure that the nutrition situation in camps is monitored and reported regularly, using the Basic Indicator Reporting format and other reporting forms in iRHiS, so that partners can respond quickly if the situation changes. The iRHiS team is available to provide remote and direct support. Contact [email protected].

Infant feeding programmes in camps must respect UNHCR´s standard operating procedure on breastmilk substitutes (BMS). UNHCR actively discourages inappropriate distribution and use of BMS, which are not to be included in general or untargeted distributions, and are only provided to specific infants after a professional assessment. UNHCR does not accept unsolicited donations of BMS. Inappropriate handling of milk products can negatively affect feeding practices and increase infant morbidity and mortality.

Resources and partnerships

Staff

• A trained UNHCR public health officer, with knowledge of nutrition, to coordinate the response.
• An experienced nutritionist from UNHCR to lead the nutrition response in cases of severe under-nutrition, ensuring that refugees are integrated in available national services, or that services are created or improved; an experienced nutritionist from UNHCR or a partner organisation where nutrition features heavily yet is not so severe and where under-nutrition and infant feeding problems are a more minor feature of the response, the UNHCR public health officer will support the partners.
• Community outreach workers provide support in the camp (or surrounding community), and nutrition/health assistants at the nutrition centres, either from UNHCR or a partner organisation.

Partners

• Nutrition partners to implement or support nutrition surveys, screenings, and nutrition programmes may include relevant the ministry of health, NGOs (international or national) and UN agencies such as WFP and UNICEF.
• Establish partnership agreements at field level early on so that interventions can be implemented rapidly.