Nutrition specific interventions to prevent and treat malnutrition in emergencies

Emergency Phase

Acute malnutrition management

Acute malnutrition is a severe health condition characterized by rapid deterioration in nutritional status. Global Acute Malnutrition (GAM) serves as a measure of acute malnutrition, reflecting recent nutritional deterioration in children aged between 6 and 59 months. The UNHCR's objective is to maintain the prevalence of acute malnutrition below 10% among the refugee population. To support this UNHCR and its partners must ensure the availability of appropriate treatment programs for acutely malnourished refugees. This involves supporting refugee access to host community facilities, ensuring their capacity aligns with refugee needs, and establishing new facilities if necessary.

Treatment programs should adhere to the principles of community-based management of acute malnutrition (CMAM) as outlined by the World Health Organization (WHO), UNHCR, and national guidelines. CMAM focuses on identifying malnourished individuals, providing suitable treatment, and ensuring follow-up care. The model comprises various components tailored to the severity of malnutrition.

Key response actions include:

• Systematic screening of individuals for malnutrition using anthropometric measurements Mid Upper Arm Circumference (MUAC, weight-for-height/length), followed by applying validated cut-off points for classification. Priority for treatment is determined based on severity.
• To treat severe acute malnutrition (SAM), inpatient and outpatient services should be made available. This should be in collaboration with UNICEF to ensure the supply of therapeutic products and capacity building support for staff as outlined in the UNHCR/UNICEF global MOU. Wherever feasible, programmes should leverage and strengthen existing health system capacity.
• Cases of SAM with medical complications require stabilization as inpatients, where therapeutic feeding, medical treatment, and monitoring are administered. Transition to outpatient care is initiated once stabilization is achieved.
• Treating SAM that doesn't necessitate inpatient care involves outpatient therapeutic care. Support includes provision of ready-to-use therapeutic food (RUTF), medical care, and consistent follow-up visits for monitoring, nutritional counseling, and caregiver support.
• Treating moderate acute malnutrition (MAM) entails outpatient services in collaboration with WFP, ensuring the provision of supplementary food products as per the UNHCR/WFP global MOU. Supplementary feeding programs provide wet or dry rations or facilitate access to a complementary healthy diet.
• Establishing robust links between the various CMAM program components (community mobilization, communication, active case-finding, referral, follow-up, inpatient management, outpatient treatment, and supplementary feeding) and health and prevention services. Informing the community about malnutrition and involving the population in efforts to enhance nutrition outcomes is crucial.
• Nutrition support for malnutrition management should also systematically include pregnant and breastfeeding mothers and be integrated into care and treatment services for people affected by HIV/AIDs and TB patients. The support should also be sensitive to age, gender, and disability.
• A comprehensive monitoring and evaluation framework to track CMAM performance should be established. This should include coverage, quality, and treatment outcomes. Regular review and analysis of this should inform program adjustment and improvements.

IYCF-E (Infant and Young Child Feeding in Emergencies)

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.

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 should be adopted. Community outreach workers and staff in health and nutrition centres at transit/reception centres, refugee settlements 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.

UNHCR and partners must ensure support services and facilities for infant and young child feeding should always be available to refugees at the various service provision contact points.

Key response actions include:

• Ensure availability of breastfeeding and complementary feeding support infrastructure including the establishment of baby friendly spaces at the various contact points at reception centers, within the health and community structures. These should have the capacity to offer infant and young child appropriate feeding screening, promotion, counselling and psychosocial support where indicated or referral for support. Initial information dissemination to demystify any identified myths and misconceptions around ability of women to breastfeed in emergencies should be also ensured.
• Ensure programs provide clear messages to encourage early initiation of breastfeeding, exclusive breastfeeding for the first 6 months and continuation of breastfeeding for all infants who are breastfed or are mixed fed. Note higher risk infants, children, and mothers that may face increased feeding difficulties in emergencies including (but are not limited to) low birth weight infants, any wasted children, children with disabilities, HIV exposed infants, and orphaned infants and mothers who are malnourished or severely ill. Mother-child pairs facing timely initiation and continuation of breastfeeding difficulties should be identified and provided with appropriate support.
• For infants who are exclusively dependent on formula milk, ensure early identification and support to access code compliant sustainable infant formula supply, and equipment for safe preparation and feeding, in line with country specific standard operating procedures.
• Promote the provision of age- appropriate complementary foods for infants and young children 6-23 months and availability and continuity of a nutritious diet for pregnant and breastfeeding women.
• Despite the ratification of the International Code of Marketing of Breastmilk Substitutes  by many countries, nearly every emergency provides a new example of inappropriate donations of powdered infant formula and other infant foods. These donations have been shown to displace breastfeeding in crises. Ensure prevention and control by assessing whether Breast Milk Substitutes (BMS) donations is an issue and ensuring the communication of code compliance. UNHCR does not call for, support, accept or distribute commercial products targeted to infants or young children, including BMS (infant formula, other milk products, commercial complementary foods) and feeding equipment (such as bottles, teats, and breast pumps).  Required BMS supplies should be purchased by UNHCR or a designated partner and provided as part of a sustained package of coordinated care based on assessed needs. This should be compliant with International Code of Marketing of Breast milk Substitutes as reflected in the Infant and Young child feeding in emergencies operational guidance.
• Using the IYCF multisectoral framework of action all sectors should consider the specific needs of infants, young children, breastfeeding mothers, and carers to enabling easy access to basic services (e.g., shelter, security, food assistance, Water Sanitation and Hygiene promotion (WASH), health) and also to ensure that humanitarian assistance does not undermine safe IYCF pract(ices with inappropriate interventions See video detailing the IYCF linkages with other sectors. https://www.youtube.com/watch?v=biQC7HXMkWA) 
• In collaboration with the other nutrition partners consider issuing a joint statement and SOP to help secure immediate, coordinated, multi-sectoral action on IYCF at the onset of the emergency calling for all involved in the response to the refugee crisis to protect, promote, and support the feeding and care of infants and young children and their mothers as well as pregnant women noting this as critical to support maternal and child health and survival, growth, and development and to prevent malnutrition.

Micronutrient Deficiency Reduction Interventions in Emergencies

Micronutrient deficiencies can easily develop or worsen during an emergency, presenting significant health risks, particularly for vulnerable groups such as children and women. Limited access to diverse food and poor dietary diversity plays a major role in this. Children and mothers deficient in micronutrients face increased susceptibility to infections, illnesses and even mortality. Addressing these deficiencies is crucial for their survival, as well as their overall growth, and development.

Key response actions:

• Assess prevalence and identify high-risk groups: Micronutrient programs must be strategically designed based on a clear understanding of contributing factors and the risks associated with deficiencies. It's essential to identify the main causes of micronutrient deficiencies, such as inadequate access to nutrient-rich foods, inadequate care for women and children, limited healthcare services, and unhealthy environments. This assessment should consider factors like the existing diet compared to recommended nutritional intake, feeding practices, cultural food habits, and access to healthcare services.
• Ensure access to food, nutrition, and health programs: The prevention and management of micronutrient deficiencies during emergencies heavily rely on comprehensive food, nutrition, and health interventions. It's imperative to ensure that the general food ration and/or dietary intake adhere to international nutritional standards for micronutrient adequacy. When these standards are not met, the consideration of micronutrient-fortified supplementary options becomes crucial, especially for children and women with increased nutrient requirements. In instances of identified deficiencies, supplementation (e.g., vitamin A campaigns for children, iron, and folate supplementation for pregnant and breastfeeding women) and appropriate treatment should be provided.
• Reinforce important health and nutrition practices: Apart from dietary interventions, it is equally vital to emphasize the need for appropriate IYCF practices, disease and parasite control, water, sanitation, and hygiene (WASH), and access to healthcare services. These factors play a critical role in preventing and addressing micronutrient deficiencies in emergencies.

Key overall considerations:

• UNHCR must ensure that adequate food/cash for food assistance, programmes to treat acute malnutrition, and infant feeding support are provided either by integration of refugees into the national systems or where this fall short through improvement or establishment of these services. Where indicated establish partnership agreements early so that interventions can be implemented rapidly by ministry of health or NGO partners in collaboration with WFP and UNICEF.
• An experienced nutritionist from UNHCR or a trained UNHCR public health officer with proficient nutrition in emergencies knowledge should lead the nutrition response in cases of severe under-nutrition and/or infant feeding is a general problem.
• UNHCR should also ensure that the nutrition situation is monitored and reported regularly, using the basic integrated refugee health information system (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].