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Humanitarian Charter and Minimum Standards in Humanitarian Response

Management of acute malnutrition and micronutrient deficiencies standard 1: Moderate acute malnutrition

Moderate acute malnutrition is addressed.

Key actions (to be read in conjunction with the guidance notes)

Key indicators (to be read in conjunction with the guidance notes)

These indicators are primarily applicable to the 6–59 month age group, although others may be part of the programme.

Guidance notes

  1. Programme design must be based on an understanding of the complexity and dynamics of the nutrition situation. Supplementary feeding can take a targeted or a blanket approach. The decision regarding which approach to take should depend on levels of acute malnutrition and caseload, risk of an increase in acute malnutrition, the capacity to screen and monitor that caseload using anthropometric criteria, available resources and access to the disaster-affected population. Targeted supplementary feeding generally requires more time and effort to screen and monitor individuals with acute malnutrition but requires fewer food resources, whereas a blanket approach generally requires less staff expertise but more food resources. Effective community mobilisation will support the population’s understanding and effectiveness of the programme. Links to therapeutic care, health systems, HIV and AIDS and tuberculosis (TB) networks and food security programmes including food, cash or voucher transfers are important. The disaster-affected population should be involved in deciding where to locate programme sites. Consideration should be given to vulnerable people who may face difficulties in accessing sites. Exit strategies or plans for longer-term support should be considered from the outset.
  2. Coverage refers to individuals who need treatment against those actually receiving treatment. Coverage can be affected by the acceptability of the programme, location and accessibility of programme sites, security situation, frequency of distributions, waiting time, service quality, extent of mobilisation, extent of home visiting and screening, and admission criteria alignment. Programme sites should be close to the targeted population in order to reduce the risks and costs associated with travelling long distances with young children and the risk of people being displaced to them. Methodologies to measure coverage vary in the level of reliability and type of information generated. The method used must be stated when reporting. Current guidance should be consulted when deciding which method is appropriate in the given context. Coverage assessment should be seen as a management tool so should not be left to the end of an emergency support phase.
  3. Admission criteria: Individuals other than those who meet anthropometric criteria defining acute malnutrition may also benefit from supplementary feeding, e.g. people living with HIV (PLHIV) or TB, discharges from therapeutic care to avoid relapse, individuals with other chronic diseases or persons with disabilities. Monitoring and reporting systems will need to be adjusted if individuals falling outside of anthropometric criteria are included.
  4. Dischargecriteria should be according to national guidelines, or international guidelines where no national guidelines are available, and should be specified when reporting performance indicators (see guidance note 5).
  5. Performance indicators relate to discharged individuals ending treatment. The total number of discharged individuals is made up of all who have recovered, died, defaulted or are non-recovered. Individuals who are referred for complementary services (such as health services) have not ended the treatment and will either continue treatment or return to continue the treatment later. Individuals transferred out to other sites have not ended the treatment and should not be included in performance indicators. Performance-related indicators are as follows:

    Proportion of discharges recovered =

    Number of individuals recovered


    x 100 per cent


    Total number of discharged


    Proportion of discharges died =

    Number of deaths


    x 100 per cent


    Total number of discharged


    Proportion of discharges defaulted =

    Number of defaulters


    x 100 per cent


    Total number of discharged


    Proportion of discharges non-recovered =

    Number of individuals non-recovered


    x 100 per cent


    Total number of discharged


    Individuals admitted after being discharged from therapeutic care should be reported as a separate category in order to avoid biasing results towards better recovery. Children with acute malnutrition secondary to disability, cleft palate or surgical problems, etc., should not be excluded from programme reporting. When reporting, the core group is children aged 6–59 months. In addition to the indicators outlined above when analysing performance, systems should monitor the population’s participation, acceptability of the programme (a good measure of this is the default and coverage rate), the quantity and quality of food being provided, coverage, reasons for transfers to other programmes (particularly children whose nutrition status deteriorates to severe acute malnutrition) and number of individuals admitted and in treatment. External factors should also be considered, such as morbidity patterns, levels of undernutrition in the population, level of food insecurity in households and in the population, complementary interventions available to the population (including general food distributions or equivalent programmes) and the capacity of existing systems for service delivery. Causes of defaulting and failure to adequately respond to treatment should be investigated on an ongoing basis.

  6. Health inputs and considerations: Targeted supplementary feeding programmes are an important contact point for screening and referring for illness. Programmes should take into account the capacity of existing health services and ensure effective provision of antihelminthics, Vitamin A supplementation, iron and folic acid combined with malaria screening and treatment, zinc for treatment of diarrhoea and immunisations (see Essential health services - control of communicable disease standard 2 and Essential health services - child health standard 1 and Child health standard 2).In areas of high HIV prevalence, HIV testing and prophylactic treatment should be available and the quality and quantity of the supplementary food ration should be given special consideration.
  7. Breastfeeding mothers of acutely malnourished infants under 6 months should be admitted to supplementary feeding, independent of maternal nutrition status. Moderately malnourished mothers can successfully breastfeed and need adequate nutrition support to protect their own nutritional status. Mothers should receive supplementary feeding rations, skilled breastfeeding support on exclusive breastfeeding and advice on safe, nutritious and responsive complementary feeding. Infants under 6 months who are acutely malnourished should be referred appropriately for skilled breastfeeding support and inpatient care as necessary.
  8. Rations: Dry rations or ready-to-use foods provided on a weekly or bi-weekly basis are preferred to on-site feeding but their composition and size should take into account household food security and the likelihood of sharing. Clear information should be given on how to prepare and store supplementary food in a hygienic manner, how and when it should be consumed (see Food security–food transfers standard 6, guidance note 1) and the importance of continued breastfeeding for children under 24 months of age. Vulnerable people, such as those with mobility challenges, may require programme adaptations to meet their specific needs.