1. MAM Decision-making Tool

2.  Review the MAM decision-making tool  Work through country situation  Provide feedback on  Content  Usability  Layout Meeting Objectives

3. Background  Review of supplementary feeding programs (2007)  WHO consultations MMI (2008) and MMII (2010)  Dietary needs  Programme approaches to manage MAM  NUGAG review on MAM  Limited guidance on programming  Differing approaches  Increase in products available for programming Moderate Acute Malnutrition (MAM) CONFUSION!!!

4.  Burden of MAM  11 million children affected globally  41 million children  3 x risk of death compared to well-nourished  Increased risk of acute malnutrition in emergencies Moderate Acute Malnutrition (MAM)

5.  Formed by the Global Nutrition Cluster  UNHCR  UNICEF  WFP  OFDA  ACF  Save the Children  CDC MAM Taskforce Additional Members WHO ECHO

6.  Guide practitioners to identify most appropriate and feasible strategies to address MAM  Prevention  Management (treatment)  Harmonize nutrition programme decision-making on MAM in emergency situations  Incorporate contextual situational factors into the decision making process  Beyond nutritional status  Engage in discussion Tool Objectives Decision making process grounded by data, but is subjective on some levels

7.  Limited to emergency contexts  Rapid/sudden onset  Slow onset  Protracted emergencies  Acute emergency within a chronic emergency setting  Local or large-scale emergencies  Not for refugee contexts  UNHCR/WFP Guidelines for Selective Feeding: The Management of Malnutrition in Emergencies 2011 http://www.unhcr.org/4b7421fd20.pdf Caveats of Tool

8.  Primary objective: prevent morbidity and mortality associated with MAM  Linkages: MAM cannot be addressed in isolation  SAM  IYCF-E  Other sectors (WASH, health, food security)  Re-assessment Caveats of Tool

9. MAM decision tool steps Step 1: Programme Type/Objective Step 2: Modality Step 3: Programme Operation Step 4: Review and Revise Prevention/treatment Prevention Treatment No additional programme Supplementary feeding Cash/voucher Infant and Young Child Feeding Target group Product Duration Delivery Regularly throughout the emergency

10.  Prevalence of GAM in the affected area (current or historical)  Information nature and severity of the crisis (risk)  Baseline health data in affected areas  Expected impact on morbidity  Food security situation  Expected impact on food security  Population data  Displacement  Density Data Needs

11. MAG scenarios for the tool  High >15%  Medium 8-15%  Low <8% Sources  Trend data  Seasonality  Admission data (coverage should be assessed)  Screening data Nutritional Data

12. Risk of DeteriorationAnalysisScoreSum Score Risk Category Increased morbidity (acute watery diarrhea, measles, acute respiratory infections) High3 Score 6-8: High Score 4-5 :Medium Score <3: Low Medium2 Low1 Food availability and/or access disrupted (markets, prices and/or production) High3 Medium2 Low1 Significant population displacement Yes1 No0 Populati0n densityYes1 No0 Risk of Deterioration

13.  Malnutrition Infection Cycle  Likelihood of morbidity and/or outbreak to impact GAM  Baseline data  Vaccination coverage, vitamin A coverage, disease profile  WASH services  Access to care Morbidity Risk of DeteriorationAnalysisScore Increased morbidity acute watery diarrhea measles acute respiratory infections High3 Epidemic (outbreak) Medium2 Increasing incidence High levels Low1 Stable incidence Low levels

14.  Magnitude, extent, severity and duration of the crisis on food security  Household consumption and market data sources Food Security Risk of DeteriorationAnalysisScore Food availability and/or access disrupted (markets, prices and/or production) High3 Extreme food consumption gaps Livelihood assets being depleted Irreversible coping strategies Medium2 Significant food consumption gaps Irreversible coping strategies Initial depletion of livelihood assets Low1 Food consumption reduced No deficient intakes No negative coping strategies

15.  Influences type and frequency of programme  Many different contexts and types of displacement  Dispersed settlements, mass shelter in collective centers, reception and transit camps, self settled camps, planned camps (official and unofficial), IDPs with host populations Displacement Risk of DeteriorationAnalysisScore Significant population displacement Yes1Displacement increasing and concentrated No0 No displacement No increase in displacement Sparsely populated area

16.  Risk of morbidity  Consider in programme delivery design  Example: low GAM, but high density= large number of children in need  Haiti, post earthquake in Port au Prince  Kenya, post election violence in urban centers Population Density Risk of DeteriorationAnalysisScore Populati0n densityYes1 Urban area Dense population concentration No0All other areas

17. Risk of DeteriorationAnalysisScoreSum Score Risk Category Increased morbidity (acute watery diarrhea, measles, acute respiratory infections) High3 Score 6-8: High Score 4-5 :Medium Score <3: Low Medium2 Low1 Food availability and/or access disrupted (markets, prices and/or production) High3 Medium2 Low1 Significant population displacement Yes1 No0 Populati0n densityYes1 No0 Risk of Deterioration

18. Programme Recommendations

19. MAM decision tool steps Step 1: Programme Type/Objective Step 2: Modality Step 3: Programme Operation Step 4: Review and Revise Prevention/treatment Prevention Treatment No additional programme Supplementary feeding Cash/voucher Infant and Young Child Feeding Target group Product Duration Delivery Regularly throughout the emergency

20. Blanket Supplementary Feeding  Provision of supplementary food  Platform for other interventions  Screenings + referrals  Child survival (deworming, vit A, immunisation)  Health/nutrition education Cash or Voucher  Cash/voucher if food and nutrient availability is good, markets functioning, caring practices maintained  Further research needed  Specialised product + cash  Cash 4X value of specialised product Prevention: Modality IYCF-E support Infant & Young Child Feeding in Emergencies Component

21.  Children under 5 at increased risk mortality  Target children 6-59 months  If logistical constraints consider reducing target group  PLW  No standard criteria for enrollment  Impact on IYCF-E  MAM treatment programming exist  Low birth weight  Prioritise  children over PLW  lactating over pregnant women (protecting 0-6 month old infants) Prevention: Target Group BSFP should not be expanded to beyond 6-59 months and PLW except under serious conditions The general food distribution (GFD) should meet the needs of other household members. Advocacy for improving the GFD or other food security measures.

22. Considerations  Government approval  Objective of the intervention & target group  Some products are targeted for 6-23/36 months  Household’s ability to cook  Are there cooking facilities, easy access to fuel and water?  Cultural practices and food preferences  Corn, wheat & rice based supercereals  RUFs- peanut, chickpea and milk based (limited quantities)  Nutrient gap (energy & micronutrient)  Decide upon higher or lower level energy  HH food security, diet diversity, baseline diets, chronic malnutrition, micronutrient deficiencies  Sharing practices, household use of foods, access to other foods Prevention: Product

23. Product Sheet Nutrition Specialised Products

25. Target groupPrimary RecommendationInterim/Alternative Treatment of MAM 6- 59 monthsRUSF Supercereal Plus Supercereal/oil/sugar premix PLWSupercereal/oil/sugar Older ChildrenSupercereal/oil/sugarRUSF or Supercereal Plus Prevention of MAM 6-23 or 6-59 monthsSupercereal Plus LNS medium quantity RUSF± Supercereal/oil/sugar ½ sachet RUSF PLWSupercereal/oil/sugarLNS medium quantity Recommended Products and Alternatives ± Only where supplement is the primary source of available food

26.  Duration of BSFP based on scale & severity of emergency  GAM + Risk of deterioration  Generally 3-6 months  Example start at least 1 month prior to leans season and run until post-harvest  Regular re-assessment  Scaling up or down  Extension  Rolling admission and no discharge (exiting) until end of programme (even if child is older than upper limit at the close of programme) Prevention: Duration and Exit Strategy

27. Considerations  Access to the population  Security, seasonal, physical  Scale of crisis (total area affected)  Implementation capacity  Low or security- consider combining with GFD  Population density  Determine number of sites  If dense, may need multiple days/week for distribution Prevention: Delivery Mechanism

28. BSFP stand alone programme  Targeted directly to households with children BSFP Integrated delivery  Child’s supplementary food is added to food/cash/voucher distribution  Low security context  Rapid onset immediate programming  Exclusion and inclusion errors  Shift to parallel independent programme as soon as feasible Prevention: Delivery Mechanism

29.  Targeted Supplementary Feeding (TSFP)  Treatment for MAM with nutritious food supplement and routine medical care  Admission/discharge criteria based on anthropometric measures (national or international guidelines)  Nutrition communication  Support for IYCF-E Cash/vouchers need more evidence Treatment

30. Malnourished  children 6-59 months  Discharges from SAM  Pregnant and lactating (up to 6 months postpartum) women  Chronic illness (HIV, TB) Exceptions  Infants <6 months not admitted, support IYCF strengthened  Other vulnerable populations identified (disabled children, 5-10 years olds, older people) Treatment: Target Group

31. Considerations  Government approval  Target group  Household’s ability to cook  Are there cooking facilities, easy access to fuel and water?  Cultural practices and food preferences  Corn, wheat & rice based supercereals  RUFs- peanut, chickpea and milk based (limited quantities) Treatment: Product

32. Product Sheet Nutrition Specialised Products

33. Target groupPrimary RecommendationInterim/Alternative Treatment of MAM 6- 59 monthsRUSF Supercereal Plus Supercereal/oil/sugar premix PLWSupercereal/oil/sugar Older ChildrenSupercereal/oil/sugarRUSF or Supercereal Plus Prevention of MAM 6-23 or 6-59 monthsSupercereal Plus LNS medium quantity RUSF± Supercereal/oil/sugar ½ sachet RUSF PLWSupercereal/oil/sugarLNS medium quantity Recommended Products and Alternatives ± Only where supplement is the primary source of available food

34.  Treatment range 1-4 months  Scale down of TSFP considered when:  GAM <5%  No aggravating factors  Low numbers of admissions in MAM and SAM treatment may also be used to decide to phase out  Be mindful of programme coverage and performance Treatment: Duration and Exit Strategy

35. Considerations  Access to the population  Security, seasonal, physical  Scale of crisis (total area affected)  Implementation capacity  Low or security- consider combining with GFD  Population density  Determine number of sites  If dense, may need multiple days/week for distribution Treatment: Delivery Mechanism

36.  Linked closely to treatment of SAM under CMAM model  TSFP sites adjacent to OTP or health centres support referrals (both directions)  Large area for distribution/services  If mobile or away from health centres provide basic health interventions  Considerations  Health service coverage, existing MAM/SAM programmes, capacity to scale-up Treatment: Delivery Mechanism

37.  Both prevention and treatment may be recommended  Follow the previous steps to design each programme  Think through linkages between programmes  Ideally, children should not be simultaneously enrolled in both programmes  In reality, the risks associated with non-participation outweigh the cost of dual participation  In some large emergencies children should be enrolled in prevention programmes as they may come in and out of treatment  Example: Northern Kenya, 2011/12 Prevention &Treatment

38.  Additional programs not needed  Existing nutritional programs  Re-evaluate risk as emergency progresses  Build into nutrition response plan  Strengthen support for IYCF or micronutrient programmes No Additional Intervention Emergency programming is in addition to existing nutrition programmes

39. MAM decision tool steps Step 1: Programme Type/Objective Step 2: Modality Step 3: Programme Operation Step 4: Review and Revise Prevention/treatment Prevention Treatment No additional programme Supplementary feeding Cash/voucher Infant and Young Child Feeding Target group Product Duration Delivery Regularly throughout the emergency

40. Programme Linkages Interventions in emergencies: Addressing acute malnutrition General Food Distribution Selective feeding programmes Treatment Targeted Inpatient treatment Prevention Blanket feeding Cash/voucher Outpatient treatment Treatment for SAM MAM Programmes IYCF-E Addressing underlying causes of undernutrition Addressing micronutrient deficiencies WASH Health Food security

41.  Josephine Ippe: Global Nutrition Cluster jippe@unicef.org  Lynnda Kiess: World Food Programme lynnda.kiess@wfp.org My contact: Leisel Talley, Centers for Disease Control and Prevention: Ltalley@cdc.gov Additional Feedback