Nutritional emergencies 2015

Nutritional emergencies

Presenter: Dr. Suhasini KanyadiPG Dept. of Community Medicine

J.N.M.C, Belagavi

April 30, 2015

Heading

• Introduction 5min

• Vulnerability and triggers 5min• Types of nutritional emergencies 15min• Management of nutritional emergencies 15min

April 30, 2015 Nutritional emergencies 2

Introduction

• Basic right to adequate food and nutrition – emergency response

• Poor decisions in short-term - long-term negative impacts

• Failure to meet nutritional needs - resist and fight infectious diseases.


Introduction

• Emergency: Any situation where there is an exceptional and widespread threat to life, health and basic subsistence, which is beyond the coping capacity of individuals and the community” (Oxfam Humanitarian Policy, 2003.)


What is Nutritional emergency?


Classification Level Mortality and

malnutrition indicators

UN SCN thresholds 1995

Alert

CMR 1/10,000/dayU5MR 2/10,000/dayWasting 5–8%

Severe

CMR 2/10,000/dayU5MR 4/10,000/dayWasting >10%



FSNAU/FAO integrated food security phase classification (IPC), 2007

Generally food secure CMR < 0.5/10,000 /dayWasting < 3%Stunting < 20%

Moderately/Borderline Food Insecure

CMR < 0.5/10,000/day U5MR <1/10,000/dayWasting > 3% but <10%Stunting 20-40%

Acute food and livelihood crisis

CMR 0.5-1 /10,000/dayU5MR 1-2/10,000/dayWasting* 10-15%

Humanitarian emergency CMR <1-5 / 10,000/dayU5MR >2-10/10,000/dayWasting > 15%

Famine/Humanitarian catastrophe

CMR >2/10,000/day U5MR >10/10000/dayWasting >30%



Benchmarks of mortality indicators

Vulnerability to Nutrition Emergencies

• Existing health and nutrition situation

• HIV and AIDS

• Poverty and urban pressure

• Climate change


Who are vulnerable?

• Physiological vulnerability

• Geographical vulnerability

• Political vulnerability

• Internal displacement and refugee status


Triggers for Nutrition Emergencies

• Natural disasters

• Conflict

• Political crises and economic shocks

• Global food prices fluctuations


Types of major deficiency diseases in emergencies

• Protein energy malnutrition.

-Nutritional marasmus

-Kwashiorkor

-Marasmic kwashiorkor.• Micronutrient & vitamin deficiencies

-Nutritional anemia

-Iodine deficiency

-Vitamin-A deficiency.

-Other vitamin and mineral deficiency


Protein energy malnutrition

• Major health & nutritional problem

• Results from lack of food or infections

• Important cause of childhood mortality & morbidity

• Different forms

• Different theories


Marasmus

• Marasmos - Greek- wasting

• Wasting of muscles & fat –thin “old man “ face & baggy pants

• Low weight for height• Child is alert• Ribs prominent

• No oedema


• Appetite-good & voracious

• No hair changes• Biochemical features:

Hydroxyproline/creatinine ratio - low

Serum albumin - Normal/decreased

plasma/amino acid ratio - Normal

urinary urea/gm creatinine - Normal/decreased


Kwashiorkor

• Described as “sickness of weaning” in Ga language in Ghana.

• Red haired

• Affects 1 – 4 yr children.• Signs- oedema – moon face

-hair changes - flag sign

-skin changes - flaky paint appearance.

-loss of appetite , irritable & miserable

-hepatomegaly• Plasma/amino acid ratio- elevated


Complication of PEM

• Immediate

Hypoglycemia

Hypothermia

Septicemia

Electrolyte imbalance

• Late

Intellectual sub normality

Growth retardation


Cont…

Acute Malnutrition level Nutrition classification

<5% Situation is acceptable

5 - 9% Situation is of concern

10 – 14% Situation is serious

≥ 15% Situation is critical


Classification of public health significance of malnutrition in a population

Nutritional anaemias

• Iron deficiency, Vit-B12 & folic acid deficiency

• Iron deficiency anaemia: Widespread nutritional disorder

• Affects-young children , LBW infants , pregnant women

• Sources-red meat, green vegetables, pulses, & tubers• Enhancers-animal origin foods, vitamin-C, folic acid• Inhibitors –tea & coffee


Iron deficiency anaemia

Classification of public health significance of anaemia in a population:


Category of public health significance Prevalence of anaemia (%)

High >40

Medium 20-39.9

Low 5.0-19.9

Iron deficiency anaemia

• Prevention:

1) Dietary improvement

2) Iron fortified food

3) Breast feeding

4) Supplementation

5) Public health measures – hookworm, malaria

• Treatment: severe anaemia


Age Group Daily Dose Duration of treatment

Iron(mg) Folic acid(micro gram)

Children <2years 25 100 3 months

Children 2-12years 120 400 3 months

Adolescent, adults and pregnant women

600 400 3 months


Treatment of severe anaemia

Iodine deficiency

• Essential micronutrient, helps in synthesis of T4 & T3

• Public health problem - worldwide

• Young children and pregnant women• Preventable- Brain damage• Iodine deficiency disorders• 2 principal indicator

1) Total goiter rate

2) Urinary iodine level


Iodine deficiency

• Classification of public health significance of iodine in a population:


PREVALENCE INDICATORS

Total Goitre Rate (%) Median Urinary Iodine level (microgm/L)

Normal <5.0 >/=100

Mild 5.0-19.9 50-99

Moderate 20.0-29.9 20-49

Severe >/=30 <20

Iodine deficiency

Prevention :• Source : sea foods(100ug/100g)

• Daily requirement :150ug Iodized salt 10g ( iodine conc 20-40mg/kg)

• Alternative : Iodized oil

– Orally 3,6,12 th month (200mg capsule)

– I.M injection every 2 yrs (480mg/ml)


Vitamin deficiencies


Vitamin-A deficiency

• Introduction - reversible, preventable,seen in malnourished

• Sources- animal, plant• Requirement- 600microgm(adults)



Classification Lesions of Xeropthalmia

XN Night blindness

X1A Conjunctival xerosis

X1B Bitot’s spot

X2 Corneal xerosis

X3A Corneal ulceration

X3B Keratomalacia

XS Corneal scar

SF Xeropthalmic fundus


Reversible

Irreversible



Bitot’s spot

Corneal xerosis

Corneal ulcer

Keratomalacia


Preventive measures:

• Measles immunization• High dose vitamin A supplements• Encouraging breast feeding

• Consumption of vitamin A rich foods

• Relief foods fortified with vitamin A

• Environmental sanitation, personal hygiene



Population group Oral vitamin A dose

Infants <6months 50,000 IU once

Infants 6-12months !,00,000 IU, every 4-6months

Children >1year 2,00,000 I, every 4-6months

Pregnant women Not more than 10,000 IU daily

Lactating women 2,00,000 IU once


Prevention schedule in emergencies

Vitamin A Dosage Schedule for treatment of xeropthalmia


Timing Oral vitamin A dosage

Immediately on diagnosis

<6 months 50,000 IU

6-12 months 100000 IU

>1 year 2,00,000 IU

Following day Same age specific dose

At least 2 weeks later Same age specific dose

Vitamin-B1 (Thiamine) deficiency

• Seen when energy expenditure is high

• Oxidative pthway of glicose

• C/F-wet beri beri(acute cardiac)

-dry beri beri( peripheral neuritis)

-infantile beri beri.

• In older infants- CNS signs seen.

• Prevention -1mg thiamine daily

-whole grains, pulses, cereals, nuts & red meat


Vitamin-B1 (Thiamine) deficiency

Treatment –• Infants- 25-50mg/IV, F/by10mgIM 1wk , F/B 3-5mg /day

oral for 6wks• Adults- 50-100mg slow iv


Vitamin B3 deficiency (niacin)

• Tryptophan-precursor

• Not excreted in urine• Deficiency- pellagra• 4D’s• Milk is poor source

• Sources-pulses, nuts, meat, lightly milled cereals,fish, milk & cheese.

• Prevention -15-20 mg/day• Treatment-300mg oral for 3-4 wks.


Vitamin B3 deficiency (niacin)


Vitamin – C deficiency

• Helps in absorption of iron

• Water soluble • Most sensitive to heat• Deficiency: Scurvy• Clinical Feature:

• Requirement :40mg of vitamin C daily

• Treatment:1g Ascorbic acid daily for 2-3 wks


Vitamin C deficiency

PREVENTION-

A) Local production of fruits/ vegetable Easy

Local production of fruits/ vegetable immediately available

1) add some fruits vegetable to the ration.

2) encourage barter or purchase -10% extra ration

Local production of fruits/ vegetable not immediately available

3) Encourage household food production / necessary inputs


B) Local production of fruits/ vegetable not Easy

Provision of commodities fortified with vitamin C:

4) Fortified flour or fortified sugar

5)Fortified cereal/pulse blended foods(120mgvit c per ration)

6)Other Vitamin C rich foods

7)Provision of b Vitamin C supplements

8)Distribution of vitamin C tablet - weekly

Breast milk- good source


Vitamin D deficiency

• Kidney hormone , metabolically inactive• Forms –D2(calciferolD2(calciferol) & D3(cholecalciferol)• Deficiency – rickets , osteomalacia.

• Prevention–exposure to sunlight

(10-15min daily)

-fortification

-periodic dosing

intake-2.5 mcg-adults,

Treatment- Cap 5000 IU oral daily for 4-6 wks,

F/b 1000 IU daily for 6 months


Milk

Dry fig Legumes

Yoghurt

Salmon Broccoli

Almonds Spinach Cheese

Kale


Other communicable diseases

• Measles , meningitis & poliomyelitis• Diarrhoeal diseases• Viral hepatitis• Malaria• Acute respiratory infections• Tuberculosis• Louse-borne typhus• Typhoid fever• Scabies• Worm infections• HIV & AIDS


Management of nutrition in major emergencies



Principles

• Knowledge of nutritional requirement• Essential to identify most vulnerable group• Meeting energy & protein requirements• Meeting micronutrient & other specific nutrient

requirement

• Monitoring the adequacy of food access & intake



Daily energy requirement and safe protein intake for developing countries- FAO/WHO/UNN Expert Consultation 1985

• Energy requirement - 2100 kcal/day• Protein requirement – 46gm/day

assuming BMI- 20-22, light physical activity


Feeding programme

FEEDING PROGRAMME STRATEGY

1. General Feeding programmes Provides a standard general ration Aim- cover food and nutritional needs

2. Selective Feeding Programmes There are two forms of Selective Feeding Programme • Supplementary Feeding Programme • Therapeutic Feeding Programme


Feeding programme

General Food Distribution Selective Feeding Programme

Supplementary Feeding Programme Therapeutic Feeding programme

Targeted Supplementary Feeding Programme

Blanket Supplementary Feeding programme

Feeding programme strategy

April 30, 2015 46

Supplementary Feeding Programmes

• Provide nutritious food in addition to general ration • Aim - rehabilitate malnourished persons or

- prevent a deterioration of at risk group• Short-term measures

• Should not be seen as a means of compensating for an inadequate general food ration


Supplementary Feeding Programme

1. Targeted SFPs: • Aim - prevent moderately malnourished becoming

severely malnourished and to rehabilitate them. • Objectives – reduce prevalence of acute & severe

malnutrition

- reduce excess mortality.

• Features – individual registration ,monitoring of weight, individual medical treatment.

• Target group- mild and moderately malnourished individuals (<5 & >5yrs )and for selected pregnant and nursing mothers and individuals at-risk.



When to Start Targeted Supplementary Feeding Program?

• Malnourished individuals - prevalence of 10-14%

• Large numbers of children predicted to become malnourished - prevalence of 5-9% acute malnutrition in presence of aggravating factors



Blanket SFPs:

• Objectives – prevent increase in PEM & micronutrient deficiency rates.

• Features – no individual monitoring or registration.

- selection of children- < 110 cms in length.

- preventive medication – vitamin A , measles vaccination.



When to Start Blanket Supplementary Feeding Program

• At onset of an emergency

• Problem delivering/distributing general ration.

• Prevalence of acute malnutrition =/>15%.

• Prevalence -10-14% acute malnutrition in presence of aggravating factors.

• Anticipated increase in rates of malnutrition - epidemics.

• In case of micronutrient deficiency outbreak



Supplementary food can be distributed in two ways

1) On-site feeding or wet ration: minimum of two or three meals should be provided per day.

2) Take-home or dry ration: The regular (weekly or bi-weekly) distribution of food in dry form to be prepared at home


Therapeutic Feeding Programmes

Objective:

• Provide treatment - severely malnourished individuals .• Reduce the risk of excess mortality and morbidity

It consists of intensive medical and nutritional treatment



Criteria for Admission in Therapeutic Feeding Program

• Children younger than 5 years - severely malnourished and/or children with edema.

• Severely malnourished children older than 5 years, adolescents and adults

• Low birth weight (LBW) babies

• Orphans younger than one year

• Mothers of children younger than one year with breastfeeding failure



Criteria for Discharge from Therapeutic Feeding Program:

The common procedure is to refer a child to a targeted SFP when he/she:

• Maintains a weight-for-height >= 75% of the reference media or “>= -2.5 Z-score” for two consecutive weeks.

• Shows a good appetite and is free of illness.



Nutritional Rehabilitation

Phase 1: Acute phase (intensive care)

-In 24-hour inpatient intensive care- treatment to control infection and dehydration

- Electrolyte balance is restored and nutritional treatment is initiated.

-Very frequent feeds with therapeutic milk (10-12 per day)

- Phase should not be extended beyond one week


Phase 2: Rehabilitation phase

-Providing at least 6 meals per day in order to regain most of the weight loss.

-Psychological and medical care is vital

- Phase not expected to last more than five weeks


Programme indicators

• Vulnerability indicators

Structural risk

Process• Outcome indicators

Prevalence of PEM

Prevalence of micronutrient deficiencies

Mortality

Morbidity/epidemics


Indicators of effectiveness of nutritional relief

General feeding programme:

• Coverage• Adequacy of ration : Exit survey

Household survey• Impact


Selective feeding programme:

• Registration• Attendance• Impact: Household level

Rehabilitation centres

• Biochemical assessment of micronutrients



References

• Park’s textbook of Preventive And Social Medicine 23rd edition• O.P Ghai Text book of Pediatrics- 5th edition• The management of nutrition in major emergencies – WHO• Text book of Preventive & Social Medicine- MC Gupta, BK Mahajan• Modern nutrition in health & disease 9th edition• Som Nath Singh.Nutrition in emergencies: Issues involved in

ensuring proper nutrition in post-chemical, biological, radiological, and nuclear disaster. J Pharm Bioallied Sci. 2010 Jul-Sep; 2(3): 248–252

• Food security and nutrition in emergency – John Hopkins and International Federation of Red Cross

• A Toolkit for Addressing Nutrition in Emergency Situations, IASC June 2008.


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