MAM Decision-making Tool
Meeting Objectives
 Review the MAM decision-making tool
 Work through country situation
 Provide feedback on
 Content
 Usability
 Layout
Moderate Acute Malnutrition (MAM)
Background
 Review of supplementary feeding programs (2007)
 WHO consultations MMI (2008) and MMII (2010)
 Dietary needs
 Programme approaches to manage MAM
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NUGAG review on MAM
Limited guidance on programming
Differing approaches
Increase in products available for programming
CONFUSION!!!
Moderate Acute Malnutrition (MAM)
 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
MAM Taskforce
 Formed by the Global Nutrition Cluster
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UNHCR
UNICEF
WFP
OFDA
ACF
Save the Children
CDC
Additional Members
WHO
ECHO
Tool Objectives
 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
Decision making process grounded by data, but is subjective on some levels
Caveats of Tool
 Limited to emergency contexts
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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
 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
MAM decision tool steps
Step 1:
Programme Type/Objective
Step 2:
Modality
Prevention/treatment
Prevention
Treatment
No additional programme
Supplementary feeding
Cash/voucher
Infant and Young Child Feeding
Step 3:
Programme Operation
Target group
Product
Duration
Delivery
Step 4:
Review and Revise
Regularly throughout the
emergency
Data Needs
 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
Nutritional Data
MAG scenarios for the tool
 High >15%
 Medium 8-15%
 Low <8%
Sources
 Trend data
 Seasonality
 Admission data (coverage should be assessed)
 Screening data
Risk of Deterioration
Risk of Deterioration
Analysis
Score
Increased morbidity (acute watery
diarrhea, measles, acute
respiratory infections)
High
3
Medium
2
Low
1
Food availability and/or access
disrupted (markets, prices and/or
production)
High
3
Medium
2
Low
1
Significant population
displacement
Yes
1
No
0
Populati0n density
Yes
1
No
0
Sum
Score
Risk Category
Score 6-8: High
Score 4-5 :Medium
Score <3: Low
Morbidity
 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
Risk of Deterioration
Analysis Score
Increased morbidity
• acute watery
diarrhea
• measles
• acute respiratory
infections
High
3
• Epidemic (outbreak)
Medium 2
• Increasing incidence
• High levels
Low
• Stable incidence
• Low levels
1
Food Security
 Magnitude, extent, severity and duration of the crisis on food security
 Household consumption and market data sources
Risk of Deterioration
Analysis Score
Food availability and/or
access disrupted (markets,
prices and/or production)
High
3
• Extreme food consumption gaps
• Livelihood assets being depleted
• Irreversible coping strategies
Medium 2
• Significant food consumption gaps
• Irreversible coping strategies
• Initial depletion of livelihood assets
Low
• Food consumption reduced
• No deficient intakes
• No negative coping strategies
1
Displacement
 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
Risk of Deterioration
Analysis
Score
Significant population
displacement
Yes
1
Displacement increasing and
concentrated
No
0
• No displacement
• No increase in displacement
• Sparsely populated area
Population Density
 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
Risk of Deterioration
Analysis
Score
Populati0n density
Yes
1
• Urban area
• Dense population concentration
No
0
All other areas
Risk of Deterioration
Risk of Deterioration
Analysis
Score
Increased morbidity (acute watery
diarrhea, measles, acute
respiratory infections)
High
3
Medium
2
Low
1
Food availability and/or access
disrupted (markets, prices and/or
production)
High
3
Medium
2
Low
1
Significant population
displacement
Yes
1
No
0
Populati0n density
Yes
1
No
0
Sum
Score
Risk Category
Score 6-8: High
Score 4-5 :Medium
Score <3: Low
Programme Recommendations
MAM decision tool steps
Step 1:
Programme Type/Objective
Step 2:
Modality
Prevention/treatment
Prevention
Treatment
No additional programme
Supplementary feeding
Cash/voucher
Infant and Young Child Feeding
Step 3:
Programme Operation
Target group
Product
Duration
Delivery
Step 4:
Review and Revise
Regularly throughout the
emergency
Prevention: Modality
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
Infant &
Young Child
IYCF-E
support
Feeding
in
Emergencies
Component
 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: Target Group
 Children under 5 at increased risk mortality
 Target children 6-59 months
 If logistical constraints consider reducing target group
 PLW
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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)
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.
Prevention: Product
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
Product Sheet
Nutrition Specialised Products
Product Sheet
Nutrition Specialised Products
Recommended Products and
Alternatives
Target group
Primary Recommendation
Interim/Alternative
6- 59 months
RUSF
Supercereal Plus
Supercereal/oil/sugar
premix
PLW
Supercereal/oil/sugar
Older Children
Supercereal/oil/sugar
RUSF or Supercereal Plus
6-23 or 6-59 months
Supercereal Plus
LNS medium quantity
RUSF±
Supercereal/oil/sugar
½ sachet RUSF
PLW
Supercereal/oil/sugar
LNS medium quantity
Treatment of MAM
Prevention of MAM
± Only where supplement is the primary source of available food
Prevention:
Duration and Exit Strategy
 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: Delivery Mechanism
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
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
Treatment
 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: Target Group
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: Product
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)
Product Sheet
Nutrition Specialised Products
Recommended Products and
Alternatives
Target group
Primary Recommendation
Interim/Alternative
6- 59 months
RUSF
Supercereal Plus
Supercereal/oil/sugar
premix
PLW
Supercereal/oil/sugar
Older Children
Supercereal/oil/sugar
RUSF or Supercereal Plus
6-23 or 6-59 months
Supercereal Plus
LNS medium quantity
RUSF±
Supercereal/oil/sugar
½ sachet RUSF
PLW
Supercereal/oil/sugar
LNS medium quantity
Treatment of MAM
Prevention of MAM
± Only where supplement is the primary source of available food
Treatment:
Duration and Exit Strategy
 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: Delivery Mechanism
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
 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
Prevention &Treatment
 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
No Additional Intervention
 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
Emergency programming is in addition to existing nutrition programmes
MAM decision tool steps
Step 1:
Programme Type/Objective
Step 2:
Modality
Prevention/treatment
Prevention
Treatment
No additional programme
Supplementary feeding
Cash/voucher
Infant and Young Child Feeding
Step 3:
Programme Operation
Target group
Product
Duration
Delivery
Step 4:
Review and Revise
Regularly throughout the
emergency
Programme Linkages
Interventions in emergencies:
Addressing acute malnutrition
Selective feeding
programmes
General Food
Distribution
IYCF-E
Addressing
underlying causes
of undernutrition
WASH
Health
Food
security
Addressing
micronutrient
deficiencies
MAM
Programmes
Prevention
Blanket feeding
Cash/voucher
Treatment
Targeted
Treatment for SAM
Outpatient
treatment
Inpatient
treatment
Additional Feedback
 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