1. Therapeutic Feeding Programs.

2. Therapeutic Feeding Programs Type of program:Therapeutic feeding program (TFP) Objectives:To provide medical and nutritional treatment for the severely malnourished. To reduce and prevent excess mortality. Target group:Severely malnourished children 6-59 months of age, with <-3 Z scores (<70% reference median) WFH and/or edema Other severely malnourished individuals based on WFH, MUAC, BMI and/or edema, illness or lack of appetite When to start:When existing health/nutritional services are inadequate to handle the number of severely malnourished individuals, and when resources are available

3. Therapeutic Feeding Programs: Entry and Discharge Criteria Entry: <-3 Z scores (<70% reference median) WFH and/or edema Other anthropometric or clinical signs or lack of appetite Discharge: Discharge: >=-2.5 Z scores or >=75% reference median WFH for 2 successive weeks Good appetite Free of illness Dealt with causes at household level to prevent relapse

4. Therapeutic Feeding Programs Severe PEM is a medical emergency! Major causes of death: starvation, hypoglycemia, hypothermia. In cases of kwashiorkor: other medical complications including congestive cardiac failure Phase 1: Intensive Care Phase (24 hr care – 1 week) Objectives: control infection, rehydrate, treat malaria, intestinal parasites, septic shock, dermatitis of kwashiorkor, measles immunization and Vit A Feeding: 10-12 feeds/day with therapeutic milk (F75, F100) Aiming for 80-100 kcals/kg body weight/day, micronutrients Continued breastfeeding for infants whenever possible Phase 2: Rehabilitation Phase (daily care – 5 weeks) Objectives: Weight gain, train caretaker Feeding: 6 meals/day with mixture of therapeutic milk and cereal- based porridge based on fortified blended foods, transition to a local diet. Feed as much as the child will eat – aiming for at least 150 kcals/kg body weight/day

5. Therapeutic Feeding Programs: Program Monitoring AcceptableAlarming Recovery rate - % enrollees who are no longer registered because of recovery >70%<50% Death rate - % enrollees who are no longer registered because of death <10%>15% Default rate - % enrollees who stop attending program for 48 hours <15%>25% Weight gain (g/kg/day)>=8<=8 Coverage>50-70%<40% Mean length of stay<3-4 weeks >6 weeks

6. Therapeutic Feeding Programs: Phasing Out TFP should be phased out as soon as existing health facilities are adequate to care for severely malnourished individuals with appropriate services, follow-up and sensitization are implemented in cases of malnutrition, and no large-scale nutritional deterioration is expected.

7. Key references WHO. The Management of Nutrition in Major Emergencies (2000). Mason, J. Lessons on the Nutrition of Displaced People. J Nutr. 132: 2096S-2103S, 2002 ACC/SCN. Fourth Report on the World Nutrition Situation (2000). WHO. Field Guide on Rapid Nutritional Assessment in Emergencies (1995). ACC/SCN. Assessment of Nutritional Status in Emergency-Affected Populations: Adolescents (2000). ACC/SCN. Assessment of Nutritional Status in Emergency-Affected Populations: Adults (2000). Emergency Nutrition Network. Infant Feeding in Emergencies: Policy, Strategy and Practice (1999). WHO. Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers (1999). MSF. Refugee Health (1997). ACC/SCN. Report on the Nutrition Situation of Refugees and Displaced Populations (2001).