1. TOM BROWN: A community based approach for the management of moderate acute malnutrition

2. Overview
CRS, prior to its Tom Brown program concentrated on active case finding through community MUAC screenings and referral mostly to out-patients therapeutic program (OTP) and SC.
CRS also at the initial stage referred MAM cases to WFP’ s SFP program in two locations (Gubio and Magumeri LGAs).
CRS thought to apply and try out the one of its developmental projects’ (Feed the Future) nutrition interventions where this nutritious home meal ‘Tom Brown’ was packaged in powder form and distributed to MAM kids identified to prevent deterioration to SAM.
Considering the emergency context where MAM kids easily deteriorate into SAM, and considering available fund, CRS agreed to target only children diagnosed with MAM with the objective to prevent more children from falling into SAM. Screenings and follow ups are carried out by trained nutrition community volunteers.
CRS’s Tom Brown programing is firstly implemented in locations where CRS’s food security program exists, so covers children of food benefitting households who have been diagnosed with MAM.
 On the field level, CRS coordinates with nutrition actors who provide OTP and In-patient (SC) services by strengthening referral pathways.

3. Tom Brown
Tom Brown’ is a nutrient rich supplemental food for children with Moderate Acute Malnutrition (MAM) for children between 6 and 59 months of age. There is a significant amount of fiber that makes one feel fuller as well as plenty of protein, iron, magnesium, potassium, carbohydrate, vitamin B6 and Vitamin B12 and lot more. A dry powder is created from millet, sorghum, soya beans, ground nuts (peanuts), sugar, and cloves which families can store until combining with hot water to make a porridge. After preparation, milk, sugar and fruit can be added to enrich the meal and sweeten to personal preference.

4. Sugar to taste and cloves to serve as a preservative
Recipe
6 measures of millet, sorghum and/or maize seeds (3 measures of millet, 3 measures of Sorghum)
 3 measures of soya beans
 1 measure of ground nuts
 Sugar to taste and cloves to serve as a preservative 
Soya Beans
Groundnut/Peanut
Millet
Sorghum

5. Preparation: Day 1
Soak the soya beans in clean water for hours: This soaking allows for it
easier to remove the husk from soya bean and reduces the high toxin levels.
Soak the millet, sorghum and/or maize in water for 2 hours: This allows the grains
to be free of debris and softer for milling later the next day. if using maize, it also
would need to be de husked so soaking is a critical step if the caregiver is using maize

6. Preparation: Day 2 Remove the water
Caregivers removing the husks from Soya beans
Remove the water
Wash all the items with clean water
Remove the husks. This is one of the more time
intensive components and requires many caregivers
to support to make the process move quicker.
Place the items in the shade for drying. The items
should remain in the shade for drying until they are
completely dry. They should not be placed in the sun

7. Preparation: Day 3
Washed grains placed in the shade to dry
Roast the dry soya beans and ground nuts until gold brown:
The origin of Tom Brown’s name is believed that the frequent
description during preparation is to “turn brown”
Lightly roast the sorghum and millet
Mix all the ingredients together
Ground ingredients together into a powder
Portion and package the mixed powder into air tight
containers: (1.5kg) for the child’s portion for the week

8. Tom Brown Powder

9. Cooked Tom Brown cooling, image captured during training of Lead Mothers to highlight the consistency and color of the porridge to be prepared at home. This is not an individual portion for a household.  

10. Nutritional Value of Tom Brown

11. Nutritional Value of Tom Brown Cont.

12. Nutritional Value of Tom Brown Cont.

13. Daily Ration’s Analysis
The ration of approximately 1.5kg per week / 214g per child per day is intended to be provided in multiple servings based on child age and appetite requirements and is presented to families as something to be fed to their children above and beyond their normal daily diet (including continued breastfeeding).
The 214g daily ration provides 869Kcal, 43g of protein, 28g of fat, 15.8mg of Iron. 
Ration size took into account PD/Hearth guidance that menus intended to rehabilitate malnourished children in the community should generally include Kcal and 25-27g of protein, but were increased slightly from these guidelines, recognizing:
take home rations were more likely to be shared than wet rations used in PD/Hearth
that the ration may displace some other meals despite guidance to use Tom Brown as extra food for the child
that protein sources are particularly in the diets of young children in the target area.  A typical child of about 7Kg would require 1,050Kcal to 1,540Kcal per day to meet WHO’s recommendation of Kcal per KG body weight per day during the recuperation period.  The Tom Brown ration provides 56-83% of this need.

14. Implementation: Community Engagement
Tom Brown is prepared by caregivers on a weekly basis through the support of the Lead Mother and Community Mobilizers. This is done in the Lead Mother’s house, which prior to her selection as a Lead Mother has been assessed for this purpose for cleanliness and the practice of good hygiene. It is also important that there is a shaded area available for the drying of the raw foods and for the caregivers to prepare foods out of the sun. The process of production takes three days and occurs on a weekly basis for all eight weeks.

15. Benefits of Tom Brown Programing
Sustainability
Increased knowledge on IYCF and hygiene and food diversity/ positive behavioral change
Strengthens the local markets
Approach to engaging the caregivers in preparing and packaging for distribution is also an opportunity to reinforce learning on how to feed and care with appropriate hygiene practices
A source of income generation for women

16. Limitation Mitigation
Does not target all children under 5 years of age
Time consuming
Security challenge
Mitigation
Encourage beneficiaries to teach friends and relatives
Double grain ration distributions

17. Hygiene Provide handwashing soap for each lead mother
All caregivers wash their hands upon arrival and repeat before they touch any food grain
Train lead mothers and caregivers on standard handwashing
Sensitize lead mothers and caregivers on the importance of good hygiene practices
Train lead mothers on IYCF and hygiene

18. MAM Recovery Rates
In 2018, one of the pilot programs in Kaga LGA, provided a 65% of MAM cases recovered with four weeks of community-based supplementary feeding. A different pilot program in Magumeri and Gubio yielded a 77% recovery rate in four weeks
In the third and most recent pilot program, held in Gubio LGA for 223 children with MAM, 87% recovered.
In the first phase of FFP Tom Brown programing, CRS further increased duration from 6 weeks to 8 weeks to reduce rate of relapse. CRS enrolled 982 in 5 locations. 85% recovery rate was achieved (this phase recorded measles outbreak)
FFP Phase II, 91% of 1652 children ere enrolled for 8 weeks in 6 locations

19. Table1: Middle Upper Arm Circumference (MUAC) Readings During Tom Brown Programming in Gubio LGA (2019 pilot program). These MUAC readings are from the initial registration to program closure

20. Table2: Middle Upper Arm Circumference (MUAC) Readings During Tom Brown Programming; FFP V Phase 1 (2019)

21. Table3: Middle Upper Arm Circumference (MUAC) Readings During Tom Brown Programming; FFP V Phase II (2019)

25. THANK YOU