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Community-based management of severe and
moderate acute malnutrition during emergencies in
Sri Lanka: Challenges of implementation
Renuka Jayatissa, Aberra Bekele, A. Kethiswaran, and A. H. De Silva
Abstract at 34%, which is higher than the national prevalence
of 25%, in spite of supplementation with 200% of the
Background. With the documentation of high rates of Recommended Nutrient Intake of iron and vitamin A.
acute malnutrition in children under 5 years of age, the Conclusions. Proper targeting of feeding programs
Ministry of Health of Sri Lanka established a Nutrition with good coverage can reduce the rates of acute malnu-
Rehabilitation Program in Jaffna District of the Northern trition in emergencies. It is important also to consider
Province. the control of anemia in emergencies.
Objective. To assess the impact of community-based
management of acute malnutrition among children
under 5 years of age and its operational challenges. Key words: Integration, MAM, SAM, supplementary
Methods. The Nutrition Rehabilitation Program food, therapeutic food
was introduced and implemented in phases covering
the entire district and was integrated into the routine
healthcare system from the beginning. Children were Background
categorized into severe acute malnutrition (SAM) and
moderate acute malnutrition (MAM) groups according Despite substantial achievements that the country has
to World Health Organization weight-for-height growth made in reducing maternal and child mortality, under-
standards. Children with SAM were given ready-to-use- nutrition remains a significant public health problem
therapeutic food (RUTF), and children with MAM were among Sri Lankan children.
given 100 g (450 kcal) of high-energy biscuits (HEBs) With the hostilities that raged on between the
provided by UNICEF. All children received daily supple- Government of Sri Lanka and the Liberation Tigers
mentary food consisting of locally produced Thriposha of Tamil Eelam, many people were left homeless and
or 50 g of corn–soya blend provided by the World Food displaced in the Northern and Eastern provinces of
Programme that provides approximately 200 kcal in Sri Lanka. But after the implementation of the peace
addition to the general food ration. The children were treaty in 2001, many displaced people returned to
followed up according to the guidelines stipulated in the their homes. Ironically, just as the smoke of war began
Nutrition Rehabilitation Program manual. to settle, uncertain times began yet again, after a short
Results. An endline representative survey conducted 2 period of peace. The re-emergence of conflict led
years after implementation of the Nutrition Rehabilita- to displacement of populations and establishment
tion Program revealed that the prevalence of global acute of camps for displaced people in schools, churches,
malnutrition (GAM) among children under five dropped temples, etc. Many families were repeatedly displaced
from 18% to 9.6%, a reduction of 47%, while the preva- during the past 5 years, before the peace process, and
lence of SAM dropped from 3.5% to 0.7%, a reduction even the 2004 tsunami did not spare them.
of 80%. However, the prevalence of anemia remained Jaffna District in the extreme north of the country
was one of those districts affected by the conflict and
Renuka Jayatissa and A. H. De Silva are affiliated with the population displacement. Approximately 599,000
Ministry of Health, Colombo, Sri Lanka; Aberra Bekele was 2
formerly affiliated with UNICEF, Colombo; A. Kethiswaran people were living in a land area of 1,025 km in Jaffna
is affiliated with the Ministry of Health, Jaffna, Sri Lanka. District. The district is known as the Jaffna Peninsula
Please direct queries to the corresponding author: Renuka because it is nearly surrounded by the sea and is joined
Jayatissa, Department of Nutrition, Medical Research Insti- to the mainland at only one point. The majority of the
tute, Baseline Road, Colombo 08, Sri Lanka; e-mail: renuka- population in the district are of Sri Lankan Tamil eth-
jayatissa@ymail.com. nicity and Hindu religion.
Food and Nutrition Bulletin, vol. 33, no. 4 © 2012, The United Nations University. 251
252 R. Jayatissa et al.
Health and nutrition services in the district were food among the lower socioeconomic groups became
provided through the well-structured network of an issue due to the closure of the main road to Jaffna
free government health services, administered by the District, which was the only land entry point. A second
Regional Director of Health Services (RDHS) under nutrition survey in November 2006 found that among
the policy guidance of the central Ministry of Health, children under 5 years of age, the prevalence of global
which provides both preventive and curative health ser- acute malnutrition (GAM) was 18.0% and the preva-
vices. Preventive health services were provided through lence of severe acute malnutrition (SAM) was 3.5%.
maternal and child health clinics by public health The rates of stunting and underweight were 18.2% and
staff. The services include immunization, deworm- 30.8%, respectively. However, no cases of kwashiorkor
ing, growth monitoring and promotion, vitamin A or marasmus were reported [2].
supplementation, supplementary feeding program for
children with growth faltering, and others. Curative
health services were provided through a network of Methods
hospitals by the government health staff. Although
trained human resources were limited in the district, Jaffna has seven Medical Offices of Health Areas under
extensive coverage was achieved through mobile clinics the administration of the RDHS. The field health staffs
and specialized medical services with the assistance of in Jaffna were extremely understaffed, with less than a
United Nations agencies and various nongovernmental third of the cadre in place. Seven Medical Offices of
organizations. Health Areas that were supposed to be managed by
Food distribution for the whole district was mainly medical officers were managed by Senior Public Health
provided by the Government Agent with the assistance Inspectors. The RDHS office also had limited supervi-
of the World Food Programme (WFP). However, the sory capacity due to lack of supervising staff. Therefore,
supply was not regular due to closure of the main the implementation of the Nutrition Rehabilitation
road that links Jaffna with the rest of the country and Program was done in six phases: planning phase,
the security and logistic difficulties of sea transport. implementation phase 1, national review, implementa-
This led to limited availability of foods in retail shops tion phase 2, maintenance phase, and evaluation phase
and a drastic rise in food prices. At the same time, by the RDHS Jaffna in collaboration with the Depart-
disruption of livelihood activities constrained people’s ment of Nutrition, the Medical Research Institute, and
capacity to purchase food, resulting in an alarmingly UNICEF, as shown in table 1.
high percentage of the population under the threat of
nutrition insecurity. Planning phase
In June 2006, a nutrition survey conducted in the dis-
trict by the Medical Research Institute found prevalence During the planning phase, a range of activities was
rates of global wasting (< –2 SD of weight-for-height), implemented. Consensus was built on the need for the
stunting (< –2 SD of height-for-age),and underweight establishment of the Nutrition Rehabilitation Program,
(< –2 SD of weight-for-age) in children under 5 years and a manual for health workers on the management of
of age of 15.9%, 17.9%, and 27.9%, respectively [1]. acute malnutrition was prepared, adopting the World
The prevalence of severe wasting (< –3 SD of weight- Health Organization (WHO) manual but excluding the
for-height) was 1.3%, and the prevalence of moderate provision of antibiotics for all children [3–5].
wasting (between –3 SD and –2 SD of weight-for- Capacity-building. Health staff were provided with
height) was 14.6%. In August 2006, the affordability of a series of three one-day training sessions during a
2-month period of hands-on training in taking anthro-
TABLE 1. Time frame of the Nutrition Rehabilitation Pro- pometric measurements,implementation of the Nutri-
gram process tion Rehabilitation Program at the community level,
Nutrition Rehabilitation and implementation of the Nutrition Rehabilitation
Program process Time frame Program at the hospital level. Initial training sessions
were completed in January and February 2007. Then
Planning December 2006–February 2007 monthly 1- or 2-day visits for 6 months for support,
Implementation phase 1 March–July 2007 refresher training, ad hoc training, problem-solving
(First screening) sessions, simulation sessions, and assistance with
National review August 2007 supplies were held. Ministry of Health and UNICEF
Implementation phase 2 September 2007–January 2008 staff provided ongoing supervision and assessment of
(Second screening) adherence to the guidelines. All of the supplies were
Maintenance phase February 2008–August 2008 kept ready, and stocks were also identified for 1 year.
(Third screening) Registration and monitoring forms and utensils needed
Evaluation phase April 2009 to prepare therapeutic milk were procured and distrib-
(Endline survey) uted to hospitals.
Community-based management of acute malnutrition 253
Therapeutic food. Formula 100 (F-100) therapeutic g, which provided 190 kcal per day (table 2). In addi-
milk for hospital management of children with SAM tion, the Ministry of Health has conducted a routine
and BP-100 biscuits and Plumpy’Nut spreads for supplementary feeding program with locally produced
community-based management of children with SAM Thriposha for children aged 6 to 59 months who are
were used as ready-to-use-therapeutic food (RUTF). below –2 SD of weight-for-age and have growth falter-
A daily ration of 200 kcal per kilogram of body weight ing. Thriposha, which means “triple nutrients,” is a
was provided for each child (table 2). precooked, ready-to-eat, cereal/legume/milk-based
Supplementary food and other supplies. All chil- food that provides energy, protein, and micronutrients
dren with moderate acute malnutrition (MAM) were (table 2). A difficulty of this program was the irregular
provided with 100g of high-energy biscuits (HEBs), supply of Thriposha.
containing 450 kcal.
Blanket feeding and other routine programs. Based Implementation: Phase 1
on the prevalence of wasting, food availability, and
aggravating factors such as population displacements, At the beginning, all displaced children from Jaffna
the Ministry of Health, with the support of the WFP, District living in public places such as schools,
implemented a blanket supplementary feeding pro- churches, temples, etc. (known as Internally Displaced
gram, in addition to the general ration,for all children 6 Persons [IDP] camps) were screened. Altogether 60
to 59 months of age. Corn–soya blend (CSB) provided IDP camps in the Jaffna District were screened over a
by the WFP was used for blanket feeding as a take- 1-month period, as described below.
home ration. The daily ration size for each child was 50 Community awareness. All families with children
TABLE 2. Composition of therapeutic and supplementary food supplied in comparison with RNI for children 1 to 5 years of age
Name of food (daily ration size) with nutrients per 100 g
BP-100 Plumpy’Nut CSB with CSB or MAM food-
(200 kcal/ (200 kcal/ Thriposha CSB HEB HEB Thriposha based daily
Nutrient kg) kg) (50 g) (50 g) (100 g) (150 g) (50 g) RNI
Energy (kcal) 527 500 398 380 450 640 199 956–1,202
Protein (g) 14.5 12.5 20 18 15 24 10 23–30
CHO (g) 47.5 — 61.9 60 56 86 31 —
Fat (g) 31.0 32.9 7.8 6 16 19 3.9 —
Calcium (mg) 470 276 900 800 250 650 450 570–740
Magnesium (mg) 110 84.6 96 100 30 80 48 190–250
Iron (mg) 10 10.6 18 18 15 24 9 9–10
Phosphorus (mg) 470 276 670 600 170 470 335 570–750
Iodine (µg) 50 92 44 50 30 55 22 190–250
Folic acid (µg) 130 193 200 200 5 105 100 210–270
Zinc (mg) 12 12.9 3 3 0 2.5 1.5 12–16
Copper (mg) 1.5 1.6 0 0 0 0 0 650–850
Selenium (µg) 25 27.6 0 0 0 0 0 30–35
Potassium (mg) 860 1,022 0 700 0 350 0 1,350–1,750
Sodium (mg) < 290 — 0 300 0 150 0 530–680
Vitamin B1 (mg) 0.52 0.55 0.76 0.7 1.2 1.55 0.38 0.5–0.75
Vitamin B2 (mg) 0.52 1.66 0.56 0.5 1.3 0.55 0.28 0.77–0.99
Vitamin B6 (mg) 0.87 0.55 6.0 0.7 1.5 1.85 3.0 0.77–0.99
Niacin (mg) 6.5 4.88 8.0 8.0 12 16 4.0 8–11
Vitamin B12(µg) 1.3 1.7 4.0 4.0 0 2 2.0 0.96–1.24
Vitamin A (IU) 1,567 840 1,700 1,700 1,500 2,350 850 920–1,190
Vitamin D (IU) 172 15 (µg) 200 200 90 190 100 7–9 (µg)
Vitamin E (mg) 3.5 18.4 6.0 8.0 5 9 3.0 11–14
Vitamin C (mg) 40 49 40 40 0 20 20 10–90
Ca–D–panto- 2.2 2.85 3.0 3.0 0 1.5 1.5 3–3.5
thenate (mg)
Biotin (µg) 62.5 60 0 0 0 0 0 9.5–12.5
CHO (Carbohydrate), CSB, corn–soya blend; HEB, high-energy biscuit; MAM, moderate acute malnutrition; RNI, Recommended Nutrient
Intake
254 R. Jayatissa et al.
under 5 years of age living in IDP camps were made Program with RUTF. Children under 6 months of age
aware of the program through the public health staff, were followed up to ensure continued breastfeeding. If
rural health workers (recruited by the Ministry of breastfeeding was not available or reestablished, infant
Health with the support of UNICEF to fill the vacant formula feeding was started under the supervision of
cadres of health staff), health volunteers, and camp the public health midwife.
managers, and were asked to bring their children to a Children without complications were followed up in
specified location identified for screening inside the the clinic or IDP camp fortnightly and were provided
camps on the specified date. Mobilization of the com- with take-home rations of RUTF. They also received
munity and scheduling of activities took place over 1 other services (deworming, vitamin A supplementa-
week in February 2007. tion, age-appropriate immunization, etc.). BP-100 was
Community screening and case finding. When a used as RUTF (table 2). Children below 1 year of age
child under 5 years of age was brought to the clinic were given BP-100 as a porridge dissolved in boiled,
or a specified location, weight was measured with a cool drinking water; children above 1 year were given
UNICEF UNISCALE, and height or (in children up to BP-100 as biscuits with an appropriate quantity of
2 years of age) length was measured with a height board water. Mothers or caretakers were given instructions on
provided by UNICEF. SAM and MAM children were how to prepare the porridge with boiled, cool water at
identified by health workers using a weight-for-height each feeding. Preparation of the first few feedings was
chart prepared according to WHO 2006 standards observed by the public health midwife.
during the screening, using the following case defini- Children with MAM were followed up fortnightly
tions [5]. SAM is defined as weight-for-height < –3 SD, and were provided with a take-home daily ration of
and MAM is defined as weight-for-height between 100 g of HEBs.
–2 SD and –3 SD. Colored weight-for-height charts The health workers completed the screening of chil-
were provided for easy categorization of SAM and dren in the IDP camps in the district over a period of
MAM children during screening for different schemes 4 weeks in March 2007.
to follow-up. Follow-up. The Nutrition Rehabilitation Program
Children over 6 months of age with SAM were centers were established, and operated every fortnight
recorded in the Nutrition Rehabilitation Program inside the camps where the progress of children was
register maintained at the screening sites by the health monitored as well. The Jaffna Teaching Hospital pro-
workers and provided with a Nutrition Rehabilitation vided stabilization care for children suffering from
Program card. Children with SAM were assessed by SAM with complications. The child’s weight was
health workers for any medical complications, such recorded at each visit on the weight chart provided on
as no appetite or inability to eat a test dose of RUTF, the Nutrition Rehabilitation Program card and was
intractable vomiting, fever > 39°C or hypothermia used to determine whether the child had gained weight
< 35°C, lower respiratory tract infections according to and could be discharged from the program. Height was
integrated management of childhood illness guidelines measured monthly and recorded in the child health
for age, any chest in drawing, severe palmar pallor, development record provided for each child at birth by
extensive superficial infections requiring systemic the Ministry of Health or on the Nutrition Rehabilita-
treatment, very weak, apathetic, unconscious, convul- tion Program card. At each visit, the child was assessed
sions, or severe dehydration based on history. for edema of the feet, loss of appetite, and any medical
Children with SAM who were under 6 months of problems.
age, or who were between 6 and 59 months of age and Recovery. Ideally, children with SAM or MAM would
had any of the above complications, were referred to be followed up until they reached a weight-for-height
the hospital for inpatient management under a pedia- > –1 SD, at which point they would be considered
trician with a referral letter and the Nutrition Rehabili- recovered. However, in the present study, because of
tation Program card. Children under 6 months of age the limited quantity of therapeutic food available for
were investigated for failure to thrive by the pediatri- children following discharge, children were considered
cian, and appropriate treatment was given to ensure recovered when they reached a weight-for-height ≥ –3
continued breastfeeding. Children between 6 and 59 SD for children with SAM and ≥ –2 SD for children
months of age were given Formula 75 (F75) during the with MAM.
stabilization phase, then Formula 100 (F100) alternat- Duration. The maximum length of stay in the pro-
ing with RUTF during the transition phase (return of gram was 2 months for children with SAM and 3
appetite and reduced edema or minimal edema) in the months for children with MAM.
hospital. When the discharge criteria were fulfilled, Nonresponse. A child whose condition deteriorated
i.e., the child’s appetite was good and the medical and required hospital care, who had weight loss for 2
complications were under control, the child was dis- consecutive weeks or a constant weight for 4 consecu-
charged from the hospital with a referral to the nearest tive weeks, or had remained in the program for the
clinic and followed up in the Nutrition Rehabilitation maximum period (more than 8 weeks for SAM and
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