Maternal, infant and young child nutrition in East and Southern African countries: moving to national implementation
Maternal, infant and young child nutrition in East and Southern African countries: moving to national implementation
Report of a World Health Organization workshop Entebbe, Uganda, 26–28 November 2013
WHO Library Cataloguing-in-Publication Data Maternal, infant and young child nutrition in East and Southern African countries: moving to national implementation, report of a World Health Organization workshop, Entebbe, Uganda, 26–28 November 2013. 1.Malnutrition – prevention and control. 2.Child Nutrition Disorders – prevention and control. 3.Infant Nutrition Disorders – prevention and control. 4.Maternal Welfare. 5.Growth. 6.National Health Programs. 7.Africa, Eastern. 8.Africa, Southern. I.World Health Organization. ISBN 978 92 4 150887 5 (NLM classification: WD 100)
© World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/ copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Design by Ana Sabino Suggested citation WHO HQ/AFRO. Maternal, infant and young child nutrition in East and Southern African countries: moving to national implementation. Report of a World Health Organization workshop. Entebbe, Uganda, 26–28 November 2013. Geneva: World Health Organization; 2014.
Contents
4 5 6 8 10 11
Acknowledgments Abbreviations Executive summary Background Introduction and overview Global nutrition challenges and the WHO Comprehensive implementation plan on maternal, infant and young child nutrition Technical updates on maternal, newborn, child and adolescent nutrition, including new initiatives, tools and guidelines 1. WHO Child Growth Standards 2. Essential nutrition actions 3. Actions targeting infants 0–5 months old 4. Actions targeting infants and young children 6–23 months old 5. Nutrition recommendations in the context of HIV/AIDS 6. Actions targeting adolescents and women of reproductive age (15–49 years old) 7. Management of severe acute malnutrition (SAM): adaptation and implementation of new guidelines Review and harmonization of 2014/2015 biennium plans of countries in relation to WHO nutrition-related guidelines: group work Review and harmonization of 2014/2015 biennium plans of countries with intercountry and regional plans Orientation on resource mobilization, opportunities for integration and collaboration Conclusion and next steps Additional comments Annex 1: Workshop agenda Annex 2: List of participants Annex 3: References and bibliography Annex 4: Templates for group work Annex 5: Evaluation form
14 14 15 17 18 19 21 23
28
43 43
44 46 47 50 56 60 64
Acknowledgments
This workshop report was prepared by Dr Hana Bekele. The workshop was convened by the Regional Office for Africa (AFRO) of the World Health Organization (WHO). AFRO acknowledges the coordination work of the Intercountry Supports Teams (IST) for East and Southern Africa (ESA) and for West Africa as well as the Department of Nutrition for Health and Development (NHD) of WHO in Geneva, Switzerland. In particular, we thank Dr Juan Pablo Peña-Rosas, Dr Maria del Carmen Casanovas and Ms Zita Weise Prinzo from the Evidence and Programme Guidance Unit of NHD for their technical input for the preparation of the workshop and this report. We are grateful to Dr Abdulaziz Adish, Deputy Regional Director, Micronutrient Initiative (MI) Africa, for his technical contributions at the workshop and Ms Jesca Maswera, administrative assistant for IST/ESA, for providing logistic and administrative support. WHO/AFRO gratefully acknowledge the technical input of the workshop participants, especially the chairs and the country teams that prepared documentation for this workshop. We would like to thank all the participants of the workshop for their technical input to the discussions.
Financial support
WHO thanks the Micronutrient Initiative (MI) for providing financial support for this workshop and for publication of this report.
4
Abbreviations
AIDS acquired immunodeficiency syndrome AFRO Regional Office for Africa ART antiretroviral therapy ARV antiretroviral BCC behaviour change communication BFHI Baby Friendly Hospital Initiative BMI body mass index CIFF Children’s Investment Fund Foundation EBF exclusive breastfeeding eLENA e-Library of evidence for nutrition actions ESA East and Southern Africa F-75 therapeutic milk used in stabilization phase of the treatment of SAM F-100 therapeutic milk used in transition and recovery phases of the treatment of SAM g gram GAIN Global Alliance for Improved Nutrition HIV human immunodeficiency virus IDA iron deficiency anaemia IFAS iron and folic acid supplementation IIFAS intermittent iron and folic acid supplementation IMCI integrated management of childhood illnesses IST Intercountry Support Team IU international unit IYCF infant and young child feeding IYCN infant and young child nutrition k kilogram L litre LBW low birth weight MAM moderate acute malnutrition MI Micronutrient Initiative mm millimetre μmol micromole MNP micronutrient powder MoH Ministry of Health MTCT mother-to-child transmission (HIV) MUAC mid-upper-arm circumference NHD Department of Nutrition for Health and Development (WHO) PMTCT prevention of mother-to-child transmission (HIV) REACH Renewed Efforts against Child Hunger RUTF ready-to-use therapeutic food SAM severe acute malnutrition UN United Nations UNICEF United Nations Children’s Fund VAD vitamin A deficiency VLBW very low birth weight WCO WHO Country Office WHA World Health Assembly WHO World Health Organization WRA women of reproductive age
5
Executive summary
This workshop was organized by the Intercountry Support Team (IST)/ East and Southern Africa (ESA)/Nutrition Regional Office for Africa (AFRO) in collaboration with IST/West Africa, AFRO and the Department of Nutrition for Health and Development (NHD) at the World Health Organization (WHO) headquarters in Geneva, Switzerland, with financial support from Micronutrient Initiative (MI). The aim of the workshop was to present recently published WHO evidence-informed guidelines for nutrition actions, and to introduce participants to existing WHO tools available for supporting a constructive collaboration between the different stakeholders who have direct or indirect influence on the evidence-informed policy-making process at the national level. The updated guidelines are expected to assist implementing partners to reflect these changes in the existing national nutrition programmes being implemented at the country level. The participants comprised of WHO Country Office (WCO) staff responsible for nutrition programmes and Ministry of Health (MoH) nutrition programme managers from each of the selected countries, WCO staff members responsible for nutrition programmes at AFRO and NHD at WHO headquarters as well as IST/West Africa and IST/ESA nutrition focal persons. All sessions were conducted in English. A total of 47 participants from WHO and national MoH offices participated in the workshop. Ethiopia, Mozambique, Rwanda and South Africa did not participate in the workshop. A mix of methods was used during the workshop proceedings that included presentations, discussions, group work and plenary sessions. Global nutrition challenges and the WHO Comprehensive implementation plan on maternal, infant and young child nutrition, endorsed by the World Health Assembly (WHA65.6), were presented. Discussions were held on the six global nutrition targets with a focus on actions that need to be undertaken by Member States to achieve these targets, including: (i) ensuring a supportive environment for nutrition policies; (ii) strengthening health interventions to encompass maternal, child and adolescent health that have direct impacts on nutrition; (iii) mainstreaming nutrition in other sectoral policies; (iv) strengthening human and financial resources; and (v) carrying out monitoring and evaluation of implementation of policies and programmes. A technical update was presented on maternal, newborn, child and adolescent nutrition, including new initiatives, tools and guidelines with a focus on the WHO Child Growth Standards, essential nutrition actions using a lifecycle approach, nutrition in the context of HIV/AIDS and management of severe acute malnutrition (SAM) in infants and children. Countries developed work plans that helped them align their biennium plans for 2013/2014 in line with the current standards and guidelines discussed in the workshop. In addition, a presentation on the global and regional work of MI was given to share experiences and foster
6
relationships in countries where MI is present in Africa. Biennium plans for AFRO and IST/ESA also were presented to help harmonize with country plans and identify consolidated plans for collaboration between IST and AFRO for coordinated support to countries. In addition, orientation was provided to countries on how to access the Children’s Investment Fund Foundation (CIFF) as a source of funding to strengthen nutrition and child survival programmes. Overall, the workshop provided an opportunity to orient countries on current nutrition updates and draft a harmonized nutrition plan with IST/ ESA and AFRO for coordinated technical support needed to implement countries plans for 2013/2014.
7
Background
In 2012, the Sixty-fifth World Health Assembly endorsed the Comprehensive implementation plan on maternal, infant and young child nutrition (WHA65.6 ) and urged the World Health Organization (WHO) Member States to put it into practice, as appropriate (1,2), including: (i) developing or, where necessary, strengthening nutrition policies so that they comprehensively address the double burden of malnutrition and include nutrition actions in overall country health and development policy, and establishing effective intersectoral governance mechanisms in order to expand the implementation of nutrition actions with particular emphasis on the framework of the global strategy on infant and young child feeding (IYCF); (ii) developing or, where necessary, strengthening legislative, regulatory and/or other effective measures to control the marketing of breastmilk substitutes; (iii) establishing a dialogue with relevant national and international parties and forming alliances and partnerships to expand nutrition actions with the establishment of adequate mechanisms to safeguard against potential conflicts of interest; and (iv) implementing a comprehensive approach to capacity-building, including workforce development. WHO Member States endorsed six global targets for improving maternal, infant and young child nutrition and committed to monitoring progress. The targets are vital for identifying priority areas for action and catalysing global change, including a 40% reduction in the number of children under 5 years old who are stunted; a 50% reduction of anaemia in women of reproductive age; a 30% reduction in low birth weight (LBW); no increase in childhood overweight; an increase in the rate of exclusive breastfeeding (EBF) in the first 6 months up to at least 50%; and reduction and maintenance of childhood wasting to less than 5%. In 2013, the United Nations Children’s Fund (UNICEF), WHO and the World Bank updated their joint database on child malnutrition and released new global and regional estimates for 2012 (3). Between 2000 and 2012, stunting prevalence declined from 33% to 25% and the burden declined from 197 million to 162 million. In 2012, 36% of all stunted children lived in Africa. It was estimated that 99 million children under 5 years old were underweight in 2012. Between 1990 and 2012, underweight prevalence decreased from 25% to 15%, which remains insufficient to meet the Millennium Development Goal of halving the 1990 prevalence by 2015. In 2012, 29% of all underweight children lived in Africa. Wasting and severe wasting prevalence in 2012 were estimated at almost 8% and just less than 3%, respectively, with approximately 28% of all severely wasted children living in Africa. The global trend in overweight prevalence and burden is rising and it was estimated that between 2000 and 2012 overweight prevalence increased from 5% to 7% and the global burden increased from 32 million to 44 million. The rise in overweight prevalence is reflected in all regions, while the burden is increasing in Africa where the overweight prevalence was highest in Southern Africa (18%). Global mean haemoglobin improved slightly between 1995 and 2011, from 125 g/L (95% credibility interval [CI]
8
123–126) to 126 g/L (124–128) in non-pregnant women, and from 112 g/L (111–113) to 114 g/L (112–116) for pregnant women. In 2011, mean concentrations of haemoglobin were lowest and anaemia prevalence was highest in Central and West Africa. In 2011, the prevalence of anaemia in non-pregnant women in Southern Africa was 28% (16–44), a reduction from a prevalence of 33% (21–47) in 1991. The progress made in addressing undernutrition since 2008 was reported in the 2013 Lancet maternal and child nutrition series (4). Although this positive change is encouraging, countries have to do more to further accelerate the reduction of stunting by 40% by 2025, from the 2010 level, as stated in Resolution WHA65.6. The current global stunting reduction is estimated to be 2.1% per year; to achieve the global target, the reduction rate has to increase to 3.9% per year. Achieving the anaemia global target calls for a more concerted effort with a focus on adolescent and maternal nutrition by using the lifecycle approach. To comprehensively address this unfinished agenda for undernutrition, WHO affirms the need for a coherent and harmonized approach by using standardized guidelines and tools to guide the implementation process. In support of this, WHO has been updating the existing nutrition guidelines based on the current technical evidence. These updates serve as a basis for updating the national nutrition guidelines of participating countries to align and fine-tune their nutrition programmes as per the recommended nutrition interventions. In line with these developments, some countries have started requesting technical support to revise and update their national nutrition guidelines in order to reflect these changes. Whereas some countries are up to date on such developments, not all countries in the ESA subregion are fully aware of the existence of the evidence-informed guidelines on safe and effective nutrition interventions. To fill this gap, this workshop was organized by the Intercountry Support Team (IST)/ESA/Nutrition Regional Office for Africa (AFRO) in collaboration with IST/West Africa, AFRO and NHD at WHO headquarters in Geneva, Switzerland, with financial support from MI.
9
Introduction and overview
This workshop was organized by IST/ESA/Nutrition AFRO in collaboration with IST/West Africa, AFRO and NHD at WHO headquarters in Geneva with financial support from MI.
Aim and objectives of the workshop
The aim of the workshop was to present recently published WHO evidence-informed guidelines for nutrition actions, and to introduce participants to existing WHO tools available for supporting a constructive collaboration between the different stakeholders who have direct or indirect influence on evidence-informed policy-making processes at the national level. The updated guidelines are expected to assist implementing partners to reflect these changes in the existing national nutrition programmes being implemented at the country level. Specific objectives were to: • present technical updates on maternal, newborn, child and adolescent nutrition, including new initiatives, tools and guidelines; • review and harmonize 2014/2015 biennium plans of countries in relation to WHO nutrition-related guidelines; • review and harmonize 2014/2015 biennium plans of countries with intercountry and regional plans; • orient participants on evidence-informed policy-making mechanisms.
The participants comprised of WHO Country Office (WCO) staff responsible for nutrition programmes and Ministry of Health (MoH) nutrition programme managers from each of the selected countries, WCO staff members responsible for nutrition programmes at AFRO and NHD at WHO headquarters as well as the IST/West Africa and IST/ESA nutrition focal persons. All sessions were conducted in English. A total of 47 participants from WHO and national MoH offices participated in the workshop. Ethiopia, Mozambique, Rwanda and South Africa did not participate in the workshop. A mix of methods was used during workshop proceedings that included presentations, discussions, group work and plenary sessions. The workshop started with an official opening from the Uganda MoH and presentations on interventions by the WHO ESA country subregional offices, the Rwanda WCO, MI and WHO headquarters. Highlights included the presence of 45 participants from 15 countries, the interest of all the countries, notably Uganda, in implementing the Comprehensive implementation plan on maternal, infant and young child nutrition and the potential of MI providing technical and financial support to countries interested in implementing maternal, infant and young child nutrition as well as micronutrient actions. The MoH stressed the importance of the workshop and the fact that Uganda is moving towards implementation of nutrition guidelines and policies.
10
Global nutrition challenges and the WHO Comprehensive implementation plan on maternal, infant and young child nutrition
For over three years, UNICEF, WHO and the World Bank standardized and harmonized procedures used in estimating child anthropometric estimates. Their first publication was released in September 2012, and the estimates were updated in September 2013. The Lancet series on maternal and child nutrition 2013 (5) includes overweight and obesity; this series identifies 34 countries accounting for the global burden of malnutrition. The main issues stressed from the Lancet series are that stunting is a major problem in Africa and the prevalence is still high, with levels about 40%. The number of stunted children is still increasing in comparison to Asia where there is a decrease both in population numbers and prevalence of stunting due to strong policies and good interventions. Data show that children are already stunted at birth; 20% of stunting in children up to 23 months old can be attributed to children being small for gestational age. Wasting is highest in Africa and Asia. Discussion with participants helped to clarify that data on stunting, as presented in the Lancet, show only a global picture, not country-specific information; the 34 countries identified with the highest burden were those having at least 20% prevalence of stunting, taking into account the population factor. However, it was clarified that problems of malnutrition can begin in utero. Participants expressed concern because at a meeting held in Namibia it was stated that there was no relationship between maternal nutrition and the newborn; therefore, it was clarified that there is a direct correlation between maternal nutrition and birth weight. The indicator for LBW includes preterm babies. There are many parameters that impact on preterm babies such as physiological and pathological, among others. Currently, WHO is collecting indicators for preterm babies as there is a wide demand for these data. The children most prone to stunting are the babies small for gestational age. Namibia has mobilized resources to conduct a nutrition landscape and emphasized that countries should do the same to avoid waiting for nutrition problems to worsen. Stunting also affects mothers, who usually require assisted delivery. Iron deficiency is still a problem among women and children alike, thus the need for a comprehensive plan that addresses maternal and child health. Environmental issues similarly impact on child health and birth weight. Worryingly, child overweight is on the rise, which is unacceptable. WHO carried out a review of nutrition policies in 2009 by, but most Member States have not translated these results into programmes. Considering the existing situation, the World Health Assembly endorsed the Comprehensive implementation plan on maternal, infant and young child nutrition and set six global nutrition targets to be attained; the targets are aligned along different development agendas that will run from 2012 to 2025. Implementation of the plan will necessitate:
11
• Supportive environment for nutrition policies: including increasing access to nutrition programmes, working with other partners, involving communities in the design of programmes and the need to include partners in dialogue. Many governments are developing multisectoral platforms. • Health interventions: to encompass maternal child and adolescent health with direct impacts on nutrition. • Nutrition in other sectoral policies: including diversified food production, access to clean water and sanitation, school health (Resolution WHA63.14).1 It was noted that stunting is high where food is produced since many mothers resort to agriculture, thereby leaving the children to suffer. Thus dialogues are important with the agricultural and private sector as well. Nutrition requires skills, knowledge and leadership reinforcing the need for a multisectoral approach. • Human and financial resources: including a capacity-building plan. Governments need to budget for nutrition or boost the budget line for nutrition programmes. • Monitoring and evaluation: implementation of policies and programmes also is key. There is nothing more powerful than having quality information. • Good surveillance systems can be put in place so we can see what we are doing well and what we are not doing well.
The need of intersectoral discussion to move forward the comprehensive plan of action at the country level was stressed by speakers and participants. An important point was raised: of the six global targets, four are directly related to child nutrition and growth. As there was a need to define indicators to follow up on implementation of the comprehensive plan of action, WHO proposed a list of 46 indicators for consideration by Member States; 29 of the indicators could be in the global monitoring framework (6 primary outcome indicators; 7 intermediate outcome indicators; 13 process indicators; and 3 indicators of policy environment); the remaining 17 indicators to be considered as alternatives or relevant to specific country situations. The indicators were not approved because of complexity and dynamics and the need of more time for consultation. Similarly, there was a need to consider the pathways of collecting the indicators. For example, stunting requires two methods of monitoring: periodic outcome monitoring and process monitoring. Even though there are funds for monitoring and evaluation, there are challenges for implementation that have been registered. Countries were advised to continue working on their indicators in the meantime as the process by WHO/UNICEF might take longer to finalize. In summary, there is a need for much consultation and harmonization in order to have 1 Resolution to reduce the impact on children of the marketing of foods high in saturated fats, transfatty acids, free sugars or salt by restricting marketing, including in settings where children gather, for example, at schools.
12
a final list of indicators to be presented to Member States and approved by the World Health Assembly. There is ongoing work in this area. To finalize the overview, there was a presentation and discussion on the WHO evidence-informed guideline development process. A WHO guideline is a document containing recommendations about health interventions – both clinical and public health policy recommendations. To develop a guideline, WHO follows an evidence-informed development process with key steps. Among the steps is the scoping of the document, which involves what WHO wants the guidelines to look like. The process of guideline development was discussed, highlighting the importance of appropriately managing real or perceived conflicts of interest and how that affects the selection and nomination of members of the guideline development and external review groups. WHO recognizes different types of guidelines such as rapid advice guidelines, standard guidelines, full guidelines and a compilation of guidelines. During the workshop, examples of each type were presented. WHO works with various stakeholders such as MI, academia and other United Nations (UN) agencies such as UNICEF when developing nutrition guidelines, as nutrition is a cross-cutting issue. WHO guidelines are available on the WHO website and through the electronic library of evidence for nutrition actions (eLENA).
13
Technical updates on maternal, newborn, child and adolescent nutrition, including new initiatives, tools and guidelines 1. WHO Child Growth Standards The presentation of technical updates started with an update of the WHO Child Growth Standards and the use of the growth charts for assessing the growth of children under 5 years old (6,7). The WHO Child Growth Standards were launched in 2006 and adopted by the majority of countries. Growth is measured to monitor individual children’s growth, track changes in growth in groups of children and educate parents and others. It is now widely acknowledged that stunting is prevalent, even though it is a hidden problem since stunted children may tend to look better than their counterparts because they are older. However, stunted children have many development problems; some consequences of childhood stunting include low intelligence quotient, high dropout rate and high risk of premature deaths and infections. Successful growth assessment requires correct measurements, techniques, plotting and interpretation, and anthropometric equipment. It was explained that growth indicators vary and are gender specific (for girls and boys). It is necessary to use multiple indicators for correct assessment and it is crucial to follow up growth trajectories. Some challenges in growth assessments include absence of equipment, inadequate skills in taking correct measurements, plotting and interpretation. During the discussion, the use of weight-for-height z-scores and body mass index (BMI) was stressed; and pointed out that biomarkers are better for school age children and adolescents. Besides the Child Growth Standards for children up to 5 years old, WHO has references for growth for children and adolescents 5–17 years old. Another point that was highlighted is that child overweight is on the rise and there are still issues around measuring overweight and obesity in children. Botswana asked if tracking growth twice would be considered enough and the response was that it was not nearly enough in the first two years of life, at which time measurements should be taken every two to three months. Examples from countries that are now measuring height on a regular basis were provided. It also was indicated that linear growth is more susceptible to modifiable factors; in addition, there is a need to use gender-specific charts as boys and girls do not grow following the same paths. Namibia indicated that it is adopting growth charts, but implementation is not easy and was interested in implications of using the same charts for both boys and girls.
14
2. Essential nutrition actions
In 1999, WHO/BASICS/UNICEF published a tool for essential nutrition actions. It was a comprehensive tool that included water, sanitation and hygiene with effective, feasible and affordable actions to reduce infection and improve nutrition/health outcomes. The evidence for essential nutrition actions was published by WHO in 2013 after a standard review procedure and was organized into two parts: the first one refers to the interventions and the second to community actions (8). The review of intervention was based on the lifecycle with different interventions described for the different components of the lifecycle and evidence-based actions described for each intervention. A subset of key essential nutrition actions was selected in relation to the window of opportunity from conception to 2 years old. However, it is recognized that some actions should start even before a woman becomes a mother. Table 1, which shows the list of actions by age group, was presented, listing the target group, intervention areas, evidence-based actions and context/criteria.
Table 1. Evidence-informed nutrition actions over the lifecycle
Target group Infants (0–5 months old)
Intervention areas Early initiation of breastfeeding Exclusive breastfeeding
Evidence-informed actions Counselling and support at the facility and community levels Implementation of Baby Friendly Hospital Initiative Implementation of the International Code of Marketing Breast-milk Substitutes Maternity protection
Context/criteria All countries
All countries
Feeding of low birth Counselling and support weight infants Infant feeding in the context of HIV Infants and young Continued children (6–23 months old) breastfeeding mothers Counselling and support at the facility and community levels Implementation of the International Code of Marketing Breast-milk Substitutes Appropriate complementary feeding
All countries, children born with weight <2500 g
Counselling and support to HIV-positive All countries, children born to HIV-positive mothers All countries
Counselling and support for appropriate All countries complementary feeding Use of multiple micronutrient powders for home fortification of foods 6–23 months old Populations where the prevalence of anaemia in children under 2 years old
consumed by infants and young children is 20% or more
15
Infants and young Vitamin A status children (6–23 months old)
Vitamin A supplementation for infants and children 6–59 months old
Populations where the prevalence of night blindness is 1% or higher in children 24–59 months old or where the prevalence of vitamin A deficiency (serum retinol 0.70 μmol/L or lower) is 20% or higher in infants and children 6–59 months old
Vitamin A supplementation for children with measles Iron deficiency Daily iron supplementation for infants and young children 6–23 months old Zinc status Iodine deficiency Zinc supplementation for children with diarrhoea Iodine supplementation for children
All countries, all children with measles Countries where the diet does not include foods fortified with iron or where anaemia prevalence is above 40% All countries, children with diarrhoea Countries where less than 20% of households have access to iodized salt, until the salt iodization programme is scaled up
Severe acute malnutrition Moderate acute malnutrition Nutrition of children living with HIV Nutrition in the context of emergencies Women of reproductive age Iron and folic acid deficiency
Outpatient and inpatient management of severe acute malnutrition Management of children with moderate acute malnutrition Nutritional care and support of children 6 months–14 years old living with HIV
All countries, children with severe acute malnutrition All countries, children with moderate acute malnutrition All countries, children living with HIV
Nutritional care and support for children Countries in emergency situations living in emergency situations Intermittent iron and folic acid supplementation in menstruating women Countries where the prevalence of anaemia among non-pregnant women of reproductive age is 20% or higher
16
Pregnant women
Iron and folic acid deficiency
Daily iron and folic acid supplementation Countries where anaemia in pregnant for pregnant women Intermittent iron and folic acid supplementation for non-anaemic pregnant women women is 40% or higher Countries where prevalence of anaemia among pregnant women is lower than 20% of night blindness is 5% or higher in pregnant women or 5% or higher in children 24–59 months old
Vitamin A deficiency
Vitamin A supplementation for pregnant Populations where the prevalence women
Calcium status
Calcium supplementation for pregnant women
All countries; all pregnant women, particularly those at higher risk of hypertension Countries where less than 20% of households have access to iodized salt, until the salt iodization programme is scaled up
Iodine deficiency
Iodine supplementation for pregnant and lactating women
Nutrition in the context of emergencies Global Micronutrient status
Nutritional care and support for pregnant and lactating women living in emergency situations Wheat and maize flour fortification
Countries in emergency situations
Countries where industrially produced flour is regularly consumed by large population groups
3. Actions targeting infants 0–5 months old
WHO recommends early initiation of EBF by placing babies in skin-toskin contact with their mothers immediately following birth for at least one hour and encouraging mothers to recognize when their babies are ready to breastfeed, offering help if needed. The recommendation on early initiation dates back to 1989, with updates in 1998. Optimal breastfeeding along with appropriate complementary feeding has the potential to reduce child mortality by 19%. Evidence shows that EBF infants have lower incidence of gastrointestinal illnesses, while mothers practising EBF benefit from lactation amenorrhoea. It was emphasized that there should be consistency across the board about breastfeeding messages, from promoters to clinicians to academicians. The International Code of Marketing of Breast-milk Substitutes was first adopted in 1981 (9). It is interesting that the more advanced society becomes, the more society tends to look down on breastfeeding. There is a need for health professionals to expound the benefits of EBF because the evidence exists to support it. EBF aims to provide adequate and safe nutrition for infants. A working mother should be given at least one breastfeeding break to either express her breast milk or breastfeed her baby, based on International Labour Organization standards. The Baby Friendly Hospital Initiative (BFHI) was launched in 1991, spearheaded by WHO and UNICEF with the aim to give every baby the best start in life. The goal of BFHI is twofold, one purpose being to
17
transform hospital maternity wards through the implementation of the Ten Steps for successful breastfeeding. There was a detailed explanation on the importance of feeding LBW and very low birth weight (VLBW)2 babies on their own mother’s milk as the first choice or donor milk in the event the mother is unable to breastfeed. The use of infant formula and sometimes fortified formula is acceptable in VLBW babies failing to grow after close monitoring. There is evidence that both mortality and infection are significantly reduced (18% and 60%, respectively) when LBW and VLBW babies are fed on their own mother’s milk. During the discussion a question was raised about the designation of hospitals by external assessors; it was clarified that these assessors must be external to the facility being assessed, although not necessarily from out of the country.
4. Actions targeting infants and young children 6–23 months old
It was stressed that breast milk is the best food for infants and young children, and continued breastfeeding provides a continuum of care up to 2 years old and beyond. Complementary feeding needs to meet evolving nutritional requirements for infants and should be nutritionally adequate, safe and sourced from locally available foods. The importance of caregivers/mothers to practise responsive feeding was underscored. In relation to complementary feeding, the recommended practices are included in two sets of guiding principles: one set for complementary feeding of the breastfed child; and one set for feeding non-breastfed children 6–24 months old. Embedded in these guiding principles are the recommendations for feeding infants and young children who are ill, both during and after illness. Complementary feeding practices and quality of diet affect growth and development. There are several publications available on this (10,11,12) as well as software available to develop complementary feeding recommendations adapted to each environment (e.g. ProPAN and Optifood software). The use of micronutrient powders (MNPs) is discouraged if institutions do not have all the necessary requirements in place. Vitamin A interventions cannot be conducted as standalone programmes, instead it is advised that they be integrated into existing programmes. WHO does not recommend zinc for prevention. Since oral rehydration salts are usually used at the community level, community health workers should be trained to use zinc as part of diarrhoea case management. 2 VLBW babies weigh less than 1500 g.
18
Iodine supplementation for infants under 6 months old is not recommended as the child receives iodine through breast milk. Finally, it was mentioned that while nutrition in emergency areas is a huge topic, it would not be covered in the workshop, although guidelines were available in different WHO publications. During the discussion, it was indicated that it is generally not advisable to add salt to food for infants since many foods are usually salty, and 6 months old is too early to start adding salt to infants’ food. This also applies to sugar and other condiments. Spicing of food depends on culture and household preferences. WHO does not go into detail on salt, sugar, etc., and instead gives nutritional recommendations; but it is worth considering that it would be better not to let a child become used to too much salt or sugar. Regarding the increase in childhood obesity and how feeding recommendations are applied to prevent this problem, it was indicated that WHO has started working with a pool of experts to review feeding of children 2–5 years old. There are no recommendations so far and not much research has been done for older children. Some experts have started reviewing guidelines for children under 2 years old. If a child under 2 years old is overweight, then it would be necessary to assess and manage the child on an individual basis.
5. Nutrition recommendations in the context of HIV/AIDS
Significant programmatic experience and research evidence regarding HIV and infant feeding that has been accumulated since 2006, and the guidelines were updated in 2010 (13). Evidence shows that antiretroviral (ARV) interventions can reduce the risk of postnatal transmission of HIV. This means that 65% of children born to mothers will not become infected with HIV (Figure 1). A review on the subject also showed that the use of ARVs reduces risk of transmission from 35% to 5% as shown in Figure 2.
pregnancy labour & delivery 15% breast feeding 15% never hiv-infected 65%
5%
total ~35%
pregnancy
labour & delivery
breast feeding 0-24m
5-8%
10-20%
5-20%
total ~35%
Figure 1. Risk of mother-to-child transmission in pregnancy, labour and delivery, and breastfeeding for two years: without ARV interventions
19
No ARVs
pregnancy
labour & delivery
breast feeding 0-24m
5-8%
10-20% With ARVs
5-20%
total ~35%
pregnancy 0-1% labour & delivery 1-2% Figure 2. Risk of mother-to-child transmission in pregnancy, labour and
breast feeding 0-12m with ARVs 2-3% total ~5%
delivery, and breastfeeding for two years: without and with ARV interventions
When developing the guidelines on HIV and infant feeding, it was highlighted that if ARV drugs are not immediately available, breastfeeding still provides infants born with HIV a greater chance of HIV-free survival. It is important to inform mothers known to be HIV-infected about infant feeding alternatives. Current main infant feeding recommendations for HIV-infected women include EBF for the first 6 months of life with continued breastfeeding, while providing appropriate complementary foods after 6 months old; or formula feeding when conditions for safe use of formula exist. If Infants and young children are known to be HIV-infected, mothers are strongly encouraged to exclusively breastfeed for the first 6 months of life and continue breastfeeding as per the recommendations for the general population, that is, up to 2 years old or beyond. As a general principle in all populations irrespective of HIV infection rates, breastfeeding should continue to be protected, promoted and supported. The updated 2010 WHO guidelines on the prevention of mother-tochild transmission (PMTCT) and infant feeding include new evidence on: • the best time to start lifelong antiretroviral therapy (ART) for women who need treatment for HIV; • the use of ARVs for PMTCT (prophylaxis), including during breastfeeding; • safe feeding practices for HIV-exposed babies.
The PMTCT guidelines are based on two key areas: lifelong ART for HIV-positive women in need of treatment for their own health, which also is safe and effective in reducing mother-to-child transmission (MTCT); and ARV prophylaxis (short term) to prevent MTCT during pregnancy, delivery and breastfeeding for HIV-infected women who do not need treatment for their own health. Three options for PMTCT programmes were presented (Table 2).
20
Table 2. Options for PMTCT programmes
Woman receives Treatment (for CD4 count ≤350 cells/mm ) 3
Infant receives Prophylaxis (for CD4 count >350 cells/mm3) Antepartum: AZT from 14 weeks Intrapartum: at onset of labour NVP and first dose AZT/3TC Postpartum: daily AZT/3TC through 7 days postpartum Daily NVP from birth through 1 week beyond complete cessation of breastfeeding (if not breastfeeding or mother on treatment then through 4–6 weeks)
Option A
Triple ARVs starting as soon as diagnosed and continued for life
Same initial ARVs for both Option B Triple ARVs starting as soon as diagnosed and continued for life Triple ARVs from 14 weeks continued intrapartum and through childbirth if not breastfeeding (or until 1 week after cessation of breastfeeding) Same for treatment and prophylaxis Option B+ Regardless of CD4 count, triple ARVs starting as soon as diagnosed and continued for life Daily NVP or AZT through 4–6 weeks Regardless of feeding method
AZT = Zidovudine NVP = Nevirapine 3TC = Lamivudine
Regarding HIV-infected children, there was a brief presentation on the guidelines for nutritional care and support of HIV-infected children (6 months–14 years old) included in three documents (14). The guidelines are organized into 3 sections with 10 steps, each with a key message. The first component, growth assessments and monitoring, is significant, and the guide also covers many components of complementary feeding. It was emphasized that an HIV-infected child is usually in a family that has HIV and should be taken into account. During the discussion, Namibia asked if WHO has decided on the mid-upper-arm circumference (MUAC) cut off points for children with HIV. It was indicated that not much work has been done on adolescents, which is a forgotten group. In reference to continued breastfeeding after introducing complementary foods, it was clarified that it is understood that ARVs are being used in these situations.
6. Actions targeting adolescents and women of reproductive age (15–49 years old)
The recommendation is that interventions for adolescents include iron and folic acid supplementation (IFAS) to break the generational anaemia problem. This applies where anaemia prevalence is 20% or higher. The need for baseline studies to produce evidence of prevalence was underscored. Intermittent iron folic acid supplementation (IIFAS) is preferable due to the limitations of the intestines to absorb iron and could be integrated into national programmes for adolescent and reproductive
21
health. The importance for compliance and adherence was emphasized, indicating that this could be improved through behaviour change communication (BCC) strategies and education campaigns. It also was indicated that resource allocation is important for BCC because it increases compliance and adherence. For pregnant women, part of the antenatal care package includes daily IFAS because anaemia is a public health problem affecting 41.8% of pregnant women globally (50% due to iron deficiency). The speaker stressed that pregnant women receiving daily iron supplementation are less likely to have LBW babies (15).3 For non-anaemic pregnant women, IIFAS is recommended to prevent anaemia (one supplement once a week). It was explained that daily IFAS is limited in some settings due to lack of compliance4 and availability of supplements. In malaria endemic areas, IFAS should be implemented in conjunction with malaria control and prevention strategies. Vitamin A: Vitamin A deficiency (VAD) affects 19 million women, with 9.8 million affected by night blindness. Although there is increased requirement for vitamin A supplementation in the last trimester, it is recommended as a preventive measure only where night blindness is prevalent. Calcium: WHO recommends supplementation for pregnant women of 1.5 g and 2.0 g of elemental calcium per day, respectively, in areas where dietary intake of calcium is low and for women at a higher risk of developing hypertensive disorders during pregnancy, which is a leading cause of maternal death in low-income countries. Iodine: Iodine deficiencies during pregnancy jeopardize brain development in utero. It was stated that it is cheaper and better for countries to opt for universal salt iodization. Actions to promote Iodine supplementation include: • promote consumption of iodized salt; • work with partners to increase access to universal salt iodization; • support a monitoring and regulatory system; • develop national guidelines for iodine supplementation if access to • universal salt iodization is limited.
During the discussion, there were various questions about calcium supplementation. The presenter indicated that supplementation with calcium is only recommended in a setting where calcium intake is low. Surveillance needs to be done at the country level. There are many meetings about this issue and Uganda does not have data on surveillance, but if you opt for calcium supplementation, then there are several situations 3 Body weight greater by 30.81 g compared to control group. 4 Due to dark stools, nausea, constipation and metallic taste in the mouth.
22
to consider. The disadvantage of calcium is that it affects absorption of other micronutrients and metals. The decision to begin supplementation should be based on confirmatory evidence. If a population is not consuming foods rich in calcium, such as milk and other dairy products, then pregnant women should receive supplements. The guideline indicates that there are multiple channels of management such that once the population starts consuming foods rich in calcium the consumption should be reviewed so that not too much is taken. There is enough evidence to support calcium supplementation (e.g. Cochrane reviews) although the difficulty is in practicality for use. We do not have the cost analysis for calcium supplementation because we do not have enough programmatic experience in this area. This recommendation will be updated in 2016. Regarding the multiple micronutrient supplements, it was clarified that multiple multivitamin supplements for pregnant women would not have the appropriate mix of key minerals and vitamins. It also was clarified that IIFAS is recommended for all women of reproductive age and not just for pregnant women. Depending on the situation, BCC for increased consumption of iron-rich foods and deworming could be applicable where iron supplementation is not possible. WHO guidelines reflect what is recommended for pregnant women. Prevention of anaemia is crucial for pregnant women. In the case of a country such as the Seychelles, where there is a high prevalence of anaemia (25%), it was suggested that the representative make the argument for supplementation based on the guidelines.
7. Management of severe acute malnutrition (SAM): adaptation and implementation of new guidelines
Participants were referred to the WHO website (who.int) where the complete guideline document on management of SAM is available, including evidence notes. The definition of SAM is low weight-for-height and/or low MUAC and/or presence of bilateral pitting oedema.5 Children with SAM who have severe bilateral oedema+++ should be admitted to inpatient care. Children with + or ++ bilateral pitting oedema but present with medical complications and have no appetite should be admitted for inpatient care. Guidelines on SAM are developed to enable governments to implement policies and improve capacity of countries and partners to manage severe and moderate undernutrition in crises as well as stable situations. Of the 14 key guiding questions, 8 key areas were identified for SAM: 1. admission/discharge criteria; 2. where to manage children with SAM and oedema; 3. use of antibiotics; 4. vitamin A supplementation; 5 Definition of SAM: low weight–for-height (WFH <-3 z-score) and/or low MUAC (<115 mm) and/or presence of bilateral pitting oedema. Classification of oedema: ± feet; ±± legs and hands; ±±± generalized oedema including face.
23
5. therapeutic feeding approaches, e.g. ready-to-use therapeutic food (RUTF) and transition from liquid to solid food; 6. fluid management with and without shock; 7. management of HIV (when to introduce ARVs, etc.); 8. identifying and managing infants under 6 months old.
The new recommendations were cleared in August 2013. The presenter discussed each of the recommendations in detail and informed participants that more research is needed in the treatment of SAM. Discharge from a SAM programme needs to be followed up by a moderate acute malnutrition (MAM) programme since the child is still moderately malnourished. The MAM programme could include a supplementary feeding programme or counselling and support, depending on the case. Since research is still required on use of antibiotics in management of SAM, this recommendation is conditional, meaning that national health authorities would decide to include it in their guidelines depending on their situation or local context. It also was stressed that there is huge emphasis placed on the need to monitor antimicrobial resistance. Vitamin A should be given to children with SAM as a recommended nutrient intake of 5000 IU throughout the treatment period either as an integral part of therapeutic foods or as a supplement or be given as a high dose of vitamin A if children are given therapeutic foods that are not fortified with vitamin A, such as F-75, and no daily supplements are given. It was commented that there are no evidence/data to suggest that RUTF improves diarrhoea in patients with SAM. Depending on the situation and/or preference, there are two proposals on how to transition from F-75 (stabilization) to RUTF. Fluid management with or without shock: The presenter also commented that fluid management in SAM cases has generated interest because dehydration is difficult to diagnose. The current recommendation aims to rehydrate and manage shock in children with SAM. HIV and SAM: HIV-infected children are more susceptible to diarrhoea and opportunistic infections such as tuberculosis. WHO recommends ART only after the child has stabilized. Infants 0–6 months old with SAM: The presenter stated that there are physiological differences between young infants (0–6 months old) and older children. This group is new to SAM guidelines and recommendations. The importance of feeding approaches that prioritize reestablishment of EBF was stressed. Feeding of infants with SAM: Options include: supplementary suckling approaches, where feasible; expressed breast milk; commercial (generic) infant formula; F-75 and then diluted F-100. F-100 is not recommended for infants because of the risk of renal overload. Participants were
24
informed that the updated manual will include outpatient care. Similarly, the discharge criterion has been revised. The importance of stimulating a child with SAM to improve mental development was stressed. The presentation on the guidelines concluded by saying that even though MAM has not been discussed in this workshop, it is an important area and there is a Technical Note with 10 guiding principles for the management of MAM. Participants asked questions on several specific points, for example: (i) the transitioning options (during transitioning, if the child does not consume the required kilo calories per day, the difference should be given in F-75); (ii) discharge criteria (the child is discharged from the SAM programme once weight-for-height is above -2 standard deviations; then the child should be integrated into a MAM programme); (iii) provision of vitamin A if a child has received vitamin A in the last six months (if the child has had vitamin A in the last six months, then a high dose of vitamin A should not be given; 5000 IU is the standard daily low dose for vitamin A in management of SAM, noting that it is not a one-off treatment but instead incorporated in food; (iv) breastfeeding is stressed at all times for infants and children 6–23 months old. The presentation on SAM included case management, indicating that case finding is very important in managing SAM for increased coverage and early referral. There are three ways children are identified with SAM: (i) active case finding; (ii) passive; and (iii) self-referral. Community mobilization usually results in increased self-referrals. The child should pass the appetite test6 during the stabilization phase. Children should be followed up regularly, even while in outpatient care. If the mother can breastfeed, then the child does not need naso-gastric feeding, which is a quite common practice. Health workers should be well trained to treat MAM with complications to prevent death of the child. WHO has many materials in the form of modules and videos on the training course for management of SAM. Botswana, Lesotho, Namibia, Swaziland and Zambia are already using these materials. The management of SAM follows three phases: stabilization; transition; and rehabilitation. Stabilization is the most critical phase with most deaths occurring at this point. When stabilizing the severely malnourished child, the initial management is crucial and measures should be taken immediately to prevent death. The first 48 hours are critical and regular monitoring to watch for danger signs is important (every 2 hours). Feeding must begin cautiously with F-75 in frequent small amounts. Participants were informed that the WHO 5-day training course is comprehensive and health workers should allocate sufficient time for the 6 To pass the appetite test, the child must eat at least one third of a packet of RUTF (92 g) or 3 teaspoons from a pot within 30 minutes.
25
training and to undergo the course in its entirety. It is unfortunate that very little time is allocated for inpatient management in most countries. When implemented well, management of SAM would help achieve the goal of less than 5% deaths due to SAM. The SAM child relies on the health worker for survival, calling for the need of comprehensive training to be re-emphasized. Management of SAM is easier in terms of training, but difficult to implement. One of the challenges is that when children survive initial management, then health workers tend to slack off on the daily monitoring and care. Another challenge regarding training is when staff/health workers are moved frequently or promoted, making it is necessary to train new staff frequently, which can be costly. Emotional stimulation for the child suffering from SAM, who usually has delayed mental and behavioural development, is very important. The mother or caregiver should feel as if she is part of the caring process both in hospital and later at home. In Nigeria, a food safety and water, sanitation and hygiene component has been included in training. There is a need for health systems strengthening and creation of malnutrition wards in hospitals. Contributions from participants included the need to have a strong institutional management. As health professionals, we should encourage a continuum of care. Children with SAM are already immune-compromised and death is more likely to occur in an institutional setting, thus participants were discouraged from institutional management of SAM cases. In Ethiopia, for example, health workers try to identify children with MAM before it worsens; and they endeavour to identify these children as early as possible to prevent development of SAM. During the discussion, participants asked about ways to maximize self-referral, and the responses included that self-referrals can be maximized by increasing community awareness to recognize the signs of malnutrition. In terms of training alternatives, it was mentioned that hospitals could consider on-the-job training. Similarly, WHO is looking into how to involve academia so that the curricula for medical and nursing students would include training components. The quality of training is compromised when it is shortened and integrating nutrition training in the medical and nursing curricula is one way of making the exercise sustainable. Zimbabwe commented that resources for different types of training are limited, so they combined infant and young child nutrition (IYCN) training with management of malnutrition based on the current recommendations. However, the aspect of involving mothers in the caring process for children with SAM is not adequately covered, although the MoH is in the process of updating the manuals in conjunction with the University of Zimbabwe to be included in the curricula for medical students. The chair handed over to the facilitators to moderate group work.
26
International nongovernmental organization work on supporting policy development
The representative from MI presented the organization’s vision and areas of focus, indicating that it is dedicated to ensuring that women and children receive essential nutrition services with a focus on four areas: child survival; child health, growth and development; women and newborn survival; and global impact. MI has offices in five countries, including Burkina Faso and Ethiopia. The organization tests new developments and ideas in these five countries and then scales up globally and at the country level to eliminate hidden hunger. It focuses on the first 1000 days of life for IYCN with zinc and vitamin A supplementation for children. They found gaps in complementary feeding, particularly for calcium, iron and zinc in a study in India. Similarly, acute and chronic malnutrition is high; therefore, focus is on prevention to make an impact on child survival. Participants were informed that MI does not work in isolation but collaborates with partners on programmes such as the Global Alliance for Improved Nutrition (GAIN), which represents the private sector, and UNICEF for technical assistance with independent renowned research institutions carrying out the monitoring and evaluation. In Ethiopia, they conducted a national food consumption study as well as a comprehensive regional food consumption study. From these studies it was easier to develop a model that fills the micronutrient gaps: pulses and grains are mixed to see what Optifood can be attained. MI uses locally available foods in the development of complementary food. Ideally, food consumption surveys should be carried out every five years. During the discussion, participants asked about how the model used in developing Optifood accounts for food safety. It was mentioned that standard operating procedures for grain banks are used to meet specific standards to minimize contamination and ensure food safety. However, the use of the Optifood model at the regional level and experiences of scaling up were described as limited. Therefore, to improve consumption of Optifood MI uses two approaches: • Rural practical approach: where families bring food/grain, which is then mixed and given back, whereby if they bring 2 kg they get back 3 kg. The downside of this is that people ended up bringing only grain because it was well subsidized and MI had to buy the legumes. • Commercial approach: through GAIN (private sector), whereby complementary food is produced, packaged and sold. This model uses BCC strategies to create demand for the complementary food.
WHO HQ/AFRO commented on how commercial production of these complementary foods affects access by at risk groups. For those at most in need and with limited access to commercial foods, MI promotes the use of locally available ingredients and foods.
27
Review and harmonization of 2014/2015 biennium plans of countries in relation to WHO nutrition-related guidelines: group work
Participants formed groups by country and a WHO Technical Officer discussed individual country biennium plans to identify strengths, weaknesses and gaps in implementation of the interventions that were discussed throughout the workshop. Tables 3 and 4 summarize the results of working group discussions conducted during the 3-day workshop, starting with a joint discussion on nutrition indicators and adoption of the WHO Child Growth Standards and continuing with country-specific discussions on the WHO Child Growth Standards, 0–5 months old, 6–23 months old, SAM and adolescents/women of reproductive age.
Table 3. Group presentation – nutrition indicators and adoption of the WHO Child Growth Standards
Question Which nutrition indicators are being tracked in your countries?
Group 1 EBF, minimum dietary adequacy (for 6–24 months old), weightfor-age, weight-forheight, height-for-age, LBW, community management of MAM coverage, vitamin A supplementation, anaemia, MUAC Maternal factors: IDA, postpartum vitamin A supplementation, iodine deficiency disorder, monitoring, urinary iodine, zinc supplementation
Group 2 Weight-for-age, height-for-age, weight-for-height, BMI for age, MUAC, EBF for the first 6 months
Group 3 Prevalence of stunting, underweight, overweight and wasting, number of children EBF before 6 months old, early initiation of breastfeeding, number of BFHI, number of households adequately using iodized salt and number of children receiving vitamin A and deworming tablets, number of pregnant women receiving IFAS, deworming and vitamin A within eight weeks of delivery, prevalence of anaemia in women and children under 5 months old, number of women counselled in IYCF and number of clients assessed in nutrition and counselled
Group 4 Weight-for-age, weight-for-height, height-for-age, MUAC, BMI for adults, birth weight
28
What were the these indicators?
Malnutrition burden, guidelines, health management and information system, prevalence
WHO/UNICEF recommendations
Member States adopted from WHO
Adopted and adapted from WHO, MUAC for community management of MAM; note that BMI for children is complicated
selection criteria for adoption of WHO
How often and at what level are these
Health facilities: monthly months, every year and at five years
Routine/periodic
Health facilities: monthly National level: quarterly
Variable
indicators collected? surveillance, every six
What is required to tackle these indicators (e.g. supplies and equipment; human resources)?
Training on the personnel, supplies, equipment, human resources (personnel and supervision)
Equipment, trained surveillance systems, software
Human resources, infrastructure, technical capacity
Salter scales, uniscabeam balance for babies, length/height boards, MUAC tapes, charts (to plot child and for teaching), age calculator, under 1 year old register, child welfare register, human resources, computer (database and software)
standards, guidelines, staff, supplies,
equipment, stationary, les, hanging scales,
What is needed to the WHO Child Growth Standards
Adoption of standards Consultations with all stakeholders, agreement with the WHO Child Growth Standards sustainability of the
Human resources, capacity-building
Consensus-building, external technical assistance, capacitybuilding both in human resources and equipment and materials
systematically adopt and guidelines,
implementation of the MoH to adopt the
at the national level? standards
List the areas where the capacity of health workers should be strengthened to effectively implement the WHO Child Growth Standards at the health facility and community levels.
Training on the guidelines/standards, proper use of the interpret and analyse
Data collection techniques, analysis, interpretation, and follow-up
Trained on use of standards
Anthropometric measurements (plotting, interpreting) and what actions to take
standards, capacity to counselling, referral
29
Table 4. Group presentation on actions required to implement essential nutrition actions and management of SAM Name of country:
Botswana Intervention
Key issues/gaps software does not analyse all collected indicators/variables
Priority actions required upgrade NNSS (software, training, hardware) Funding to continue training and improve BCC strategies at the community level Higher level advocacy for IYCF policy finalization Funding and technical assistance for capacity supervision) Technical and financial assistance on BCC strategies and IYCF counselling to communities to increase rates of EBF Technical assistance to review BMFHI implementation and advocacy to speed up “buying in” Higher level advocacy for maternity protection (maternity leave, “BF [breastfeeding] corners”)
WHO Child Growth Standards implementation
National nutrition surveillance system (NNSS) Technical assistance and funding support to
0–5 months old
IYCF policy still in draft form Low rates of early initiation of breastfeeding Low EBF rates on Baby Mother Friendly Hospital Initiative
Certification of hospitals and maternity wards development (in-service training, formative
6–23 months old
Poor BCC strategies for continued breastfeeding as well as for timely complementary feeding
Higher level advocacy and technical plus financial support Technical assistance in formulating effective BCC strategies Financial support for community training for effective complementary feeding
Adolescents and women of reproductive age
No current baseline data for micronutrient deficiencies Lack of food consumption study Poor advocacy strategies Poor BCC strategies
Financial and technical support to conduct surveys to come up with the country’s micronutrient profile (prevalence rates) Financial and technical support to conduct a food consumption study to be able to recommend a food vehicle for fortification Financial assistance to increase buffer stock for vitamin A, zinc, iron and folate Technical assistance to develop guidelines for the recommended micronutrients for this age group
30
Management of acute malnutrition
Partnerships with other programmes (IMCI, Nutrition Rehabilitation) Poor BCC strategies Continuous training Hard to reach areas
Technical assistance and funding to integrate management of SAM into other programmes Capacity-building (in particular, training and formative supervision of inpatient SAM) Assist with good BCC strategies for community and health-care workers Assist with strategies to access hard-to-reach populations as well as other areas Funding to increase buffer stocks: RUTF; F-75, F-100; rehydration solution for malnutrition (ReSoMal); combined mineral and vitamin mix (CMV)
Biennium plans
WHO Technical Officer yet to share country biennium plan
31
Name of country:
Comoros
Intervention WHO Child Growth Standards implementation 0–5 months old 6–23 months old
Key issues/gaps Standards not adapted
Priority actions required Adapt the standards, dissemination and training of health personnel and community involvement
Decrease in the practice of exclusive breastfeeding Lack of knowledge of the nutritional value of locally available foods Low rate of continued breastfeeding Weak integration of nutrition into
Reactivate BHFI and the training of community health workers Promote use of locally available foods and protection Promote and support breastfeeding Strengthen the integration of nutrition into coordination meetings
programmes such as IMCI and immunizations different programmes through advocacy and Adolescents and women of reproductive age Lack of interventions targeting adolescents and women of reproductive age Finalize and disseminate the Strategy for Adolescent Health Develop tools for micronutrient supplementation (iron and folic acid) for adolescents and women of reproductive age Nutrition and HIV Management of acute malnutrition Standards are not available National protocol is not adapted and health staff are not trained; not enough material is available Biennium plans National policy on food and nutrition has not been translated into a plan of action No tools for the management of acute malnutrition Nutrition surveillance system for children under 5 years old is outdated Weakness in the coordination, supervision and reporting of nutrition data Development of standards and training of health-care staff Adaptation of the protocol Capacity-building of health-care staff Provide appropriate materials to health facilities Finalize the action plan for implementing the National Nutrition Policy Develop and adapt the modules and tools, and ensure the training of health-care staff, including community health workers Update the database for nutrition surveillance Strengthen the coordination and integration of child-related programmes Revitalize the collection and dissemination of data
32
Name of country:
Eritrea
Intervention WHO Child Growth Standards implementation 0–5 months old
Key issues/gaps Standards not yet adapted, implementation is ongoing Maternity protection
Priority actions required Adapt the standards Provide WHO guidelines (materials) Maternity protection situation should be strengthened through legal action and highlevel advocacy
6–23 months old
BCC guidelines not yet adapted MNP not introduced Daily iron supplementation for infants and children 6–23 months old
Introduce use of multiple MNPs for home fortification of foods consumed by infants and young children High-level advocacy Evidence-based data for action Technical and financial support
Adolescents and women of reproductive age
No policy on IIFAS for adolescents and women of reproductive age No policy and strategic plan for vitamin A and
Technical and financial support to adapt an IFAS policy and strategy for adolescents and women of reproductive age nutrition policy to address gaps
calcium supplementation for pregnant women Technical and financial support to review
Nutrition and HIV Management of acute malnutrition Biennium plans
New guideline adapted Review and strengthen ongoing intervention on MAM Collaboration and partnership with stakeholders Most priorities of the MoH addressed Technical and financial support to review MAM interventions Strengthen collaboration with partners such as UNICEF, United Nations Population Fund, World Food Programme
33
Name of country:
Madagascar Intervention
Key issues/gaps Low coverage of health workers trained International Code of Marketing of Breastmilk Substitutes not implemented Feeble maternity protection Feeble implementation of BFHI in the private sector Low implementation of feeding LBW infants Infant feeding in the context of HIV not updated
Priority actions required Scaling up the health workers trained, with more financial support Implementation of the International Code of Marketing of Breast-milk Substitutes Strengthen maternity protection Relaunch the implementation of the BFHI in the private sector Strengthen feeding of LBW infants Update infant feeding in the context of HIV Adjust the evidence-based nutrition actions Adjust the evidence-based nutrition actions Update infant feeding in the context of HIV Integrate the new update in the national protocol of SAM management revised Integrate the gaps of new update in the plans
WHO Child Growth Standards implementation 0–5 months old
6–23 months old Adolescents and women of reproductive age Nutrition and HIV Management of acute malnutrition Biennium plans
To be updated To be adjusted
34
Name of country:
Malawi
Intervention WHO Child Growth Standards implementation 0–5 months old
Key issues/gaps Lack capacity of service providers to implement the standards during growth monitoring and promotion Ineffective implementation of BFHI Marketing of Breast-milk Substitutes Inadequate information on how facilities feed LBW babies
Priority actions required Training Supervision Review meetings Assessments and training Code of Marketing of Breast-milk Substitutes monitors, service providers, health workers and stakeholders Assessment of health facility feeding of LBW babies
Weak monitoring of the International Code of Review meetings and training of International
6–23 months old
Capacity for IYCF counselling and promotion of BFHI services at the facility level Feasibility of daily iron supplementation for infants and children 6–23 months old
Training and routine supervision and updates Conduct literature review (locally available data) Advocacy for inclusion of School Health Nutrition Advocate for policy change Develop fortification standards for centrally processed maize flour Update job aids and guidelines and orientation of service providers Review of nutrition care, support and treatment guidelines to incorporate emerging issues Conduct regular supervision and follow-up Update and incorporate all the above issues
Adolescents and women of reproductive age
No IIFAS for menstruating women No vitamin A supplementation for pregnant women Lack of standards for wheat and maize flour fortification
Nutrition and HIV
Job aids and guidelines not updated in line with 2010 WHO infant feeding recommendations Outdated guidelines for nutritional care and support of children 6 months–14 years old living with HIV (and adults)
Management of acute malnutrition Biennium plans
Inadequate follow-up and supervision 2014/2015 biennium plan for nutrition still in draft form
35
Name of country:
Namibia
Intervention WHO Child Growth Standards implementation 0–5 months old
Key issues/gaps Human resource constraints International Code of Marketing of Breastmilk Substitutes integrated into the Public Health Act Lack of monitoring of International Code of Marketing of Breast-milk Substitutes violations Assessment and reassessment of BMF hospitals never done
Priority actions required Finalize child health passport (health card) Cascade training, supervision and follow-up Advocate for standalone International Code of Marketing for Breast-milk Substitutes Technical assistance and training on International Code of Marketing of Breastmilk Substitutes Monitoring Cascade training for BMFI Assessment of hospitals Strengthen the quality of maternal and infant and young child nutrition through integration with antenatal care/PNC/EPI/ GMP/ IMNCI Micronutrient survey Micronutrient guideline and policy development (iron, folate, calcium)
6–23 months old
Weak complementary feeding counselling at the health facility level
Adolescents and women of reproductive age Nutrition and HIV Management of acute malnutrition
Key target group that were neglected
No uniform nutritional management of children 6 months–14 years old High staff turnover Weak supervision Poor adherence to guidelines
Incorporating new recommendations in the revised nutrition and HIV guidelines Adopt the new WHO recommendations and training materials Cascade training Strengthen supervision Finalize policy briefs
Biennium plans
Nutrition is under programme support (tuberculosis/HIV/ malaria /neglected tropical diseases)
36
Name of country:
Swaziland Intervention
Key issues/gaps Inadequate knowledge and skills among health workers at all levels Inadequate equipment and supplies
Priority actions required Financial and technical support to complete adoption process of the standards Capacity development for health facilities and health workers Advocacy to join the SUN movement and enactment of the International Code of Marketing of Breast-milk Substitutes Financial support to build capacity of health workers Integrate early initiation of breastfeeding into hospital policies and quality assurance programmes Revitalize BFHI and strengthen community systems for ongoing support for mothers
WHO Child Growth Standards implementation
0–5 months old
Not yet members of the Scaling Up Nutrition (SUN) movement New technical updates to be communicated to health workers Fragmented legal frameworks at the health facility level
6–23 months old
Inadequate knowledge and skills among health workers at all levels Weak referral and follow-up at all levels
Train more counsellors Strengthen referral and follow-up Strengthen supportive supervision and integration with other programmes Community mobilizations for creating demand
Adolescents and women of reproductive age Nutrition and HIV
Establish evidence to inform policy and programming Guidelines reviewed in light of new recommendations
Conduct School and Nutrition Assessment Develop framework for IIFAS Build capacity of health workers Technical assistance to review guidelines in light of the new HIV guidelines Orient health workers on updated guidelines Review and update national guidelines Build capacity of health workers Set up a nutrition surveillance system Advocacy to support government to fast track the process of being members of the SUN movement Support national coordination mechanisms and establishment of SUN (support national coordination mechanisms and establishment) Support implementation of the nutrition component of the Comprehensive Africa Agriculture Development Programme (CAADP) investment plan
Management of acute malnutrition Biennium plans
Guidelines reviewed in light of new recommendations
37
Name of country:
Seychelles Intervention
Key issues/gaps Currently not using the standards Based on our own context using the early childhood development study Implementation of BFHI not always in place Very low EBF (2%)
Priority actions required Adoption of the standards?
WHO Child Growth Standards implementation 0–5 months old
Refresher training on baby-friendly guidelines Funds for research on behavioural determinants for EBF Group support for mothers
6–23 months old
Food introduced is very poor in nutritional value Cow’s milk is introduced very early
Support for training of complementary feeding and continued breastfeeding Advocacy for government policies to adopt the supplementation of calcium and IFAS in women of reproductive age
Adolescents and women of reproductive age
Status of anaemia only known at pregnancy IFAS only given when women are diagnosed anaemic No IFAS for all women of reproductive age Calcium supplement not given but instead calcium rich food are encouraged to be consumed
Nutrition and HIV
Only done for infants where infant formula is recommended and breastfeeding is not promoted Regarding children there are too few children living with HIV/AIDS, therefore, no policy in place for nutrition and HIV infection
Despite low prevalence of children living with HIV/AIDS there is a need to develop a guideline on nutrition and HIV
Management of acute malnutrition Biennium plans
Not applicable Research on stunting and micronutrient deficiency carried out as currently it is assumed that undernutrition is not present in the country Research study on stunting and micronutrient deficiency Partnership with other UN agencies as funds allocated under WHO are very limited
38
United Republic of Tanzania Intervention WHO Child Growth Standards implementation
Name of country:
Key issues/gaps Growth monitoring booklets not finalized Inadequate capacity for using the new standards Inadequate equipment and supplies
Priority actions required Finalize and print the new standards monitoring booklets Conduct training for health-care providers at the facility level Procurement of length and height boards and weighing scales
0–5 months old
Inadequate number and functioning of BFHI Inadequate capacity of feeding and care for LBW babies National Code of Marketing of Breast-milk Substitutes not yet disseminated
Reassessment and re-accreditation of existing BFHI facilities Scale up BFHI facilities through training Capacity-building and establishment of Kangaroo Mother Care (KMC) at hospitals Conduct training at the primary health care provider level on IYCF counselling and support for breastfeeding Conduct dissemination workshops on the National Code of Marketing of Breast-milk Substitutes at the zonal level
6–23 months old
Low coverage of multiple MNPs for home fortification
Procure and distribute MNPs Conduct training and social marketing of MNPs at all levels Support establishment of revolving fund for procurement of MNPs
Adolescents and women of reproductive age
Low coverage of utilization of iodized salt in some regions Low coverage of maize flour fortification Updates on some of the recommended supplements are not yet in the national policy and guidelines
Facilitate enforcement of universal salt iodization Strengthen monitoring and evaluation of food fortification Conduct training on small-scale maize millers Conduct social marketing of fortified food products Conduct stakeholders’ meeting on updates on new recommended supplements for pregnant women and adolescent girls
Nutrition and HIV
Inadequate counselling and support for HIVpositive mothers
Train community health workers on counselling and support for breastfeeding Mobilize and create breastfeeding mother support groups
Management of acute malnutrition
Low coverage of facilities trained and providing SAM management services Low coverage of community-based SAM management
Conduct training to health-care providers on SAM management guidelines Procure and distribute commodities (e.g. F-75, F-100, RUTF) Conduct training to community health providers Procure supplies (e.g. MUAC tapes, RUTF)
Biennium plans 39
Uganda
Name of country:
Intervention WHO Child Growth Standards implementation 0–5 months old
Key issues/gaps Lack of equipment: height board, weight scales Policy for maternal protection not updated according to International Labour Organization recommendations
Priority actions required Provide anthropometric equipment Print growth chart and mother chart passport Capacity-building for implementation Support for capacity-building and community mobilization Advocacy across sectors and monitoring enforcement of the International Code of Marketing of Breast-milk Substitutes Advocacy for revision of the policy for maternal protection
6–23 months old
Low rate of continued breastfeeding Quality of complementary feeding poor No policy for iron supplementation for children 6–23 months old Inadequate lab capacity to analyse micronutrient biomarkers
Strengthen BCC, community education Tailor local foods, technical support for using Optifood and PROPAN tools Translate policy into actions Promote use of MNPs to enhance quality of complementary feeding Review vitamin A guidelines and MAM guidelines Roll out micronutrient programme Equip laboratory to analyse biomarkers
Adolescents and women of reproductive age
IIFAS in menstruating women not yet implemented Low coverage of daily IFAS for women during pregnancy the policy Vitamin A supplementation for pregnant women not in the policy Calcium supplementation for pregnant women edible oil fortification regulation
Review anaemia policy and make it relevant Roll out multisectoral anaemia action plan Social mobilization Male involvement survey) to see if current policy is effective Understand national needs, broadly discussed in the development of the micronutrient guideline Equipment, capacity-building, monitoring mobilization Orient health workers, community mobilization Local partners to continue work with MoH AIDS control programme
IIFAS for non-anaemic pregnant women not in Operational research (client satisfaction
Issuance of mandatory wheat, maize flour and and quality assurance, social marketing and Nutrition and HIV New recommendations on PMTCT programme option B+ not widely disseminated to health workers and at the community level Nutrition management under AIDS programme and PMTCT policies Management of acute malnutrition Management of inpatient SAM mainly ideal for national and regional referral hospitals and a few lower-level facilities New recommendations not included Biennium plans Review training modules to include new recommendations Funding for scale-up
40
Zambia
Name of country:
Intervention WHO Child Growth Standards implementation
Key issues/gaps Standards not adapted Inadequate supplies and equipment Inadequate number of people trained Inadequate finances
Priority actions required Funds to procure equipment, supplies and training Print training materials, information, education and communication materials and monitoring tools Continuous adaptation of national guidelines to incorporate changes from WHO guidelines Print training materials, IEC materials and monitoring tools Funds to procure equipment, supplies and training Continuous advocacy for support to revitalize issues concerning infants 0–5 months old Advocacy Integrate IDA control into malaria programmes Review of legislation on breast-milk substitutes Secure resources for equipment, supplies and training Conduct training to update newcomers in the field Intensify programmes that will improve the quality of complementary feeds
0–5 months old
Inadequate supplies and equipment Inadequate number of people trained Inadequate finances Frequent changes of guidelines Emphasis on correct breastfeeding practices has declined due to new health workers not trained on how to manage this age group
6–23 months old
Quality of complementary food Food insecurity Inadequate knowledge on preparation of complementary food Increased infectious diseases Inadequate in-service training in nutrition Increased number of companies producing IYCF Finances for scaling up Training materials Capacity-building of health and community staff Inadequate equipment and supplies Data capturing tools
Adolescents and women of reproductive age
Limited partners interested Limited programming area Limited access to guidelines on adolescents and maternal nutrition Inadequate stocks of iron and folic acid Non-availability of instruments to support maize meal and flour fortification
Advocacy for more partners to support adolescents and women reproductive age Finalize guidelines on maternal and infant and young child nutrition Source for funding to procure nutrition supplements Expedite enactment of statutory instrument on maize meal fortification Advocacy for support in the area of HIV/ nutrition
Nutrition and HIV
Limited partners interested Limited finance Limited equipment, supplies and commodities
41
Management of acute malnutrition
Limited resources for capacity-building, supplies, monitoring tools and commodities Limited human resources Increase in the number of cases of SAM Poor reporting by implementers Few partners interested in SAM/MAM Adaptation of training materials based on revised WHO guidelines
Adapt training materials based on revised WHO guidelines Source for funding to procure supplies, commodities, monitoring tools and build capacity in community and health workers Strengthen reporting system
Biennium plans
Aligned to the WHO biennium plans
Zimbabwe Intervention
Name of country:
Key issues/gaps Inadequate height boards Capacity of staff to take anthropometric measurements and standardization of anthropometric equipment
Priority actions required Procure height boards Resources for capacity-building for staff on anthropometry Advocacy and continuous support with financial and technical resources for training and mentorship Advocacy at the ministerial level Advocacy and resources for International Code of Marketing of Breast-milk Substitutes monitoring Financial resources for continuous training and updating of guidelines Integrate guidelines into in-service training Adopt policy for IFAS for adolescent girls Advocacy and further research Financial and technical resources to update guidelines Procure height boards Continuous training of health workers Integration in pre-service training Resource mobilization Add monitoring and evaluation component
WHO Child Growth Standards implementation
0–5 months old
Low commitment to achieving BFHI status due to competing priorities Alignment of labour regulations with EBF target Weak International Code of Marketing of Breast-milk Substitutes monitoring
6–23 months old
Inadequate capacity for counselling at the facility and community levels Zinc supplementation for diarrhoea management is not part of the nutrition policy
Adolescents and women of reproductive age Nutrition and HIV Management of acute malnutrition Biennium plans
No IFAS in adolescents No routine calcium supplementation Nutrition and HIV guidelines outdated Inadequate height boards Inadequate skills among health workers for management of acute malnutrition Resources inadequate for generating local evidence on nutrition for strengthening synergies in nutrition
Monitoring and evaluation component lacking to biennium plans
42
Review and harmonization of 2014/2015 biennium plans of countries with intercountry and regional plans
The regional 2014/2015 plan for nutrition was presented. Nutrition is now under noncommunicable diseases (Category 2) at AFRO. The regional plan has two outcome indicators: • number of stunted children under 5 years old; • proportion of women of reproductive age with anaemia.
All countries are contributing to these two outcomes. Deliverables for the outcome indicators include capacity-building for maternal and infant and young child nutrition interventions and introduction of innovative approaches. WHO is monitoring how countries are implementing the Comprehensive implementation plan on maternal, infant and young child nutrition. WHO regions have the same deliverables, which are unchangeable. The priority deliverables and top tasks for AFRO and IST include: (i) implementation of the Comprehensive implementation plan on maternal, infant and young child nutrition; (ii) strengthening the nutrition information system; (iii) supporting countries to adapt recent guidelines; and (iv) distributing technical tools to inform their nutrition programmes and carrying out operational research as needed. Countries are advocating the nutrition agenda through different strategies, for example, involving athletes in Uganda.7 The linkages with other sectors – such as agriculture, finance, and water, sanitation and hygiene – were highlighted. Limited funds have been allocated for implementation of nutrition activities in the region. Based on the presentation, the country representatives worked in groups to consider IST/AFRO plans to identify areas of support they needed to implement their biennium plans (Table 3 presents the outcomes and actions required).
Orientation on resource mobilization, opportunities for integration and collaboration
An overview of the Children’s Investment Fund Foundation (CIFF), as a possible source of financing for nutrition and child survival programmes, was presented. AFRO is interested in encouraging countries to work with their country counterparts to submit a letter of intent to CIFF, with a copy to the Head of Health Promotion to follow up with CIFF directly. The foundation website was provided as a source for further information. Countries interested in more information and advice were asked to contact IST/AFRO representatives to learn about the experiences of other countries that have already submitted a letter of intent and are waiting for responses.
7 At the time of the workshop, the Nutrition Department in the Uganda MoH was involved in a run with renowned athlete and Olympic gold medal winner Stephen Kiprotich in Bushenyi district, Uganda.
43
Conclusion and next steps
The participants identified issues and gaps in their respective countries through group work and exercises. Some of the key issues include general lack of evidence or baseline data on prevalence rates for certain micronutrients. All countries identified the need for advocacy and BCC strategies. Countries have hard-to-reach areas where services and interventions may not be accessible to the neediest. Many strategies require male involvement, which is generally lacking, hence the need for good BCC strategies. Overall, there is high staff turnover and human resources constraints in the institutions. In addition, capacity-building and continuous training are required for staff, yet many institutions are financially constrained and unable to fund these activities. Participants cited technical and financial assistance as requirements for reviews, implementation, training and supervision. Formulation of effective BCC strategies similarly requires financial and technical assistance. There is need to strengthen collaboration and partnerships with other programmes, partners and stakeholders. Countries cited the need to advocate for policy changes as well as updates on recommendations and guidelines. Participants underscored the requirement for technical and financial assistance to support baseline surveys. Procurement of or increasing buffer stock for vitamin A, iron, folic acid, F-75, F-100 and RUTF as well as equipment such as MUAC tapes, scales and software is necessary. Biennium plans should be updated and incorporate a monitoring and evaluation component. Reporting systems need to be strengthened and policy briefs finalized.8 As next steps, countries agreed to finalize their biennium plans using the updates and tools shared during the workshop. IST/ESA also is committed to harmonize its plan with country plans where actions from IST are required based on the details in Table 5.
8 Action points, although somewhat similar, vary from country to country. For more information, Table 3 describes consolidated action plans for individual countries.
44
Table 5. Key nutrition indicators in participating countries a,b Country IDA among WRA Botswana Comoros Eritrea Lesotho Madagascar Malawi Mauritius Namibia Seychelles Swaziland of Tanzania Uganda Zambia Zimbabwe a
IDA among All anaemia in children -----23 -c
All anaemia in children 43 51 59 49 50 52 44 49 37 42 61 (urban) 58 (rural) 57 (urban) 74 (rural) 59 58
VAD in children 6–59 months old -----40 ----20e 4 (urban) 3 (rural) 54a -c
VAD in WRA
EBF % (0–5 months old)
Stunting % 31c 47 44 39c 52 47 -29 -28 35 33c 45c 32 c c c c
Wasting %
Underweight % Overweight in children %
WRA % (non pregnant) 28 30 33 38 (urban) 24 (rural) 32 47 d
--f ----9 c
-----3 c
20c 21 69 c
9c 13 15 4c 15 4 c
12c 25 35 13c 37 13 -17 -5 c c c
15c 25 2 17c 7 5 -5 -13 7 6 11 6c
54 51 71 -24 -44 50 63 61c 32 c
-35 --c
23 c
-----15 (urban) 21 (rural) 13c --
-8 -3 7 5c 5c 3 c c
63 -----
33 21 30 43 (urban) 39 (rural) 35 (urban) 52 (rural) 29 39 (urban) 37 (rural)
United Republic --29 --
14 14c 15c 10 c
51c --
Sources of data: WHO global database on child growth and malnutrition;
WHO vitamin and mineral information system; WHO global data bank on infant and young child feeding. b c d e f
All countries had high coverage for households utilizing iodized salt. Sources of data: Personal report by country representatives. 38% in pregnant women. Children 6–71 months old. “--“ means no data available.
Additional comments
For the most part, the participants felt that the workshop was wellorganized. In particular, they expressed satisfaction over the content and choice of participants. The range of topics covered by the workshop was found to be relevant especially on policy implication and programming for measurable results. The participants also felt that the workshop provided a forum for WHO and Ministry of Health technocrats to share knowledge and experiences, thereby strengthening operational partnerships. In addition, the participants thought the presentations were well prepared and the facilitators good. One recurrent issue was the length of the workshop. The 3-day duration was considered to be too short, which limited the time spent on questions and answers and discussions. It was recommended that an extra day be added to similar workshops to enable thorough deliberation and also allow participants to prepare for return travel. It was also suggested that individual country group work should be completed prior to the workshop to save time. Furthermore, some participants reported that their invitations were delivered so late that they were unable to make adequate preparations. While a few participants felt at a disadvantage by the lack of a translator (2 out of the 13 countries were francophone), most felt the quality of the sound and visibility of the presentations were poor due to the size of the room and could be improved in future.
46
Annexes
Workshop: Maternal, infant and young child nutrition in East and Southern African (ESA) countries: moving to national implementation Annex 1. 26–28 November 2013 Workshop agenda Imperial Golf View Hotel – Entebbe, Uganda
Time 08:00– 09:00 09:00–10:00 Activity Registration Official opening ceremony Welcome remarks and objectives and expected outcomes Brief opening remarks by WCO/Uganda Brief opening remarks by WHO headquarters Opening remarks by Uganda MoH Security briefing and administrative announcements 10:00– 10:15 10:15– 10:30 Session 1 Objective 1: Present technical updates on maternal, newborn, child and adolescent nutrition, including new initiatives, tools and guidelines Objective 2: Review and harmonize 2014/2015 biennium plans of countries in relation to WHO nutrition-related guidelines Day 1 Chairs: Dr Elizabeth Kiboneka (Uganda) and Dr Mercy Chikoko (AFRO) Day 1 Rapporteurs: Uganda and Zambia (overall rapporteurs – United Republic of Tanzania and Zimbabwe) 10:30–10:40 10:40–11:10 11:10–11:25 11:25– 12:00 12:00–12:15 12:15– 12:45 12:45– 13:00 13:00–14:00 14:00–15:15 Nomination of chairs and co-chairs Global nutrition challenges and the way forward with special focus on the African Region Discussion WHO Comprehensive implementation plan on maternal, infant and young child nutrition Discussion Tracking the implementation of the Comprehensive implementation plan on maternal, infant and young child nutrition Discussion Lunch break WHO Child Growth Standards and assessing growth presentation Questions and answers Country group work (adoption of the standards and indicators used in the Facilitators country, availability of supplies and equipment…) 15:15–16:00 Guidelines development process and dissemination – eLENA Presentation Demonstration of the use of eLENA Questions and answers 16:00–16:30 16:30– 17:15 Break Introduction to essential nutrition actions: a lifecycle approach Presentation Questions and answers 17:15–18:00 Facilitators meeting Dr C Casanovas Secretariat Dr C Casanovas Dr M de Onis Dr M de Onis Dr H Bekele Dr H Bekele Dr M de Onis Group photograph Break Dr H Bekele WR Uganda Dr M de Onis MoH/Uganda WCO Ms J Maswera – IST/ESA Ms J Maswera – IST/ESA Responsible person Ms J Maswera – IST/ESA
Day 1: Tuesday 26 November 2013
47
Day 2: Wednesday 27 November 2013 Session 2 Objective 1: Present technical updates on maternal, newborn, child and adolescent nutrition, including new initiatives, tools and guidelines Objective 2: Review and harmonize 2014/2015 biennium plans of countries in relation to WHO nutrition-related guidelines Day 2 Chairs: Ms Doreen Hotive (Seychelles) and Ms Danisile B Vilakati (Swaziland) Day 2 Rapporteurs: Botswana and Kenya (overall rapporteurs – United Republic of Tanzania and Zimbabwe) 08:30–08:45 08:45– 09:30 Recap of Day 1 Micronutrient Initiative work Presentation Questions and answers 09:30– 10:15 Interventions for infants 0–5 months old – recommendations and rationale (early initiation, EBF, LBW, BFHI, International Code of Marketing of Breast-milk Substitutes implementation and monitoring, maternity protection) Presentation Questions and answers Country work (status of implementation of interventions for infants 0–5 months old, integration of actions into their plans) 10:15–10:30 10:30– 11:30 11:30– 13:00 Break Country work (status of implementation of interventions for infants 0–5 months old, integration of actions into their plans) (continuation) Interventions for infants and young children 6–23 months old – recommendations and rationale Presentation Questions and answers Country work (status of implementation of interventions for infants and young children 6–23 months old, integration of actions into their plans) 13:00– 14:00 14:00– 15:30 Lunch break Nutrition recommendations in the context of HIV/AIDS Presentation Questions and answers Country work (status of implementation of interventions, integration of actions into their plans) 15:30– 17:00 Nutrition interventions for adolescents and women of reproductive age Presentation Questions and answers Country work (status of implementation of interventions, integration of actions into their plans) (break included at the time of group work) 17:00–17:30 Facilitators meeting Country groups to finalize work related to integration of global guidelines considering their context Secretariat Facilitators available Facilitators Dr H Bekele Facilitators Dr C Casanovas Facilitators Dr C Casanovas Facilitators Facilitators Dr H Bekele Rapporteurs of Day 1 Dr Abdulaziz Adish
48
Day 3: Thursday 28 November 2013 Session 3 Objective 1: Present technical updates on maternal, newborn, child and adolescent nutrition, including new initiatives, tools and guidelines Objective 2: Review and harmonize 2014/2015 biennium plans of countries in relation to WHO nutrition-related guidelines Day 3 Chairs: Mr Frank Msiska (Malawi) Day 3 Rapporteurs: Namibia and Swaziland (overall rapporteurs – United Republic of Tanzania and Zimbabwe) 08:30–08:45 08:45– 09:30 Recap of Day 2 Updates on management of SAM – adaptation and Implementation of the new guidelines Presentation Questions and answers 09:30– 11:00 Comprehensive management of SAM Presentation Questions and answers Country work (status of implementation of interventions, integration of actions into their plans) (break included) Session 4 Objective 2: Review and harmonize 2014/2015 biennium plans of countries in relation to WHO nutrition-related guidelines Objective 3: Review and harmonize 2014/2015 biennium plans of countries with intercountry and regional plans Chair: Mr Frank Msiska (Malawi) Rapporteurs: Lesotho and Swaziland (overall rapporteurs – Zambia and Zimbabwe) 11:00– 13:00 Presentation of IST plans Country group work to finalize review of biennium plans and identify area of support by IST/headquarters 13:00– 14:00 14:00– 16:30 Lunch break Country group presentations Presentations highlighting key issues Feedback Session 5 Objective 4: To orient participants on resource mobilization, opportunities for integration and collaboration and wrap up Chair: Mr Frank Msiska (Malawi) Rapporteurs: Lesotho and Swaziland (overall rapporteurs – United Republic of Tanzania and Zimbabwe) 16:30– 17:00 17:00– 17:30 Orientation on how to access CIFF and discussion on the way forward (break included) Workshop evaluation and closing Secretariat Dr H Bekele Dr H Bekele Facilitators Facilitators Ms Z Weise Prinzo Ms Z Weise Prinzo Rapporteurs of Day 2
49
Annex 2: List of participants Country representatives Mr Emmanuel Ahimbisibwe Health Services Manager Ministry of Health Kampala, UGANDA Ms Agness Aongola Chief Nutrition Liaising Officer Ministry of Health Lusaka, ZAMBIA Dr Vicent D Assey Assistant Director Nutrition Services Ministry of Health and Social Welfare Dar-es Salaam, UNITED REPUBLIC OF TANZANIA Dr Mary Azayo National Child Health Coordinator Ministry of Health and Social Welfare Dar-es Salaam, UNITED REPUBLIC OF TANZANIA Dr Agnes Chandia Baku Nutritionist Ministry of Health Kampala, UGANDA Ms Yvonne T Chinyanga Senior Health Nutrition Officer Ministry of Health Gaborone, BOTSWANA Mrs Amleset Hagos Nutrition Head Ministry of Health Asmara, ERITREA Ms Asha Hassan Salmin Nutritionist Ministry of Health Zanzibar, UNITED REPUBLIC OF TANZANIA Mr Ahmed Mohamed Point Focal National Nutrition Ministry of Health Moroni, COMOROS
50
Mr Frank Msiska Chief Nutritionist Ministry of Health Lilongwe, MALAWI Ms Monica Muti Nutrition Intervention Manager Ministry of Health and Child Care Harare, ZIMBABWE Mr Mike Mwanza Principal Nutritionist Food & Nutrition Commission Lusaka, ZAMBIA Ms Sarah Ngalombi Senior Nutritionist Ministry of Health Kampala, UGANDA Mrs Jerida Nyatsanza Food and Nutrition Council Harare, ZIMBABWE Ms Celia Ponzo Nutrition Health Promotion Officer Ministry of Health Victoria Mahe, SEYCHELLES Mrs Sadhana Purgus Senior Nutritionist/Dietician Ministry of Health and Quality of Life Port Louis, MAURITIUS Dr Harinelina Randriamasiarijoana Point Focal National Nutrition Ministry of Health Miusau, MADAGASCAR Mrs Neheng Relebetse Moeketsi Senior Nutritionist Ministry of Health Maseru, LESOTHO Ms Marjorie Van Wyk Health Programme Officer/Nutritionist Ministry of Health Windhoek, NAMIBIA
51
Ms Danisile B Vilakati Director Swaziland National Nutrition Council Ministry of Health Mbabane, SWAZILAND
Partners
Dr Abdulaziz Adish Deputy Regional Director Micronutrient Initiative Addis Ababa, ETHIOPIA Mr Martin Ahimbisibwe Nutrition Advisor World Food Programme Kampala, UGANDA Ms Nelly Birungi Nutrition Specialist UNICEF Kampala, UGANDA Dr Ellen Girerd-Barclay International Facilitator REACH Kampala, UGANDA Dr Harriet Kivumbi National Facililtator REACH Kampala, UGANDA Ms Beatrice Okello National Programme Officer Food and Nutrition Support Food and Agriculture Organization Kampala, UGANDA
Secretariat
Dr Hissani AbdouBacar Focal Point Nutrition Comoros Country Office World Health Organization Moroni, COMOROS
52
Dr Isiaka Alo Nutrition Technical Officer Tanzania Country Office World Health Organization Dar es Salaam, UNITED REPUBLIC OF TANZANIA Dr Hana Bekele Food and Nutrition Focal Point Intercountry Support Team East and Southern Africa World Health Organization Harare, ZIMBABWE Dr Maria del Carmen Casanovas Technical Officer Evidence and Programme Guidance Unit Department of Nutrition for Health and Development World Health Organization Geneva, SWITZERLAND Dr Mercy Chikoko Nutrition Technical Adviser WHO Regional Office for Africa Brazzaville, CONGO Mr Admire Chinjekure National Programme Officer/Nutrition Zimbabwe Country Office World Health Organization Harare, ZIMBABWE Dr Ferima Coulibaly-Zerbo Nutrition Technical Officer West Africa Intercountry Support Team World Health Organization Ouagadougou, BURKINA FASO Dr Mercedes de Onis Coordinator Growth Assessment and Surveillance Unit Department of Nutrition for Health and Development World Health Organization Geneva, SWITZERLAND
53
Ms Dudu Dlamini FHP Officer Swaziland Country Office World Health Organization Mbabane, SWAZILAND Dr Yohannes Ghebrat National Programme Officer Disease Prevention and Control Eritrea Country Office World Health Organization Asmara, ERITREA Dr Andemichael Ghirmay MCHM Officer Namibia Country Office World Health Organization Windhoek, NAMIBIA Ms Doreen Hotive National Programme Officer Health Information and Promotion Seychelles Country Office World Health Oranization Victoria, SEYCHELLES Dr Susan Kambale National Programme Office Child and Adolescent Health/Nutrition Malawi Country Office World Health Organization Lilongwe, MALAWI Ms Jesca Maswera Food and Nutrition Administrative Assistant Intercountry Support Team East and Southern Africa World Health Organization Harare, ZIMBABWE Ms Chipo Mwela National Programme Officer/Nutritionist Zambia Country Office World Health Organization Lusaka, ZAMBIA
54
Miss Vivian Nambozo Nutritionist NDC/Private Consultant Kampala, UGANDA Dr Priscilla Ravonimanantsoa Nutrition Technical Officer Uganda Country Office World Health Organization Kampala, UGANDA Dr Angeline Razanatsoa National Programme Officer Nutrition/Child and Adolescent Health Madagascar Country Office Antananarivo, MADAGASCAR Dr James Teprey Technical Officer Kenya Country Office World Health Organization Nairobi, KENYA Ms Mantsane Tsoloane-Bolepo National Programme Office Lesotho Country Office World Health Organization Maseru, LESOTHO Ms Zita Weise Prinzo Technical Officer Evidence and Programme Guidance Unit Department of Nutrition for Health and Development World Health Organization Geneva, SWITZERLAND
55
Annex 3: References and bibliography References 1. Resolution WHA65.6. Comprehensive implementation plan on maternal, infant and young child nutrition (http://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf, English; http://www.who.int/nutrition/topics/WHA65.6_resolution_fr.pdf, French). 2. Annex 2 – Comprehensive implementation plan on maternal, infant and young child nutrition (http://www.who.int/nutrition/topics/WHA65.6_annex2_en.pdf, English; http://www.who.int/nutrition/topics/WHA65.6_annex2_fr.pdf, French). 3. UNICEF, WHO, World Bank Joint Child Malnutrition Estimates. New York: UNICEF; Geneva: WHO; Washington DC: World Bank; 2012 (http://www.who.int/nutgrowthdb/estimates/en/index.html). 4. Maternal and child nutrition: executive summary. Lancet Maternal and Child Nutrition Series, 2013. 5. Maternal and child nutrition. Lancet Maternal and Child Nutrition Series II, June 2013. 6. WHO Child Growth Standards documentation (http://www.who.int/childgrowth/standards/en/, English; http://www.who.int/childgrowth/standards/fr/index.html, French). 7. WHO Multicentre Growth Reference Study (MGRS) (http://www.who.int/childgrowth/mgrs/en/, English; http://www.who.int/childgrowth/mgrs/fr/index.html, French). child health and nutrition. Geneva: WHO; 2013 (http://www.who.int/nutrition/publications/infantfeeding/essential_ nutrition_actions/en/index.html). 9. International Code of Marketing of Breast-milk Substitutes. Geneva: WHO; 1981. 10. Guideline: use of multiple micronutrient powders for home fortification of foods consumed by infants and children 6–23 months of age. Geneva: WHO; 2011 (http://www.who.int/nutrition/publications/micronutrients/guidelines/ guideline_mnp_infants_children/en/index.html). 11. Guideline: vitamin A supplementation in infants and children 6–59 months of age. Geneva: WHO; 2011 (http://www.who.int/nutrition/publications/ micronutrients/guidelines/vas_6to59_months/en/index.html). 12. Daelmans B et al. Designing appropriate complementary feeding recommendations: tools for programmatic action. Mater Child Nutr. 2013;9 (Suppl. 2):116–30. 13. Guidelines on HIV and infant feeding 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. Geneva: WHO; 2010 (http://www.who.int/maternal_child_adolescent/ documents/9789241599535/en/index.html). 14. Guidelines for an integrated approach to the nutritional care of HIV-infected children (6 months–14 years old) (handbook, chart booklet, adaptation guide). Geneva: WHO; 2009. 15. Peña-Rosas et al. Daily oral iron supplementation during pregnancy. Cochrane Database Syst Rev. 2012; (12):CD004736. DOI:10.1002/14651858.CD004736. pub4. 8. Essential nutrition actions: improving maternal, newborn, infant and young
56
Bibliography
Baby-Friendly Hospital Initiative: revised, updated and expanded for integrated care. New York: UNICEF, Geneva: World Health Organization; 2009 (http://www.who.int/nutrition/publications/infantfeeding/bfhi_ trainingcourse/en/index.html). Global nutrition policy review: What does it take to scale up nutrition action? Geneva: World Health Organization; 2013 (http://www.who.int/nutrition/publications/policies/global_nut_ policyreview/en/index.html). Guideline: calcium supplementation in pregnant women. Geneva: World Health Organization; 2013 (http://www.who.int/nutrition/publications/micronutrients/guidelines/ calcium_supplementation/en/index.html). Guideline: updates on the management of severe acute malnutrition in children under-five. Geneva: World Health Organization; 2013 (http://www.who.int/nutrition/publications/guidelines/ updates_management_SAM_infantandchildren/en/). Guideline: daily iron and folic acid supplementation in pregnant women. Geneva: World Health Organization; 2012 (http://www.who.int/nutrition/publications/micronutrients/guidelines/ daily_ifa_supp_pregnant_women/en/index.html). Guideline: intermittent iron and folic acid supplementation in menstruating women. Geneva: World Health Organization; 2011 (http://www.who.int/nutrition/publications/micronutrients/guidelines/ guideline_iron_folicacid_suppl_women/en/index.html). Guideline: intermittent iron and folic acid supplementation in non-anaemic pregnant women. Geneva: World Health Organization; 2012 (http://www.who.int/nutrition/publications/micronutrients/guidelines/ guideline_intermittent_ifa_non_anaemic_pregnancy/en/index.html). Guideline: vitamin D supplementation in pregnant women. Geneva: World Health Organization; 2012 (http://www.who.int/nutrition/publications/micronutrients/guidelines/ vit_d_supp_pregnant_women/en/index.html). Guideline: neonatal vitamin A supplementation. Geneva: World Health Organization; 2011 (http://www.who.int/nutrition/publications/micronutrients/guidelines/ vas_neonatal/en/index.html). Guideline: use of multiple micronutrient powders for home fortification of foods consumed by pregnant women. Geneva: World Health Organization; 2011 (http://www.who.int/nutrition/publications/micronutrients/guidelines/ guideline_mnp_pw/en/index.html). Guideline: vitamin A supplementation in pregnancy for reducing the risk of motherto-child transmission of HIV. Geneva: World Health Organization; 2011 (http://www.who.int/nutrition/publications/micronutrients/guidelines/ vas_mtct_hiv/en/index.html). Guideline: vitamin A supplementation in infants 1–5 months of age. Geneva: World Health Organization; 2011 (http://www.who.int/nutrition/publications/micronutrients/guidelines/ vas_infants_1-5/en/index.html).
57
Guideline: vitamin A supplementation in postpartum women. Geneva: World Health Organization; 2011 (http://www.who.int/nutrition/publications/micronutrients/guidelines/ vas_postpartum/en/index.html). Guideline: vitamin A supplementation in pregnant women. Geneva: World Health Organization; 2011 (http://www.who.int/nutrition/publications/micronutrients/guidelines/ vas_pregnant/en/index.html). Guiding principles for feeding non-breastfed children 6–24 months of age. Geneva: World Health Organization; 2005 (http://www.who.int/maternal_child_adolescent/documents/9241593431/ en/index.html). Guiding principles for complementary feeding of the breastfed child. Washington DC: Pan American Health Organization; 2003 (http://www.who.int/nutrition/publications/infantfeeding/a85622/en/index.html). Nutrient adequacy of exclusive breastfeeding for the term infant during the first six months of life. Geneva: World Health Organization; 2002 (http://www.who.int/nutrition/publications/infantfeeding/9241562110/ en/index.html). Report of the expert consultation of the optimal duration of exclusive breastfeeding. Geneva, Switzerland, 28–30 March 2001. Geneva: World Health Organization; 2001 (http://www.who.int/nutrition/publications/infantfeeding/WHO_ NHD_01.09/en/index.html). The optimal duration of exclusive breastfeeding: a systematic review. Geneva: World Health Organization; 2001 (http://www.who.int/nutrition/publications/infantfeeding/WHO_ NHD_01.08/en/index.html). WHA63.23 Infant and young child nutrition. Geneva: World Health Organization; 17–21 May 2010 (http://www.who.int/nutrition/topics/WHA63.23_iycn_en.pdf, English; http://www.who.int/nutrition/topics/WHA63.23_iycn_fr.pdf, French). WHA61.20 Infant and young child nutrition: biennial progress report. Geneva: World Health Organization; 19–24 May 2008 (http://www.who.int/nutrition/topics/WHA61.20_iycn_en.pdf, English; http://www.who.int/nutrition/topics/WHA61.20_iycn_fr.pdf, French). WHA58.32 Infant and young child nutrition. Geneva: World Health Organization; 16–25 May 2005 (http://www.who.int/nutrition/topics/WHA58.32_iycn_en.pdf, English; http://www.who.int/nutrition/topics/WHA58.32_iycn_fr.pdf, French). WHA59.21 Infant and young child nutrition 2006. Geneva: World Health Organization; 22–27 May 2006 (http://www.who.int/nutrition/topics/WHA59.21_iycn_en.pdf, English; http://www.who.int/nutrition/topics/WHA59.21_iycn_fr.pdf, French). WHA59.11 Nutrition and HIV/AIDS. Geneva: World Health Organization; 22–27 May 2006 (http://www.who.int/nutrition/topics/WHA59.11_nutandhivaids_en.pdf, English; http://www.who.int/nutrition/topics/WHA59.11_nutandhivaids_fr.pdf, French).
58
WHA55.25 Infant and young child nutrition. Geneva: World Health Organization; 13–18 May 2002 (http://www.who.int/nutrition/topics/WHA55.25_iycn_en.pdf, English; http://www.who.int/nutrition/topics/WHA55.25_iycn_fr.pdf, French). WHA54.2 Infant and young child nutrition. Geneva: World Health Organization; 14–22 May 2001 (http://www.who.int/nutrition/topics/WHA54.2_iycn_en.pdf, English; http://www.who.int/nutrition/topics/WHA54.2_iycn_fr.pdf, French). WHA49.15 Infant and young child nutrition. Geneva: World Health Organization; 20–25 May 1996 (http://www.who.int/nutrition/topics/WHA49.15_iycn_en.pdf, English; http://www.who.int/nutrition/topics/WHA49.15_iycn_fr.pdf, French). WHA47.5 Infant and young child nutrition. Geneva: World Health Organization; 2–12 May 1994 (http://www.who.int/nutrition/topics/WHA47.5_iycn_en.pdf, English); http://www.who.int/nutrition/topics/WHA47.5_iycn_fr.pdf, French). WHA45.34 Infant and young child nutrition and status of implementation of the International Code of Marketing of Breast-milk Substitutes. Geneva: World Health Organization; 4–14 May 1992 (http://www.who.int/nutrition/topics/WHA45.34_iycn_en.pdf, English; http://www.who.int/nutrition/topics/WHA45.34_iycn_fr.pdf, French). WHA43.3 Protecting, promoting and supporting breastfeeding. Geneva: World Health Organization; 7–17 May 1990 (http://www.who.int/nutrition/topics/WHA43.3_iycn_en.pdf, English; http://www.who.int/nutrition/topics/WHA43.3_iycn_fr.pdf, French). WHA41.11 Infant and young child nutrition. Geneva: World Health Organization; 2–13 May 1988 (http://www.who.int/nutrition/topics/WHA41.11_iycn_en.pdf, (English); http://www.who.int/nutrition/topics/WHA41.11_iycn_fr.pdf, (French). WHA39.28 Infant and young child feeding. Geneva: World Health Organization; 5–16 May 1986 (http://www.who.int/nutrition/topics/WHA39.28_iycn_en.pdf, English; http://www.who.int/nutrition/topics/WHA39.28_iycn_fr.pdf, French). WHA37.30 Infant and young child nutrition. Geneva: World Health Organization; 7–17 May 1984 (http://www.who.int/nutrition/topics/WHA37.30_iycn_en.pdf, English; http://www.who.int/nutrition/topics/WHA37.30_iycn_fr.pdf, French). WHA35.26 International Code of Marketing of Breast-milk Substitutes. Geneva: World Health Organization; 3–14 May 1982 (http://www.who.int/nutrition/topics/WHA35.26_iycn_en.pdf, English; http://www.who.int/nutrition/topics/WHA35.26_iycn_fr.pdf, French).
59
Annex 4: Templates for group work
Infants 0–5 months old interventions Name of country _____________________________________________
Target group Intervention areas
Evidence-informed actions
Contained in National Nutrition Policy? (YES or NO)
Contained in National Plan of Action? (YES or NO)
Not implemented
National
Subnational
Support required
Infants (0–5 months old)
Early initiation of breastfeeding Counselling and support at the facility and community levels EBF Implementation of BFHI Implementation of the International Code of Marketing of Breast-milk Substitutes Maternity protection Feeding of LBW infants Infant feeding in the context of HIV Counselling and support Counselling and support to HIV-positive mothers
Infants and young children 6–23 months old interventions Name of country _____________________________________________ Intervention Contained in National Nutrition Policy? (YES or NO) Counselling and support at the facility and community levels Implementation of the International Code of Marketing of Breast-milk Substitutes Use of multiple MNPs for home fortification of foods consumed by infants and young children Vitamin A supplementation for infants and children 6–59 months old Daily iron supplementation for infants and young children 6–23 months old Zinc supplementation for children with diarrhoea Iodine supplementation for children SAM management MAM management Nutritional care and support of children 6 months–14 years old living with HIV Contained in National Plan of Action? (YES or NO) Not implemented National Subnational Level of Implementation Support required (Indicate if from headquarters, AFRO, etc.)
Interventions for adolescents and women of reproductive age Name of country ___________________________________ Target group Intervention areas Evidence-informed actions Contained in National Nutrition Policy? (YES or NO) Women of reproductive age Pregnant women Iron and folic acid deficiency Iron and folic acid deficiency IIFAS for non-anaemic pregnant women VAD Calcium status Iodine deficiency Nutrition in the context of emergencies Micronutrient status Wheat and maize flour fortification Vitamin A supplementation for pregnant women Calcium supplementation for pregnant women Iodine supplementation for pregnant and lactating women Nutritional care and support for pregnant and lactating women living in emergency situations Daily IFAS for women during pregnancy IIFAS for menstruating women Contained in National Plan of Action? (YES or NO) Not implemented National Subnational Level of implementation Support required
Template for group work interventions on acute malnutrition Name of country _____________________________ Intervention Reflected in National Nutrition Policy Community mobilization/ screening SAM outpatient SAM inpatient MAM Linkages (e.g. IYCF, IMCI and others) Reflected in National Plan of Action Training conducted? With what materials? Supplies available National budget for interventions for SAM Level of coverage Not implemented National Subnational Challenges Support required
Additional question: Have the new recommendations on SAM been integrated into your national protocol/training material? If no, when are you planning on integrating them and what support do you need?
Annex 5: Evaluation form
Workshop/meeting/conference evaluation form Anonymous evaluation Please kindly take time to provide your honest assessment about this meeting/conference. The purpose of this anonymous evaluation is to enable WHO to improve the quality of services related to subregional, regional and international meetings and conferences taking place in Harare. Your opinion counts! Meeting title: Workshop on Maternal, infant and young child nutrition in East and Southern African (ESA) countries: moving to national implementation Meeting dates: 26–28 November 2013 Venue: Golf View Hotel, Entebbe, Uganda
Assessment of services: please check the appropriate box 1 2 3 4 5 6 7 8 9 10 11 12 Services Invitation and travel arrangements Meeting information note Visa processing Flight experience Airport shuttle Hotel facilities and rooms Hotel staff support Coffee/tea and meals Plenary room Sound and interpretation Intercountry team staff support Secretariat support Very good Good Not Not Satisfactory satisfactory applicable
Additional comments or suggestions on the items listed above …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… ………………………………………………………………………………………………………… …………………………………………………………………………………………………………… Which aspects related to this meeting/conference not listed above would you like to comment on? …………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………... Thank you for your attention and cooperation.
64
Figure 3. Participants at the WHO workshop: Maternal, Infant and Young Child Nutrition in East and South African countries: Moving to National Implementation held at the Imperial Golf View Hotel, Entebbe, Uganda, 26–28 November 2013
65
For more information, please contact: Department of Nutrition for Health and Development Evidence and Programme Guidance World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 4156 Email: nutrition@who.int www.who.int/nutrition