26 May 2015   

Meeting the Nutrition Needs of Children in Disaster and Development

United Nations Convention on the Rights of the Child stipulates that every child have the right to adequate food, water, shelter and education. Every year, malnutrition contributes to 3.5 million preventable deaths of children under the age of five. Disasters, whether they be sudden-onset or chronic long-term events, have massive impact on food security, disease and nutritional status of at-risk groups, especially children, pregnant and lactating mothers. At a time when climate change is projected to increase the risk of hunger and undernutrition over the next few decades to severely impact development progress, it is increasingly imperative that greater support is put behind initiatives to protect the nutritional status of children and mothers to allow for faster recovery, resilience and development.  As World Hunger Day approaches on May 28th, this article is a timely reminder of the need to reduce food insecurity experienced by children and ensure they are provided with sufficient nutrients to develop and fully tackle the scourge of malnutrition globally. .

The United Nations Food and Agriculture Organisation (FAO) estimates that the number of children under five years affected by chronic under –nutrition has now surpassed 200 million. More than 70 percent of malnourished children live in Asia, 20 percent in Africa and 4 percent in Latin American and the Caribbean. Malnutrition has long-term far-reaching consequences beyond health: decline in academic performance during childhood translates into reduced earning potential as adults, which enforces the cycle of poverty making individuals less able to improve their futures and that of their children, families and communities (1,000 Days Global Partnership, 2010).The World Bank (2010) reports that collectively this has the potential to reduce the economic output of countries by 2-3 percent annually.

This snapshot into the dire status of global nutrition for children clearly shows that much more investment is needed to access to the right information and types of foods needed to improve nutritional status. This is especially true for developing countries where child malnutrition may already be a significant factor, and where small-scale disasters can tip communities into full blown crisis. Malnutrition on this scale can worsen the burden of disease, exposing more children to deadly measles and malaria. FAO reports that the estimated proportion of deaths where under nutrition is an underlying factor are similar for diarrhoea, malaria, pneumonia, and measles.  This makes programmes aimed at emergency immunisation, vitamin supplements and therapeutic feeding centres a top priority.

The urgency could not be clearer: as people continue to be confronted by ever more frequent, intense and unpredictable weather patterns, investment in maternal and child nutrition can improve countries ability to respond to and overcome these crises.  

There is collective agreement that the first 1,000 days between pregnancy and age two is a crucial window to improve maternal and child nutrition.  As the 1,000 Days Global Partnership emphasises: “[m]alnourished mothers often have malnourished children. Under-nutrition among pregnant women in developing countries is responsible for 1 of 6 cases where infants are born with low weight.” Global momentum for health such as Scaling Up Nutrition Movement (SUN) have been important for spotlighting the first “1,000 day window of opportunity” to improve maternal and child nutritional status through direct nutrition intervention and integrating nutrition into broader national health and development initiatives.

Breast milk alone provides ideal nutrition for young infants. Breastfeeding reduces the chance of infection from contaminated water used for making infant milk formula. Save the Children (2010) has argued that exclusive breastfeeding would reduce child mortality by 13 percent. However, during a crisis, myths around breastfeeding means there is little recognition for the need to promote and protect breastfeeding during emergencies.  These include beliefs that mothers under stress or suffering from malnutrition cannot produce milk for their babies or that women who stop breastfeeding cannot start again. Breastfeeding myths will clearly need to be addressed to ensure mother and communities have access to the right information on infant and child feeding.

The World Food Programme (WFP) uses a wide range of specialised foods to assist young children in their nutritional intake. These include Fortified Blended Foods, Ready-to-Use Foods, High Energy Biscuits and compressed bars.

The Global Nutrition Cluster has argued the following represents an essential set of combined action to ensure “effective humanitarian response to nutritional needs during an emergency” (Nutrition Cluster of the Inter-Agency Standing Committee, 2008):

• General food assistance.
• Management of severe acute malnutrition.
• Management of moderate malnutrition. 
• Delivery of micronutrients.
• Infant and young child feeding in emergencies.
• Delivery of micronutrients.
• Treatment of diarrhoea with oral rehydration therapy/zinc.
• Prevention and treatment of vitamin A deficiency.
• Food and nutrition assistance for people with HIV.
• The psychosocial component of nutrition.
• Nutritional care for groups with special needs.   

These specific needs will need to be integrated into long term humanitarian and development planning, not just focusing on emergencies. World Vision (2012) devised four recommendations to tackle chronically undernourished children aimed at governments, regional institutions, UN agencies, civil society and international organisations:

1. Make reduction of child under-nutrition central to resilience, through coordinated national plans especially prioritising children under two and pregnant women.
2. Harness small-scale agriculture for resilience and improved nutrition, ensuring sustainability and resilience and not just an increase in production.
3. Invest in social protection and services for the poorest households, particularly for households that are chronically food-insecure as distinct from those periodically suffering in shocks.

Develop a new plan for how the national governments, international donors, and agencies should work together to prevent hunger crises, breaking down the barriers between the development and humanitarian approaches, between ‘normal’ and ‘crisis’ responses

Child-centred disaster risk reduction (DRR) This requires focusing on the specific risks faced by children but also including children in initiatives and efforts to reduce disaster risk. UNICEF has provided several core actions around DRR management (prevention, preparedness and response) focused on nutrition: Prevention: Incorporate disaster risk assessments into existing nutrition assessments and monitoring, and ensure nutrition sector provides input into national and community level disaster risk assessments. Reduce vulnerability through promoting improved care practices (such as exclusive breast-feeding and appropriate complementary feeding) and protect nutritional status in hazard prone areas. Strengthen community health systems for early diagnosis, referrals and follow-up of cases with acute malnutrition. Preparedness Link nutrition actors and services to disaster early warning systems at national, sub-national and community level.  Preposition stocks (regional and national hubs) for identified ‘at risk’ populations. Scale up communication for change behaviours in at risk communities. Response: Use the opportunity of the emergency to build the sustainable capacity of government and other nutrition partners. Establish and strengthen ongoing nutrition assessment/ surveillance mechanism. Focus on alternative sources of food and how different food sources can be combined to maximise nutrition outcomes for communities.

 

As World Health Day reminds us, the food quality and food safety is equally important as food quantity.  Early intervention to prevent stunting, wasting and malnutrition is necessary to minimise children’s nutritional vulnerabilities and improve the impact of nutritional response in the long term.  Collectively, much of the work on DRR for nutrition requires a multisectoral approach from the humanitarian and development sector to support community-based management of acute malnutrition (CMAM).

For example, the European Commission for Humanitarian Aid and Civil Protection (ECHO) has partnered with WFP and national-based NGOs to foster local capacity to tackle acute under-nutrition and integrate under-nutrition prevention and treatment into the national health system. In Bangladesh, where poor dietary conditions and cyclic devastation of climate change has ranked it fourth on the global scale of the worst hit by malnutrition (World Bank, 2011), the ECHO led programme reached over 6,000 children under age five and 12,000 pregnant or lactating mothers.

CMAM in India: A Game Changer at the World’s Malnutrition Epicentre. CMAM is of crucial importance in non-emergency situations. In India, a recent ‘Rapid Survey on Children’ carried out by UNICEF and the union of Ministry of Women and Child Development (2015), revealed that the proportion of children underweight has fallen from 45.1 percent in 2005 to 30.1 percent in 2013, the sharpest in 25 years since such data has been collected. Despite this, India still has the highest number of underweight children under five in the world. The World Health Organisation (WHO) estimate 1.3 million children die every year in India due to malnutrition and is the direct cause of 70 percent of children being anaemic and 48 percent of 61 million children under five being stunted. Directly linked to this is the fact that approximately 42 percent of women in India start their pregnancies underweight. UNICEF estimates that 60 percent of women in South Asia are anaemic, with India reaching 83 percent during pregnancy. More than half of TB cases in India are the result of chronic lack of adequate food. Every year, tuberculosis (TB) claims 2.7 million lives, that’s one very two minutes.  The Observer Research Foundation (2015) has highlighted the importance of tackling social conditions such as rising inequality, malnutrition, poverty and overcrowding in the spread of TB.  Dr. Anurag Bhargava, Himalayan Institute of Medicine, emphasises how the right diet can contain and prevent the disease:  “Over 90% of those carrying the TB bug are able to prevent the infection from becoming TB disease with the help of the body's immune system. Anything that reduces the strength of one's immunity, like lack of good nutritious food, increases the risk of contracting TB.” Dr. Bhargave pointed to Directly Observed and Supported Treatment programmes that would be specifically tailored to India’s needs by offering TB patients and their families nutritional support and counselling to generate behavioural change alongside their treatment. Médecins Sans Frontières (MSF) has identified CMAM programmes as effective means to cure the rate of severely acute malnourished children. In Bihar, MSF has managed to achieve a cure rate of 88.4 percent through its CMAM programme, the only one of its kind currently operating in India. In its report, the statistics provided revealing information from which future programmes will need to bear in mind, particularly the fact that a significant majority of children were from socially and economically marginalised communities and households, between 6 months and 2 years old and more than half were girls. Suffice to say, severe malnutrition will affect the most at-risk groups in society.  CMAM programmes provide the corrective measure needed to sustainably lower mortality and develop high cure rates in severely malnourished children who complete their treatment. Integrating water, sanitation and hygiene (WASH) programmes with CMAM initiatives will provide a more comprehensive solution-based approach. A comparative study by Forum for Learning and Action with Innovation and Rigour (FLAIR) reveals states like Kerala, Manipur, Mizoram and Sikkim, where over 80 percent of the rural population have access to toilets, have the lowest recorded levels of child malnutrition in India. However, states like Bihar where MSF is operating, Pradesh and Jharkhand, where most households are without toilets, record high rates of child malnutrition. Dr. Raj Bhandari of FLAIR asserts: “There is an urgent need for the government to introduce nutrition as a development indicator in various other schemes such as the Integrated Child Protection Scheme (ICPS), Sarva Shiksha Abhiyan (SSA) and Integrated Child Development Scheme (ICDS).” There is therefore a clear imperative to drive forward integrated schemes and CMAM initiatives within India’s public health system to successfully reduce the burden of acute malnutrition.

 

 

In Bangladesh, the World Bank has supported an initiative beginning in December 2014 aimed at implementing conditional cash transfers for women, which is set to reduce poverty and improve nutrition levels. Bangladesh has on of the highest prevalence of child malnutrition in the world, despite reducing the rate of malnutrition as the economy grows.  The Income Support Program for the Poorest (ISPP) Project will provide conditional cash transfers to 600,000 poorest mothers. Mothers will receive payment when they complete activities aimed at improving their children’s nutrition and cognitive development, including attending four antenatal care visits and monitoring their child’s growth as well as attend child nutrition and development educational sessions.  The project is set to benefit 2.7 million people in 42 of the poorest regional administrations in the country.

As of April 16 2015, Power Nutrition has launched a fund that is seeking to unlock a billion dollars to tackle child undernutrition in the world’s poorest countries. Backed by the private sector and international development organisations, including the UK’s DFID, UBS Optimus Foundation, World Bank and UNICEF, the funds raised by Power of Nutrition will directed to mitigate the driver factors causing malnutrition by creating large-scale, high-impact nutrition programmes.

“We believe that undernutrition is one of the world’s most serious but least addressed public health challenges,” said Sri Mulyani Indrawati, Managing Director and Chief Operating Officer, World Bank Group. “Children who escape undernutrition are 33% more likely to escape poverty as adults. Countries in Africa and Asia are losing up to 11% of their GDP to undernutrition. We want children and countries to reach their full potential. This is why we are tracking stunting as a predictor of development and see initiatives like The Power of Nutrition as key to achieving our goal of ending extreme poverty.”

Plan International’s work in Kenya has shown the clear dividends good nutrition can have on educational development for children. Machakos County had nearly 20 percent school drop-out rate because of the scarcity of water and poor nutrition.

In 2010, Plan started work on community resilience projects that provided nearly 12,000 people access to portable water, improved sanitation, enhanced subsistence and horticultural farming.  In all, this had a massive affect on school attendance, with more families able to grow and prepare their own food, boosting their nutrition levels. Clearly, having adequate supply of water to grow the right foods is just as important as having a plentiful supply of food to meet a range of nutritional needs for children.

Furthermore, school feeding provides an integrated approach to tackling nutrition and developmental learning for children. Play Therapy Africa’s research that covered Ethiopia’s food crisis in 2008 found that children’s weight and survival rates can increase more when nutrition intervention services are provided alongside early stimulation. Twinning health and education will provide more growth in child development overall.

mNutrition is also breaking ground by closing the nutrition knowledge gap. While the problem faced by mothers in the developing world is commonly the lack of access to the right types of food, almost all mothers have access to a mobile phone. With the ascent of the mWorld, there are now new innovations to empower normally excluded groups to have better informed decision-making power on the health of the children, families and communities.  In South Africa, more than 100,000 mothers have signed up to StartSmart, a government-backed-service run by the Global Alliance for Improved Nutrition (GAIN) that provides mothers with information on ways to better nourish their babies and young children. SmartSmart is part of the wider programme of NurtiMark, which highlights the “1,000 day window of opportunity”. Dominic Schofield, director and senior technical advisor at GAIN, states the motivation of the programme:

“A new mum will be at a clinic getting her child immunised and she’ll get all kinds of messaging about how to look after her child,” says Dominic. “On her way home she’ll pass by a kiosk and be confronted by more messaging about different products, and then perhaps an NGO worker will knock on the door with yet more messaging. A new mum is so vulnerable to all this information, and the messaging can often be contradictory. We wanted to create something which mothers could have on hand all the time. “Not just information on posters at the clinic.”

“Cell phones are no longer just a tool; they’re part of the fabric of our lives, our social structure,” as such they provide a vital resource in the fight against some of the worst chronic issues facing communities across the globe.

The malnutrition crisis is not isolated to developing countries. America is one of the leading countries in the western hemisphere with a growing malnutrition epidemic, with approximately 85 percent of Americans do not consume the US Food and Drug Administrations (FDA) recommended daily intake of essential vitamins and minerals vital for optimum physical and mental development.  According to a recent Journal of Nutrition study, more than half of American children get insufficient amounts of vitamin D and E, and more than a quarter do not receive enough calcium, magnesium or vitamin A. This increases the risk of a poor immune system, stunted growth, reduced cognitive development, susceptibility to chronic disease and even death. Yet, this is avoidable through regular intake of multivitamins or eating fortified foods. 

In all, these programmes and recommendations help support governments and communities to create more solid foundations for malnutrition recovery and optimal development. Without more concentrated efforts around building resilience for children to address the range of risks they face, more children will grow up facing long-term adverse affects. Taking notice of the many programmes fighting malnutrition on a regional, country and local level will help combat the global crisis of undernutrition. In doing so, more children can be saved and be supported to reach their full potential.