Nutritional Status Assessment in Emergencies

Session Objectives
By the end of the session, participants will be able to: explain the importance of assessing the nutritional status of individuals during emergencies; identify common forms of malnutrition during emergencies; demonstrate competencies in: (a) measuring weight, height and MUAC (b) interpreting anthropometric results for response planning

What is Malnutrition?
a relative lack of nutrient

pathological state resulting from . . .

an absolute deficiency of nutrient/s

an excess of nutrient/s

What is Malnutrition?
Impaired physical function to point that cannot maintain adequate levels of performance at . . . . . physical work recovering from effects of disease maintaining adequate level of growth processes of pregnancy and lactation

What are the common forms of malnutrition?

Undernutrition Specific-nutrient deficiency Overnutrition

What is undernutrition and its common forms?

Refers to consequence of consuming and/or absorbing insufficient nutrients or using or excreting them more rapidly than they can be replaced. It refers to a range of conditions:

acute malnutrition (wasting/thinness) chronic malnutrition (stunting/shortness) micronutrient deficiencies (vitamin A deficiency, iron deficiency anemia, and iodine deficiency disorders).

Why do we need to address malnutrition during emergencies?

Malnutrition and infection are intimately related a malnourished child is more susceptible to disease, and a sick child is more likely to become malnourished Malnutrition increases the risk to infections and fatal diseases such as malaria, measles, diarrheal disease, pneumonia, HIV and AIDS

Infectionundernutrition
Inadequate diet

Loss of appetite Malabsorption Increased nutritional requirements

Weight loss Growth faltering Lowered immunity

Increased incidence, severity and duration of disease

Why do we need to address malnutrition during emergencies?

Moderate acute malnutrition (MAM) needs to be addressed to: prevent from getting worse protect the childs right to sufficient food, growth and well-being and to prevent more serious illness and death Moderate malnutrition is also significantly cheaper to treat than severe malnutrition

Why do we need to address malnutrition during emergencies?

Malnutrition contributes to between 35 and 55 percent of all childhood deaths In acute emergency situations, malnutrition can account for even more deaths

Intergenerational cycle of growth failure

Who are most vulnerable to malnutrition?

Low birthweight babies 0-24 month old children Pregnant and breastfeeding mothers Older people Disabled people People with chronic illnesses People with HIV and AIDs

How do we assess the nutrition situation during emergencies?

Rapid Nutrition Assessment Survey Nutrition Surveillance

What is Rapid Nutrition Assessment?

assessment of nutritional status based on simple anthropometric data: Weight Height Mid-upper arm circumference or MUAC limited to children of preschool age, who serve to represent the general population limited to protein-energy malnutrition without attempting to assess other nutritional deficiencies as further variables can add workload and cause unnecessary delay

Source: National Policy on Nutrition Management in Emergencies and Disasters

Why conduct Rapid Nutrition Assessment (RNA)?

RNA can provide:

a quick snapshot of the nutrition situation important source of information especially at the onset of emergency to determine the magnitude and severity of crisis basis for determining whether a more detailed assessment is required to establish the actual prevalence of acute malnutrition or whether an emergency response is required initial screening for inclusion in a selective feeding program

When should we do nutritional assessment during an emergency?

At the soonest possible time but may not be feasible or practical during the early stage of the emergency Should be done in the intermediate and extended phases since the disaster or emergency may have negative effects on the nutritional status especially of the nutritionally vulnerable

Source: National Policy on Nutrition Management in Emergencies and Disasters

What are the stages of emergency?

Early Emergency It is the period immediately following a disaster, lasting from one to two days, or even for just a few hours depending on the nature of the calamity The period is characterized by stress, anxiety and in some cases, shock where food supply is cut-off; no productive labor is possible and people are hungry but not starving.

Source: National Policy on Nutrition Management in Emergencies and Disasters

What are the stages of emergency?

Intermediate Emergency It is the transition period from initial onset of disaster to rehabilitation Conditions are still far from normal but the initial shock is over. Extended Emergency. It is the period after the worst is over Rehabilitation to near-normal conditions takes place At this phase, families start to go back to their homes to continue their everyday life.

Source: National Policy on Nutrition Management in Emergencies and Disasters

What are the types of malnutrition?

Acute Malnutrition (wasting) Chronic Malnutrition (stunting)

What is Chronic Malnutrition?

Most common form of malnutrition and causes stunting due to long-term state of poor nutrition Its long-term effects are associated with impaired physical and mental development in children It is an irreversible condition

What is Acute Malnutrition?

A drastic deterioration of nutritional status in a short time due to deprivation of food or bout of infection in the immediate past and is manifested by muscle wasting Associated with an increased risk of morbidity and mortality Strong evidence indicates that a child with severe acute malnutrition has a greatly increased risk of dying

What is Acute Malnutrition?

Acute malnutrition or wasting (thin individuals) can be reversed and is of particular concern during emergencies because it can quickly lead to death. The prevalence of acute malnutrition among children under five years is a sensitive and objective crisis indicator, reflecting the wider situation of emergency affected populations, including their food security, livelihoods, public health and social environment. Acute malnutrition can be moderate or severe.

What is Severe Acute Malnutrition (SAM)?

Characterized by a weight that is below minus 3 z-scores of the median growth standards In the Philippine context, these are those classified as severely wasted, based on the revised tables on weight and height measurements using the WHO Child Growth Standards (CGS) SAM is also indicated if mid-upper arm circumference (MUAC) is less than 115 mm (11.5 cm. or 4.5 in); and when bilateral edema is present.

Why is the management of SAM a key intervention in emergencies?

Children with SAM have a 10 to 20-fold risk of dying compared to well nourished children SAM can be a direct cause of child death, or it can act as an indirect cause of death by dramatically increasing case fatality in children suffering from common childhood illnesses such as diarrhoea and pneumonia.

Why is the management of SAM a key intervention in emergencies?

This is particularly heightened in conditions of poor sanitation, hygiene and poor provision of health services that often characterize emergency situations. Timely and effective interventions for the management of SAM, which achieve high coverage, could prevent hundreds of thousands of child deaths.

What are the clinical forms of Severe Acute Malnutrition (SAM)?

Marasmus Kwashiorkor Marasmic Kwashiorkor

Marasmus

The most frequent form of protein energy malnutrition found in emergencies Caused by:

prolonged starvation chronic or recurring infections with marginal food intake

The main sign is a severe wasting away of fat and muscle, which makes the child appear very thin.

Marasmus

Marasmus (non-oedematous malnutrition): There may be folds of skin on the buttocks and thighs that make it look as if the child is wearing baggy pants. Weight-forage and weight-for-length/height are likely to be very low.

Kwashiorkor

The second form of acute protein energy malnutrition

Kwashiorkor

The main sign is edema, which usually starts in the lower limbs and spreads in more severe cases to the face and hands

Marasmic Kwashiorkor

Marasmic kwashiorkor is a mixed form of Protein Energy Malnutrition. Severe form of acute malnutrition characterized by bi-lateral edema and weight for height of less than -2 SD.

What is Moderate Acute Malnutrition (MAM)?

Characterized by a low weight-for-height (between minus 3 and minus 2 z-scores of the median growth standards) In the Philippine context, these are those classified as moderately wasted, based on the revised tables on weight and height measurements using the WHO Child Growth Standards (CGS) MAM is also indicated if mid-upper arm circumference (MUAC) is less than 125 mm (12.5 cm. or 4.9 in) but 115 mm.

What types of malnutrition occur in emergencies?

Acute Malnutrition (wasting) Micronutrient deficiencies especially in iron, vitamin A and iodine as well as vitamin C, thiamine and niacin deficiencies.

What are the methods of nutritional assessment?

Anthropometric Biochemical Clinical Dietary

malnutrition?
(as per National Policy on Nutrition Management in
Emergencies and Disasters)

assessment of nutritional status will be based on simple anthropometric data:

Weight Height Mid-upper arm circumference or MUAC sex, age and presence of edema

How do we measure malnutrition?

(as per National Policy on Nutrition Management in Emergencies and Disasters)

limited to children of preschool age who represent the general population limited to protein-energy malnutrition without attempting to assess other nutritional deficiencies as further variables can add workload and cause unnecessary delay

How do we measure malnutrition?

(as per National Policy on Nutrition Management in Emergencies and Disasters)

Weighing and height measurement of preschool children should be done monthly until full normalcy is achieved, by which time the OPT system can be used for nutritional assessment. The nutrition cluster should spearhead the assessment and supervise its conduct to ensure that quality data is generated and shared.

What do we measure during RNA?

Weight for Height

widely used nutritional or anthropometric index, and is the best indicator of wasting recommended for assessments of recent nutrition, and is especially important for assessments of nutrition-related humanitarian emergencies

same height

What do we measure during RNA?

If measuring weight and height is not possible, the MUAC could be used as index for screening preschool children.

What do we measure during RNA?

Bilateral oedema

an essential indicator for determining the presence of Severe Acute Malnutrition or kwashiorkor. It presents first in feet, then in ankles and lower limbs. edema may be detected by the production of a definite pit as a result of moderate pressure for three seconds with the thumb just above the ankle.

What do we measure during RNA?

Bilateral oedema

all children with nutritional edema are automatically classified as severely malnourished.

Weighing the child

*Adapted from the BNS Training Modules developed by IHN-UPLB

Kinds of Weighing Scales

Salter Scale

Infant Beam Scale Beam Balance

Proper Handling of Weighing Scales

Hooks complete and in good condition

Proper Handling of Weighing Scales

Adjustment screw
working

Proper Handling of Weighing Scales

Needle or pointer moving freely

Proper Handling of Weighing Scales

Weighing pants clean and without a tear

Proper Handling of Weighing Scales

Rope, strong, long enough, and tied well

Proper Use of Salter Scale

Hang the scale from a tree branch, ceiling beam or pole.

Attach the empty weighing pants to the hook of the scale, adjust the scale to zero, and then remove from the scale.

 Check if the face or dial of the scale is at eye level, not lower or higher.

How to weigh the child

Check if the child is barefoot, in minimum clothing and with empty pockets. Ask mother or someone to hold the child.

 Put the measurers hands through leg holes.

Gently pull legs through the leg holes making sure that the strap is in front of the child.

 Put arms around the child and attach the strap of the basket/sling to the hook of the scale and allow the child to hang freely. Check the childs position. Make sure the child is not touching anything.

 Hold the scale and read the weight at eye level to the nearest 0.1kg. Read the measurement when the scale needle is not moving and record data.

 Put arms around the child and gently lift the child by the body. Remove the strap from the scale. Remove the weighing pants.

 Give child to mother or caregiver.

hecklist for the Practice Weighing

Item Preparation for weighing
1.

Yes/Remarks

Hooks of weighing scale complete and in good condition

2. Adjustment screw is working 3. Needle or pointer moves freely 4. Weighing pants are clean 5. Weighing pants are free from tear 6. Rope is strong and long enough 7. Weighing scale was calibrated and adjusted accordingly

hecklist for the Practice Weighing

ITEM YES/REMARKS

Actual weighing 1. Weighing scale was adjusted to 0 with the weighing pants 2.Face or dial of scale at eye level, not lower or higher 3.Child was barefoot 4.Child was not wearing heavy clothes 5.Childs pocket was checked, heavy objects were removed 6.Child was put in the weighing pants correctly

hecklist for the Practice Weighing

ITEM YES/REMARKS

7.The strap of the weighing pants was in front of the child 8.One hand held the child while the other hand placed the weighing pants with the child on the hook 9.The child was not holding on to anything when being weighed, and no one was holding onto the child while he/she was being weighed

hecklist for the Practice Weighing

ITEM YES/REMARKS

10.Tone in interviewing mother or caregiver was friendly 11.Birth certificate was used to validate childs birthday (Note: For this exercise age of child will not yet be taken) 12.Reading of weight was done when needle was no longer moving

Measuring the height/length

Measuring the height

Depending on a childs age and ability to stand, measure the childs length or height. A childs length is measured lying down (recumbent). Height is measured standing upright.

Height board

To measure height, use a height board (sometimes called a stadiometer) mounted at a right angle between a level floor and against a straight, vertical surface such as a wall or pillar.

Standing height

If the child is aged 2 years or older and able to stand, measure standing height.

Length board

To measure length use a length board (sometimes called an infantometer) which should be placed on a flat, stable surface such as a table.

Recumbent length

If a child is less than 2 years old, measure recumbent length.

In measuring height

In general, standing height is about 0.7 cm less than recumbent length. This difference was taken into account in developing the WHO growth standards used to make the charts in the Growth Record. Therefore, it is important to adjust the measurements if length is taken instead of height, and vice versa.

Reminders in measuring the height/length

If a child less than 2 years old will not lie down for measurement of length, measure standing height and add 0.7 cm to convert it to length. If a child aged 2 years or older cannot stand, measure recumbent length and subtract 0.7 cm to convert it to height.

Reading the measurement

This is a picture of part of a measuring tape. The numbers and longer lines indicate centimetre markings. The shorter lines indicate millimetres. The gray box shows the position of the footboard when a length measurement is taken.

Assessing the childs nutritional status using

MUAC

What is MUAC?
Mid-upper Arm Circumference is the circumference of the left upper arm, measured at the mid-point between the tip of the shoulder and the tip of the elbow (acromion and the olecranon process )

Why use MUAC?

MUAC is used for rapid screening of acute malnutrition from the 6-59 month age range MUAC is used for identification of severe acute malnutrition (SAM) during screening at the community level and admission for treatment at the health facility. Using MUAC alone as independent criteria for SAM was endorsed by WHO.

Why use MUAC?

MUAC is:

simple quick accurate inexpensive

Why use MUAC?

It is more sensitive. MUAC is a better indicator of mortality risk associated with malnutrition than weight-for-height. It is therefore a better measure to identify children most in need of treatment. It is less prone to mistakes. Comparative studies have shown that MUAC is subject to fewer errors than weight-for-height (Myatt et al, 2006).

How is MUAC measured?

Persons involved: 1 Measurer 1 Assistant/Recorder
Keep your work at eye-level and sit down when possible. A very young child can be held during the procedure by the parent or carer, who should also remove any clothing that covers the childs left arm.

How is MUAC measured?

How is MUAC measured?

Make sure that the tape is flat against the skin.

How is MUAC measured?

Read the measurement to the nearest 0.1 cm.

What does the MUAC tell us?

For Children 6-59 months RED YELLOW GREEN SAM MAM Normal MUAC < 115 mm and/or bilateral edema MUAC 115 mm and < 125 mm MUAC 125 mm