United Nations

High Commissioner
For Refugees

World Food
Programme

UNHCR/WFP GUIDELINES FOR

SELECTIVE FEEDING PROGRAMMES
IN EMERGENCY SITUATIONS

February 1999

United Nations High Commissioner for

Refugees

World Food Programme

UNHCR/WFP GUIDELINES FOR
SELECTIVE FEEDING PROGRAMMES IN EMERGENCY SITUATIONS

Contents
I.
II.
III.
IV.
V.
VI.
VII.
VIII.

Purpose
Basic Principles
Feeding Programme Strategy
Supplementary Feeding Programmes
Therapeutic Feeding Programmes
Monitoring and Evaluation
Food Commodities
Management Issues

Figures and Tables

Figure 1:
Conceptual Framework of Malnutrition
Figure 2:
Feeding Programme Strategy
Figure 3:
Framework: Selective Feeding Programmes
Figure 4:
Admission and Discharge Criteria
Table 1:
Table 2:
Table 3:
Table 4:
Table 5:
Table 6:

Types of Selective Feeding Programmes

Indicators for Monitoring Supplementary Feeding Programs
Indicators for Monitoring Therapeutic Feeding Programs
Examples of Daily Rations
Home-made Substitutes for Breastmilk
Projected Demographic Breakdown

Annexes
Annex 1:
Annex 2:
Annex 3:

References
Reporting Form: Supplementary Feeding Programmes
Reporting Form: Therapeutic Feeding Programmes

I. PURPOSE

1.
These guidelines describe the basic principles and design elements concerning food
and nutrition related aspects of Selective Feeding Programmes in Emergencies and Relief
situations. They are intended to provide guidance to WFP and UNHCR and other relief staff in
the design, implementation and monitoring of Selective Feeding Programmes in both
emergencies and protracted relief situations. The nutrition strategies addressed in these
guidelines are to enable an effective response and nutrition rehabilitation. Medical and other
care approaches are not dealt with in these guidelines. For more information a list of
references is provided in Annex 1.
2.
Every situation has individual features which lead to different objectives being set, and
to different approaches to Selective Feeding Programmes. These guidelines cannot cover the
wide range of situations. The type of supplementary feeding programme should therefore be
designed according to the situation but should nevertheless remain in line with the frame work
of these guidelines.

II. BASIC PRINCIPLES

3.
In emergency situations, WFP and UNHCR try to ensure that the food needs of the
population are met through the provision of an adequate general ration. However, in
certain situations there may be a need to provide additional food for a period of time, to
specific groups who are already malnourished and/or are at risk of becoming malnourished.
4.
These interventions have to be seen in the context of a general ration being
distributed. The impact of Selective Feeding Programmes aimed at compensating for
inadequate general rations has proven very limited and not cost-effective. Thus to be effective,
the extra ration must be additional to, and not a substitute for, the general ration.
5.
Many factors influence nutritional status (as shown in Figure 1). It should therefore be
kept in mind that interventions must be multi-sectoral and cover food, health, hygiene,
sanitation and care. A properly designed nutrition survey and complementary analysis of the
causes of malnutrition can help to guide the need to implement Selective Feeding
Programmes.
6.
National health authorities and NGOs have an important role to play in nutritional
interventions. In emergency situations NGOs usually organize and implement Selective
Feeding Programs. They form an integral part of the efforts to prevent and treat malnutrition
among young children, women and other at-risk groups.
7.
Selective Feeding Programmes should have clear objectives and criteria, defined from
the beginning, for opening, admission, discharge and closure. In order to be effective,
Selective Feeding Programmes need to be integrated into Community Health Programmes,
which offer health and nutrition services like Safe Motherhood, immunisations, nutrition and
health education and growth monitoring. Integration facilitates referrals between services and
the phasing out of Selective Feeding Programmes.
8.
In addition to nutritional and medical treatment, care is an essential part of
rehabilitation. Care in nutrition refers to the practices of the care givers in the household which
translates food security and health care into rehabilitation, growth and development. These
practices include care for women, breast-feeding, infant feeding, psycho-social care,
sanitation and hygiene practices, food processing and preparation, and home health practices
(1). These issues can be addressed through Selective Feeding Programmes in the form of
education, individual counselling, social activities and involvement of caretakers in the
programme.

9.
The community must be consulted to the extent possible during programme design
and women must take part in the decision making from the outset (2).
10.
Proximity of feeding centres to the population and availability of trained health staff are
a prerequisite when Selective Feeding Programmes are being considered.
11.
The policy of UNHCR and WFP concerning safe and appropriate infant and child
feeding, in particular the protection, promotion and support of breast feeding must be
respected (3).
12.
When planning the food needs of Selective Feeding Programmes the energy density
as well as the fat, protein and micronutrient content of food commodities must be considered.
In addition, micronutrient supplements (especially vitamin A, iron and folic acid) should be
given.
13.
It must be kept in mind, that adolescents, adults and elderly persons may also be
malnourished and should be included in Selective Feeding Programmes.
14.
The effectiveness of Selective Feeding Programmes, and their impact on mortality
and morbidity of affected populations, should be monitored regularly.
15.
The need to set up Selective Feeding Programmes after the initial stage of an
emergency often represents a serious warning that the assistance as a whole is insufficient.
16.
For interpretation of nutrition surveys, results are presented both in weight-for-height
Z-scores and percentage of the median. However, during admission and discharge to feeding
programmes, percentage of the median is often being used. At present, no consensus has yet
been reached on the use of Z-score in feeding programmes.
17.
The standards mentioned in these guidelines meet the set of minimum standards in
disaster response as mentioned in the Sphere Project (4).

Figure 1: Conceptual Framework of Malnutrition

Child malnutrition,
death and disability

Outcomes

Immediate
causes

Underlying
causes at
household/
family level

Inadequate
dietary
intake

Insufficient
access to
Food

Disease

Inadequate
maternal & child
caring practices

Poor water/
sanitation &
inadequate
health services

Inadequate and/or inappropriate knowledge and

discriminatory attitudes limit household access to
actual resources

Quantity and quality

of actual resources human, economic
and organizational and the way they are controlled

Political, cultural, religious, economic and

social systems, including status of women,
limit the utilization of potential resources

Basic
causes in
society

* Source:

UNICEF, 1997.

Potential resources
environment,
technology, people

III. FEEDING PROGRAMME STRATEGY

18.
There are two mechanisms through which food may be provided:
General Food Distribution
Selective Feeding Programmes.
19.
General Food Distribution provides a standard general ration to the affected
population with the aim to cover food and nutritional needs (5,6) .
20.
There are two forms of Selective Feeding Programmes:
Supplementary Feeding Programmes
Therapeutic Feeding Programmes
21.
Supplementary Feeding Programmes (SFPs) provide nutritious food in addition to
the general ration. They aim to rehabilitate malnourished persons or to prevent a deterioration
of nutritional status of those most at-risk by meeting their additional needs, focusing
particularly on young children, pregnant women and nursing mothers.
22.
SFPs are short-term measures and should not be seen as a means of compensating
for an inadequate general food ration. The objectives of the feeding programme should be
realistic and should be achieved within a period determined in advance. Figure 2 illustrates the
different types of feeding programmes.

Figure 2: Feeding Programme Strategy

Feeding Programs

General Food
Distribution
Selective Feeding
Programs

Supplementary
Feeding Programs
(SFP)

Targeted Supplementary
Feeding Programs

Therapeutic Feeding
Programs
(TFP)

Blanket Supplementary
Feeding Programs

23.

SFPs comprise two different types:

Targeted SFPs: The main aim of a Targeted SFP is to prevent the moderately
malnourished becoming severely malnourished and to rehabilitate them. These
types of programmes usually provide a food supplement to the general ration for
1
mild and moderately malnourished individuals and for selected pregnant and
nursing mothers and other nutritionally individuals at-risk.
Blanket SFPs: The main aim of a blanket SFP is to prevent widespread
malnutrition and to reduce excess mortality among those at-risk by providing a
food/micronutrient supplement for all members of the group (e.g. children under
five or under three, pregnant women and nursing mothers, etc.).

24.

Supplementary food can be distributed in two ways:

On-site feeding or wet ration: The daily distribution of cooked food/meals at
feeding centres. The number of meals provided can vary in specific situations, but
a minimum of two or three meals should be provided per day.
Take-home or ration: The regular (weekly or bi-weekly) distribution of food in dry
form to be prepared at home. It may be necessary to increase the amount of food
to compensate for intra-household sharing.

25.
It is generally accepted that take-home rations should always be considered first as
such programmes require fewer resources and there is no evidence to show whether on-site
SFPs are more effective. Other advantages of dry ration feeding are that it:
carries less risk of cross-infection as large numbers of malnourished and sick
children do not have to sit in close proximity while feeding.
takes less time to establish than on-site feeding programmes which require setting
up and equipping centres.
is less time consuming for mothers who only have to attend every week or fortnight
and as a result leads to better coverage and lower default rates.
keeps responsibility for feeding within the family.
is particularly appropriate for dispersed populations many of whom would have to
travel long distances to attend daily.
On-site feeding may be justified when:
food supply in the household is limited so it is likely that the take home ration will
be shared with other family members.
firewood and cooking utensils are in short supply and it is difficult to prepare meals
in the household.
the security situation is poor and beneficiaries are at-risk when returning home
carrying weekly supplies of food.
26.
Therapeutic Feeding Programmes (TFPs) are to rehabilitate severely malnourished
persons. The main aim is to reduce excess mortality. In most emergency situations, the
2
majority of those with severe wasting are young children. There have, however, been cases
where large numbers of adolescents and adults have become wasted. In such situations,
separate TFP facilities may be established for these groups.

those with a weight and height that is between minus three and minus two standard deviations (between -3 and 2 Z-scores) or between 70% and 80% from the median weight-for-height as compared to the reference population.

reflects severe malnutrition: weight and height that is below minus three standard deviations (<-3 Z-scores) or
below 70% from the median weight-for-height as compared to the reference population and/or oedema.

IV. SUPPLEMENTARY FEEDING PROGRAMMES

TARGETED SUPPLEMENTARY FEEDING PROGRAMMES

Objective
27.
Targeted Supplementary Feeding Programmes (SFPs) are directed at selected
individuals who are at risk. Their aim is to:
rehabilitate moderately malnourished children, adolescents, adults and elderly
persons.
prevent the moderately malnourished from becoming severely malnourished.
Reduce mortality and morbidity risk in children under 5 years.
provide a food supplement to selected pregnant and nursing mothers and other
individuals at risk.
Provide follow-up to referrals from Therapeutic Feeding Programmes
Figure 3 explains the decision making framework concerning the implementation of Selective
Feeding Programmes.
When to Start?
28.
Targeted SFPs should be implemented when one or more of the following situations
occur:
There are large numbers of malnourished individuals ! prevalence of 10-14%
3
acute malnutrition among children.
There are large numbers of children predicted to become malnourished due to
factors like poor food security and high rates of disease ! prevalence of 5-9%
4
acute malnutrition in presence of aggravating factors .
Criteria for Admission
29. The following target groups could be considered for admission to a Targeted SFP:
Moderately malnourished children under 5 years:
between 70% and 80% of the median weight-for-height or
between -3 and -2 Z-scores weight-for-height
5
Malnourished individuals (based on weight-for-height, Body Mass Index (BMI) ,
6
Mid Upper Arm Circumference (MUAC) or clinical signs):
older children (between 5 and 10 years)
adolescents
adults and elderly persons
medical referrals
Referrals from a Therapeutic Feeding Programme.
Selected pregnant women (from date of confirmation of pregnancy) and nursing
mothers (until 6 months after delivery), for instance using MUAC<22 cm as a cutoff indicator for pregnant women.
Criteria for Discharge
30.
The following are the criteria for discharge:
Children who have maintained at least 85% of median weight-for-height for a
period of two weeks (wet SFP) or one month (dry SFP).

Prevalence of acute malnutrition (or: acute malnutrition rate) reflects the proportion of the child population (6
months to 5 years) whose weight-for-height is below -2 Z-scores or less than 80% of the median NCHS/WHO
reference values, and/or oedema.
4
Aggravating factors are normally defined as inadequate general food ration, crude mortality rate above
1/10,000/day, epidemics measles or whooping cough, and high prevalence of respiratory or diarrhoeal diseases.
5
BMI: Body Mass Index defined as the (weight in kg)/(height in m)2 for assessing the nutritional status of
adolescents and adults.
6
MUAC: Circumference of the mid upper arm, used for rapid screening of children.

 Individuals older than 5 years who have attained a stable and satisfactory
nutritional status and who are free from disease.
31.
Children and adults who have not shown signs of improvement after two weeks (wet
SFP) or one month (dry SFP) should be assessed to find out the cause and if required should
be referred for medical and community care.
When to Close?
32.
Targeted SFPs can be closed when all of the following criteria are satisfied:
General food distribution is adequate (meeting planned nutritional requirements).
Prevalence of acute malnutrition is below 10% without aggravating factors.
Control measures for infectious diseases are effective.
Deterioration in nutritional situation is not anticipated.
In some situations where prevalence of acute malnutrition is below 5% (in
presence of aggravating factors) or 10% (with no aggravating factors) but the
absolute number of malnourished children may still be considerable, the closure
of Targeted SFP may not be appropriate. The same may apply in unstable and
insecure situations, where these programmes may be maintained as a safety net.
Remarks
It is essential to integrate Targeted SFPs with community health services from the onset of the
emergency in order to facilitate the referral to these services for medical reasons. Also where
the number of beneficiaries has become small, it may be more efficient to manage the
beneficiaries through community health facilities. In the absence of Targeted SFPs, individual
attention should always be given to malnourished children through other community health
services.

BLANKET SUPPLEMENTARY FEEDING PROGRAMMES

Objective
33.
Blanket Supplementary Feeding Programmes are aimed primarily to prevent a
deterioration in the nutritional status of the population, but also to reduce the prevalence of
acute malnutrition in children under 5 years thereby reducing the mortality and morbidity risk.
They are meant to provide a food/micronutrient supplement for all members of groups at
high risk of becoming malnourished.
34.
When an adequate general ration is being effectively distributed, there is normally no
need for Blanket SFPs. However, this may be done exceptionally when nutritional needs are
not met by the general ration or other ways.
When to Start?
35.
Blanket SFPs may be set up under one or a combination of the following
circumstances:
At the onset of an emergency when general food distribution systems are not
adequately in place.
Problems in delivering/distributing the general ration.
Prevalence of acute malnutrition equal or greater than 15%.
Prevalence of 10-14% acute malnutrition in presence of aggravating factors.
Anticipated increase in rates of malnutrition due to seasonally induced epidemics.
In case of micronutrient deficiency outbreaks, to provide micronutrient-rich food to
the target population.
Criteria for admission
36.
The primary target groups for Blanket SFPs are:
All children younger than 5 or 3 years using height as a cut-off point (5 years = 110
cm; 3 years = 90 cm).
Pregnant women from the time of confirmed pregnancy, and nursing mothers until
maximum 6 months after delivery.

 Other at-risk groups (for instance sick and elderly persons).

When to Close?
37.
Blanket SFPs can be closed when all following conditions are met:
General food distribution is adequate and is meeting planned minimum nutritional
requirements.
Prevalence of acute malnutrition is below 15% without aggravating factors.
Prevalence of acute malnutrition is below 10% in presence of aggravating factors.
Disease control measures are effective.

Remarks
Normally a maximum time limit of 3 months is envisaged for a blanket SFP because it is
anticipated that by this time the situation will have improved (adequate food, epidemics are
under control, and safe and sufficient water). The nutritional status of the population should be
reviewed (e.g. through a nutrition survey) at this time.

Figure 3: Framework: Selective Feeding Programmes (Modified from: Nutrition

Guidelines; MSF, 1995)

MA LNUTRITION RA TE
> = 15%

OR

GENERAL
RATION
< 2,100 Kcals/
person/day

MA LNUTRITION RATE
10 - 14 %
in presence of
AGGRAV A TING
FACTORS (*)

MA LNUTRITION RATE
10 - 14%

OR

ALWAYS
IMPROVE
GENERAL
RATION

MA LNUTRITION RATE
5 - 9%
in presence of
AGGRAV A TING
FACTORS (*)

MA LNUTRITION RATE
< 10%
WITH NO
AGGRAVATING FACTORS

MA LNUTRITION RATE
< 5%
in presence of

SERIOUS
BLANKET supplementary
feeding programme
THERAPEUTIC feeding
programme

ALERT
TARGETED supplementary
feeding programme
THERAPEUTIC feeding
programme

ACCEPTABLE
No need for population level
interventions
(individual attention for
malnourished through
regular community services)

AGGRAVATING FACTORS

Aggravating Factors
General food ration below the mean energy requirements.
Crude mortality rate > 1 per 10,000 per day
Epidemic of measles or whooping cough
High prevalence of respiratory or diarrhoeal diseases

Malnutrition rate:
Proportion of child population
(6 months to 5 years) whose weight-for-height
is below -2 Z-scores or less than 80% of the
median NCHS/WHO reference values, and/or oedema.

V. THERAPEUTIC FEEDING PROGRAMMES

Objective
38.
The aim of Therapeutic Feeding Programmes (TFP) is to provide treatment to
severely malnourished individuals to reduce the risk of excess mortality and morbidity. It
consists of intensive medical and nutritional treatment.
When to Start?
39.
The establishment of a TFP is justified when the number of severely malnourished
individuals cannot be treated adequately in other facilities. The availability of trained health
staff is a prerequisite for establishing TFPs.
Criteria for Admission
40.
The following groups are considered for admission to a TFP:
Children younger than 5 years (or less than 110 cm in height) who are severely
malnourished (weight-for-height less than -3 Z-scores or less than 70% of
7
median) and/or children with oedema .
Severely malnourished children older than 5 years, adolescents and adults can be
admitted based on available weight for height standards or presence of oedema.
8
Low birth weight (LBW) babies.
Orphans younger than one year (only when traditional care practices are inadequate)
Mothers of children younger than one year with breastfeeding failure ( only in
exceptional cases where re-lactation through counselling and traditional alternative
feeding have failed)
Criteria for Discharge
41.
The common procedure is to refer a child to a targeted SFP when he/she:
Maintains a weight-for-height >= 75% of the reference median or >= -2.5 Z-score
for two consecutive weeks.
Shows a good appetite and is free of illness.
When to Close?
42.
If the number of patients in TFP is decreasing (for example when the number drops
below 20) and adequate medical and nutritional treatment in either a clinic or a hospital is
available for all severely malnourished patients, it may not be justifiable to continue TFP.
Nutritional Rehabilitation
43.
Nutritional rehabilitation for patients with severe malnutrition must include intensive
medical and nutritional care (7,8):
Phase 1: Acute phase (intensive care). In 24-hour inpatient intensive care, medical
treatment is started to control infection and dehydration, thereby reducing the
mortality risk. Electrolyte balance is restored and nutritional treatment is initiated.
9
Very frequent feeds with therapeutic milk (10-12 per day) are essential to prevent
10
11
death from hypoglycaemia and hypothermia . This phase should not be extended
beyond one week because of the limited energy content of the diet.
Phase 2: Rehabilitation phase. The nutritional rehabilitation is started by providing at
least 6 meals per day in order to regain most of the weight loss. Psychological and
medical care is vital, the mother must be involved throughout the process and trained

Accumulation of fluid in inter-cellular spaces of the body related to a deficiency in the diet
Liveborn babies with a birth weight less than 2500 g reflecting inadequate nutrition and ill health of the mother
9
Special milk for treatment and rehabilitation of severely malnutrition, also known as F-100
10
An extreme low blood sugar level, common cause of death among severely malnourished children during the
first 2 days of treatment. It is caused by a serious infection or when a malnourished child has not been fed for 4-6
hours
11
An extreme low body temperature, occurring usually together with hypoglycaemia among severely malnourished
children and forms a common cause of death.
8

to continue care at home, and preparations are made for discharge of the child to a
Targeted SFP. This phase is not expected to last more than five weeks.
44.
The total duration of stay in a TFP should not exceed six weeks. If the child does gain
weight during this period the implementation of the feeding regime should be reviewed. If this
is not the reason for weight gain, there may be other underlying causes i.e. medical/social
issues (HIV-AIDS, tuberculosis, lack of care, etc.) which should be addressed accordingly.
45.
Table 1 summarises the types, objectives and criteria of Selective Feeding
Programmes and Figure 4 illustrates the criteria for admission and discharge.
Figure 4: Admission and Discharge Criteria (Modified from: Nutrition Guidelines; MSF,
1995)
Admission

Admission

W /H* < 70%

(or < -3 Z-scores**)
and/or oedema

Referral

W /H* between 70 and 80%

(or between -3 and -2
Z-scores**)
Discharge

THERAPEUTIC
FEEDING
PROGRAMME***

1) W /H* >= 75%

(or >= -2.5
Z-score**)
2) Appetite restored
3) Free of illness

TARGETED
SUPPLEMENTARY
FEEDING
PROGRAM ME

W /H* >= 85%

(or >= -1.5 Z-scores**)

W /H* < 70%

(or < -3 Z-scores**)
Return to TFP

* Weight-for-height
** No consensus yet exists about the preferred indicator to be used, %W/H or Z-score..
*** Where no Targeted SFP exists discharge criteria from TFP is W/H* >= 85% (or >= -1.5 Z-score)

Table 1: Types of Selective Feeding Programmes

Program

Objectives

Criteria for selection and target group

Targeted SFP

Blanket SFP

Correct moderate malnutrition.

Prevent moderately malnourished from
becoming severely malnourished
Reduce mortality and morbidity risk in
children under 5 years
Provide nutritional support to selected
pregnant women and nursing mothers.
Provide follow up services to those
discharged from therapeutic feeding
programs

Prevent
deterioration
of
nutritional
situation.
Reduce prevalence of acute malnutrition in
children under 5 years
Ensure safety net measures

Children under 5 years moderately malnourished:

between 70% and 80% of the median weight-forheight or:
between -3 and -2 Z-scores weight-for-height
Malnourished individuals (based on weight-for-height,
BMI, MUAC or clinical signs):
older children (between 5 and 10 years)
adolescents
adults and elderly persons
medical referrals
Selected pregnant women (from date of confirmed
pregnancy) and nursing mothers (until 6 months after
delivery), for instance using MUAC<22 cm as a cut-off
indicator for pregnant women
Referrals from TFP
Children under 3 or under 5 years
All pregnant women (from date of confirmed pregnancy)
and nursing mothers (until maximum 6 months after
delivery)
Other at-risk groups


TFP

Reduce mortality and morbidity risk

Reduce excess mortality and morbidity risk

in children under 5 years
Provide medical/nutritional treatment for
the severely malnourished

Children under 5 years severely malnourished:

<70% of the median weight-for-height and/or
oedema or:
<-3 Z-scores weight-for-height and/or oedema
Severely malnourished children older than 5 years,
adolescents and adults admitted based on available
weight for height standards or presence of oedema.
Low Birth Weight babies

VI. MONITORING AND EVALUATION

Supplementary Feeding Programs

46. Ongoing monitoring should include collection of data to analyse the efficiency and
effectiveness of Selective Feeding Programmes, in accordance with the objectives. This can
be done through nutrition monitoring (surveys, growth monitoring) and the regular collection
of feeding center statistics. Indicators are illustrated in Table 2 and forms for monthly reporting
on SFPs are attached in Annex 2.

Table 2: Indicators for Monitoring Supplementary Feeding Programs

SFP Indicators
Recovery rate
Death rate
Defaulting rate

Acceptable
(%)
>70
<3
<15

Alarming
(%)
<50
>10
>30

Therapeutic Feeding Programs

47. Monitoring of TFPs includes the regular collection of feeding center statistics (Table 3)
as well as regular surveillance to ensure compliance with therapeutic protocols for the
provision of nutrition and medical care. Specific forms for monthly reporting on TFPs are
attached in Annex 3.

Table 3: Indicators for Monitoring Therapeutic Feeding Programs

TFP Indicators
Recovery rate
Death rate
Defaulter rate
Weight gain (g/kg/day)
Coverage
Mean length of stay

Acceptable
(%)
> 75
< 10
< 15
>=8
>50-70%
<3-4 weeks

Alarming
(%)
< 50
> 15
> 25
<=8
<40%
>6 weeks

VII. FOOD COMMODITIES FOR FEEDING PROGRAMMES

SUPPLEMENTARY FEEDING PROGRAMMES

48. The size and type of the daily food supplement will depend on the adequacy of the
general food supply situation, the malnutrition and mortality rate, and the feeding programmes
modalities.
49.
Food must be energy dense and rich in micronutrients, culturally appropriate, easily
12
digestible and palatable. Usually, a blended food , fortified with micronutrients such as Corn
Soya Blend (CSB), Unimix, Famix is being used. In situations when cooking may not be
feasible, ready to eat items, such as high-energy biscuits or locally made snacks, can be
used. Provision of food commodities is carried out according to the Memorandum of
Understanding (MOU) between WFP and UNHCR (6).
50.
Energy density is an important feature of a suitable food for Supplementary Feeding
Programmes. Energy-dense supplementary food must contain at least 100 kcal per 100
grams with at least 30% of the energy coming from fat (9). Unimix, Famix and CSB have a fat
content of only 6%, and as a consequence approximately 10 grams of oil should be added to
100 grams blended food during preparation and be distributed as a dry pre-mix or cooked
porridge.
51.
It is recommended not to use either fresh
because of the discouraging effect it has on
reconstitution and bacterial contamination through
utensils (3). Milkpowder can be distributed in
commodities (cereal flour, sugar, oil).

milk or milkpowder in a take-home ration

breastfeeding, the danger of incorrect
use of unsafe water and unclean feeding
dry form only when mixed with other

52.
On-site feeding or wet ration should provide from 500 to 700 kcals of energy per
person per day, including 15 to 25 g of protein (Table 4, rations 3-7). The food commodities
provided could include blended food, oil, sugar, cereals, high energy biscuits and pulses.
53.
Take-home or dry ration should provide from 1,000 to 1,200 kcal per person per day
and 35-45 g protein (Table 4, rations 1-2). Commodities include blended food, oil and sugar.

Table 4: Examples of Typical Daily Rations for SFPs (in grams per person per day)
Take-home or
dry ration
Item
Blended food,
fortified
Cereal
High Energy Biscuits
(HEB)
Oil, fortified with
vitamin A
Pulses
Sugar
Salt, iodized
Energy (Kcal)
Protein (g)
12

On-site feeding or wet ration

Ration 1

Ration 2

Ration 3

250

200

100

Ration 4

Ration 5

Ration 6

Ration 7

125

100

10

10

10

10

605
23

510
18

125
125
25

20

20

15

1250
45

1000
36

15

20

30

30

5
620
25

560
15

700
20

A blend, composed of pre-cooked cereals and legumes/soybeans, fortified with vitamins and minerals.

Fat % Kcal

30

30

30

30

28

26

29

THERAPEUTIC FEEDING PROGRAMMES

54.
The type of food used in the treatment of severe malnutrition is of paramount
importance.
55.
In the acute phase only milk-based diets are given to the patients. Therapeutic Milk
(TM) is used for treatment of severely malnourished children. However, if TM is not available
13
High Energy Milk could be used (8).
56.
In the rehabilitation phase a cereal based porridge, made of blended food (fortified),
oil and sugar is given in addition to the TM. Other foods including high-energy biscuits can
also be given at this stage and local food items should gradually be introduced to bring the
patient back to the family diet.
57.
Orphans younger than one year and infants whose mothers cannot produce adequate
breastmilk often become malnourished. Unless a wet nurse can be found, breastmilk
substitutes are the only option. Commercial infant formulas are often neither available nor
affordable. An alternative is a formula based on cows milk, dried skim milk or dried whole milk
as described in table 5 (8,10).

Table 5: Home-made substitutes for breast milk

Type of milk

Cows milk, boiled

a, b

Full-cream milk
powder

Dried Skim Milk

(DSM)

Ingredients
Milk
Water, boiled
Sugar
Oil

125 ml
75 ml
15 g
-

15 g
200 ml
15 g
-

10 g
200 ml
15 g
5g

Approximate value/100 ml
Energy (kcal)
Protein (g)

70
4.1

70
3.9

70
3.6

Management of nutrition in major emergencies, WHO (in press) & Manual on Feeding Infants and Young
Children, M. Cameron and Y. Hofvander, 1984
b
For infants up to six months of age, if no breast milk is available or when the breast milk supply is not enough.
Average total volume needed per day is about 150 ml/kg. The ingredients given will make 200 ml.
c
At least fortified with vitamin A, if available supplemented with the vitamin/mineral mixes as described in
Manual for Management of Severe Malnutrition: A Manual for Physicians and other Senior Health Workers;
WHO (1999).

13
High Energy Milk is composed of Dried Skim Milk (DSM), oil and sugar, mixed and fortified with minerals
and vitamins, used for the treatment of severe malnutrition.

VIII. MANAGEMENT ISSUES

58.
For planning purposes, the food needs and facilities for the feeding centers need to be
estimated (see example). When recent nutrition survey data and demographic data are
available, the maximum expected number of beneficiaries can be calculated. If demographic
information is not available, table 6 below can be used as an approximation.
59. In the absence of data on the prevalence of malnutrition, it can be anticipated that in a
nutritional emergency, 15 - 20% may suffer from moderate malnutrition and that about 2 -3%
might be severely malnourished. Using these estimates, requirements for the various food
commodities can be calculated and planned for a period of time.

Example
Population of the camp = 30,000.
Estimated number under five years = 4,500-6,000 (15-20%).
Estimated prevalence of moderate malnutrition (15%); number of moderately
malnourished children = 675-900.
Estimated prevalence of severe malnutrition (2%); number of severely malnourished
children 90 - 120.

Table 6: Projected Demographic Breakdown

Group

% of the total population

Comments

under five years

5 -14 years
Pregnant
Nursing

15 - 20%
25 - 30%
1.5 - 3 %
3 - 5%

0 -59 months or < 110 cm

Addressing Food Pipeline failures

In case a serious food pipeline failure disrupts the availability of one or more important
commodities, the following measures are recommended:
1. Exercise all efforts to restore the food pipeline at the earliest opportunity
2. Replace food commodities that are not available by other food items in order to
maintain the adequate energy and protein level of the food basket as described in
Joint WFP/UNHCR Guidelines for Estimating Food and Nutritional Needs in
Emergencies (5)
3. Decrease the distribution of the missing commodity (ies) in the General Ration
4. Safeguard the supplies to the Therapeutic Feeding Programme
5. Maintain the level of the commodity (ies) concerned in the Supplementary Feeding
Rations with the following sequence of priority:
! children under 5 years of age
! pregnant women and nursing mothers
! older children
! other at-risk groups
6. In case of a prolonged food pipeline failure, the Supplementary Feeding
Programme can be expanded to other at-risk groups depending on food availability

60.
Feeding Centre organisation and staff requirements for a given population can be
found in several guidelines (11,12,13,14).

61.
For further details and technical advice, Nutritionists in the technical units in WFP and
UNHCR-Headquarters can be contacted.

Annex 1:

References

1. The Care Initiative: Assessment, Analysis and Action to Improve Care for Nutrition;
UNICEF, April 1997.
2. A Framework for People-Oriented Planning in Refugee Situations taking Account of
Women, Men and Children; UNHCR, December 1992.
3. Policy for Acceptance, Distribution and Use of Milk Products in Refugee Feeding
Programmes; UNHCR, July 1989.
4. Humanitarian Charter and Minimum Standards in Disaster Response; The Sphere Project,
1998.
5. Joint WFP/UNHCR Guidelines for Estimating Food and Nutritional Needs in Emergencies
(also in French), WFP/UNHCR, December 1997.
6. Memorandum of Understanding on the Joint Working Arrangements for Refugee,
Returnee and Internally Displaced Persons Feeding Operations (also in French);
WFP/UNHCR, March 1997.
7. Nutrition Guidelines; MSF, 1995.
8. Manual for Management of Severe Malnutrition: A Manual for Physicians and other Senior
Health Workers; WHO (1999).
9. Fats and Oils in Human Nutrition; FAO Food and Nutrition Paper 57, FAO & WHO, 1993.
10. Manual on Feeding Infants and Young Children; M. Cameron and Y. Hofvander, Oxford
University Press, 1983.
11. Good Practice Review 2, Emergency Supplementary Feeding Programmes, RNN 1997.
12. Selective Feeding Programmes, Lusty T. And Diskett P., OXFAM Practical Guide No. 1,
OXFAM Health Unit, 1984.
13. Drought Relief in Ethiopia, Planning and Management of Feeding Programmes, A Practical
Guide; SCF UK, 1987.
14. Food and Nutrition in the Management of Group Feeding Programmes, FAO Food and
Nutrition Paper 23 Rev.1; FAO, 1993.

Annex 2: Reporting Form: Supplementary Feeding Programme

COUNTRY:

PERIOD:

LOCATION:
AGENCY:

TOTAL POPULATION:
UNDER (<) 5 POPULATION:
MODERATE MALNUTRITION RATE:
TARGET < 5 (MODERATE MALNUTRITION

RATE * < 5 POP.):

THEORETICAL

COVERAGE

<

(NEW

TOTAL (J)/TARGET):

CATEGORIES
<5 years
M
F

>=5 years
M
F

Pregnant
women

Lactating
women

TOTAL

Total at end last

month (A)
New
Admissions:

<80% WFH or
<-2 Z-score
Others

Total New
Admissions (B)
Re-admissions
(C)
Total
Admissions
(D=B+C)
Discharged in
this Period :
Discharges (E)

percentage
for <5 yrs
(target):
E/I * 100%=

Deaths (F)

F/I * 100%=

Defaulters (G)

G/I
100%=

Referrals (H)

( 15%)

(> 70%)

(< 3%)

Total
Discharged
(I=E+F+G+H)
New Total at
end this month
(J=A+D-I)

Average length of stay in the program (from all or a sample of 30 recovered children) (target <60 days) =

Total No of days of admission of all (or 30) recovered children

No of recovered children (or 30)

Comments:

Annex 3: Reporting Form: Therapeutic Feeding Programme

COUNTRY:
LOCATION:
AGENCY:

PERIOD:

TOTAL POPULATION:
UNDER (<) 5 POPULATION:
SEVERE MALNUTRITION RATE:
TARGET < 5 (SEVERE MALNUTRITION

RATE * < 5 POP.):

THEORETICAL

COVERAGE

<

(NEW

TOTAL (J)/TARGET):

<5 years
M
F

CATEGORIES
>=5 years
Adults
M
F
M
F

Total

Total at end of last

month (A)
New Admissions:
<70% WFH or:
<-3 Z-score
Kwashiorkor
Others
Total New Admissions
(B)
Re-admissions (C)
Total Admissions
(D=B+C)
Discharged this month:

Discharged (E)

percentage
for <5 yrs
(target):
E/I * 100%=

Deaths (F)

F/I * 100%=

Defaulters (G)

(<10%)
G/I * 100%=

(>75%)

(<15%)
Referrals (H)
Total Discharged
(I=E+F+G+H)
New Total at end of this
month (J=A+D-I)
Causes of death:
Average weight gain during last month (from all or a sample of 30 children) (target: >8 g/kg/day) =

weight at end of month (or on exit) - lowest weight recorded during month
lowest weight recorded in last month x No of days between lowest weight recorded and end of month
(or on exit)

Average weight gain for marasmus (include only children in phase II) =
Average weight gain for kwashiorkor (include only children in phase II after complete loss of oedema) =
Average length of stay in the program (from all or a sample of 30 recovered children) (target <30 days) =

Total No of days of admission of all (or 30) recovered children

No of recovered children (or 30)
Comments: