General nutrition support standard 2: at-risk groups
The nutritional and support needs of identified at-risk groups are met.
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Key indicators (to be read in conjunction with the guidance notes)
Infants under six months are exclusively breastfed or, in exceptional cases, have access to an adequate amount of an appropriate breast milk substitute (see guidance notes 1-2).
Children aged 6-24 months have access to nutritious, energy-dense complementary foods (see guidance note 3).
Pregnant and breastfeeding women have access to additional nutrients and support (see guidance note 4).
Specific attention is paid to the protection, promotion and support of the care and nutrition of adolescent girls (see guidance note 4).
Appropriate nutritional information, education and training is given to relevant professionals, care givers and organisations on infant and child feeding practices (see guidance notes 1-4 and 8).
Older people's access to appropriate nutritious foods and nutritional support is protected, promoted and supported (see guidance note 5).
Families with chronically ill members, including people living with HIV/AIDS, and members with specific disabilities have access to appropriate nutritious food and adequate nutritional support (see guidance notes 6-8).
Community-based systems are in place to ensure appropriate care of vulnerable individuals (see guidance note 8).
Guidance notes
1. Infant feeding: exclusive breastfeeding is the healthiest way to feed a baby under six months. Babies who are exclusively breastfed receive no prelactates, water, teas or complementary foods. Rates of exclusive breastfeeding are typically low and so it is important to promote and support breastfeeding, especially when hygiene and care practices have broken down and the risk of infection is high. There are exceptional cases where a baby cannot be exclusively breastfed (such as where the mother has died or the baby is already fully artificially fed). In these cases adequate amounts of an appropriate breast milk substitute should be used, judged according to the Codex Alimentarius standards, and relactation encouraged where possible. Breast milk substitutes can be dangerous because of the difficulties involved in safe preparation. Feeding bottles should never be used, as they are unhygienic. Professionals should be trained in providing adequate protection, promotion and support for breastfeeding, including relactation. If infant formula is distributed, care givers will need advice and support on its safe use. Procurement and distribution must adhere to the International Code of Marketing of Breastmilk Substitutes and relevant World Health Assembly resolutions.
2. HIV and infant feeding: if voluntary and confidential testing for HIV/AIDS is not possible, all mothers should be supported to breastfeed. Alternatives to breast milk are too risky to offer if a woman does not know her status. If a woman has been tested and knows she is HIV-positive, replacement feeding is recommended if it can be done in a way that is acceptable, feasible, affordable, sustainable and safe. HIV-positive mothers who choose not to breastfeed should be provided with specific guidance and support for at least the first two years of the child's life to ensure adequate feeding.
3. Young child feeding: breastfeeding should continue for at least the first two years of life. At the age of six months, young children require energy-dense foods in addition to breast milk; it is recommended that 30% of the energy content of their diet comes from fat sources. Where children aged 6-24 months do not have access to breast milk, foods must be sufficient to meet all their nutritional requirements. Efforts should be made to provide households with the means and skills to prepare appropriate complementary foods for children under 24 months. This may be through the provision of specific food commodities or of utensils, fuel and water. When measles or other immunisation is carried out, it is usual practice to provide a vitamin A supplement to all children aged 6-59 months. Low birth-weight infants and young children can also benefit from iron supplementation, though compliance with daily protocols is very difficult to maintain.
4. Pregnant and breastfeeding women: the risks associated with inadequate nutrient intakes for pregnant and breastfeeding women include pregnancy complications, maternal mortality, low birth weight and impaired breastfeeding performance. The average planning figures for general rations take into account the additional needs of pregnant and breastfeeding women. When the general ration is inadequate, supplementary feeding to prevent nutritional deterioration may be necessary. Low body weight at conception is strongly associated with low birth weight which means that, where they exist, mechanisms for providing nutritional support to adolescent girls should be used. Pregnant and breastfeeding women should receive daily supplements of iron and folic acid but as with children, compliance can be problematic. It is therefore important to ensure that steps are taken to reduce the prevalence of iron deficiency through a diversified diet (see General nutrition support standard 1). Post-partum women should also receive vitamin A within six weeks of delivery.
5. Older people can be particularly affected by disasters. Nutritional risk factors which reduce access to food and can increase nutrient requirements include disease and disability, psychosocial stress, cold and poverty. These factors can be exacerbated when normal support networks, either formal or informal, are disrupted. While the average planning figures for general rations take into account the nutritional requirements of older people, special attention should be paid to their nutritional and care needs. Specifically:
- older people should be able to easily access food sources (including relief food);
- foods should be easy to prepare and consume;
- foods should meet the additional protein and micronutrient requirements of older people.
Older people are often important care givers to other household members and may need specific support in fulfilling this function.
6. People living with HIV/AIDS (PLWH/A) may face greater risk of malnutrition, because of a number of factors. These include reduced food intake due to appetite loss or difficulties in eating; poor absorption of nutrients due to diarrhoea; parasites or damage to intestinal cells; changes in metabolism; and chronic infections and illness. There is evidence to show that the energy requirements of PLWH/A increase according to the stage of the infection. Micronutrients are particularly important in preserving immune function and promoting survival. PLWH/A need to ensure that they keep as well nourished and healthy as possible to delay the onset of AIDS. Milling and fortification of food aid or provision of fortified, blended foods are possible strategies for improving their access to an adequate diet and in some situations it may be appropriate to increase the overall size of any food ration (see Targeting standard).
7. Disabled people may face a range of nutritional risks which can be further exacerbated by the environment in which they are living. Nutritional risks include difficulties in chewing and swallowing, leading to reduced food intake and choking; inappropriate position/posture when feeding; reduced mobility affecting food access and access to sunlight (affecting vitamin D status); discrimination affecting food access; and constipation, particularly affecting individuals with cerebral palsy. Disabled individuals may be at particular risk of being separated from immediate family members (and usual care givers) in a disaster. Efforts should be made to determine and reduce these risks by ensuring physical access to food (including relief food), developing mechanisms for feeding support (e.g. provision of spoons and straws, developing systems for home visiting or outreach) and access to energy-dense foods.
8. Community-based care: care givers and those they are caring for may have specific nutritional needs: e.g. they may have less time to access food because they are ill/caring for the ill; they may have a greater need to maintain hygienic practices which may be compromised; they may have fewer assets to exchange for food due to the costs of treatment or funerals; and they may face social stigma and reduced access to community support mechanisms. The availability of care givers may have changed as a consequence of the disaster e.g. due to family break-up or death, children and older people can become the main care givers. It is important that care givers be supported and not undermined in the care of vulnerable groups; this includes feeding, hygiene, health and psychosocial support and protection. Existing social networks can be used to provide training to selected community members to take on responsibilities in these areas.
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