Malnutrition, including micronutrient deficiency, is associated with increased risk of morbidity and mortality for affected individuals. Therefore, when rates of malnutrition are high, it is necessary to ensure access to services which correct as well as prevent malnutrition. The impact of these services will be considerably reduced if appropriate general support for the population is not in place - for example, if there is a failure in the general food pipeline, or acute food insecurity, or if supplementary feeding without general support is being done for security reasons. In these instances, advocacy for general nutritional support should be a key element of the programme (see Response standard).

There are many ways to address moderate malnutrition, for example through the improvement of the general food ration, improving food security, improving access to health care and to sanitation and potable water. In disasters, targeted supplementary feeding is often the primary strategy for correction of moderate malnutrition and prevention of severe malnutrition (standard 1). In some instances, rates of malnutrition may be so high that it may be inefficient to target the moderately malnourished and all individuals meeting certain at-risk criteria (e.g. those aged 6-59 months) may be eligible. This is known as blanket supplementary feeding.

Severe malnutrition is corrected through therapeutic care which can be delivered through a variety of approaches, including 24-hour in-patient care, day care and home-based care (standard 2). The provision of in-patient care relies on other standards being achieved, such as the provision of functioning water and sanitation facilities (see Water, Sanitation and Hygiene Promotion). The correction of micronutrient deficiencies (standard 3) relies on the achievement of standards in health systems and infrastructure and control of communicable diseases (see Health Services).

Key indicators (to be read in conjunction with the guidance notes)

1. Design of targeted supplementary feeding: programme design must be based on an understanding of the complexity and dynamics of the nutrition situation. Targeted supplementary feeding programmes should only be implemented when anthropometric surveys have been conducted or are planned and if the underlying causes of moderate malnutrition are being addressed simultaneously. Targeted supplementary feeding programmes may be implemented in the short term, before General nutrition support standard 1 is met. The purpose of the programme should be clearly communicated and discussed with the target population (see Participation standard).

2. Coverage is calculated in relation to the target population, defined at the start of the programme, and can be estimated as part of an anthropometric survey. It can be affected by the acceptability of the programme, location of distribution points, security for staff and those requiring treatment, waiting times, service quality and the extent of home visiting. Distribution centres should be close to the targeted population, to reduce the risks and costs associated with travelling long distances with young children and the risk of people being displaced to them. Affected communities should be involved in deciding where to locate distribution centres. The final decision should be based on wide consultation and on non-discrimination.

3. Exit indicators: exits from a feeding programme are those individuals no longer registered. The total of exited individuals is made up of those who have defaulted, recovered (including those who are referred) and died.

Proportion of exits defaulted =
number of defaulters in the programme x 100%
number of exits

Proportion of exits died =
number of deaths in the programme x 100%
number of exits

Proportion of exits recovered =
number of individuals successfully discharged in the programme x 100%
number of exits.

4. Admission criteria: individuals other than those who meet anthropometric criteria defining malnutrition may also benefit from supplementary feeding e.g. people living with HIV/AIDS or TB or those who have a disability. Monitoring systems will need to be adjusted if these individuals are included. In situations where emergency feeding programmes are overwhelmed with the numbers of individuals eligible for treatment, this may not be the best way to address the needs of these individuals, who will also remain at risk beyond the duration of the disaster. It may be better to identify alternative mechanisms for providing longer-term nutritional support e.g. through community home-based support or TB treatment centres.

5. Health inputs: targeted supplementary feeding programmes should include appropriate medical protocols such as the provision of anti-helminths, vitamin A supplementation and immunisations, but delivery of these services should take into account the capacity of existing health services. In areas where there is a high prevalence of particular diseases (e.g. HIV/AIDS), the quality and quantity of the supplementary food should be given special consideration.

6. On-site feeding: dry take-home rations, distributed on a weekly or bi-weekly basis, are preferred to on-site feeding but their size should take into account household sharing. On-site feeding may be considered only where security is a concern. Where fuel, water or cooking utensils are in short supply, such as in populations which are displaced or on the move, distributions of ready-to-eat foods may be considered in the short term, provided they do not disrupt traditional feeding patterns. For take-home feeding, clear information should be given on how to prepare supplementary food in a hygienic manner, how and when it should be consumed and the importance of continued breastfeeding for children under 24 months of age (see Food aid management standard 3).

7. Monitoring systems: systems should monitor community participation, acceptability of the programme (a good measure of this is the rate of defaulting), rates of readmission, the quantity and quality of food being provided, programme coverage, admission and discharge rates and external factors such as morbidity patterns, levels of malnutrition in the population, level of food insecurity in households and in the community, and the capacity of existing systems for service delivery. Individual causes of readmission, defaulting and failure to recover should be investigated on an ongoing basis.