WHO Malawi Nutrition Activities WHOs general approach is to develop integrated strategies focused on the immediate effects of malnutrition

(capacity to treat malnourished children) and on the underlying causes (absent or insufficient primary health care services, food security), targeting the most vulnerable communities. The initial intervention will look at building capacity within Malawi to treat severe acute malnutrition and to initiate the process of collecting nutritional data. Initial interventions include: Improvement of the capacity of Ministry of Health and NRU (Nutrition Rehabilitation Unit) staff to effectively treat acute malnutrition. Together with UNICEF and AAH (Action Against Hunger) WHO will identify key national staff to be included in a training of trainers, and will assist in the facilitation of the training in the correct protocol for the treatment of severe acute malnutrition and in the use of F75 and F100 milk. WHO will work with UNICEF on the development of the training strategy and protocol for the training programme for NRU staff , in nutrition protocol and the use of F75 and F100. Treatment of moderate and severe acute malnutrition through training and technical support initially to 35 Nutritional Rehabilitation Units (NRUs) at district and rural area. WHO will work with UNICEF to identify key staff to be trained from these NRUs, and will identify the steps to be taken to train the staff of these core NRUs. Ongoing supervision and on-the-job training of NRUs which have been trained. Following the initial training exercise, WHO will work on the establishment of a national system of surveillance in collaboration with the Ministry of Health. The purpose of this system will be to provide regular information on nutritional status, in order to be able to predict and avert potential future nutritional crises.

Activities Training of Trainers for Ministry of Health staff in the treatment of severe acute malnutrition and correct use of nutritional products. In terms of the treatment of malnutrition, special attention should be given to collaboration with the Ministry of Health. The recent assessment in Malawi revealed that there is an urgent need to improve the knowledge-base and capacity at national level of

nutritionists and other key staff within the Ministry of Health, in order for them to be able to train and support staff involved in the treatment of severe acute malnutrition. WHO will work with UNICEF and AAH (Action Against Hunger), to identify key technical facilitators to be included in the training of trainers, and will assist in the facilitation of training these staff in the correct protocol for the treatment of severe acute malnutrition. WHO will work with UNICEF to develop the training strategy and protocol for this training programme and for the training of NRU staff, in nutrition protocol. Training will be also carried out specifically on the use of F75 and F100 provided by UNICEF. In order to try to decrease the dependency on imported products such as F75 and F100, WHO will work with UNICEF and the MoH to try to identify and develop suitable appropriate alternatives for the treatment especially for the Phase 1 and the transition phase, during which the Likuni Phala (soya beans and maize flour fortified with vitamin A and vitamin D) is not either appropriate (Phase 1) or should be complemented (transition phase). Training of staff of 35 core NRUs in the diagnosis and treatment of severe malnutrition and the correct use of nutrition products including F75 and F100 In Malawi Nutrition Rehabilitation Units are inadequately equipped, in terms of training, protocols, human and material resources, to effectively diagnose and treat acute malnutrition. WHO together with UNICEF and AAH intends to undertake training workshops and onthe-job training on nutrition issues and the diagnosis and treatment of malnutrition at national, regional and district level, for selected staff from 35 pre-selected core NRUs. This training will take place on a cascade basis, following the initial Training of Trainers. Nutrition and medical products including F75 and F100 will be provided by UNICEF, directly to the NRUs. Likuni Phala will be provided by WFP. It is envisaged that approximately 6000 severely malnourished children will be treated through the NRUs. Monitoring and ongoing training of core NRUs Following the training programme of ToT and NRUs staff, WHO will work together with UNICEF and AAH to monitor the effectiveness of the treatment of severe acute malnutrition by the trained core NRU staff, and will provide technical support and advice where necessary, as well as on-the job training. In order to achieve this, WHO and AAH will pay regular visits to the core NRUs throughout this programme period.

Treatment protocol to be implemented in the NRUs WHO and UNICEF have finalized the protocol to be used in NRUs for the treatment of severe malnutrition within the NRUs, and which selected and NRU staff will receive training in. However, the protocol below outline the basis of the approach, which has been discussed and agreed with the MoH. Children admitted to the NRUs, with the exception of those under 6 months of age, will follow the following standard protocol: Phase1 W/H< 70% F-75 8 milk meals 130ml/kg/day Transition W/H> 70% F-100 (High Energy Milk) 8 milk meals 130ml/kg/day Phase2 W/H < 80% F-100 6 milk meals + +1 porridge meal 200ml/kg/day

The objective of phase one is to correct any major medical problems and imbalances in metabolism and to prepare the child for re-feeding. Each beneficiary receives small regular meals that are relatively low in calories and protein, as the digestive system in a malnourished case is not able to cope with large quantities of rich food. The F-75 diet has a balance of vitamins and minerals sufficient to cover the childs daily requirements. This phase lasts an average of 4 days. When a child no longer has diarrhea or vomiting and is eating well, he/she is transferred to the transition phase. The objective of the transition phase is to get the child used to the F-100, which contains higher protein content. This normally takes two days. Phase 2 is a period of intensive re-feeding. The diet is high in protein and calories and enables a rapid gain of weight. Iron is added to the diet to complete the balance of micronutrients. The number of meals is reduced, as the beneficiaries are now able to tolerate larger feeds. This phase usually lasts an average of 12 to 15 days. After reaching discharge criteria, each beneficiary will be assigned to the nearest SFC/ health centre for follow up supplementary rations. If this is not possible, supplementary rations will be distributed from the NRU to cured patients for a period of three months. Weight gain will continue to be monitored and relapses will be referred back to the NRU.

Activities to be offered at community level Identify health centers and their out-reach points in the communities through assistance of health staff (Health Surveillance Officers). Establish SFP centers in these communities through assistance of village health committees, central health committees and Health Surveillance Officers. Nutritional Screening of under five, pregnant and lactating mothers using: (i) Weight for Height (W/H), MUAC and physical assessment for under five children and explain nutrition status to the mothers. (ii) MUAC for pregnant and lactating mothers and explain nutrition status to the mothers. (iii) Clinical screening of under five children, pregnant and lactating mothers by health staff if necessary. Record the measurements and any necessary information during new admissions and take height measurement every month. Refer severely malnourished children to the nearest nutrition rehabilitation unit and constantly monitoring their progress by physically visiting them. Educate mothers by training them on : (i) (ii) (iii) (iv) (v) (vi) (vii) how to identify a malnourished child, how to weight the child and to take care of a malnourished child; how to identify simple symptoms (e.g. dehydration); how to prepare different kinds of food (cooking demonstrations) and how to store food properly; the importance of immunization for U/5 children; train them on hygiene (personal, household and environmental hygiene); the importance of antenatal and postnatal care; train the mothers in self-sustaining activities for example community gardening.

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