Worldwide, undernutrition contributes to about one third of the 24,000 deaths of children under five that occur daily. In eastern Burma, food insecurity and aggravating health factors such as intestinal worms, respiratory infections and malaria are catalysts for malnourishment, contributing to the under-five death rate of 138 per thousand.
Screening for malnutrition in small children is based on mid-upper arm circumference (MUAC). A circumference of 110 mm or less indicates severe malnourishment. A circumference of 111 to 125 mm indicates moderate malnourishment. A randomized cluster survey of 5754 households in eastern Burma in 2008 found a global acute malnutrition rate (combined severe and moderate malnutrition rates for children under 5) of 12.6%. According to the WHO Standing Committee on Nutrition, a global acute malnutrition rate over 10% qualifies as a serious humanitarian emergency requiring action. Recommended actions include community-based programs for managing malnutrition.
In 2008, with technical assistance from the Global Health Access Program (GHAP), KDHW initiated a malnutrition intervention for children under five years old. The initial training of Targeted Feeding Program (TFP) health workers included nutrition theory, malnutrition screening of children under five, and targeted feeding practices. The TFP health workers are given biannual refresher trainings. Through 2010, eight health workers had completed five trainings, eight health workers had completed four trainings, and three had completed two trainings.
The program was introduced at two mobile health clinics in December, 2008. It was extended to one more clinic in July, 2009, and to a fourth clinic in July 2010. These four clinics in the TFP also are in the immunization program. The TFP was introduced as well at two other clinics, where, like the Immunization Program, it later was suspended because of military incursions.
Following a baseline survey at each clinic, program health workers conduct bi-annual under-five screening using MUAC. Through 2010, six screenings had been conducted at the first two clinics, five at the third clinic, and two at the fourth clinic. Two screenings were conducted in a fifth program area before the villagers fled fighting between the SPDC and DKBA in June, 2009. A third screening was done of those villagers in September, 2009 in two refugee camps, but no further screening was possible following the villagers’ forced repatriation. The program was resumed at the clinic in 2012, however, and screening has begun.
Following each biannual screening, the clinic workers distribute weekly food supplements to the families of moderately malnourished children (MUAC 110-125mm), providing an extra 1,000 cal/day in accordance with dry-ration guidelines. The supplements include rice flour, powdered milk, sugar, and vegetable oil. The workers also provide education to the families on food preparation and storage, and on the importance of encouraging their malnourished children to finish their meals.
Severely malnourished children (MUAC <110 mm) are treated with high-energy milk in the clinics, in accordance with the Burmese Border Guidelines. The children must stay at the clinic until they improve to being only moderately malnourished. On average, severely malnourished children transition to being moderately malnourished after about two weeks and then can return home, where they continue to receive supplements for moderate malnourishment. After one month they are re-examined to ensure that they still are not severely malnourished.
Moderately malnourished children are discharged from the program when their MUAC exceeds 125 mm. On average it takes about eight weeks of targeted feeding for a moderately malnourished child to be discharged. The longest period of targeted feeding until being discharged, for two children, was six months.
During the first two years, all children who have remained to be treated in the program, whether severely or moderately malnourished, have been discharged and have remained adequately nourished when evaluated a month after discharge. Recovery from malnourishment for treated children is only a matter of time.
Results of screening for the first two years of the program are given in the table below. The overall decline of about 50% in prevalence of acute malnutrition in the screened portions of the population from the first to the second year of the program suggests that the program is having a positive impact. Since the samples screened were not random, however, we do not evaluate the significance of the decline.
Table: Results of Screening for Acute Malnutrition
KDHW hopes in the future to be able to expand program coverage to more remote clinic areas.
We thank our partners in the TFP:
- Child’s Dream (funding)
- Global Health Access Program (technical assistance)
- Not on Our Watch (funding)