Addressing considered the lead agency for the Global

Addressing Moderate Acute Malnutrition in
the Setting of a Refugee Camp


While each humanitarian emergency has
unique components that necessitate individual adjustments, the cluster approach
has become the cornerstone of emergency response over the past fifteen years.

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First conceived in 1991, the concept evolved over the next two decades to its
first implementation in response to the devastation caused by the Pakistani
earthquake in 2005 (Humanitarian Response, 2018).  The concept involves uniting a multitude of
organizations, both UN and non-UN, to address eleven different facets of a
humanitarian emergency and better achieve predictability and accountability in
response to a humanitarian crisis (UNHCR). Ultimately overseen by the
Inter-Agency Standing Committee, each organization focuses on its individual
specialty but continues to work closely with other groups to coordinate optimal
care, and provide both less gaps and less overlaps in the assistance delivered
because often, the involvement of multiple partners can result in a  “scramble
for relevance and scarce resources such as human, financial and logistics which
increases the cost and reduces the effectiveness of emergency response” (Olu,

The nutrition cluster is
comprised of various entities committed to aiding in the response to a
nutritional emergency. It is comprised of NGOs, Academic Institutions, UN
agencies, research and development groups and private donors all working at
both global and country levels. The United Nations Children’s Fund UNICEF is
considered the lead agency for the Global Nutrition Cluster, and is joined in
this task by, among others, the World Food Project, Save the Children, US-AID,
Samaritan’s Purse and MSF (Global Nutrition Cluster, 2018)

year, approximately 5.9 million children around the world die before their
fifth birthday” (Trahan, 2015) from various causes; the top two being
prematurity and pneumonia. However, various degrees of malnutrition contribute
heavily to worldwide under-5 mortality rates and predispose children to more
severe complications of diarrhea, measles, and pneumonia (Black, 2013). “Acute malnutrition
is caused by insufficient and poor quality food intake, malabsorption or loss
of nutrients due to increased metabolic needs associated with illness, and  most often related to a sudden decrease in
caloric intake or dietary quality, often in combination with pathological
causes (Lenters et al., 2016). Moderate acute malnutrition is defined as
between two to three standard deviations less than typical child’s
weight-for-height score and/or a middle upper arm circumference of between 115
and 125mm.

A qualified nurse should
recognize that these children falling into the category of moderately
malnourished are in a very precarious situation. They are normally still
healthy enough to be treated in an outpatient community setting and with close
monitoring and proper dietary adjustments, can often avoid long-term
complications and catch up to their properly-nourished peers. However, without
rapid intervention, these children can quickly decline to severe acute
malnutrition and poor outcomes.

In areas where communities and
families have long been established, with adequate access to sustainable foods
and farming, a nutritional dietary counseling program may be sufficient to
manage MAM. A nurse or locally trained representative may visit these
identified at-risk children’s homes and work closely with parents to educate on
“food and feeding practices that are affordable, feasible, and acceptable to
families” in order to correct nutritional deficits. However, refugee camps are,
more often than not, areas where food shortage and insecurity is widespread.

Due to the constantly changing and instability of food supply in a refugee camp,
nutrition dietary counseling may not be the most appropriate intervention.

At the onset of a humanitarian
emergency, a general food distribution with specific monitoring of those
already identified as MAM would be the ideal program for a nurse to establish.

This type of program protects the nutritional status of the community from
sinking into a general state of malnourishment due to the change in or sudden
unavailability of food. However, since this camp has been established for two
years already, this also may not be the nurse’s most appropriate course of

A Selective Supplementary Feeding
Program would likely be the nurse’s most appropriate choice in this situation.

The goal of this type of program is to “rehabilitate moderately 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 lactating mothers.” (UNHCR 2018).

specifics of this program can be tailored based on many different concerns the
nurse may identify about this particular environment. What is the general
nutritional status of the camp, and would blanket feeding be indicated, or is
the food supply in the household appropriate to where those receiving targeted
distribution could be trusted not to share with the rest of the household? How
large is this refugee camp? Can people travel to the center daily to collect
rations, or would a weekly distribution be more appropriate? What is the
security situation in the camp, and would those transporting home weekly
rations be placed at risk? (UNHCR 46-47)

country of Somalia experienced an extended famine at the beginning of the
twenty-first century, and a comprehensive field guide was published by the
United Nations Office for the Coordination of Human Affairs (UNOHCA), in
conjunction with the Nutrition Working Group of the Somalia Support
Secretariat, to direct the supplemental feeding program established in that
area. While not set in a refugee camp, many of the protocols used in the Somali
scenario would be beneficial resources in establishing this specific program and
the previously mentioned field guide would serve as a valuable reference for
the implementation of this feeding program.

For the
sake of this exercise, certain details about this camp and the surrounding
environment will be assumed. This program will focus specifically on children
6-59 months, although in many situations it is also prudent to include
pregnant, elderly, or chronically ill adults as well. It will also be implied
that the prevalence rate in this community between 5-9% with aggravating
factors such as poor food security and high rates of diarrheal and respiratory
diseases, prompting the nurse’s initiation of a targeted supplementary feeding
program (IASC toolkit 36).

At the
program’s inception, each family settled in the refugee camp will first be
asked to bring their children to a centrally or otherwise conveniently located
screening center for evaluation, and new refugee families will be screened upon
arrival and included as indicated. Home visits can be made to those who do not voluntarily
present for assessment.  While this scenario assumes that
the refugee camp has a separate health center set up to manage childhood
vaccines and other concerns that fall more appropriately under the umbrella of
the health cluster, all children screened, even if they do not meet criteria
for MAM and supplementary feeding, will receive a dose of antihelminths
(mebendazole or albendazole), repeated every six months as resources and supply
allows to ensure adequate weight gain or maintenance. Middle upper
arm circumference (MUAC) will be measured by trained local assistants and used
to identify children at risk, as outlined in the table below (UNHCR 2018).

weight-for-height score is another, often more accurate way to classify
children MAM, this scenario states that the local assistants span various
degrees of literacy, so a standardized measurement that is both simple to
explain and to carry out would be the more appropriate choice. If children have
bilateral pitting edema present, they will be directly referred to the closest
therapeutic feeding program, as they are classified as severely acutely
malnourished and will need interventions beyond what a supplemental feeding
program for moderate acute malnutrition can provide (UNOCHA). Once these
children are appropriately categorized and an interventional group is
identified, each caretaker will be given a ration card to concisely store data
about the course of treatment.  

initial counseling session should be offered to each caregiver involved in the
program to address any baseline questions or concerns, as well as explain the
plan of care and expectations for each child. These opportunities could be held
as group sessions if time and resources necessitate, but an individualized
approach is more likely to reap maximum benefit and allows the approach to be
more tailored to the family’s specific situation.  Demonstration sessions can also be held, addressing
topics such as treating and storing drinking water, preparing ORS to treat
diarrhea, proper food hygiene and storage of cooked food.

Food supplements
can be distributed as either a “dry” ration to be taken home and prepared, or
as a “wet” ration, referring to food that is pre-cooked and consumed on site
(UNOCHA 12). In this particular refugee camp, it will be assumed that safety
and food availability are such that can allow take-home portions, and when
available, extra portions will be sent home with families to account for the
sharing that will inevitably occur between siblings and other hungry relatives.

Food supplements such as Plumpy’Nut or Plumpy’Sup will be distributed on a
bi-weekly basis (either Monday/Thursday, Tuesday/Friday, or Wednesday/Saturday)
and at each visit, MUAC will be measured and documented.


The most
widely-accepted standard of care is to continue treatment and food distribution
until a child is considered “discharged” after measuring a MUAC greater than or
equal to 125 at two consecutive visits. However, a study published in the Journal of Pediatric Gastroenterology and
Nutrition in 2015 suggested that children treated with supplementary
feeding for a fixed period of 12 weeks instead of to a WHZ score of (-2) or
MUAC of 125 generally had better outcomes and were less likely to relapse into
a malnourished state (Trehan 2015).

The ultimate goal of any project is to create a sustainable
program that can run long after an immediate crisis has subsided and outside
aid has pulled out. In a refugee camp, it seems unlikely that the program will
ever close, as there are consistently new families joining the community and
presenting for evaluation. A refugee camp will also likely always be a
recipient of some kind of outside assistance, until it can be dispersed and its
occupants returned home or permanently settled elsewhere. However, the nurse’s
contract is only for one year, so throughout this program’s instillation a
significant focus should be on training local workers to independently manage
the treatment of moderate acute malnutrition.



I chose to use Rolfe’s Model of Reflection to further
unpack what I learned during my time in the DTN course. I was introduced to a significant
amount of new information, and also had the chance to become more comfortable
with topics and diseases I deal with already in my work as an emergency nurse
in the US. The content and pace was often overwhelming, but I feel like I came
away with knowledge that’s going to prove priceless in my future. I often find
group work frustrating as I am a fairly independent person, but I was reminded
through our various group activities that collaboration is not just a necessary
part of life, but especially so when working in low-income, low-resource
settings. So, if I was in this situation of having to establish a MAM clinic in
a refugee camp, or any other similar environment, I feel I would be better
prepared to collaborate with others to come to a common understanding of what
would best benefit the population I was tasked with helping because of the DTN
program. I believe I will be ultimately more confident in my work as a nurse,
speaking up when I have knowledge in certain areas where my department is
generally uninformed. I also learned how to be more compassionate in my
interactions with people, especially those who come to my ER from foreign
countries needing interpreters and how to see myself in their shoes. Now, after
returning home and back to my job, I feel like I am better prepared to both
care for the patients I see on a day to day basis in the emergency department
and for future work overseas in LMIC. I need to take the time to sit down and
really process through future opportunities and the logistics of making a major
life change, and I hope to encourage others to think outside the box regarding
what impact they could have on a global scale.