Special section
Complementary feeding in emergencies

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A global perspective on
improving the diets of infants
and young children
Grainne Moloney is Senior
Nutrition Advisor at UNICEF
headquarters, New York.

Linda Shaker Berbari is
Nutrition Specialist at UNICEF
headquarters, New York.

Harmonie Bucher is Nutrition
Officer at UNICEF
headquarters, New York.

Dear readers,
Together with colleagues from ENN, we aredelighted to present this special section of
Field Exchange (FEX) focusing on complementary feeding programming in fragile and emergency contexts. Our aim is to provide you withan array of experiences from multiple contexts
documenting actions for improving the dietsof young children. The section provides a snapshot of recent developments related to complementary feeding, involving research, experiences and guidance development. It also includes an overview of the latest UNICEF actions
at the global, regional and country level tosupport complementary feeding in fragile settings. As well as the publications here in print,
additional articles from the series are available
at https://www.ennonline.net/fex/68/en
We have made the decision to support thisspecial section as there is a need to understandand share learning about complementary feeding programming, especially in challenging
contexts. This is also timely given the multiple
crises we are facing around the world and thecompounding effects of climate-induced
emergencies (including droughts and environmental degradation), widespread conflict
including the war in Ukraine, and the continuing socioeconomic impacts of the COVID19 pandemic.
In this special section, we present experiencesthat show how the UNICEF Action Framework
for improving young children’s diets (UNICEF,
2020a) has been applied and used in contexts
such as in Sudan, Nigeria, Myanmar and Yemen.
We feature examples of the first step in the
Action Framework, which consists of conducting
a landscape analysis of drivers and determinants
at both the regional and country level. We also
feature country experiences of the multi systems
approach to improving diets in early childhood,including through the health system in Egypt
and the Social Protection system in Kenya. We

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also present specific emergency response actions, such as in Cox’s Bazar in Bangladesh, theState of Palestine and Brazil, and innovative
approaches such as the complementary feeding
bowl and spoon.
We hope that this special series will help
you in your efforts to design ambitious andeffective programmes to protect and improvethe diets of children in early childhood, especiallywithin emergency contexts and protect ourmost vulnerable populations from malnutrition
So why is this issue of such importance:

Many children under the ageof two are not getting thefood or nutrients they need to
thrive and grow well, whichleads to irreversible
developmental harm
At least one in every three children suffers fromsome form of malnutrition at the global level.
Globally, only 53 countries are on track to meetchildhood stunting targets, and only 57 countries
are set to meet childhood wasting targets (2021
Global Nutrition Report). Regional disparities
reveal inequities in progress (UNICEF, 2021). At
the same time, an estimated 5.9% of the world’s
children under the age of five – around 40
million – are overweight (UNICEF, WHO andWorld Bank, 2021), highlighting a persistentburden of malnutrition.

Change is possible: It isalready happening at scale,but acceleration is needed
According to the UNICEF “Fed to Fail” report(UNICEF, 2021), over the last two decades theworld has made significant progress in addressing malnutrition in children under five:for example, the prevalence of child stunting
has been reduced by one-third and the number

FIELD EXCHANGE ISSUE 68, Dec 2022 www.ennonline.net/fex

of children with stunted growth has been reduced by 55 million. These formidable achievements indicate that positive change for childnutrition is possible and is happening at scale
in many countries and regions. Despite suchprogress, we have collectively failed to protect
the right of all children to good nutrition. Thishas contributed to a situation where an estimated 149.2 million children have stunted
growth (with around 45% of these children
living in fragile or conflict-affected countries)and 340 million children under the age of fiveare suffering from deficiencies in vitamins andother essential micronutrients (UNICEF, 2019).

Children carry the scars ofpoor diets and feedingpractices for life
The period between 6–23 months of age iscritical in a child’s life, as the six-month markrepresents the moment when a child’s energy
and nutrient needs begin to exceed what isprovided by breast milk alone. Exceptionalchanges happen, including rapid physical growth,which lead to high nutrient needs. Poor diet(inadequate quality and/or quantity of first
foods; poor feeding practices) in this age group
therefore contributes to poor nutritional status.
The risk of stunting increases rapidly between
6–23 months and, globally, more than half of
all children with wasting are under the age oftwo. Improving children’s diets is critical forchild growth and development, as well as toaddress and prevent different forms of malnutrition (micronutrient deficiencies, wasting,stunting, overweight and obesity), which allcontributes to achieving the Sustainable Development Goals by 2030. Critical to this is continued breastfeeding between 6–23 months,
which safeguards children’s survival, growthand development and provides essential fats,proteins and other nutrients that are important
to lifelong health in all settings.

Progress in improving dietary
practices has been slow andthere is a need to accelerateactionCurrently, diets are failing in terms oftimeliness, frequency and diversity
Globally, about half of all children aged 6–23
months (48%) are not fed the minimum recommended number of meals; over two-thirds(71%) are not fed the minimally diverse diets
they need to grow and develop; and over onequarter (27%) lack the benefits of the most nutrient-rich foods such as fruits, vegetables, eggs,
fish or meat. In addition, around one-third(35%) of children aged 12–23 months are nolonger continuing to be breastfed (UNICEF,
2021). According to the most recent Child Food
Poverty Report, one in three children lives insevere food poverty (defined as eating fewer
than two food groups a day) and, in the Saheland Horn of Africa, 50% of children living insevere food poverty are fed only one – or none
– of the eight recommended food groups(UNICEF, 2022). The state of children’s diets
therefore remains a persistent bottleneck togreater progress on nutrition.
In many contexts – including fragile, foodinsecure and humanitarian contexts – families
struggle to find and afford nutritious complementary foods for their children. The feedingof infants and young children may also bejeopardised by limited access to clean andpotable drinking water, a lack of access toquality health services, and altered practices
due to social disruptions (such as family andcommunity breakdown, stress, time, space,lack of preparation/ cooking facilities/equipment, etc.). Shortages in national food supplies,
seasonal scarcities, displacement and poorroad infrastructure constrain access to nutritious
foods especially for the poorest and most marginalised populations. Physical access is also
problematic in poor urban communities where
there are fewer shops selling affordable nutritious foods. When income is limited, families
tend to prioritise the frequency of feeding andfuller stomachs over the quality of foods foryoung children. This shift was clearly documented during the COVID-19 pandemic, where,
for example, in Indonesia a survey conductedamong urban households in Jakarta, reported
the percentage of young children consuming
the minimum recommended number of foodgroups fell by one third in 2020 compared to2018 (UNICEF, 2021).

Improving diets of young children
is possible and important even infragile settings
Experiences in countries that have recorded asignificant improvement in diet quality overthe past decade, provide evidence that change
is possible at scale with the right focus, identification of barriers and investment. In line with
its Global Nutrition Strategy 2020–2030 (UNICEF,

Views© UNICEF/UN0707664/Katragadda

Special section
Complementary feeding in emergencies

Mary Mai Sundi, a disabled Anganwadi
Sewika, initiates Annaprashna - a ceremony
to initiate eating food – to Nandi Sundi’s
daughter, Laxmi Sundi (7 months), at theAnganwadi in Jharkhand. India, 2022

2020b), UNICEF is committed to improving thediets of infants and young children as a contribution to preventing all forms of malnutrition.

Multiple actions are needed for
improving diets of infants andyoung children
For far too long, efforts to improve the diets ofyoung children have been inadequate in scale,fragmented and fail to reach most vulnerable
children. These efforts have also not addressed
the challenges that caregivers face in feedingchildren what they need to grow well in a comprehensive manner. In recognition of this, we
at UNICEF have developed programming guidance for improving the diets of infants andyoung children during the complementary
feeding period (UNICEF, 2020a) (Box 1) tosupport more effective action through a multisystems approach. This guidance, together withthe 2021 Child Nutrition Report (UNICEF, 2021),
calls for governments to take the lead in upholding every child’s right to food and nutrition,
as well as for the mobilisation of policies, resources and actors across multiple systems(specifically food, health and social protection,
and water, sanitation and hygiene [WASH]).
So why a multi systems approach ?– at UNICEF
we believe that different systems have key roles
to play to improve diets in early childhood?
The health system provides multiple contact points at the facility and community levels
to inform, counsel and support caregivers on
infant and young child feeding and care practices, as well as to distribute dietary supplements and home fortificants (as appropriate)
where poor diets and micronutrient deficiencies
are common.

The food system comprises the policies,
services and actors involved in the production,
processing, distribution and marketing of food.
It influences whether foods are available, accessible, affordable, nutritious, safe and sustainable, and can make it easier – or more difficult – for caregivers to make nutritious foodchoices for their young children
The social protection system forms a crucial
safety net to protect vulnerable children against
poverty and social exclusion, including in emergencies. It can increase families’ physical or financial access to nutritious diets by providing
social transfers (food, cash and/or vouchers)
and offers a platform for the delivery of essential
nutrition services and the promotion of positive
nutrition practices.
The water and sanitation system aims toensure a population’s access to, and use of,safe drinking water and sanitation. These are
critical to protecting young children’s diets, as
poor WASH can expose children to pathogens
that cause diarrhoea and other infections andcan result in environmental enteropathy, leading
to impaired structure and function of the small
intestine. Improved access to basic WASH services can reduce the risk of diarrhoea and otherinfectious diseases.
Achieving the outcome of good diets forchildren in the first two years of life, meansthat countries need to leverage all four systems,
prioritising strategic actions that are evidencebased, equitable and sustainable based on acountry-specific analysis of barriers and bottlenecks on the determinants and drivers. This
will serve to inform the programming context
and the systems’ capacity to deliver.

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Special section
Complementary feeding in emergencies

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Box 1 UNICEF programming guidance: An Action Framework for improving the diets of infants and young children
In February 2020, UNICEF published programming guidance on improving young children’s diets during the complementary feeding
period (UNICEF, 2020a). The guidance describes recent evidence
on improving complementary feeding, explores the determinants
and drivers of young children’s diets, and presents Action Frameworks for delivering nutrition results for children through the food,health, WASH, and social protection systems. It also provides guidance on monitoring and evaluating complementary feeding programmes and outcomes.
The guidance highlights the determinants and drivers of poor diets
in young children, emphasising the role of adequate food, services
and practices (Figure 1). Poor diets are determined by the adequacyof foods, which is in turn driven by the availability, access, affordability,and desirability of such foods. Equally, the availability, affordability,
quality and use of health, nutrition, WASH, and social protection services influence the quality of children’s diets. The feeding, care andhygiene practices of caregivers are key determinants of the qualityof young children’s diets. These practices are driven by caregivers’
knowledge and time, household dynamics and social norms.

Figure 1 The determinants of young children’s diets

The guidance describes the most recent evidence for improving complementary foods and feeding, highlighting implementation across different systems, including health, food, social protection and WASH, atmultiple levels (policy, institutional and community/household). The interventions include:
1. Nutrition counselling and social and behaviour change communication
2. Counselling and education on responsive feeding and stimulation
3. Use of vitamin and mineral supplements in settings where nutrientpoor diets prevail
4. Access to diverse and nutritious complementary foods at house
hold level
5. Access to fortified foods as needed, aligned with global andnational standards
6. Promoting improved accessibility and use of safe complementary
food, water and a clean household environment
7. Access to affordable and nutritious foods through social protection
programmes and counselling services
The guidance provides a framework of action as a tool to apply thesystems approach (Figure 2).
The Action Framework has four elements that interplay to facilitate thedesign and implementation of evidence-based programmes: a situation analysis to understand the status, drivers, and determinants ofyoung children’s diets; strategic actions to be implemented throughsystems; the adaptation to the programming context; and the need formonitoring, evaluation and learning.

What is next for the programming guidance?
UNICEF has implemented a plan for the uptake of its programming guidance at regional and country level. Regional workshops on improving
the diets of infants and young children were conducted over the last
two years to sensitise regional and country offices on the guidance
and will continue. Regional landscape analyses, which provide a starting
point for the planning of actions at both regional and country level,
were also conducted.
For this issue of FEX we will share examples of applying and adapting
the Action Framework, and the programming guidance to improve thediets of infants and young children particularly in fragile, food insecureand humanitarian settings

Figure 2 The UNICEF Action Framework to improve the diets of young children during the complementary feeding period

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Special section
Complementary feeding in emergencies

Box 2 Using the programming guidance in humanitarian and fragile settings?
In 2019, the Infant Feeding in Emergencies (IFE) Core Group conducted a review oncomplementary feeding in emergencies, which identified gaps including in coordination, assessment, preparedness and programming capacity, among others. The
review found that, despite existing guidance on infant and young child feeding inemergencies (OG-IFE), there is still a gap in clear guidance on actions related tocomplementary feeding in emergencies. Although the UNICEF programming guidance
was not specifically designed for humanitarian contexts, a review conducted by ENN
and the IFE Core Group with an “emergency lens” found that its content remains relevant to emergency settings, as it considers the requirements for emergencies inmost actions and identifies what elements apply to both emergency and non-emergency contexts.

Programming context
The guidance emphasises the importance of understanding the programming context and therefore of:•

Adapting and expanding actions to respond to the specific setting, e.g.
challenges affecting access and affordability of food and health services, or
security issues•

Ensuring appropriate coordination to ensure within- and across-sector
coordination is taking place, including strengthening multi-sector planning andclearly defining the roles of different actors•

Understanding the policy environment and legal frameworks driving complementary feeding outcomes in a particularly dynamic environment

Situation analysis
Any assessment of an emergency situation should consider the challenges anddrivers related to the feeding of infants and young children, even if no specific complementary feeding in emergencies assessment is planned. Building on existingdata and evidence can also provide insights into the drivers and determinants offeeding practices prior to an emergency. The situation analysis should review existing
barriers, bottlenecks, gaps and risks that may negatively affect programming toplan actions to strengthen response and preparedness.

Multiple intervention channels
The guidance identifies actions for different humanitarian settings, including sudden
onset displacement, and slow-onset emergencies. It highlights that humanitarian
emergencies can aggravate existing drivers of poor nutrition, such as reducing accessto nutritious foods and services, and emphasises the importance of prioritising vulnerable families with services that mitigate these risks.
The needs of specific population groups, such as young children and caregivers with

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Food insecure and fragile contexts
heighten the vulnerability ofchildren and narrow the windowof opportunity to intervene
In fragile contexts, it is important to ensure timely
and appropriate response to protect, promote andfulfil children’s right to nutrition. In contexts characterised by limited availability of, or access to, nutritious food, the inclusion of child-centred foodassistance may be warranted. This may include providing rations of specialised nutritious food to prevent wasting, or cash-based transfers where markets
function. The appropriate use of these interventions
should be closely monitored, and the use of specialised products should be discontinued as soon
as the situation allows the shift to more appropriate
and sustainable home food diets. Box 2 provides
an elaboration on how the UNICEF programming
guidance applies in emergency contexts.

What’s next?
As promoted and advocated for in the Fed to Failreport, governments must take the lead in upholding
every child’s right to food and nutrition. Together
with national civil society, development and humanitarian partners, and the private sector, governments must mobilise the food, health and social
protection systems to deliver nutritious, safe andaffordable diets, essential nutrition services andpositive nutrition practices for every child.
The need to transform how we tackle poor-quality
diets in early childhood is urgent. If activated in theright way and held accountable, the food, healthand social protection systems – and their public andprivate sector actors – can ensure that children
benefit from the nutritious, safe and affordable dietsand the essential nutrition services and practices
they need to grow and develop to their full potential,
especially in fragile and emergency settings.
For more information, please contact Grainne Moloney at gmmoloney@unicef.org

disabilities, are also emphasised, highlighting the unique challenges faced in humanitarian settings and the importance of addressing these needs through tailoredinterventions.

Systems strengthening
The guidance emphasises the importance of building the emergency response on
existing systems – food, health, social protection and WASH – to deliver nutrition
results for young children. Examples of strategic actions to undertake at the policy,
institutional and community/household levels are illustrated to address the driversof children’s diets through these systems.
The guidance recommends an approach that involves building institutional capacity
and supporting the government to mitigate the effect of a humanitarian crisis andfacilitate sustainable recovery. It highlights that, when systems strengthening efforts
continue during emergencies, they can promote community resilience and help institutionalise actions to improve children’s diets over the long term.

Monitoring and evaluation
In humanitarian and fragile settings, the generation, documentation, sharing andapplication of knowledge may become challenging due to the volatile nature of thecontext. The guidance nevertheless emphasises the importance of maintaining aframework to ensure the monitoring of infant and young child feeding indicators. A
context-specific results matrix serves as a useful tool to facilitate monitoring, evaluation and learning as part of the complementary feeding response.

References
Global Nutrition Report (2021) 2021 Global Nutrition
Report. https://globalnutritionreport.org/reports/ 2021global-nutrition-report/
UNICEF (2019) The State of the World’s Children 2019.
Children, Food and Nutrition: Growing Well in a Changing
World. UNICEF, New York. https://www.unicef.
org/reports/state-of-worlds-children-2019
UNICEF (2020a) Improving Young Children’s Diets During
the Complementary Feeding Period. UNICEF Programming
Guidance. UNICEF, New York.
https://www.unicef.org/documents/improving-youngchildrens-diets-during-complementary-feeding-period-u
nicef-programming
UNICEF (2020b) Nutrition, for Every Child: UNICEF Nutrition
Strategy 2020–2030. UNICEF, New York. https://www.unicef.
org/reports/nutrition-strategy-2020-2030
UNICEF (2021) Fed to Fail? The Crisis of Children’s Diets in
Early Life. Child Nutrition Report. UNICEF, New York.
https://www.unicef.org/reports/fed-to-fail-child-nutrition
United Nations Children’s Fund (UNICEF). Child Food
Poverty: A Nutrition Crisis in Early Childhood. UNICEF, New
York, October 2022.
UNICEF, WHO and World Bank (2021) Joint Child
Malnutrition Estimates, 2021 Edition.
https://www.who.int/data/gho/data/themes/topics/jointchild-malnutrition-estimates-unicef-who-wb

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