Delivering essential nutrition services for children after the Nepal earthquake
Authors: Víctor M Aguayo, Anirudra Sharma, Giri Raj Subedi
Journal: The Lancet Global Health (2015)

On April 25, 2015, a powerful 7·8-magnitude earthquake struck Nepal. The Nepalese Government declared 14 of the country's 75 districts as severely affected (ie, 5·6 million people). As of July 25, 2015, the confirmed number of casualties was 8897 with a further 22 310 people injured, and 887 356 houses fully damaged.1UNICEFNepal earthquake. Humanitarian situation report. Three month review, 25 July, 2015. United Nations Children's Fund Nepal Country Office, Kathmandu2015http://www.unicef.org/appeals/files/UNICEF_Nepal_Humanitarian_Three_Month_Interactive_Situation_Report_25_July_2015.pdfGoogle Scholar Immediately after the earthquake, the Government of Nepal declared a state of emergency and requested the UN to activate the humanitarian clusters. The Nutrition Cluster, led by the Ministry of Health and Population and including 28 national and international partners, devised a 3-month (May–July, 2015) Emergency Nutrition Response aiming to: (1) protect, promote, and support breastfeeding for children aged 0–23 months and avoid the distribution or use of unsolicited donations of breastmilk substitutes;2Government of Nepal and Nepal Nutrition ClusterJoint statement on untargeted distribution of infant formula and breastmilk substitutes in emergencies.http://nutritioncluster.net/nepal-nutriiton-cluster-joint-statement-iycf/Google Scholar (2) improve complementary feeding for children aged 6–23 months through information, counselling, and the distribution of multiple micronutrient powders (MNPs) for home fortification of child foods; (3) identify and treat children aged 6–59 months with severe acute malnutrition through community management of acute malnutrition; (4) improve the micronutrient intake of children aged 6–59 months through MNPs and vitamin A supplementation; and (5) improve the micronutrient intake of women during pregnancy and the early post-partum period through iron-folic acid supplementation.3United Nations Office for the Coordination of Humanitarian Action (OCHA)Flash appeal for response to the Nepal earthquake.http://reliefweb.int/sites/reliefweb.int/files/resources/nepal_flash_appeal.pdfDate: May–July, 2015Google Scholar A key component of the Emergency Nutrition Response was the implementation of a Child Nutrition Week to deliver a package of essential nutrition services for children younger than 5 years and their mothers before the onset of the monsoon rains. The Child Nutrition Week built on the experience of child health days. In non-emergency settings, such days involve delivery of several child survival interventions periodically and efficiently while improving coverage and equity among populations not reached by routine services.4Doherty T Chopra M Tomlinson M Oliphant N Nsibande D Mason J Moving from vertical to integrated child health programmes: experiences from a multi-country assessment of the Child Health Days approach in Africa.Trop Med Int Health. 2010; 15: 296-305Crossref PubMed Scopus (50) Google Scholar, 5Palmer AC Diaz T Noordam AC Dalmiya N Evolution of the Child Health Day strategy for the integrated delivery of child health and nutrition services.Food Nutr Bull. 2013; 34: 412-419Crossref PubMed Scopus (25) Google Scholar, 6Chopra M Sharkey A Dalmiya N Anthony D Binkin N on behalf of the UNICEF Equity in Child SurvivalHealth and Nutrition Analysis TeamStrategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition.Lancet. 2012; 380: 1331-1340Summary Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 7Oliphant NP Mason JB Doherty T et al.The contribution of Child Health Days to improving coverage of periodic interventions in six African countries.Food Nutr Bull. 2010; 31: 248-263Crossref Google Scholar, 8Flisser A Valdespino JL Garcia-Garcia L et al.Using national health weeks to deliver deworming to children. Lessons from Mexico.J Epidemiol Community Health. 2008; 62: 314-317Crossref PubMed Scopus (14) Google Scholar These child health days have been ranked as “very cost-effective” and “pro poor” by the WHO and the World Bank.9Gwatkin DR Wagstaff A Yazbeck AS Reaching the poor with health, nutrition, and population services. What works, what doesn't, and why. World Bank, Washington, DC2005Crossref Google Scholar Nepal's Child Nutrition Week was planned as a fixed-day, village-based strategy to deliver a package of six nutrition interventions to at least 80% of a target population including 467 425 children aged 0–59 months, pregnant women, and breastfeeding mothers. The Ministry of Health and Population, supported by the Nutrition Cluster, developed district-level guidelines for the implementation of Child Nutrition Week. In each district, Child Nutrition Week was planned and implemented by the district officials of the Ministry of Health and Population with the support of a Health and Nutrition Cluster partner in coordination with the District Disaster Relief Committee, and the Village Development Committee (municipality) and ward (village) authorities. An on-site coaching approach was used to train over 15 000 implementers: health workers, female community health volunteers, and volunteers from civil society organisations. A mobilisation strategy through Radio Nepal and 63 local radios before and during Child Nutrition Week raised awareness about the importance of the programme and when and where to avail its services. Child Nutrition Week—implemented between June 28, and July 8, 2015—reached 410 795 children younger than 5 years, pregnant women, and breastfeeding mothers (ie, 87·9% of target). 153 478 mothers with a child aged 0–23 months (91·4% of target) received counselling on the benefits of breastfeeding and the risks of artificial feeding; 142 026 mothers with a child aged 6–23 months (112·7% of target) were supported to continue breastfeeding and received a 2-month supply of MNPs to improve the nutrient density of children's complementary foods. Of the children aged 6–59 months, 314 898 (97·4% of target) received a 2-month supply of MNPs, and 360 984 (111·8% of target) benefitted from vitamin A supplementation while 24 902 women (88·3% of target) received a 2-month supply of iron-folic acid (table).TableChild Nutrition Week (Nepal, June 28–July 8, 2015)—services delivered, population reached, and coverage attainedAge groupIntended coverageNumber targetedNumber reachedAchieved coveragePromote exclusive or continued breastfeeding on demand and avoid the use of breastmilk substitutes or any other form of artificial feeding0–5 months (exclusive) 6–23 months (continued)≥80%168 000153 47891·4%Support improved complementary feeding for infants and young children through counselling and MNPs6–23 months≥80%126 000142 026112·7%Improve the nutrient quality and density of foods for older children through the use of MNPs24–59 months≥80%197 201172 87287·7%Provide vitamin A supplements (100 000 IU for children aged 6–11 months; 200 000 IU for those aged 12–59 months) to strengthen children's immune system6–59 months≥80%323 000360 984111·8%Provide iron and folic acid supplements to pregnant women and lactating mothers combined with counselling on maternal nutritionPregnant womenLactating mothers≥80%28 214*On the basis of the existing data, it was estimated that about a third of women in the 2nd or 3rd trimester of pregnancy or in the first 45 days post partum would have not received iron and folic acid supplements during antenatal care visits; these were the women targeted by the Child Nutrition Week.24 90288·3%Screen children for SAM using MUAC to identify children with severe wasting6–59 months≥80%397 441374 44194·3%Refer children with MUAC less than 115 mm to the nearest CMAM programme to receive therapeutic care and ready-to-use therapeutic foods6–59 months≥80%1650†The Nutrition Cluster estimated a caseload of 2500 children with SAM over the 3-month period of May–July, 2015. Therefore, the estimated caseload for the 2-month period of May–June was 1650 children.1119‡Includes 195 children already admitted to the CMAM programme in the 14 districts.67·8%MNPs=multiple micronutrient powders. SAM=severe acute malnutrition. MUAC=mid-upper arm circumference. CMAM=community management of acute malnutrition.* On the basis of the existing data, it was estimated that about a third of women in the 2nd or 3rd trimester of pregnancy or in the first 45 days post partum would have not received iron and folic acid supplements during antenatal care visits; these were the women targeted by the Child Nutrition Week.† The Nutrition Cluster estimated a caseload of 2500 children with SAM over the 3-month period of May–July, 2015. Therefore, the estimated caseload for the 2-month period of May–June was 1650 children.‡ Includes 195 children already admitted to the CMAM programme in the 14 districts. Open table in a new tab MNPs=multiple micronutrient powders. SAM=severe acute malnutrition. MUAC=mid-upper arm circumference. CMAM=community management of acute malnutrition. Lastly, 374 441 children aged 6–59 months (94·3% of target) were screened with mid-upper-arm-circumference tapes, and 1119 children with severe acute malnutrition (67·8% of target) were referred to the community management of acute malnutrition programme. Such coverage, lower than the intended 80%, is probably due to an overestimation of the expected number of children with severe acute malnutrition. This number was estimated on the basis of the proportion of children aged 6–59 months with weight-for-height Z score lower than –3 (severe wasting) before the earthquake, whereas the detection of children with severe wasting during Child Nutrition Week was based on a mid-upper-arm-circumference of less than 115 mm. Evidence indicates that the use of a mid-upper-arm-circumference of less than 115 mm can lead to lower numbers of severely wasted children than would the use of a weight-for-height Z score WHZ lower than –3.10Luque-Fernandez MA Delchevalerie P Van Herp M Accuracy of MUAC in the detection of severe wasting with the new WHO growth standards.Pediatrics. 2010; 126: e195-e201Crossref PubMed Scopus (50) Google Scholar Nepal's Child Nutrition Week has been an effective platform to deliver a package of essential nutrition services to the most vulnerable children and mothers in the earthquake-affected districts before the onset of the monsoon rains. To our knowledge, this is the first time that a Child Nutrition Week approach has been used in south Asia as part of an emergency response. Building on the successful implementation of Child Nutrition Week, the Government of Nepal is considering the implementation of bi-annual Child Nutrition Weeks to deliver an integrated package of nutrition services as an extension of the routine services provided by the primary health-care system. The opinions expressed here are those of the authors and do not necessarily represent an official position of the organisations they are affiliated with. We declare no competing interests. Rebuilding NepalNepal is a country of immense variety: from its flat southerly regions in the Ganges plain to the roof of the world atop Mount Everest, this landlocked nation nestles between India and China and is home to 125 ethnic groups and castes speaking almost as many languages. 6 months ago, however, a shared catastrophe struck—on the morning of April 25, a 7·8-magnitude earthquake hit the centre of the country, its shockwaves rippling outwards and affecting an estimated 6 million of the 31·5 million population. Full-Text PDF Open Access