Moderate Acute Malnutrition: A Decision Tool for Emergencies


I. Introduction to the MAM Decision Tool

A. Background and rationale for the decision tool:

A review of targeted supplementary feeding programmes in emergencies found that there was very limited data on the effectiveness of these programmes. The WHO convened a meeting in 2008 to review dietary management of children with moderate acute malnutrition. As a result, over the past several years there have been significant changes to strengthen nutrition programming in emergencies including the development of new specialised nutritious foods and a shift to greater emphasis on preventing acute malnutrition.

Different programming approaches have been used for prevention of acute malnutrition and treatment of MAM in recent emergencies (Haiti, Niger, Pakistan, etc.) based on the different situations in these countries. This variation in responses raised questions about how to best guide emergency nutrition responses to prevent acute malnutrition and to treat MAM. To address these concerns, the Global Nutrition Cluster convened a MAM Task Force under the leadership of WFP to develop a decision-making tool and guidance for prevention of acute malnutrition and treatment of MAM in emergencies. The Task Force considered current global thinking and available operational evidence in developing this guidance; however, it is intended as interim operational guidance while further normative guidance is under development. Revisions and updates to this document will be made as needed and noted below:


B. Aims and approach of the decision tool:

The decision-making tool aims to:

  • guide program managers to identify the most appropriate and feasible programme strategy to address MAM in a particular emergency setting

  • harmonize nutrition programme decision-making to MAM in emergency situations

  • explicitly incorporate a range of contextual situational factors into the decision making process, in addition to population level nutrition status before and during the emergency

The tool is designed to guide decision-making on the type of programme(s) to implement (e.g., prevention, treatment, both), the programme modality (e.g., food supplement, cash/voucher, social and behaviour change communication (SBCC)), the risk groups to target, the specialised nutritious foods to use, the programme duration and the delivery mechanism for the programme(s). There are likely to be existing MAM programmes in the country affected by the emergency and this guide is intended to augment rather than supersede these programmes, as appropriate. The recommendations from this MAM decision-making tool will need to be further developed into an action plan for the emergency response. The tool was developed for addressing MAM in emergency settings and at this stage is not intended to guide decision-making on addressing MAM in nonemergency settings.

C. Information required for using the decision tool:

Different types of information and data are required to use this decision-making tool and process effectively, including data on

  • prevalence of GAM in the affected area

  • information on the nature and severity of the crisis

  • baseline health data in the areas affected and expectations of the crisis impact on illness

  • food security situation and expectations of crisis impact on food security

  • estimates of displacement and population density

D. Audience for the decision tool and guidance:

The primary audience for the tool is nutrition staff from national governments and the key international and national organisations involved in nutrition emergencies addressing MAM.
The government (or government body) should be the lead or a major partner in establishing the nutrition response in an emergency. In the immediate stages after onset of an emergency, the members of the IASC nutrition cluster at the country level (or a sector coordination structure, sub working group or other equivalent of this group if the cluster is not active) will also be key users of this decision tool as part of an exercise to develop a broader strategy for the overall nutrition response to the emergency. A quorum of key agencies should be at the table to make decisions about addressing MAM, including the national government and WFP as the lead UN agency for MAM, the national cluster coordination or other coordinating body, UNICEF as the nutrition cluster lead, WHO and key potential implementing partners. The decision tool is a guidance note and considerable discussion and interpretation of the context will be required in order to develop the MAM response strategy for the specific emergency.

E. Timeline for using the tool:

To move forward with a MAM response strategy, a consensus should be achieved within the nutrition stakeholder community (outlined above) and led by the national government. In effort to expedite the decision making process concerning MAM in emergencies, it is important that the tool is reviewed and program decisions in various scenarios are discussed as part of country level emergency preparedness and response planning. In exceptional circumstances that call for the use of a revised protocol (see Appendix D), the nutrition cluster or coordinating body led by government should agree in consultation with UNICEF and WFP on the circumstances that justify temporary activation of a revised protocol and circulate this criteria within the nutrition coordination body. Reaching consensus on the activation of a revised protocol is highly encouraged during the first meeting in which a case is presented in effort to allow immediate action during acute crises situations.

F. Caveats for using the tool:

For the purpose of this tool, the primary objective of MAM programming is to prevent mortality and morbidity, reduce the incidence of SAM, and the increase in acute malnutrition that often occurs in emergencies.

MAM cannot be addressed in isolation in emergencies; therefore, the decision-making process presented in this guidance note should be seen as part of a broader nutrition response and as part of a multi-sectoral response to nutrition in an emergency. For instance, treatment of SAM in emergencies is an essential component of an emergency response and this guidance follows the internationally recognized community based management of acute malnutrition (CMAM) approach, which calls for integration of management of SAM and treatment of MAM. In contexts where the CMAM protocol cannot be applied, such as in the absence of an Outpatient Therapeutic Program (OTP), temporary options may be appropriate for these exceptional circumstances (see Appendix D).

Support for IYCF-E and SBCC is also an essential component of an emergency response.
Finally, linkages to food security interventions, health and water/sanitation programming are also important in order to help ensure the multi-sectoral causes of nutrition are being addressed simultaneously. There should be strong advocacy and support where feasible for these other essential components of the MAM and broader nutrition response. Some of these potential linkages are briefly described in this guidance note (Section C).

As the emergency situation evolves, the nutrition response may need to be adjusted. The decision-making tool can be used to re-evaluate the context and make programme adjustments accordingly. It can be used ultimately to provide direction for nutrition programming in the recovery phase. Plans for a clear exit strategy for MAM programming once the emergency is stabilised should also be developed as part of the response. For instance, if key nutrition problems prior to the emergency are stunting and micronutrient deficiencies, the response plan should help the national government to ultimately transition back to programmes that address these issues.

The decision-making tool can be used in different types of emergencies, including rapid or sudden onset, slow onset, protracted or acute emergencies within a chronic emergency situation. The tool can be equally applied to localised or very large-scale emergencies but the scale of the emergency is likely to influence where to implement (prioritisation) and other steps in the process (e.g., delivery). In emergencies that involve IDPs or refugees the decision-making process should be similar but there are some additional issues to consider in terms of coordination. For refugees inside and outside of camps, nutrition issues fall under the leadership and coordination of UNHCR and the host government. IDPs still remain legally under the protection of their own government and under the coordination of the Nutrition Cluster led by UNICEF. However, given its expertise on displacement, UNHCR (with IFRC), under the cluster approach has been designated the lead role in overseeing the protection and shelter needs of IDPs as well as coordination and management of camps (with IOM).

The guidance note is structured as follows: Section II described how to use the tool, sSction III summarises some information on different new specialised nutritious foods (including a products sheet in Appendix C) and Section IV summarises information on parallel programming in health, water/sanitation and food security that is often needed to address the multi-sectoral causality of undernutrition. Appendices are provided in Section VI.