Sustainable and multi-dimensional interventions are essential for comprehensively tackling both acute and chronic malnutrition, particularly in addressing under-nutrition during crisis situations.
These observations were made in an article on ‘Addressing childhood malnutrition during the economic crisis: The Feed A Child programme’ which was authored by Professor in Paediatrics attached to the Sri Jayewardenepura University, G. Liyanage, and published in the Sri Lanka Journal of Child Health's 54th Volume's First Issue, March.
Major upheavals in the Sri Lankan economy during 2022-2023 drove many people into poverty and unemployment (the Central Bank's Annual Report 2022. Economic, price and financial system stability, outlook and policies). Even those assured of stable livelihoods found the affordability of essentials unrealistic. The situation disrupted local economic activities and the households' capacity to afford necessities, including adequate nutrition. The fuel shortage, which continued to intensify, contributed to rising food prices, as the paucity of transport significantly influenced food distribution. Simultaneously, fuel crises and multiple other factors reduced domestic food production (the World Bank [WB] Group's Food Security Update/WB response to rising food insecurity). The reported food inflation of 52% in June 2022 is among the highest in Asia and Sri Lanka since 2008 (the Central Bank's ‘National Consumer Price Index-based headline inflation recorded at 58.9% on a year-on-year basis in June 2022).
R. Jayatissa, A. Perera and N. De Alwis's ‘National Nutrition and Micronutrient Survey in Sri Lanka: 2022’ reported that the prevalence of stunting, wasting, and underweight was 12.7%, 13.2%, and 17.7%, respectively, while the rate of severe acute malnutrition was 1.7%. As per the Health Ministry's Family Health Bureau's (FHB) Nutrition Division's ‘Summary Report, Nutrition Month. October 2022’, growth-related issues remained more or less static over the past decade. However, the economic crisis was expected to lead to a worsening of growth-related issues.
Overpriced food items and reduced purchasing power during the financial crisis resulted in excessive reliance on non-nutritious, low-cost food items and limited portion sizes, leading to less diversified and nutritious diets in low-income households across all regions of the island. Besides, an intense decline in the general consumption of flesh based foods and dairy products emerged, causing concern about the proper nourishment of children (P. Sooriyaarachchi and R. Jayawardena's ‘Impact of the economic crisis on the food consumption of Sri Lankans: An online cross-sectional survey’).
Government interventions such as the Thriposha Supplementary Food Programme, the School Meal Programme, the Multiple Micronutrient Supplementation Programme, and the Ready-to-Use Therapeutic Food (RUTF) for the treatment of severe acute malnutrition in children, were periodically interrupted due to significant financial and raw material shortages and service-related problems in identifying beneficiaries and monitoring the recipients via the existing staff of the primary healthcare system.
In this backdrop, the Sri Lanka College of Paediatricians (SLCP) launched the ‘Feed A Child’ programme in collaboration with multiple stakeholders to address childhood malnutrition. The programme was multifaceted and aimed to address three components: Immediate and medium-term relief for families having children with severe acute malnutrition, immediate relief provision for children with moderate acute malnutrition, and an islandwide continuous professional development (CPD) programme for first-contact doctors.
Immediate and medium-term relief for children with severe acute malnutrition
The SLCP, in collaboration with the FHB and the Sri Lanka Red Cross Society, launched the immediate and medium-term relief programme in selected districts. Nuwara Eliya, Anuradhapura, and Gampaha. Later, it was replicated in other districts (e.g. Monaragala, Ratnapura) by the SOS Villages Sri Lanka organisation on a smaller scale. In addition, the FHB, in collaboration with the United Nations Children’s Fund (UNICEF), introduced a similar food ration provision programme for children less than three years recovering from severe acute malnutrition and moving on to moderate acute malnutrition. This programme planned to provide a food basket every two weeks for three months in 29 Regional Director of Health Services (RDHS) areas in the nine provinces.
Liyanage's report presents data based on the programme carried out in the Nuwara Eliya District, which was selected as it has a very high rate of childhood under-nutrition. It is an underprivileged district with a population of 697,523, and approximately 54,380 of the total district population is less than five years, in terms of age.
The role of the SLCP was the overall execution and monitoring of the programme, in addition to technical support for the initial screening for severe acute malnutrition, finding donors (individuals and organisations), creating easy-to-make low-cost nutritional recipes, nutritional education, and family empowerment.
Screening for beneficiaries
All children less than five years registered in child welfare and child nutrition clinics were screened. Children with a weight-for-height measurement of less than minus three standard deviations were identified as having severe acute malnutrition and enrolled in the programme. In selecting beneficiaries, socio-economic risk factors such as poverty were also considered, ensuring that the most vulnerable families received support (identifying beneficiaries – children with severe acute malnutrition of six months to five years – with poverty and food insecurity; the supplying of a food basket, distributed through the Red Cross Society, every fortnight for six months; home gardening and poultry farming in collaboration with the relevant Divisional Secretariat office; and monitoring growth reporting which was assisted by the Public Health Midwife [PHM] and the Medical Officer of Health [MOH], supervised by the FHB and local paediatricians).
The selected beneficiaries received a food pack every two weeks for a period of six months. The cost for a food pack was Rs. 3,500. The PHMs were responsible for entering the details of each beneficiary, including their anthropometric data, into a standardised proforma. To ensure proper tracking and monitoring, an online database was maintained at the MOH office under the supervision of the FHB.
The food items in the pack (500 g each of red dhal and kadala dhal, and green gram and chickpea and cowpea, 10 brown and white eggs, two kilograms [kg] of white and red rice, 250 g of dried sprats and kunisso [dried, salted small shrimp], four 90 g packs of soya meat, four coconuts, one 200 millilitres [ml] bottle of coconut oil, and 720 ml fresh milk for children under two years) were designed to meet the nutritional needs of the children. If consumed alone, they deliver 1,547 kilocalories (Kcal) per day and 60 g of protein.
The distribution of the food packs
The distribution of the food packs was efficiently organised through strategically identified distribution centres close to the recipients' homes. Each MOH area had multiple nearby distribution centres (i.e., weighing centres), allowing recipients to collect food packs without travelling long distances. The distribution process did not disturb the usual care provided for these families through the primary healthcare system. The food packs were collected every two weeks, and anthropometric measurements were taken in alternate visits during the child's scheduled review. In cases where the recipients were unable to collect their food packs on the designated day, the Red Cross Team took proactive measures to ensure that no one was left without assistance. They delivered the food packs directly to the recipient's doorsteps within three days. This approach ensured that all recipients received the necessary support promptly, regardless of their ability to visit the distribution centres in person.
Nutrition education
As part of the ‘Feed A Child’ programme, short videos on low-cost recipes were produced and made available through One-Pot Sri Lanka's YouTube channel. In addition, recipe booklets were developed and distributed among families in all three languages (Sinhala, Tamil, English). These booklets were published with the following International Standard Book Numbers (ISBNs): ISBN 978-624-6042-03-5 and ISBN 978-624-6042-04-2. During the educational sessions, short videos were played to offer practical cooking guidance, while live cookery demonstrations further disseminated valuable nutrition-related knowledge to the beneficiaries. The primary healthcare staff carried out these activities, donating their time to ensure that families received the resources and education needed to prepare nutritious, affordable meals.
Monitoring
The nutrition clinic protocol for monitoring the children's nutritional status was followed. Weight measurements were taken monthly to ensure the consistent tracking of any changes. Height measurements were recorded every three months to monitor growth patterns over a longer period. Outcome measures were weight, height/length, wasting, stunting, and being underweight.
Outcome assessment
A total of 647 children with severe acute malnutrition were enrolled in the ‘Feed A Child’ programme. Data were available for 90% of the enrolled children (577), while 10% could not be analysed due to missing information. Among the 577 children, 72.4% were two years or older, and 60% were male. A total of 66% showed improvement in weight/height, progressing to either moderate acute malnutrition or achieving the normal nutritional status. The median weight increment over the six months was 0.84 kg, while the median length/height increment was three centimetres (cm). Younger children (less than two years) demonstrated more significant improvement in weight/height than older children. Females showed a significantly greater improvement in weight/height than males.
Outreach nutrition clinics
The outreach clinic concept was initiated by enabling the optimal delivery of specialised care to all children closer to their home by a paediatric team. They operated across the Nuwara Eliya District and made strides, with nearly 1,000 children being assessed by all paediatricians in the region. The commitment of the RDHS, local paediatricians, the MO of Maternal and Child Health, all MOHs, PHMs and the Red Cross Society representatives was present from the inception of this initiative.
Projects for medium-term relief
The empowerment projects were initiated in the Nuwara Eliya District, focusing on families with children suffering from severe acute malnutrition to help them navigate the crisis and build resilience. Home gardening and backyard poultry initiatives were chosen to empower families, improve food security, and nurture self-reliance. The needs-elated assessment was done using a questionnaire. In addition, focus group discussions were conducted with families to gain a deeper understanding of their specific needs and the resources that they already possessed.
The home gardening initiative was designed to empower families by providing them with the necessary resources, training, and support to start and maintain their gardens. Seeds, seedlings, and organic fertilisers were distributed to participating households. In addition, agricultural experts, and field officers at the relevant District Secretariat conducted workshops and offered ongoing guidance to ensure that families could maximise their yields.
Complementing the home gardening initiative, the backyard poultry project was introduced to provide families with a sustainable source of protein and additional income. It involved raising small flocks of chickens or quail birds with the support and advice from regional veterinary doctors. The families were given quail, hens, pens, and feed, along with training on poultry care and management. The project encouraged community cohesion, as families shared knowledge and resources and supported each other in their efforts to build more resilient livelihoods. A total of 107 families benefited through these projects.
Challenges in empowerment projects
Some families faced difficulties in accessing sufficient water for their gardens, and faced issues with the weather, as well as problems brought on by poultry-based diseases. Further, a lack of enthusiasm was occasionally encountered among some of the beneficiaries.
Future directions for empowerment projects
Efforts to link these projects with local markets to sell the surplus could enhance the sustainability.
Immediate relief for children with moderate acute malnutrition
The SLCP, in collaboration with the World Food Programme (WFP), implemented an emergency moderate acute malnutrition programme in the Nuwara Eliya District. A similar food basket to that which was given to children with severe acute malnutrition was provided for these children with moderate acute malnutrition. This project was funded by the Embassy of France in Sri Lanka through the WFP. It assisted 4,874 children with moderate acute malnutrition in the Nuwara Eliya District. In the second phase, it reached the Anuradhapura District (962).
Islandwide CPD programme for first-contact doctors
The islandwide CPD programme for first-contact doctors was conducted online, ensuring accessibility and convenience for participants across the country. The programme was organised province-wise. Invitations were extended to all first-contact doctors in government hospitals including district hospitals, providing them with the opportunity to enhance their knowledge and skills in managing acute malnutrition and related paediatric issues. This approach aimed to strengthen the capacity of frontline healthcare professionals to identify, treat, and refer cases of severe acute malnutrition and moderate acute malnutrition effectively. The online platform also allowed for the inclusion of a larger audience.
Research projects undertaken
Efficacy of a nutritional intervention in children with moderate acute malnutrition: A randomised controlled trial in SL during the econ. crisis in 2023
This was a project funded by the WFP. It evaluated the efficacy of an additional nutritional intervention in improving growth-related parameters, dietary diversity, and haemoglobin levels in children aged six-59 months with moderate acute malnutrition during the 2023 economic crisis. This was a randomised-controlled trial and children with moderate acute malnutrition were randomly allocated to either the intervention group, receiving additional food transfers and nutrition education, or the control group, receiving standard care.
The outcomes were the improvement in growth-related parameters, dietary diversity and haemoglobin levels. A total of 510 children were enrolled and followed-up for six months. The intervention group showed a significant proportion of children improving to normal weight-for-height Z scores and dietary diversity than the control group. However, the two groups had no significant difference in stunting and being underweight. The study highlighted the importance of targeted nutrient-adequate food security interventions in undernourished children during a crisis to support their nutrition rehabilitation effectively.
Food security and its impact on growth among Lankan children under-five during the econ. crisis in 2022
This was a research project funded by the SLCP. In this study, food insecurity and its impact on growth in six-59-month-old children during the economic crisis were assessed. This was a community-based, descriptive, cross-sectional study conducted in 2022. The analysis included 832 children. Half of the households had moderate-severe food insecurity. One-fifth had growth faltering during the crisis. Among the children with growth faltering, 8.9% crossed the one centile line. Food insecurity, and stunting were worse than published pre-crisis data. Weight faltering showed a significant relationship to food insecurity. Similarly, stunting and wasting were associated with food insecurity and the birth weight, age, gender, household income, residential district and residential sector.
Conclusions
The immediate relief provided through specific nutritional interventions showed positive outcomes among children with severe acute malnutrition.