Implementing High-Impact Nutrition Interventions At

Scale: The ENA Framework

2014

Implementing High-Impact Nutrition Interventions At

Scale: The ENA Framework

2014

Understanding the ENA FrameworkPre-session CORE Group. May 5th, 2014

Agnes Guyon, MD, MPH

Understanding the ENA FrameworkPre-session CORE Group. May 5th, 2014

Agnes Guyon, MD, MPH

Based on proven impact: Women’s nutrition Infant & young child feeding Micronutrients

Action-oriented, with clear

guidance

Who should take what action

when?

Growing consensus that nutrition interventions need to be…

The High-Impact Nutrition Interventions

Evidence-Based Direct Interventions to Prevent and Treat Undernutrition

Promoting good nutritional practices:1. breastfeeding 2. complementary feeding for infants after the age of six months3. improved hygiene practices, including handwashing

Increasing intake of vitamins and minerals: Provision of micronutrients for young children and their mothers: 4. periodic vitamin A supplements 5. therapeutic zinc supplements for diarrhea management6. multiple micronutrient powders 7. deworming drugs for children (to reduce losses of nutrients)8. iron-folic acid supplements for pregnant women to prevent and treat anemia9. iodized oil capsules where iodized salt is unavailable

Provision of micronutrients through food fortification for all: 10. salt iodization 11. iron fortification of staple foods

Therapeutic feeding for malnourished children with special foods ($6.2 billion):

1 2. prevention or treatment for moderate undernutrition 13. treatment of severe undernutrition (“severe acute malnutrition”) with ready-to-use therapeutic foods (RUTF).

Two References (2013)

Control of Iodine Deficiency Disorders

Control of Vitamin A Deficiency

Optimal Breastfeeding (BF)Nutritional Care

of the Sick & Malnourished Child

ComplementaryFeeding with BFWomen’s Nutrition

Control of Anemia

Essential Nutrition Actions (ENA) FrameworkFirst Developed in 1997

ENA Uses the Life Cycle Approach

Focuses on the

1000 Day Window of Opportunity

Before conception

Promotion: Support Women’s Nutrition In Adolescence, Before Pregnancies, and Between Pregnancies

Promote & Support improved diet Diversified diet and appropriate amount for

adolescent needs Increase mineral intake

Provide Micronutrients Iron-folic acid supplementation and treatment of

anemia Deworming

With Delay first pregnancy Keep girls in school

WHO 2013

Promotion: Support Women’s Nutrition (1)During Pregnancy & Lactation

Promote & Support Improved Diet Diversified diet Increased food and MN intakes

1 extra meal/day when pregnant (550 Kcal/day) 2 extra meals/day when lactating (650 Kcal/day)

Consumption of iodized salt Sleep under insecticide-treated nets

With Spacing of Pregnancy Cessation of smoking, alcohol or other substances

Women’s nutrition in the context of HIV and emergencies

WHO ENA, 2013

Promotion: Support Women’s Nutrition (2)During Pregnancy and Lactation

* Countries with anemia < 20% ** Countries with night blinder>5%*** Countries with low calcium intake**** Countries with < 20% iodized salt

Provide Micronutrients Daily iron-folic acid(30-60/0.4mg)

or Weekly 2-3 intermittent iron-folic acid (120/2.8mg) for non-anemic* Daily (10 000IU) or Weekly (25 000IU) vitamin A** Daily (1.5 gr) Calcium*** Daily or annual iodine****

With Intermittent Preventive Treatment (ITP) of malaria Deworming during pregnancy (twice) Treatment of anemia Timely cord clamping

Protection-Promotion-Support Breastfeeding < 6 months

Protect Breastfeeding Legislation & enforcement of breastmilk substitutes code

Promote & Support key practices Immediate initiation of breastfeeding Exclusive breastfeeding for 6 months

Correct positioning & attachment Breastfeed day and night at least 10 times Empty one breast before switching to the other (Fore-milk vs hind milk)

Infant feeding in the context of HIV and emergencies

Other practices (control & prevention of anemia) Timely cord clamping

WHO ENA 2013

Protection-Promotion-Support (1)Complementary Feeding with Breastfeeding 6-24

Months

Promote & support Improved Diet Introduce appropriate CF at 6 months Continue breastfeeding until 24 months & more Frequency: Amount adapted to age

6-8 months: 200 kcal/day 9-11 months: 300 kcal/day; 12-23 months: 550 kcal/day

Diversity (fruits, vegetables, animal source, MNP, fortified CF, iodized salt) Density: from mashed to family food Utilization (handwashing, clean water, food & utensils) Active feeding

Protect  CFCodex Alimentarius & Marketing of complementary food

WHO ENA 2013

6-8 months: 2-3 meals/day 9-23 months: 3-4 meals/day, 1-2 snacks/day

Protection-Promotion-Support (2)Control & Prevention of MN Deficiencies

WHO ENA 2013

Provide Vitamin A Supplementation Biannual vitamin A Capsules for children 6-59 months

100 000IU for children 6-11 months 200 000IU for children 12-23 months

Provide Iron-Folic Acid Supplementation Daily iron-folic acid (2mg/kg) for 3 months for children 6-23 months

With treatment of malaria in endemic areas

Provide Micronutrient Powder (MNP) Daily for at least 2 months for children 6-23 months

Provide Iodized Oil* Annually (200 mg) for children 6-23 months

* Countries with <20% iodized salt

With Biannual deworming for children 12-59 months Malaria prevention & treatment

Nutritional Care Sick Child & Management of Acute

MalnutritionPromote & Support of Improved Diet 0 to 24 months: increase breastfeeding frequency during and after illness 6 to 24 months & older: Increase feeding during illness and after illness (e.g., feed 1 extra meal each day for two weeks after illness)

Provide Appropriate MN Treatment (following national protocols) Vitamin A Zinc for treatment of diarrhea with oral rehydration therapy AnemiaManagement of moderate & severe acute malnutritionNutritional care of HIV-positive children (6 months-14 years)

WHO ENA 2013

Promotion-SupportNutrition-Sensitive

WHO ENA 2013

Immunization EPI New vaccines (Rotavirus and Pneunococcus)

Prevention of Childhood Illnesses Essential Hygiene Actions (Handwashing, sanitation) Household water treatment Reduction of indoor air pollution Context of HIV: Mother To Child Transmission

Family Planning

Global Interventions

Wheat and Maize Flour Fortification

WHO ENA 2013

How & Where to Implement?

Control of Iodine Deficiency Disorders

Control of Vitamin A Deficiency

Optimal Breastfeeding (BF)Nutritional Care

of the Sick & Malnourished Child

ComplementaryFeeding with BFWomen’s Nutrition

Control of Anemia

We Know That a Multisectoral Approach is Critical

Source: Lancet 2013

A framework to operationalize the implementation of existing nutrition programs that: pulls together existing vertical programs in a sensible

'action-oriented' way greatly expands coverage to multi-contacts and multi-

platforms.

Provides an excellent training framework on which to train service providers and community members:

Simple Uses existing structures.

The ENA Framework

Within the health sector:Use existing nutrition programs & increase their

performance

Child HealthNewborn healthImmunization

Treatment of childhood illnesses

Management of acute malnutrition

Reproductive Health

Lactation Amenorrhea Method With Family Planning

Safe Motherhood

Infectious Diseases

Control of MalariaTuberculosis HIV and AIDS

(PMTCT)

21

DELIVERY: safe delivery, FP, STI prevention, Optimal delivery, VCT, ARVs, Delay cord clamping, early & exclusive breastfeeding, iron-folic acid, diet

PREGNANCY: TT, antenatal visits, FP, STI prevention, safe delivery, VCT, Options, Safe Sex, danger signs,Diet, iron-folic acid, deworming, anti-malarial, iodized salt, calcium, vitamin A, preparation of breastfeeding

POSTNATAL AND FAMILY PLANNING: STI prevention, child’s vaccination, VCT, Safe sex, Support to breastfeeding, diet, iron-folic acid, FP

WELL CHILD AND GMP: check and complete vaccination, VCT, Safe Sex, Monitor growth, assess and counsel on child feeding, iodized salt

SICK CHILD: assess and treat per IMCI/immunization/VCT, counsel on infant feeding, assess and treat for anemia, check and complete vitamin A, deworming

IMMUNIZATION: vaccinations, FP, and STI referral, VCT, Safe Sex, Support to infant and young child feeding, vitamin A, deworming, assess and treat infant’s anemia

Critical Contacts for Essential Nutrition Actions

Outside the Health SectorUse Existing Contacts to Extend Nutrition

CoverageAgriculture

Food diversificationFood security

Household food production

Micro-creditWomen’s farmers clubs

Pre-service EducationDoctors, nurses, and

midwives

SanitationClean water

Public health education

Mass MediaTV

RadioLocal broadcasting

Community Nutrition Community Workers

Positive deviance

SchoolsChildren & Adolescent

DewormingIron supplementation

Maximizing contacts toenhance food diversity

Critical Contacts Within the Agriculture Sector

Ultimate Goal: Saturation

Within the Agriculture Sector Within the Health Sector

The

remaining

challenge:

‘just to do

it’Thank You