RESUME L’efficacité des programmes d’alimentation supplémentaire pour les enfants malnutris âgés de 6 mois à trois ans dans la province de Dohouk (nord de l’Iraq) a été évaluée. Le critère d’admission était un poids de l’enfant en dessous du rapport poids-âge standard de 2 écarts-types ou plus. Les enfants inscrits au programme en janvier 2001 ont fait l’objet d’un suivi pendant sept mois. Les enfants ont reçu des biscuits à haute teneur protéinique et énergétique pendant le premier mois et une ration mensuelle pour la préparation d’un mélange de graines de soja pendant toute la période. Les familles ont reçu des rations alimentaires pendant les quatre premiers mois. Une amélioration a été notée chez tous les enfants, notamment au cours du premier mois. Des problèmes avec les rations et au sein des services de surveillance de la croissance ont entraîné d’importantes défections. L’utilisation de courbes de croissance standard peut être un moyen de surmonter ce problème. Des biscuits à haute teneur en protéines devraient être distribués pendant toute la période au lieu du mélange.

Improvement in the nutritional status of young children reduces morbidity and mortality [1,2]. Recognizing this fact, in 1994 the World Food Programme, in coordination with UNICEF and the directorates of health in Northern Iraq, initiated a supplementary feeding programme (SFP) for children under 5. Since then the programme has been evaluated through a nutrition surveillance system set up in all the primary health care centres involved in the SFP as well as through UNICEF-sponsored Regional nutrition surveys conducted every 6–12 months [3]. This study is aimed at the evaluation of the SFP in Dohuk province.

The study was conducted at the primary health care level under the supervision of the Directorate of Health and UNICEF. After the simple random selection of 9 (15%) of 62 primary health care centres which have growth monitoring units, the evaluation study started in Dohuk province on 1 January 2001. Two of the 9 units were located in urban areas, the rest in rural areas. The growth monitoring staff of these centres, plus 1 supervisory mobile nutrition team, were retrained in a 3-day UNICEF-sponsored course. Retraining of growth monitoring staff is a routine process, done almost every year.

At least once monthly, before distributing any rations, the staff of the growth monitoring unit should see all the children who are enrolled and record follow-up information, in particular the child’s weight. Staff are also supposed to give health and nutrition education to the mothers. The supervisory team and the author monitored and supervised staff throughout the period of the study.

During the current evaluation study, the growth monitoring staff were requested to routinely record monthly height measurements for every malnourished child enrolled in the SFP according to weight-for-age criteria.

Weight-for-age, weight-for-height and height-for-age standards used were those of the World Health Organization [4,5].

Another aspect of the current evaluation was a 1-month field trial to study the increase in the weight of a sample of 27 malnourished children who were receiving high-protein high-energy biscuits. They were compared with 27 normal control children in the same age range (6 months to 3 years). The control children were visiting the primary health care centres for routine immunization or growth monitoring. Participants were selected by taking the first 3 malnourished and the first 3 healthy children who presented to the primary health care centres involved in the study after 20 June 2001. Informed consent was obtained orally from parents, and there were no refusals. After 1 month, 2 malnourished children and 3 controls were lost to follow-up. Unpaired t-test for 2 independent samples with unequal variances (SPSS, version 10) was used to determine the increase in weight of children receiving high-protein high-energy biscuits compared to controls.

Malnourished children enrolled in the SFP in January 2001 were followed up till July 2001. There was significant drop-out, particularly in the last 2 months (Table 1).

The most prominent feature of the present study is the significant drop-out, starting in May 2001, and becoming quite significant in June and July. From May onwards, the family ration was no longer given and families of enrolled children were only receiving the small child ration, the value of which is much lower than the expense of the trip from many villages to primary health care centres. Despite the existence of good general food rations, families had become dependent on this ration to justify their visit to the primary health care centre. Providing the special ration for a malnourished child and ignoring the family may decrease food availability within the family, and make the mother less capable of breast-feeding her child.

An important factor in causing drop-out from the SFP may have been the poor palatability and difficult preparation method of the soyabean mix, the main item of the child ration. These were repeatedly mentioned by parents during the course of the study. Some families used to feed the mix to poultry rather than their children.

Another factor which contributed to drop-out from the SFP, was the instruction given by World Food Programme and Directorate of Health mobile teams to the growth monitoring staff to weigh children and record monthly data only if the ration arrived. Due to the irregular arrival of the ration, such instructions resulted in an interruption of the monitoring process. Deficiencies and changes in the staff, coupled with overcrowding in some primary health care centres, e.g. Heizel and Seeri, also contributed to the drop-out. In Heizel, for instance, a trained female staff member took a long “motherhood leave” and was replaced by an untrained health worker. Growth monitoring of enrolled children and all other children was carried out not more than once or twice weekly. The result was that, despite supervision, such problems with the staff led to the erroneous enrolment of 18 children in the SFP. This is the reason for different totals in Tables 1 and 2.

Other factors that could have increased the drop-out rate include the hot weather of June and July, which may have discouraged families from travelling. These months also coincide with the harvest season, when rural families are too busy to bring their children to the growth monitoring units (Figure 1).

The current child ration (apart from the high-protein high-energy biscuit given in the first month) lacks adequate complementary food items like animal protein and micronutrients, in particular iron and vitamin A [9]. Iron deficiency anaemia and vitamin A deficiency are considered significant health problems in the region [10,11].

There was a relatively steep decline in the number of underweight children more than 2 SD below standard weight-for-age during the first month of the SFP (Table 2, Figure 1). This may be attributed to the effect of the high-protein high-energy biscuit. Apart from the first month, follow-up of malnourished children showed a gradual and slow, rather than dramatic, improvement in nutritional status. This is obvious for the period from February to May (Table 2 and Figure 1). Afterwards, the attendance rate to the growth monitoring units was too low for a conclusion to be drawn. It may be concluded from the current study that the soyabean mix has less effect on weight gain than the biscuits, as the rate of decline in malnutrition was slower after the first month.

Further evidence for the effectiveness of the high-protein high-energy biscuit comes from the short follow-up study. After excluding 1 child who had persistent diarrhoea, children receiving the biscuits over 1 month displayed significantly higher weight gain than controls.

Lack of remarkable improvement, except for the first month of the SFP, could also reflect the emphasis by the growth monitoring staff on just giving the food ration. Other activities, in particular health education, seemed to be considered of less importance, taking into consideration the difficulties they encountered.

It is known that nutritional problems are multi-factorial with roots in many sectors of development such as health, education, demography, agriculture and rural development [2,12]. Lack of a widely based intersectoral approach toward malnutrition may explain the slow trend of improvement.

Weighing of children enrolled in the programme and recording of data must be done monthly, even if the ration arrives late. This will compensate for the incomplete registration of follow-up data and reduce the drop-out rate. Families should be educated on how to carry out the process. Since neither the growth monitoring staff nor the families used the small growth chart present on the immunization card, its importance should be emphasized for monitoring the growth of every child under 5.

Children enrolled in the SFP should preferably be given high-protein high- energy biscuits throughout the period of enrolment instead of the soyabean mix. It would then be possible to reduce the period of enrolment to 4 or 5 months because of the more rapid catch-up in growth.

Staff at primary health care centres, particularly growth monitoring staff, can be very useful in providing health and nutrition education to all caregivers provided they are well trained and retrained, supervised, supported and motivated.

A broad intersectoral and integrated approach involving all sectors of development is needed to tackle nutritional problems. Community participation programmes, using for example the Women’s Union and traditional birth attendants, are needed to educate families on the use of growth charts and supplementary food items to tackle malnutrition.

The author is grateful to UNICEF Northern Iraq for supporting this research and allowing the publication of this study.

12. Park K. Park’s textbook of preventive and social medicine, 16th ed. Jabalpur, India, Banarsidas Bhanot Publishers, 2000, 403–51.