Annex 1: Information sheet

Details requested on the following issues:

1. HISTORY OF THE CONFLICT
   In brief terms, please describe the history and developments of the conflict in your country/region (2 pages maximum), specifying to the extent possible:

   1. development of the conflict in time (e.g. cause(s), date of start, special developments/actions, end of the conflict);
   2. region(s) involved;
   3. population groups involved (e.g. rural/urban, social, economic or cultural characteristics) and the estimated number of people affected in each group;

   4. the impact over time (e.g. on population groups - displacements, demographic changes - environment, livelihoods, agriculture, market channels);

2. INFORMATION AVAILABLE AND ACCESSIBLE
   Since the scope of the study will focus on the impact of the armed conflict on the nutritional situation of children, please indicate what information is available in the country in the following fields:

   1. Nutrition (e.g. anthropometric surveys, food consumption surveys, surveys on nutritional deficiencies);
      Possible sources of information: ICN Focal point, Ministry of Health
   2. Health and provision of health services (e.g. surveys on disease patterns, immunization, morbidity and mortality data);
      Possible sources of information: WHO, Ministry of Health, NGOs
   3. Effects of the conflict on children (e.g. children in combat, orphans, abandoned children, girls and violence);
      Possible source of information: UNICEF, UNHCR, NGOs

   4. Food production in/food supply to affected areas (e.g. amounts of production, food imports including aid, sufficiency, existing problems);
      Possible source of information: FAO, UNHCR, WFP, Ministry of Agriculture.

3. MEASURES OR PROGRAMMES TO IMPROVE THE SITUATION OF CHILDREN IN ARMED CONFLICT
   Please indicate briefly if measures are taken or programmes started which can benefit children affected by armed conflict.
   Please specify kind of measure or programme implemented, the executing institution and the coverage;
   Possible sources of information: UNHCR, UNICEF, WFP, NGOs

4. OPINION/SUGGESTIONS
   If you would like to state your personal point of view on the issue of children in the armed conflict in your country or want to express any suggestions, please do so.

Annex 2: Malnutrition in conflict situations

Definition: Malnutrition, specifically protein-energy malnutrition, is due to lack of food and consumption of a diet deficient in energy, protein and micronutrients. States of deficiency are mainly of two kinds:

• a general deficiency is reflected by failure to grow or by loss of weight, usually without specific clinical or biochemical changes.
• specific, such as the avitaminoses, which lead to defined clinical outcomes, such as scurvy, beri-beri, blindness (avitaminosis A) or rickets.

Diagnosis of a nutritional situation can be based on clinical symptoms, on growth and body composition (anthropometry) and on bodily reserves, i.e. biochemical indicators of nutrients and their deficiencies (e.g. concentration of nutrients in tissues, blood and urine). Usually, only anthropometry and clinical surveys are feasible.

Ways to measure malnutrition: Anthropometric indicators are commonly used in emergency and conflict situations to assess the nutritional status of a population or group, these include:

• Weight-for-height in children up to five years old
• Mid-upper-arm-circumference (MUAC) - in children aged one to five years old.
• QUAC stick (MUAC for height)
• Body Mass Index (BMI) in adults is equal to weight (kg) divided by the height squared (metres). For individuals with normal activity levels, a BMI between 18.5 – 25 is normal, a BMI below 16 indicates severe malnutrition.

Classification of malnutrition: To identify rates of malnutrition in children under-five years of age the following cut off points are commonly used:

• 80 percent of the median (or below);
• two standard deviations (SDs) below the median;
• the third percentile.

Wasting is defined as less than -2 SDs, or less than 80 percent of the weight-for-height standards set by the National Center for Health Statistics (NCHS) for children of 6–59 months. Wasting is often referred to as acute malnutrition. For guidance in interpretation, the ACC/SCN suggests in their quarterly “Refugee Nutrition Information Report”, that a prevalence of around 5–10 percent is usual in African populations in non-drought periods. ACC/SCN regards a more than 20 percent prevalence of wasting as high and indicating a serious situation: more than 40 percent is a severe crisis. Severe wasting can be defined as below -3 SDs (or about 70 percent of reference) (ACC/SCN, 1995).

All these values are approximately the same, however, they cannot be compared other than on an indicative basis. In emergency situations a recommended indicator for the assessment of the nutritional status of a population is weight-for-height, while MUAC for rapid screening is acceptable.

Clinical signs of severe malnutrition: Two types of malnutrition can be distinguished in terms of clinical symptoms: Kwashiorkor and marasmus. Kwashiorkor is widely associated throughout the world with hunger and near-famine conditions. The disease is not a syndrome only occurring in young children. The condition is often seen in older children and nutritional oedema in adults does not seem to be very different from Kwashiorkor. However, more often a combination of the above mentioned symptoms is found in malnourished children, indicating that malnutrition is complex, and usually due to both protein and energy deficiency.

Micronutrient deficiencies: Specific deficiencies, such as the avitaminoses, lead to defined clinical outcomes. Very often there are biochemical changes which accompany or precede the clinical signs and which make possible the early diagnosis of subclinical or impending deficiencies. In many specific deficiencies there is a decreased concentration of the particular nutrient in blood or tissues. Such deficiencies often occur during times of conflict or emergency. Sometimes they are the result of less than optimal nutritional conditions. The micronutrients which are found to be lacking are:

- Iron: a diet lacking iron or predominantly providing iron from plant sources leads often to iron deficiency, causing anaemia. Groups most vulnerable to become anaemic are young children and women of child-bearing age, especially pregnant and lactating women. A diet low in vitamin C does not facilitate iron absorption. Non-diet related causes for iron deficiency are hookworm infections and both acute or chronic loss of blood due to many causes, for example, haemorrhoids, ulcers and injury.

- Iodine: the amount of iodine in foods depends on the iodine content of the soils on which they were grown. Most vulnerable to iodine deficiency are women of child-bearing age (as the lack of iodine affects the development of the foetus) and children. Iodine is needed to make the thyroid hormones in the human body. Lack of iodine leads to: goitre, an enlarged thyroid gland; mental and other changes, such as sleepiness, general slowness, feeling cold; poor physical growth and more infections among children; increased risk of miscarriage and stillbirths among women; and, poor development of the brain and nervous system of the foetus and the young child (cretinism).

- Vitamin A: vitamin A deficiency (VAD) will develop in situations where the diet is lacking in vitamin A or its precursors, particularly β-carotene. The condition is most common in children, especially those with growth failure, measles or other infections. Vitamin A deficiency causes xerophthalmia, starting out with night blindness (first stage), followed by the development of Bitot's spots (foamy patches on the white surface of the eye), in the end resulting in permanent blindness. Lack of vitamin A also affects the immune response to infections.

- Thiamine: Thiamine deficiency (also called “beri-beri”) occurs when polished rice is the principal component of the diet. Groups which are vulnerable to beri-beri include women of child-bearing age and their infants. Sometimes young, active men are also found to be deficient. Beri-beri causes loss of appetite and severe weakness especially of the legs and, sometimes, paralysis of the arms and legs or acute oedema of the body and cardiac failure.

- Niacin: Niacin deficiency, or pellagra, occurs among people who eat mainly maize or sorghum and little other food. Women, old people and young children are most at risk. Pellagra is easy to recognize because skin that has been exposed to daylight looks darker, scaly and “sunburned”, often accompanied by severe diarrhoea and sometimes even mental changes.

- Vitamin C: Vitamin C deficiency leads to scurvy. In the last decades, it has been seen, mostly in refugee settings, where people were cut off from fresh food supplies or other sources of vitamin C for several months, and they survived basically on dry, unfortified food rations, based on cereals, oil and dried beans. Those most affected are pregnant and lactating women and adolescent boys. Scurvy causes internal bleeding, leading to bleeding gums with the eventual loss of teeth, and swollen painful joints, and eventually death (FAO, 1993).

Annex 3: Nutritional status in Mogadishu 1988, 1993, 1995

* Results in Z-score are only available for the survey conducted in 1995.

Annex 4: Results of MUAC clinic screening along Nile (in barge)

WFP-Sudan, 1995.

Annex 5: Proposed guidelines for the protection and promotion of breast- and infant feeding during emergencies

Although criticized for the lack of attention to the socio-cultural constraints on breast and infant feeding, a set of very practical guidelines have been developed (Kelly, 1993). The practical recommendations for programme planning and implementation can be summarized under three headings:

1. Support to breast-feeding:

   • In programme design, it should be kept in mind that even during a disaster, the overwhelming majority of mothers will be able to continue breast-feeding, if they were doing so beforehand;
   • Work with community leaders and local health care personnel to identify suitable experienced local women and mobilise them as ‘breast-feeding facilitators’, so that they can initiate, establish or re-establish lactation;

   • Provide extra food to lactating women to guard against possible depletion of their nutrient stores and subsequent malnutrition.

2. Assistance to families of artificially fed infants

   • Do not begin distribution of infant formula unless artificial feeding was widespread before the crisis set out, and make sure that adequate supplies are available for as long as required;
   • Use a self-targeting strategy of offering either infant formula or traditional foods (to be added to the general family ration already provided) of equal market value to families of babies under six months old;

   • Implement stringent measures to ensure that formula is utilized safely:

     • print warning instructions on the containers in which infant formula is supplied;
     • provide fuel for boiling water;
     • substitute cups for feeding bottles;

     • require frequent attendance at distribution centres so that infant health and growth can be monitored.

   • Indiscriminate free distribution of infant formula during emergencies can compound existing problems by fostering dependence on an unnecessary product among a population whose ability to use it safely cannot be guaranteed. If unable to implement the measures recommended above, do not distribute infant formula.

3. General:

   • Advise all parents of infants aged four to six months old to begin to wean them on to appropriate semi-solid foods. Provide porridge pre-mix for all weanlings, supplementary milk for those who are not breast-fed, and a supplement of traditional foods for breast-feeding mothers.
   • Additional resources, including a considerable amount of skilled labour, will be required to implement the strategies outlined above.
   • Create sufficient funding.

Annex 6: The most vulnerable in Bosnia and Herzegovina

The conflict in Bosnia and Herzegovina had grave implications for the nutritional health of the affected population. As reported by vulnerability assessments conducted by WHO in 1994 and 1995, the elderly people in particular were suffering. When compared to young children and adults (18–59 years old) the elderly were found to have the highest weight loss. Among the elderly, the most vulnerable people are found to be those living alone without younger family members or friends and those living in communal houses such as old people's homes. In other words, those suffering most from the breakdown in household and communal care systems.

In 1995, following cessation of hostilities, conditions were reported to have improved for the following reasons:

• Household food stocks were 2–4 times higher in February 1995 than in February 1994
• Food prices dropped considerably between February 1994 – February 1995
• Food aid distribution was better in February 1995 than in February 1994
• Access to heating, electricity and water improved between December 1994 and February 1995
• Distribution of water purification tablets to the majority of households in Sarajevo and Zenica had occurred.

The need for integrated care programmes for the elderly should be underlined, based on the specific factors contributing to their under-nutrition, (e.g. in Bosnia distribution of hot meals, medical care, fuel, socialization schemes, and care provisions are needed) (WHO, 1994 and Vespa & Watson, 1995).

Annex 7: Distribution of infant formula: the appropriate response to child malnutrition in Iraq?

Just after the war and the subsequent internal unrest in Iraq, most of the malnutrition and much of the excess infant mortality resulting from the emergencies in Iraq were associated with bottle feeding. The story spread that women in Iraq had become unable to breast-feed as a result of malnutrition and/or psychological stress. At the same time, there was considerable pressure from various quarters to distribute infant formula as part of the relief response. Contrary to what was widely believed, the Gulf war had little impact on women's ability to breast-feed; what did change was the level of risk associated with artificial feeding. Widely practised before the war, artificial feeding became much more dangerous in 1991 as a result of the displacement of families in squalid camps, damage to water and electricity supplies, reduced access to markets and rising prices of imports.

Women in Iraq, a middle-income country where chronic under-nutrition is relatively uncommon, must have been at least as well-nourished as the average Ethiopian or Sudanese woman in a good agricultural year. In those countries no evidence was found of reduced breast-feeding even during periods of severe food shortages, e.g. in the Darfur region in Sudan during 1984–1985, and there was no increased mortality among infants. Therefore, the possibility of lactational impairment due to poor maternal nutrition must be remote, at least in the acute stages of the conflict.

Also, virtually every household in Iraq was (as of late 1991) entitled to purchase, at heavily subsides prices, basic foods, although the embargo made it more difficult for people in Iraq to obtain food. In addition, most households had some assets that they could liquidate, so women in Iraq were neither as destitute nor as hungry as women in other countries in conflict, for instance, Ethiopia during the 1983–1985 famine.

The argument that because of the war and the bombing, women in Iraq might have been under a great psychological stress, reducing breast-feeding and resulting in the high rates of bottle feeding observed during 1991 was found invalid as well. No sharp drop in the proportion of mothers breast-feeding during 1991 was observed. Moreover, on questioning, most Iraqi women said that they bottle fed their children because they did not have enough breast-milk. Psychological reasons were not mentioned often (< 10 percent of respondents), and an inadequate diet was never mentioned. The author concludes that, as with surveys conducted in western countries not experiencing conflicts, ‘insufficient milk’ is not caused by under-nutrition or psychological stress, but by unhelpful practices, usually adopted as a consequence of social changes that impede the transition of knowledge, skills and confidence that women need to breast-feed successfully, as has been happening in Iraq with its rapid economic development and urbanization over the last three decades (Kelly, 1993).

Annex 8: Percentage of malnourished children reported to be attending feeding centres distributing cooked food.

A) Data from Somalia.

B) Data from Liberia.

* Malnourished in terms of wasting (i.e. less than -2 z-scores or having oedema).
+ Attended feeding centre