Emergency Health Training: Micronutrient Deficiencies and Supplementation

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FOR HEALTH EMERGENCIES 05\
Micronutrient
Interventions during
Emergencies http://newzaroundus.blogspot.com
Nutrition in Emergencies
(NIE)
12/03/20 1
Session objectives
1. Discuss the basic principles of micronutrient
supplementation in emergencies,
2. Identify common micronutrient deficiencies
during emergencies, and
3. Enumerate other micronutrient interventions
applicable in emergency situations.
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Nutrition in Emergency (NIE) FOR HEALTH
EMERGENCIES
Common Micronutrient
Malnutrition Problems
• Vitamin A deficiency (VAD)
• Iron deficiency Anemia (IDA)
• Iodine Deficiency Disorders (IDD)
• Folate Deficiency (Neural Tube Defects)
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EMERGENCIES
Vitamin A Deficiency (VAD)
Clinical signs and symptoms
- Nightblindness
- Bitot’s Spot
- Corneal Xerosis
- Keratomalacia
- Corneal Scar
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EMERGENCIES
Iron Deficiency Anemia (IDA)
• It is the most common nutritional deficiency
• The leading cause of anemia
Clinical signs and symptoms

- Palmar pallor
- Pale conjunctiva
- Pale nail beds
- Pale buccal mucosa
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EMERGENCIES
Normal Pink
Pale Conjunctiva
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EMERGENCIES
Iodine Deficiency Disorders
Abnormalities include:
- goiter
- miscarriage
- stillbirth
- congenital anomalies
- growth and mental retardation
- physical and motor abnormalities
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EMERGENCIES
Anencephaly – 19 weeks
Folate Deficiency
• Anemia that is caused by a
deficiency of folate is often
accompanied by iron-
deficiency anemia
• Consequences:
Anencephaly - term
- neural tube defects-
– Anencephaly – most common
– literally ‘no brain’
– Spina bifida (with or without
meningomyelocele)
- megaloblastic anemia
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EMERGENCIES
Spina bifida
The fetal spinal column doesn’t close completely during the first month of pregnancy.
There is usually nerve damage that causes at least some paralysis of the legs.
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EMERGENCIES
Copenhagen Consensus:
Top 10 Investments
1 Micronutrient supplements (vitamin A & zinc) -
Malnutrition
2 The Doha development agenda - Trade
3 Micronutrient fortification (iron and iodine) - Malnutrition
4 Expanded immunization coverage for children - Diseases
5 Agricultural R&D on micronutrients - Malnutrition
6 Deworming and nutrition programs at school -
Malnutrition
7 Lowering the price of schooling - Education
8 Increase and improve girls’ schooling - Women
9 Community-based nutrition promotion - Malnutrition
10 Provide support for women’s reproductive role - Women
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EMERGENCIES
Nutrition Interventions
Cost-benefit analysis
Intervention Benefit : cost
1. Micronutrient supplementation
Vitamin A capsules <2 100:1
Therapeutic zinc, infants 14:1
2. Micronutrient fortification
Salt iodization 30:1
Iron fortification (staples) 8:1
3. Biofortification
Plant breeding (iron, zinc, A) 18:1
4. Deworming preschoolers 6:1
5. Behavior change
Community nutrition programs 13:1
6. Community treatment SAM
Source: Horton et al., Scaling Up Nutrition; What Will It Cost?, World Bank, 2010
25:1
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EMERGENCIES
ADVANTAGES OF
MICRONUTRIENT SUPPLEMENTATION
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EMERGENCIES
Vitamin A Supplementation
• Shown to reduce child mortality by
23-34%. It reduces the severity of the
disease, thus reducing childhood mortality.
• Reduces deaths from measles by 50%
• Reduces deaths from diarrhea by 40%
• Reduces deaths from malaria by 25%
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EMERGENCIES
Iron/Folic Acid Supplementation
• Improves the cognitive and motor development
of anemic preschool children
• Prevents neutral tube defects when supplement
is given to women of reproductive age starting
from 1 month prior to conception
• It reduces the risk of deaths during childbearing
by preventing severe anemia which is highly
associated with severe bleeding.
• It prevents Iron Deficiency Anemia and
increases work productivity
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EMERGENCIES
Zinc Supplementation
• Zinc supplementation in addition to ORS

significantly reduce the duration and severity of
diarrhea compared to
Oral Rehydration Solution (ORS)
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EMERGENCIES
Micronutrient Powder (MNP)
• Premix of vitamins and
minerals in powder form
– Sprinkled once daily into the
semi-liquid foods without
changing the color, taste or
texture of the food
• Evidence -MNP package is
adequate to rapidly
improve hemoglobin
concentrations
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EMERGENCIES
MS during Disasters and
Emergency Situations
• Continue routine MS for infants, children,
pregnant and lactating mothers and WRA
• Additional Vit. A should be given unless
received a similar dose in the past 4 weeks
– 6-11 mos. Old
– 12 – 59 months old
– Postpartum women
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EMERGENCIES
MS during Disasters and
Emergency Situations (2)
Give
•VAC to measles cases regardless of last dose given
•Micronutrient Powders to children 6-23 month old
•Give Reformulated ORS and Zinc for children with
diarrhea
•Give zinc for no less than 10 days
•Provide micronutrient fortified specialized food during
emergencies
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EMERGENCIES
General Guidelines
INFANTS
Iron supplements to LBW infants at 2 months
as they are born with a lower iron supply
and are high risk for IDA.
Target Clients Micronutrient Preparation Dosage/Frequenc
y/Duration
Low birth Iron Drops, 15mg Give 0.3 ml
weight elemental once a day
infants (<2.5 iron/0.6ml starting at 2
kg) mos. up to 6
mos.
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EMERGENCIES
General Guidelines
INFANTS 6-11 MONTHS OLD
1. Ensure regular iron and vitamin A supplementation
for 6-11 mos. old infants. They have high need for iron
and vitamin A due to rapid growth and development.
2. Start regular Vit. A and iron supplements at
6 mos. Their micronutrient stores from breast milk are
no longer sufficient.
3. Give therapeutic dose of iron 6-11 mos. old clinically
diagnosed with IDA
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EMERGENCIES
General Guidelines
INFANTS 6-11 MONTHS OLD
5. Give therapeutic dose of Vit. A to infants
diagnosed with high risk conditions
such as severe pneumonia, severely
underweight, persistent diarrhea and
xeropthalmia.
6. Treat infants with diarrhea with
reformulated ORS and zinc.
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EMERGENCIES
Table 1. Recommended MS Package
for 6-11 Month Old Infant
Target Clients Micronutrient Preparation Dosage/Frequency/
Duration
6-11 mos. Continue with the Drops, 15mg Give .6ml two to
Clinically iron supplement, but elemental three times a day
diagnosed with infants need to be iron/0.6ml for 3 mos.
IDA assessed for further
management
6-11 mos. Once MNP is locally Drops, 15 mg Give 60 sachets to
(Routine available, iron elemental consume in 6
Supplementation) requirement will be iron mos.
in the form of MNP 0.6ml once a
instead of iron drops for 3 mos.
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EMERGENCIES
Table 2. Recommended MS Package for
6-11 Month Old Infant
Target Clients Micronutrient Preparation Dosage/Frequency/Duration
6-11 mos. old Vitamin A Capsules Give 1 capsule upon diagnosis
with measles 100,000 IU regardless when the last dose
of VAC was given. Give
another capsule after 24
hours.
6-11 mos. Old Vitamin A 100,000 IU Give one capsule upon
with diagnosis except when child
persistent was given VAC less than 4
diarrhea weeks before diagnosis
6-11 mos. old Vitamin A 100,000 IU Give one capsule upon

with severe diagnosis except when child
pneumonia was given VAC less than 4
weeks before diagnosis
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EMERGENCIES
Target Clients Micro- Preparation Dosage/Frequency/
nutrient Duration
6-11 mos. old Vitamin A 100,000 IU Give one capsule upon
severely diagnosis except when
underweight child was given VAC less
than 4 weeks before
diagnosis
6-11 mos. Old Vitamin A Capsule Give immediately 1 capsule
with 100,000IU upon diagnosis, 1 capsule
xeropthalmia the next day, and another
2 capsule 2 weeks after
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EMERGENCIES
Duration
< 6 months old Zinc Drops 27.5 mg/ml Give 1 ml once a day for
with diarrhea (equivalent to 10 mg not less than 10 days
elemental zinc)
15 ml drops
Tablet 20 mg Give ½ tablet once a day

elemental zinc for not less than 10 days
6-11 mos. with Zinc Syrup, 55mg/5ml Give 20 mg once a day
diarrhea (equivalent to 20 mg for not less than 10 days
elemental zinc)
60 ml syrup
Tablet 20 mg Give 1 tablet once a day

elemental zinc for not less than 10 days
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EMERGENCIES
General Guidelines
12-59 MONTHS OLD CHILDREN
• Prioritize 12-23 mos. old children for iron and
vitamin A supplements
• Give iron to those who are clinically diagnosed
with anemia to correct existing anemia
• Treat 12-59 mos. old children with diarrhea
with reformulated ORS and Zinc
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EMERGENCIES
• Ensure that children 12-59 mos. old
children receive 2 doses of Vitamin A each
year. Give the vitamin supplements every
6 mos.
• Give Vit. A therapeutic dose to children
who are clinically diagnosed with
xeropthalmia, severe pneumonia,
measles, persistent diarrhea and severely
underweight.
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EMERGENCIES
Table 5. Recommended MS Package for 12-
59 Months Old Children
Duration
Routine Iron Syrup containing Give 1 tsp once a day
Supplementation 30 mg elemental for 3 months or 30mg
12-23 months old iron/5ml once in a week for 6
mos. with supervised
administration
MNP (Single Give 120 sachets in a

served sachet) year
12-59 months Vitamin A Capsule, 200,000 Give 1 capsule every 6

IU months
Therapeutic Iron Syrup 30 mg. Give 5 ml 2 to 3 times a
Supplementation elemental iron/5 ml day for 3 mos.
12-59 months old If available , give MNP for
3 mos.
with IDA
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EMERGENCIES
for 12-59 Months Old Children
12-59 months Vitamin A Capsule, Give 1 capsule upon diagnosis

old with measles 200,000 IU regardless when the last dose
of Vitamin A was given. Give
another capsule after 24hrs.
12-59 mos. old Vitamin A Capsule, Give 1 capsule upon diagnosis,
with severe 200,000 IU except when child was given
pneumonia VAC less than 4 weeks before
diagnosis.
12-59 mos. old Vitamin A Capsule, Give 1 capsule upon diagnosis,

with persistent 200,000 IU except when child was given
diarrhea VAC less than 4 weeks before
diagnosis.
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EMERGENCIES
for 12-59 Months Old Children
12-59 mos. Who Vitamin A Capsule, Give 1 cap. upon diagnosis

is severely 200,000 IU except when child was
underweight given VAC less than 4
weeks before diagnosis
12-59 mos. old Vitamin A Capsule, Give immediate 1 capsule
clinically 200,000 IU upon diagnosis, 1 capsule
diagnosed with the next day and another
xeropthalmia capsule 2 weeks after.
12-59 months Zinc Syrup, 55 mg/5ml Give 1 teaspoon once a day
with diarrhea (equivalent to, for not less than 10 days
20mg elemental OR
zinc) 60ml syrup
Tablet, 20mg Give 1 tab, once a day for
elemental zinc not less than 10 days.
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EMERGENCIES
General Guidelines
5-9 YEARS OLD
• Meet the children’s Vit. A, iron and iodine
through diet and use of Sangkap Pinoy Seal.
Regular micronutrient supplementation is not
recommended for this age group prevalence is
no longer of public health significance
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EMERGENCIES
General Guidelines
5-9 YEARS OLD
• Give Vit. A therapeutic dose to children 5-9
yrs. old clinically diagnosed with xeropthalmia
and IDA
• Bring the child to a health facility for advice,
treatment and iron supplementation if
residing in an area where malaria and
schistosomiasis are highly endemic
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EMERGENCIES
for 5-9 years Old Children
Duration
5-9 years old Therapeutic Syrup, 30mg. Elemental Give 1 teaspoons 3
clinically dose of iron iron/5ml syrup to 4 times a day for
diagnosed with based on actual 3 months
iron-deficiency body weight
anemia
5-9 yrs. Old Iron Syrup, 30mg. Elemental Give 2 teaspoons
manifesting iron/5ml syrup once a day for 2
clinical months
signs/symptoms
of malaria
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EMERGENCIES
General Guidelines
10-14 YRS. AND 15-49 YRS. OLD
• Adolescent girls are at risk of developing iron
deficiency and IDA especially when they start
menstruating
• Ensure that adolescent girls receive iron-folic
acid supplementation and throughout period
of reproductive age
• Give corresponding therapeutic dose of iron
and Vit. A who are clinically diagnosed with
IDA, xeropthalmia
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EMERGENCIES
General Guidelines
10-14 YRS. AND 15-49 YRS. OLD
• WRA before and in-between pregnancies have

increased demand for iron due to losses from
menstruation
• Ensure that WRA to meet their Iron and Vit. A
requirements
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EMERGENCIES
Table 9. Recommended MS Package for Female
Adolescents (10-14 year old) and Non-Pregnant/non-
Lactating Women of Reproductive Age (15-49 years old)
Target Clients Micronutrient Preparation Dosage/Frequency
/Duration
10-49 years old Iron/Folic Acid Tablet, 60mg elemental Give 1 tablet once
women iron with 2.8mg folic a week menarche
acid starts and until
one gets pregnant.
10-49 yrs. Old Iron/Folic Acid Tablet, 60mg elemental Give 1 tablet daily
women iron with 400mg folic for 2 months
manifesting acid
clinical
signs/symptoms
of malaria
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EMERGENCIES
Table 10. Recommended MS Package for Female
Adolescents (10-14 year old) and Non-Pregnant/non-
Lactating Women of Reproductive Age (15-49 years old)
Target Clients Micronutrient Preparation Dosage/Frequency/D
uration
10-49 years Iron Tablet: 60mg Give 2 tablets daily
old women in elemental iron for 30 days
schistosomiasi with 400 ug folic
s endemic acid
areas
10-49 years Therapeutic Tablet, 60mg Give 2 tablets once a
old clinically dose of elemental iron day until hemoglobin
diagnosed iron/folic acid with 400 ug folic reaches normal level
with IDA acid
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EMERGENCIES
Pregnant and Lactating Women
Target Micronutrient Preparation Dosage/Frequency/
Clients Duration
Iron / Folic acid Tablet, 60mg Give 1 tablet daily for
Pregnant elemental iron with 180 days as soon as
Women 400ug folic acid pregnancy is
determined
Iron / Folic acid Tablet, 60mg Give 1 tablet once a
Post-Partum elemental iron with week until one gets
or Lactating folic acid 2.8mg pregnant again
Women Vitamin A Capsules, 200,000 IU Give 1 capsule within 1
month after delivery
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EMERGENCIES
Target Clients Micro- Preparation Dosage/Frequency/Duration
nutrient
Pregnant, Post- Iron Tablet 60 mg Give 2 tablets once a day for 3
Partum/Lactating elemental months
Women clinically iron 400 ug Evaluate after 1 month. If with
diagnosed with folic acid adequate response to therapy
iron-deficiency (defined as an increase in
anemia hemoglobin by 1 to 2 g/dL,
continue supplementation and
re-evaluate after 2-3 months. If
there is no adequate response
to one month of oral iron
therapy, evaluate for possible
causes of anemia.
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EMERGENCIES
Duration
Pregnant Vitamin A Capsule, 10,000 IU Give 1 capsule of

Women 10,000 IU once a day
clinically for four weeks upon
diagnosed with diagnosis.
xeropthalmia
However, if the
pregnant woman is
currently taking
multivitamins with
Vitamin A, do not give
the 10,000 IU VAC
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EMERGENCIES
VA Supplementation:
Side effects and contraindications
• Usually no side effects if given according to
recommended dose
• If child complains of loss of appetite, vomiting,
headache, nausea, these are temporary and
disappear within 24 hours
• Precautions:
– Always ask the last dose of Vit. A given to avoid
overdose
– Never give Vit. A supplement to pregnant women
except if with xerophthalmia
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EMERGENCIES
Iron Supplementation:
Side effects
• Iron is best absorbed in empty stomach, but
with more side effects. Advise:
– Take ½ dose daily for one week then resume full
dosage
– Take iron supplement during or after meals
• When stool turn black, explain that this is due
to ferrous sulfate
• Take more fiber-rich food (vegetables and
fruits) and water to prevent constipation
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EMERGENCIES
Iodine supplementation:
Side effects
• Benefits of giving IOC far outweigh the
complications that occur
• Hypothyroidism, transitory thyrotoxicosis are
very rare
• Acute iodine poisoning- gastrointestinal
irritation, abdominal pain, nausea, vomiting
and diarrhea
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EMERGENCIES
Approaches for prevention of Micronutrient
Malnutrition in Emergencies
• Inclusion of nutrient-rich commodities in food
assistance rations
• Provision of fresh food items that are complementary
to a general ration
• Provision of micronutrient-fortified foods
• Increasing the size of the general food ration to
facilitate diet diversification by exchange or trade
• Distribution of food supplementation products for
home fortification
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EMERGENCIES
Approaches for prevention of Micronutrient
Malnutrition in Emergencies
• Distribution of micronutrient supplements
• Promotion of home gardening and agricultural
development
• Increasing income generation and improving access
to markets
• Promotion of recommended infant feeding practices
• Ensuring adequate health care and a healthy
environment
• Ensuring access to adequate non-food items
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EMERGENCIES
Micronutrient interventions in
Emergencies
• First 24-47 hours
Screening and coverage – ensure that infants,
children, pregnant and lactating mothers and
women of reproductive age continue to
receive the recommended routine
micronutrient supplementation
- Food fortification- coordinate with DSWD for
the distribution of fortified foods.
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EMERGENCIES
Micronutrient intervention during
emergencies
• From 48-72 hours
Monitoring and coverage –continue distribution
of micronutrient powders with appropriate
orientation on its use.
ensure that 6-23 months old children receive
the MNP supplement( 1 sachet/day), if
available. In addition expand the provision of
MNP to to 24-59 month-old children as well as
to pregnant and lactating women.
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EMERGENCIES
Micronutrient interventions
during emergencies
- Continue the distribution of ORS with zinc with
appropriate orientation on its use among identified
children with diarrhea.
-Food fortification
• 1 week onwards
- Regular nutrition service delivery
- Food based interventions such as home gardening,
livestock production, livelihood programms assuming
that the condition returns to normal.
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EMERGENCIES
THANK YOU
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EMERGENCIES

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FOR HEALTH EMERGENCIES 05\

Clinical signs and symptoms

• Zinc supplementation in addition to ORS

6-11 mos. old Vitamin A 100,000 IU Give one capsule upon

Tablet 20 mg Give ½ tablet once a day

Tablet 20 mg Give 1 tablet once a day

MNP (Single Give 120 sachets in a

12-59 months Vitamin A Capsule, 200,000 Give 1 capsule every 6

12-59 months Vitamin A Capsule, Give 1 capsule upon diagnosis

12-59 mos. old Vitamin A Capsule, Give 1 capsule upon diagnosis,

12-59 mos. Who Vitamin A Capsule, Give 1 cap. upon diagnosis

• WRA before and in-between pregnancies have

Pregnant Vitamin A Capsule, 10,000 IU Give 1 capsule of

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