Blanket supplementary feeding is an activity in which a supplementary ration is provided to everyone in an identified vulnerable group (e.g. children under five or women of child-bearing age) for a defined period in order to prevent deterioration in nutritional status. While there are no defined impact indicators for blanket supplementary feeding, monitoring of coverage, adherence, acceptability and rations provided are important.

The decision whether to take a targeted approach to supplementary feeding to treat acute malnutrition, or a blanket approach to prevent it  will depend on:

• levels of acute malnutrition and size of the affected population;

• risk of increased morbidity;

• risk of decreased food security;

• population displacement and density;

• capacity to screen and monitor the affected population using anthropometric criteria; and

• available resources and access to the disaster-affected people.

A blanket approach generally requires less staff expertise but more food resources.

BSFP may be set up under one or a combination of the following circumstances:
• At the onset of an emergency when the TSFP and OTP are not adequately in place or not properly functioning;
• Prevalence of GAM equal or greater than 15% (among children 6-59 months);
• Prevalence of GAM at 10-14% in presence of aggravating factors( Aggravating factors can include: Worsening of the nutritional situation; Food availability at household level is less than the mean energy requirement of 2100 kcal per person each day; The general food distribution (GFD) is below mean energy, protein and fat requirements; Crude mortality rate more than 1 per 10,000 per day; Epidemic of measles or whooping cough; High prevalence of respiratory or diarrhoeal diseases; Inadequate safe water supplies and sanitation; Inadequate shelter; War and conflict, civil strife, migration and displacement.; 
• Anticipated increase in rates of malnutrition due to seasonally induced food insecurity or epidemics;
• In case of high-risk and anticipated micronutrient deficiency, to provide micronutrient-rich foods to the target population. Where the prevalence of micronutrient deficiencies exceeds public health thresholds, blanket treatment of the population with supplements may be appropriate. Scurvy (Vitamin C deficiency), pellagra (niacin deficiency), beriberi (thiamine deficiency) and ariboflavinosis (riboflavin deficiency) are the most commonly observed epidemics to result from inadequate access to micronutrients in food aid-dependent populations. Address deficiencies by population-wide interventions as well as individual treatment.

In addition to the guidance provided in Stage 1 of the 2011 Operational Guidance for when a BSFP may be appropriate, BSFP may also be suitable in the following contexts:

1) At the onset of an emergency if a reliable pipeline for a general food distribution (GFD) is not in place, to prevent acute malnutrition in young children

2) Where there is a clear seasonal ‘hunger period’ during which children cyclically descend into malnutrition due to food shortages and/or increased rates of ill health/disease

3) When the population is difficult to reach due to logistical and/or security problems and where more frequent and targeted SFP (for treatment of moderate acute malnutrition (MAM)) is not feasible due to time, access, or partner capacity limitations 4) Where there are (or there are risks of) micronutrient deficiency outbreaks and BSFP is given to support the overall response through the provision of micronutrient-rich foods, fortified commodities, or micronutrient supplementation to the target population

5) When there is a need to provide nutritional support to other at-risk groups, such as people living with AIDS or TB, or the disabled or elderly.

Admission criteria for BSFP:

1. BSFP for children

• ALL children aged 6 to 59 months of age. This is applicable in the context where the OTP and TSFP services are not functioning properly, or there is inadequate coverage, or where there are no functional referral systems.
• • ALL children 6-23 months (focuses on the first 1,000 days of life). This is applicable in the context where the OTP and TSFP are properly functioning with adequate coverage, or where functional referral systems exist or if resources are limited.

1. BSFP for PLW

• ALL pregnant women from second trimester (visible pregnancy);
• ALL lactating women with an infant less than 6 months.

Minimum requirements to establish a nutritional site are:

• Anthropometric measurement tools ( MUAC tape, weighing scale, height/length board, height sticks)
• Admission and Discharge criteria
• Action protocols in outpatient care
• Key messages upon admission
• Health an nutrition education messages for CMAM
• National CMAM guidelines
• List of sites with Catchment area and service day (if appropriate)
• Referral slip Community Screening
• Referral for SC/ITP/OTP/TSFP
• Ration cards
• Site Tally Sheet
• Monthly Site report
• Register books
• Checklists for Supportive Supervision
• Supply checklists
• hygiene and sanitation supplies
• infrastructure (shelter/waiting bay, storage for supplies, screening and triage area)

There should be a maximum of 500 beneficiaries per BSFP site. BSFP can be conducted at any agreed-upon location in the community. Ration distributions are done once a month, on a designated day.

Test special nutritional product acceptability. Before implementing a BSFP using FBF, a well-implemented ’Rapid Acceptability Assessment’ based on participatory cooking demonstrations and nutrition and hygiene education sessions is recommended.

Rations could be:

• Generic name: Fortified Blended Food
• Product: Super Cereal Plus (CSB++)
• Target Group: Children 6-59 months and PLW
• Ration/day: 200g
• Ration/month: 6kg
• Packaging: 1.5kg packet

I have seen High Energency Biscuits, Plumpy Sup, and Plumpy Doz used in BSFPs.

Do not include infant formula and other BMS in general or blanket distributions.

The admission process is as follows:
STEP 1: REGISTER CHILDREN OR PLW
• Determine the eligibility for admission into BSFP as follows;

• For children, determine age from official records. If no records are available, use a height stick. All children measuring between 65.0cm (average length for a 6 month old) and 110.0 cm (the average length for a 59 months old) are included in the BSFP for children 6 to 59 months  while all children measuring between 65.0cm and 87.0 cm (the average length for a two-year-old) are included in the BSFP for children 6 to 23 months;
• Alternatively, if it is difficult to measure the length of infants less than 6 months of age, the child’s age can be estimated based on average growth milestones, such as teething. In this case, a child with 2 incisor median (lower jaw) is between 6-9 months and therefore is eligible for BSFP. The mother should NOT be registered as a PLW (see below).
• For PLW, include all pregnant women from second trimester (visible pregnancy) and all lactating women with infant less than 6 months of age.

• If the child or PLW meets the criteria for admission, complete the admission details in the BSFP register book and the ration card (see Annexes 21 and 23 of GOSS MOH CMAM Guidelines for samples);

Explain to the mother/caregiver or PLW the purpose and duration of the programme, and when to return for admission at the next distribution round;
If the child or PLW does not meet the criteria for BSFP, explain why the child/PLW is not included.

STEP 2: SCREEN THE CHILDREN OR PLW FOR ACUTE MALNUTRITION AND REFER AS NEEDED
ALL children and PLW:
• Assess the child or PLW for bilateral pitting oedema and take MUAC. Screening record sheets (see Annexes 22 and 24 of GOSS MOH CMAM Guidelines for samples) are used to quickly count by category. The totals are later used for reporting.
Note: Oedema in adults may be due to medical or physiological causes. Therefore, bilateral pitting oedema in PLW MUST be interpreted with caution.
If the woman is lactating:
• Assess her for any breastfeeding problems and check the infant for visible signs of wasting.
• Take actions using the BSFP action protocols (see Annexes 20 of GOSS MOH CMAM Guidelines for samples).
• Record any actions taken.
STEP 3: PROVIDE PREVENTION PACKAGE (IF AVAILABLE)
• If available, provide a prevention package consisting of: soap for hand washing, insecticide-treated bed nets (LLITN), and education sessions.

FOUR essential messages are given in the BSFP:

1. Exclusive breastfeeding (for 6 months). Mothers should understand that the ration MUST NOT BE GIVEN TO INFANTS < 6 MONTHS;
2. Complementary feeding: At 6 months introduce semi-solid and solid energy and nutrient-dense foods, prepared appropriately using locally available and affordable foods. Continue breastfeeding up to 2 years and beyond;
3. Wash hands with soap and clean running water before eating and after using the toilet/latrine;
4. Recognize danger signs and prevent illness and death through the use of LLITN, continued feeding during illness and use of ORS (in case of diarrhoea).

• To ensure the quality of the education session and not lengthen the distribution session duration, focus on one message a month;
• Record prevention items given in the register book;
• Refer all eligible children for EPI updates, and pregnant women for ANC and tetanus vaccination at the nearest health facility;
• Refer children and PLW with health problems to the nearest health facility.
STEP 4: PROVIDE RATION
• Provide the ration for one month 
• Explain how the ration is to be used/prepared and stored at home (see Annex 18 of GOSS MOH CMAM Guidelines);
• Ensure the mother/caregiver or PLW understands that the ration is intended for the index child or PLW (child or PLW registered in BSFP) and is not to be shared;
• Record the ration given in both the BSFP register book and on the BSFP ration card;
• Advise the mother/caregiver or PLW when the next distribution round will be. Remind the mother/caregiver or lactating woman to come with the child to the BSFP site for assessment;
• Other family members may accompany mother/caregiver and child or the PLW to carry the ration.
STEP 5: CONDUCT A PRACTICAL DEMONSTRATION ON THE USE/PREPARATION OF THE RATION
• In addition to the messages on how to use/prepare and store the ration (CSB+ and CSB++) at home, practical sessions should also be conducted. In order to ensure active participation, groups of NOT more than 10 mothers/caregivers should be organized per practical session.

FOLLOW-UP DISTRIBUTION ROUNDS
• Children and mothers/caregivers or PLW should attend BSFP every month.
• At every distribution round, proceed as follows:

• Assess the child and PLW for bilateral pitting oedema and measure MUAC. Record findings on screening record sheet and in the register book.
• Determine if referral is needed according to the BSFP action protocols for children and PLW (see Annex 20 of GOSS MOH CMAM Guidelines for samples). If so, complete a referral slip as needed.
• Refer children and PLW with health problems to the nearest health facility.
• Provide the ration, and record it in the register book and on the ration card. 
• Advise the mother/caregiver or PLW when the next distribution round will be.

EXIT CRITERIA FOR BSFP (WHEN TO DISCHARGE CHILDREN AND PLW FROM BSFP)
• Children are discharged from BSFP when they reach 60 months (if the BSFP is targeting children 6-59 months) or when they reach 24 months (if the BSFP is targeting children 6-23 months);
• Mothers are discharged from the BSFP when their infants reach 6 months.
• Where possible, the child should be registered in the BSFP for children.

When to close the BSFP?

The duration of a BSFP depends on the scale and severity of the disaster, and the effectiveness of the initial response.
• BSFP can be closed when all the following conditions are met:

• Food consumption is adequate;
• Prevalence of GAM (in children 6-59 months) is below 15% without aggravating factors;
• Prevalence of GAM is below 10% in presence of aggravating factors;
• Disease control measures are effective.

Other indications that a BSFP may be stopped are:

• Decreased mortality rates
• Stabilisation in any population movements (for example if there has been significant influx of refugees which may initially overwhelm camp services)
• No nutritional deterioration is expected (although if seasonal deterioration is expected in relation to the hunger gap, closure should be delayed)
• When an improvement in food accessibility and availability (quantity, quality and equity) is expected.

Steps taken and final decisions should always be made in consultation with all stakeholders.

M&E: Individual nutritional status is not monitored in BSFP because the objective is to provide nutritional protection at population level.

References:

GOSS MOH. (2017). CMAM Guidelines. https://www.nutritioncluster.net/sites/nutritioncluster.com/files/2020-04/CMAM%20guidelines%20south%20sudan%202017.pdf

SPHERE (2017). Sphere handbook. https://orange.ngo/wp-content/uploads/2017/10/Food-Security-and-Nutrition.pdf

Style, S., & Seal, A. J. (2014). UNHCR Operational Guidance on the use of Fortified Blended Foods in Blanket Supplementary Feeding Programmes. https://www.unhcr.org/5877589c7.pdf

UN. (2020). Interim Standard Operating Procedure (SOP) for Blanket Supplementary Feeding Programme (BSFP) during COVID-19. https://www.un.org.np/sites/default/files/doc_internal/2020-09/NPL_NNC_IMAM%20TWG_Interim%20SOP%20for%20BSFP%20during%20COVID-19_11%20Jun%202020_V_final_ENG.pdf

UNHCR/WFP. (1999). UNHCR/WFP guidelines for selective feeding programs in emergency situations. http://conflict.lshtm.ac.uk/media/UNHCR_WFP_Guidelines_for_SFP_In_Emergencies.pdf