Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

August 8,2019

DEPARTMENT MEMORANDUM
NO.20le- 03Gs
FOR: DOH CENTERS FOR HEALTH DEVELOPMENT DIRECTORS.
MINISTER OF HEALTH BANGSAMORO AUTONOMOUS
REGION FORMUSLIM MII\DANAO GARMM). DOH CHIEFS OF
HOSPITALS. MEDICAL CENTER CHIEFS. AI\D OTHER
CONCERNED TINITS AND OFFICES

Subject: Interim Guidelines on the Use of Lipid-Based Nutrient Supplement-

Small Ouantitv (LNS-SO) for Presnant and Lactatins Women and
Young Children Ages 6-23 months to prevent stunting

I. BACKGROTIND AND RATIONALE

Globally, stunting affects 159 million children under 5 years old mostly living in
34 countries in Asia, sub-Saharan Africa and Latin America. By 2030, the global target is
to reduce this numberby 40%o. In the Philippines, 3 out of 10 children are stunted making
it imperative to address the nutritional deficiencies of pregnant women, improve exclusive
breastfeeding (EBF) practices, introduce adequate and timely complementary feeding,
along with continued breastfeeding for up to 2 years or beyond to be able to save the lives
of 1.5 million children under 5 years of age annually.

The Philippine Plan of Action (PPAN) 2017-2022 has identifred supplementary

feeding of pregnant and lactating women and children 6-23 months old, along with the
treatment of severe and moderate acute malnutrition, as one of the drivers to stunting
reduction in its focus areas. Chronically energy deficient (CED) pregnant women have
higher chances of giving birth to Low Birth Weight (LBW) infants, thus, the need to
address their nutritional deficiencies.

Interest in the use of lipid-based nutrient supplements to combat child malnutrition

has grown, accelerated by the success of ready-to-use therapeutic foods (RUTF) for the
treatment of severely malnourished children. This has motivated the development of a
range of lipid-based products designed for different pu{poses, including treatment of
moderate acute malnutrition (MAM), and the prevention of wasting or stunting (low
height-for-age).

Building l, San lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila o Trunk Line 651-7800 local 1108, I I I l, 1l I
Direct Line: 7ll-9502;7ll-9503 Fax:743-1829 o tlRL: http://www.doh.gov.ph; e-mail: ftduque@doh.gov.ph
 While evidence on using lipid-based nutrient supplement-small quantity (LNS-SQ)
in the prevention of stunting among African children showed successful result, the World
Health Organization's (WHO) globat recommendation on its use is not strong due to
limited evidences on its continued use and potential impact in preventing stunting. In the
Philippines, LNS-SQ will be introduced as part of an operations research that will later
inform the development of the Philippine guidelines on its wide use throughout the country.

II. GOAL AND OBJECTIVES

A. Goal

To prevent Intrauterine Growth Restriction (IGR) and stunting among children 6-

23 months old belonging to women from food poor families.

B. General Objective

To provide interim guidelines for the provision and appropriate use of LNS-SQ
among pregnant and lactating women, and children 6-23 months old in selected
focus provinces registering a high prevalence of stunting.

C. Specific Objectives

1. To provide all DOH Centers for Health Development and other concerned
offices with an interim guideline on the use of LNS-SQ among pregnant and
lactating women and children6-23 months of age.
2. To ensure that CHDs and other concemed offices will have the technical
knowledge and capacities to enable them to continuously provide LNS-SQ to
target beneficiaries.
3. To standardize indicators, reporting and monitoring tools, and evaluation
mechanisms for future integration into existing information systems that will
help in planning and sustainable programming at all levels when nationwide
implementation has been guaranteed.
4. To define roles and functions of DOH Offices in the implementation and
monitoring of LNS-SQ supplementation.

ilI. SCOPE AND COVERAGE

This Order is issued for the guidance of the Centers for Health Development and other
concerned offices in the implementation of the LNS-SQ supplementation among pregnant
and lactating women and children6-23 months old.

IV. DEFINITION OF TERMS

A. Lipid-Based Nutrient Supplement (LNS) - A family of products designed to deliver

nutrients to vulnerable people. They are considered "lipid-based" because the majority
 of the energy provided by these products are from lipids. LNS provide a range of
vitamins and minerals, and energy, protein and essential fatty acids. Formulations and
doses can be tailored to meet the nutrient needs of specific groups and to fit in particular
programmatic contexts

B. Lipid-Based Nutrient Supplement- Small Quantity (LNS-SQ)- Products given in

doses of around 20g a day, also referred to as small-quantity, tend to be used for the
prevention of micronutrient deficiencies and promotion of growth in home fortification
programs (especially during the 1000 days from conception to 24 months).

C. Micronutrient- A dietary element essential only in small quantities.

D. Micronutrient Supplement - Vitamins and minerals in concentrated form alone or in

combinations taken to supplement the intake from the normal diet.

E. Micronutrient Supplementation - A short to medium term intervention intended to

prevent and/or correct high levels of micronutrient deficiencies by providing large
doses of micronutrients immediately until more sustainable food-based approaches
(e.g. food fortihcation and diet diversification) are put in place and become effective.

V. GENERAL GUIDELINES

1. The interim guidelines on LNS-SQ shall provide direction and options in the prevention
of undernutrition among children and pregnant and lactating women to support the
Philippine Plan of Action for Nutrition's goal of reducing the current stunting
prevalence to 2I.4%o in2022.

2. The DOH shall provide the required LNS-SQ to cover all identifred participating
pregnant and lactating women and children 6-23 months in selected focus provinces.

3. Agency / development partners shall secure consent from parlicipating pregnant and
lactating women and parents/guardians of participating children 6-23 months old. Only
those with consent shall be provided with LNS-SQ.

4. Baseline information of participating pregnant and lactating women and children 6-23
months old shall be collected and shall be regularly track as to the consumption of LNS-
SQ. The appropriate anthropometric and other measurements to assess the progress of
the LNS-SQ supplementation impact shall also be collected.

5. All records and reports generated by the LGUs from shall be collected and analyzed and
shall be fed back to concerned local health offices, DOH regional and national offices.
VI. SPECIFIC GUIDELINES

A. Target Population

l. Pregnant and Lactating Women (with normal nutrition status without

complications/co-morbidities)

2. Children 6-23 months old who are not acutely malnourished (not wasted)

D. Lipid-Based Nutrient Supplement Formulation

1. LNS-SQ for Children 6-23 months has the following nutritional contents

-For20g
:
Formg
{recommended . (rccommended
dail"y do€e) :

Energy '108 kcal lodine 90 g

:Protdns 2og Selenium 10 g

kcal from proteins 9.5 % Manganese 0.08 mg

Lipids '
7.1i Vitamin A 0.4 mg

kcal from lipids 59 Yo Vitamin C 30 mg

Vitamin 81
:

Calcium 100 mg :
0.3 mg

Phosphorus 82.1 mg Vitamin 82 0.4 mg

mg Vitamin BO
:
Potassium 152 ,, 0.3 mg

Magnesium 16 mg VitaminBl2 05g

::' zinc 4mg Folic acid 80 g

Copper 0.2 mg Pantothenic acid 1.8 mg

: lron 9mg Ie.t.l..---

2. LNS-SQ for pregnant and lactating women has the following nutritional contents
 a
J. Prior to administration of LNS-SQ, pregnant and lactating women and children 6-
23 months shall be assessed by the local health service providers based on the ante
natal care guidelines and guidelines for the anthropometric measurements of
children based on the WHO child growth standards, respectively. Progress
measurements shall also be done based on the agreed tracking period of the target
participants.

4. Preferably, the participating pregnant and lactating women shall also be dewormed
based on the DOH guidelines for deworming

5. The participating pregnant and lactating women and the parents/caregivers of

children shall be made to understand that the LNS-SQ is not a replacement of any
current meal but it should supplement their current food intake and shall be
considered as a snack.

C. LNS-SQ Storage

LNS-SQ are sensitive to heat but has a very low moisture content thus can be stored at
room temperature in a cool dryplace in an airtight container forprotection from insects
and rodents.

E. LNS-SQ Supplementation Guidelines

1. Before the start of supplementation, a masterlist shall be prepared, orientation of

parents of the child and, pregnant and lactating women about LNS-SQ shall be
done and written consent shall be secured.
2. For pregnant and lactating women, provision of LNS-SQ can be simultaneous with
other program or during check-up; in between check-ups, with the assistance from
barangay health workers and barangay nutrition scholars.
3. For children aged 6-23 months, LNS-SQ can be provided every 2 weeks to mother
or caregiver of children after monitoring of weight and height.
4. LNS-SQ shall be provided to the following target participants:
a. Pregnant/ Lactating Women - 1 sachet per day for at least 120 days
b. Children 6-23 months old - 1 sachet per day for at least 120 days
5. Preguant women shall no longer be provided with daily iron and folic acid tablet,
lactating women shall no longer be given post-partum dose of Vitamin A and daily
iron and folic acid. Infants and young children 6-23 months shall no longer receive
micronutrient powder (MNP) and Vitamin A.
6. All other areas in the country not included in the implementing sites for LNS-SQ
shall continue the existing nutrition interventions following the micronutrient
supplementation guidelines.
 F. Financial Support and Procurement of LNS-SQ

1. The Disease Prevention and Control Bureau through the Women, Men and
Children's Health Development Division shall procure the required LNS-SQ for
pregnant and lactating women, and children aged 6-23 months old.

2. The required LNS-SQ shall be delivered by the DOH forwarding services

directlv to the DOH ROs for further distribution to focus areas.

G. Recording and Reporling

Based on the Monitoring and Evaluation System that shall be developed for the
project, recording and reporting forms shall be developed that is aligned to the
existing Field Health Services lnformation System (FHSIS). Likewise, data quality
check and validation mechanisms shall also be put in place.

VII. IMPLEMENTINGMECHANISM

A. ROLES AND RESPONSIBILITIES

1. DEPARTMENT OF HEALTTT CENTRAL OFFTCE @OH-CO):

Disease Prevention and Control Bureau (DPCB)

a. Formulates guidelines and procedures on the implementation of LNS-SQ

supplementation and disseminate to Regional Offices, LGUs and other
stakeholders
b. Prepares a Communication plan and prototype materials for LNS-SQ
supplementation advocacy and promotion in participating LGUs
c. Procures, allocates and distributes to focus areas in a timely manner all
required LNS-SQ
d. Provides coordination mechanism spanning all levels of implementation, to
ensure the timely and effective implementation of LNS-SQ supplementation
e. Monitors the implementation of LNS-SQ supplementation in coordination with
the Centers for Health Development

2. DOH CENTERS FOR HEALTH DEVELOPMENT

The Centers for Health Development shall:

a. Disseminates guidelines and procedures on the implementation of LNS-SQ
supplementation
b. Provides and implement a mechanism of coordination and collaboration with LGUs,
partners, and other stakeholders, within the region
c. Provides technical assistance and logistics support to focus areas. Designs, updates, and
 conducts necessary training to enhance capabilities of program implementers
d. Reproduces and disseminates communication plan and prototype of IEC materials
e. Monitors the implementation of LNS-SQ supplementation and submit reports to
DOH-Central Office using the prescribed forms and following the reporting schedules.

-' sfi&
vilt:
X EFFECTIVITY

This Order shall take effect immediatelv.

L
A C. CABOTAJE,A,ID, MPH' CBSO lll
Public Health Services Team
 ALGORITHM FOR LNS SQ

Children 5-23 months

Lactatins Women : old children

', Give LNS-SQto: Give LNS-SQto:

- Pr€gnant women with normal - Childr€h 5-23 months

nutritional status 120 who are not acutely
,lf supply is still
days before delivery malnouiished (wasted)
available it can also
and Postpartum be given to oth€r , coming fiom families
women giving priority : normal pregnant in the NHTS List
to those included in , and lactating :,:
.,Givo 1 sachet per day
the NHTS List women nbt for 120 days
- Give l saihet per day , iincluded in the -.:::Dohot give Mici6nutr,ient
for 120 days NHTS,list fottow,ing Powder (MNP)and
the same guidelinei Vitamin A to children
- Do:not give lron and :Folic
as those in the :::

while being given LNS-SQ

Acid (lFA) and Post-
NHTS,LiSt ,.,
partum Vitarnin A to , Give,to,,other chif dren ,,

pregnant/lactating women 6 23 months old not

while being given LNS-SQ inCluded,in,,,the N HTS if
supply is still available
following the tame
guidelines