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Over the past 2 years there has been a growing awareness of the potential value for the U.S. Agency for International Development (USAID) to have a standing capability in the Institute of Medicine (IOM) for a more flexible, less costly response to agency needs for advice in the areas of nutrition, food, and health science policy. With support from USAID, the IOM responded in October 1993 by establishing the Committee on International Nutrition (CIN) under the aegis of the Food and Nutrition Board (FNB) and the Board on International Health (BIH).

The CIN's mandate is to answer questions of interest and concern, evaluate current nutrition activities undertaken by the agency, and make recommendations for future activities based on this review. Topics are chosen through systematic consultation with the Office of Nutrition in USAID's Bureau for Research and Development. Representing the areas of human nutrition, maternal and child health, epidemiology, economics, and program design and evaluation, the committee's six members will convene three times to produce brief reports that review specific programs, research projects, or project designs. With an initial project life of 18 months, the CIN is designed to be flexible (that is, capable of responding to specific nutrition concerns that arise abruptly) and to provide quick report turnaround.

This report is the result of the third meeting of the CIN, which was held on 19–20 January 1995. The purpose was to comment on the nutrition components of the World Health Organization's (WHO) initiative to integrate the management of childhood illness. This is often called the “Sick Child Initiative” (SCI). The report was requested by USAID's Office of Health and Nutrition, a primary funding source for the initiative, on 8 December 1994. The CIN wishes

to emphasize that the report was not requested by WHO and that WHO was not represented at the CIN meeting. Also, in spite of a major effort on WHO's part to share its latest documents with the CIN, the committee is aware that it did not have access to much of the relevant documentation. This report, then, does not represent a thorough scientific review of WHO's contribution to the nutrition components of the SCI. Rather, it should be viewed as a series of general observations concerning the draft documents available to the committee that are intended to expand the process of thinking about how to combine nutrition assessment, treatment, and advice into the integrated management of sick children and the maintenance of adequate nutrition and health.

The initial charge to the committee by USAID was as follows:

Drawing on the scientific and technical knowledge of individual members, background information and other pertinent data, the Committee is requested to make recommendations as to: (1) practicality of the nutrition components of the (SCI) algorithm; (2) whether the nutrition components of the algorithm should or should not be modified, and if to be modified, how; and (3) the additional information or data required to improve the performance of the integrated management of childhood illness algorithm's nutritional effectiveness.

Further background information and details on USAID's initial request to the CIN can be found in the memorandum to the committee from Samuel G. Kahn, USAID Office of Health and Nutrition (Appendix A). In addition to this initial request, on the first day of the meeting Caryn Miller of the USAID Office of Health and Nutrition requested that two additional questions be considered: (4) how can nutritional components be monitored during field testing or introductions, and (5) what should the role be for those with experience and expertise in nutrition as field testing or introduction evolves?

During the 2-day meeting, the CIN reviewed background information supplied by USAID. The documents that will be referred to most frequently are: “Assess and Classify the Sick Child Age 2 Months up to 5 Years ”; “Advise the Mother”; “Treat the Child”; “Management of Childhood Illness,” February 1995 drafts; “An Integrated Approach to Management of Childhood Illness: Development and Research Activities,” 4 March 1994 draft; and “Integrated Management of Childhood Illness: Research Priorities,” January 1995 draft. These documents were all generated by WHO. Additional documents available to the committee are listed in Appendix B.

The report contains four chapters and four appendixes. Chapter 1 provides background information on the SCI, the charge to the committee, and the scope of the committee's deliberations. Chapter 2 describes the nutrition algorithms in the SCI. In Chapter 3, the committee presents its responses to the five questions posed by USAID. Although the committee was not asked specifically to consider SCI in the larger context of health care and child welfare, it believes strongly that integration of SCI activities with other local resources for the treatment and prevention of illness and disease, including malnutrition, will be required for SCI to be most effective. Thus, the committee ends Chapter 3 with suggestions toward this end. The committee's overall summary and conclusions are presented in Chapter 4.

Appendix A contains the USAID memorandum outlining the initial charge for this third CIN meeting. Appendix B offers guidance for further development of the diagnostic screens used in the SCI and comments on the nutritional diagnosis and management strategies for the three categories of children that will be identified. Appendix C lists references to articles made available to the committee members, and Appendix D provides excerpts of important components of the nutrition algorithms.

The committee gives special thanks to the USAID staff from the Office of Health and Nutrition, who gave graciously of their time in providing information for the report. These included Susan Anthony, Al Bartlett, Kevin Callahan, Eunyong Chung, Cate Johnson, Caryn Miller, Samuel G. Kahn, and Andrew Siderski. The committee also thanks the following individuals for their important contributions to the evidentiary base considered in the preparation of the report: Robert E. Black, The Johns Hopkins School of Hygiene and Public Health; Caryn Bern, Centers for Disease Control and Prevention; Joanne Csete, United Nations Children's Fund (UNICEF); Katherine L. Dickin, The Manoff Group, Inc.; Mary S. Lung'aho, WellStart; and Ronald Waldman, The Basics Project. The committee would also like to express its appreciation to the IOM staff who facilitated the work of the CIN: Christopher P. Howson, study director; Jamaine L. Tinker, financial associate; Michael Edington, managing editor; Caroline McEuen, copy editor; Claudia Carl, administrative associate; and Gail Spears, administrative assistant. The committee especially thanks Susan M. Knasiak, research assistant, for her help in conducting the third meeting and for her valuable editorial advice in preparing the report draft. Finally, the committee thanks Richard G. Seifman, formerly at USAID; Polly

Harrison, IOM; and Catherine Woteki, formerly of the FNB, for their vision and hard work in realizing this project, and Allison A. Yates, FNB, for her collaborative support of the CIN's activities.

Lindsay H. Allen, Chair

Committee on International Nutrition