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Guideline: updates on the management of severe acute malnutrition in infants and children.4 The 2023 WHO guideline on the prevention and management of wasting and nutritional oedema supersedes the 2013 guideline.5 It includes evidence-informed updates to recommendations based on prioritised guideline questions and an emphasis on an integrated care approach between inpatient and outpatient/community settings.5 The guideline is timely and particularly important in the face of multiple crises including conflicts, climate change, food scarcity, rising living costs and pandemics. Table 1 Overview of recommendations and GPSs for infants and children 6–59 months of age with severe wasting and/or nutritional oedema Recommendation or GPS number Subject Strength Certainty B1 Triage at the time of entry to a health facility N/A (GPS) B2 Criteria for admission for inpatient care, in-depth assessment or enrolment to outpatient care Conditional Low B3 Criteria for transfer from inpatient to outpatient care Strong Moderate B4 Continuity of care between inpatient and outpatient services N/A (GPS) B5 Criteria for exit from nutritional treatment Conditional Very low B6 Classification of hydration status N/A (GPS) B7 Rehydration fluids for dehydration (for children who are not shocked) Conditional Very low B9 Hydrolysed formulas for infants and children who are not tolerating F-75 or F-100 Conditional Very low B10 Quantity of ready-to-use therapeutic food in outpatient care Conditional Low B17 Identification and management of wasting and nutritional oedema by community health workers Conditional Very low GPS, good practice statement; N/A, not applicable. Rigorous trials should examine not only individual child factors such as comorbidities and other biological factors, but also social factors including maternal physical and mental health, education and decision-making power, and contextual factors such as socioeconomic status, food security and access to care. [...]randomised controlled trials and studies using methods designed to evaluate dynamic, multicomponent health systems are needed to evaluate whether prognostic factor-based exit from care results in better outcomes. The recommendation regarding the quantity of ready-to-use therapeutic food (RUTF) sufficient to achieve anthropometric recovery (B10) was based on evidence from three randomised controlled trials, all of which were conducted in the same geographical location. Since these findings may not be generalisable to other regions, this constitutes a critical area for future investigation to strengthen the certainty of the related recommendation.

Correspondence to Dr Allison I Daniel; adaniel@who.int Summary box In 2023, WHO released a guideline on prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years as part of the Global Action Plan on Child Wasting, a consolidated framework to accelerate progress in prevention and management of wasting and nutritional oedema. In accordance with WHO standards and methods for guideline development, the guideline involved a collaborative, transparent, decision-making process, based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.11 Potential conflicts of interest were managed on a case-by-case basis.12 There were 27 GDG members from all WHO regions with research, programmatic and clinical expertise across the four focus areas and with gender balance. [...]the guideline places strong emphasis on the prevention of wasting and nutritional oedema. Furthermore, this supplement includes a discussion of research and methods considerations for resource use and cost-effectiveness data around interventions for wasting and nutritional oedema.20 Resources required, certainty of evidence regarding resources required and cost-effectiveness are three domains in GRADE Evidence-to-Decision frameworks requiring GDG judgements which can influence the direction and strength of recommendations.21 We outline how research on resource use and cost-effectiveness should comply with health economic evaluation reporting standards and should present data with different costing perspectives.20 We also reflect on processes and methods for developing the 2023 WHO guideline.22 Because of the complexity of the guideline questions and a lack of direct evidence in some instances, we had to apply some innovative methods to develop certain recommendations, while upholding the key principles of best practice guideline development methods such as transparency.