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Severe acute malnutrition (SAM) constitutes a substantial burden in African hospitals. Despite adhering to international guidelines, high inpatient mortality rates persist and the underlying contributing factors remain poorly understood. We evaluated the 10-year trend (2011-2021) in clinical factors and outcomes among children with severe wasting and/or nutritional edema at Malawi's largest nutritional rehabilitation unit (NRU). This retrospective study analyzed trends in presentation and outcomes using generalized additive models. The association between clinical characteristics and mortality or readmission was examined and key features were also related to time to either mortality or discharge. 1497 children (53%, females) were included. Median age at admission (23 months, IQR 14, 34) or anthropometry (i.e., weight-for-age, height-for-age and weight-for-height) did not change over the 10-years. But the prevalence of edema decreased by 40% whereas dehydration, difficulty breathing, and pallor became more common. Yearly HIV testing increased but positive-detection remained around 11%. Reporting of complete vaccination dropped by 49%, and no reduction in 'watch' antibiotic usage was detected. Overall admissions declined but mortality remained around 23% [95%CI; 21, 25], and deaths occurred earlier (5.6 days [95%CI; 4.6, 6.9] in 2011 vs. 3.5 days [95%CI; 2.5, 4.7] in 2021; p<0.001). Duration of hospitalization was shortened and readmissions surged from 4.9% [95%CI; 3.3, 7.4] in 2011 to 25% [95%CI; 18, 33] in 2021 (p<0.001). Age, wasting, having both dehydration and diarrhea, or having vomiting, cough, or difficulty breathing were associated with mortality but these associations did not show any interaction over time. Over 10 years, mortality risk remained high among hospitalized children with SAM and coincided with worsened clinical presentation at admission and increased readmission. Longitudinal data from major NRUs can identify shifts in clinical profiles or outcomes, and this information can be leveraged to promote earlier care-seeking, improved risk stratification, and implementation of more patient-centered treatments.

Ready-to-use therapeutic foods (RUTFs) have successfully promoted recovery from severe wasting and increased treatment coverage. However, RUTFs do not sufficiently improve linear growth, leaving many survivors of severe wasting at risk of persistent stunting, which is associated with high mortality risk, poor child development and non-communicable diseases in adulthood. High protein quantity and quality can stimulate linear growth. The trial aims to assess whether higher-protein-RUTF leads to higher concentrations of markers of linear growth compared to standard RUTF among 6-23 months old children with severe wasting. We designed a higher protein quantity and quality RUTF for a proof-of-concept (PoC) double-blind randomized controlled trial. These findings will help in informing the potential impact of increased protein in RUTF on linear growth when treating severe wasting towards conducting a larger clinical trial.

IntroductionThe 2023 WHO guideline on the prevention and management of wasting and nutritional oedema includes recommendations informed by best evidence from systematic reviews addressing critical and important outcomes. Multiple outcomes across trials were a challenge during guideline development, highlighting a need to establish core outcome sets (COS) for wasting and nutritional oedema. Informed by Core Outcome Measures in Effectiveness Trials (COMET) Initiative best practice methods, we aimed to develop six COS for effectiveness trials around prevention and management of wasting and nutritional oedema in infants and children.MethodsGuideline Development Group and UNICEF/WHO Technical Advisory Group on Wasting and Nutritional Oedema members were invited to participate in a Delphi process to establish these COS. This involved scoring outcomes in two rounds of a survey (Likert scale from 1 to 9), with consensus in the second round defined as a minimum of 70% of the expert panel giving a score of at least 7 and <15% scoring 3 or below.ResultsTwenty-five of 36 invited participants completed each survey, followed by multiple consensus meetings to reach agreement on the outcomes. Through this Delphi process, we developed six COS for infants <6 months of age with wasting and/or nutritional oedema and/or underweight in (1) inpatient and (2) outpatient/community settings, infants and children 6–59 months of age with severe wasting and/or nutritional oedema in (3) inpatient and (4) outpatient/community settings, infants and children 6–59 months of age with moderate wasting in (5) outpatient/community settings and (6) prevention of wasting and nutritional oedema.ConclusionPrimary research, future guidelines and related decision-making stand to be strengthened by these six COS, including the most critical outcomes from a child health perspective to be evaluated in future effectiveness trials on wasting and nutritional oedema. Uptake of these COS will inform their further development.

The 2023 WHO guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years has a broad scope aligned with WHO’s responsibility to develop a comprehensive guideline as part of the Global Action Plan on Child Wasting. A WHO technical team consisting of the WHO Steering Committee for this guideline, supported by a consultant and two independent methodologists, coordinated guideline development according to WHO’s standards and methods. The guideline contains 21 recommendations and 12 good practice statements on prevention and management across four focus areas. As can be expected from a broad guideline covering many new areas, we faced complexities. As a technical team involved throughout the 3-year process, we reflected on the challenges and our experiences in addressing these. In this paper, we summarise selected elements of processes and methods and our key reflections and learnings relevant to three challenging areas that may be useful to other guideline developers and groups addressing complex needs across contexts. Key reflections included (1) implementing comprehensive and systematic prioritisation was time well spent, allowing the most pressing guidance gaps to be addressed first, while also identifying possible future gaps; (2) evidence syntheses and evidence-to-decision approaches for broad and composite guideline questions required careful planning and coordination, which helped streamline Guideline Development Group discussions and consensus during decision-making and (3) putting steps in place aimed at ensuring consistency and rigour across multiple questions, reviews and meetings improved transparent and systematic guideline development processes.

Children with severe acute malnutrition (SAM) remain vulnerable after treatment at nutritional rehabilitation units (NRUs). The objective was to assess the concurrent pathways in a hypothesized model between caregiver body mass index (BMI), the home environment, and child nutritional status, and development (gross motor, fine motor, language, and social domains) in children with SAM following discharge from inpatient treatment. Structural equation modelling (SEM) was performed with data from a cluster-randomized controlled trial at the Moyo Nutritional Rehabilitation and Research Unit in Blantyre, Malawi. This approach was undertaken to explore simultaneous relationships between caregiver BMI, the home environment (Home Observation for Measurement of the Environment Inventory scores), child nutritional status (anthropometric indicators including weight-for-age z-scores [WAZ]), and child development (Malawi Developmental Assessment Tool (MDAT) z-scores as a latent variable) in children with SAM. These data were collected at participants’ homes six months after discharge from NRU treatment. This analysis included 85 children aged 6–59 months with SAM and their caregivers recruited to the trial at the NRU and followed up successfully six months after discharge. The model with WAZ as the nutritional indicator fit the data according to model fit indices (χ 2 = 28.92, p = 0.42). Caregiver BMI was predictive of better home environment scores (β = 0.23, p = 0.03) and child WAZ (β = 0.30, p = 0.005). The home environment scores were positively correlated with MDAT z-scores (β = 0.32, p = 0.001). Child nutritional status based on WAZ was also correlated with MDAT z-scores (β = 0.37, p<0.001). This study demonstrates that caregiver BMI could ultimately relate to child development in children with SAM, through its links to the home environment and child nutritional status.

DALYs: DALYs attributed to a specific disease or health condition are calculated by adding together the years of life lost due to early death and the years spent living with a disability because of the prevalence of the disease or condition in a population. amore information can be found here16 Suggestions for reporting of resource use and cost-effectiveness Resource use and CE analyses can quickly become very complex, involving various types of costs and health and associated benefits, such as long-term economic productivity estimated using either detailed micro-economic methods (‘bottom-up’ or detailed data collection of all costs incurred) or through gross-costing (‘top-down’ estimation of costs). CE studies on interventions to prevent wasting should not limit the assessment of costs to those for preventing new cases of wasting but should ideally also include the effect on the caseload and potential cost savings for existing wasting treatment services.9 A cost–benefit analysis can further compare prevention costs to treatment cost savings within a given context. [...]based on our observations, studies should describe the standard of care (comparator group) and the associated costs in sufficient detail to allow for a CEA. Comparing the costs for beneficiaries who received the intervention to per-protocol effectiveness results is possible; however, this analysis may be prone to selection bias.10 Caution should be exercised when simulation studies or meta-analyses combine data from effectiveness and efficacy studies.

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.

Introduction More than two-thirds of wasted children worldwide have moderate wasting, accounting for no less than 30 million children at any given time in 2024, most of whom reside in South Asia, SouthEast Asia and sub-Saharan Africa.1 This population of infants and children 6–59 months old is defined by having a mid-upper-arm circumference (a measure of lean body mass) between 115 and less than 125 mm and/or a weight-for-height between 2 and 3 SDs below the median defined by the 2006 WHO Child Growth Standards.2 While those with moderate wasting have a significantly lower mortality rate than those with severe wasting or nutritional oedema, their much larger population means that they still account for approximately 30%–40% of the deaths due to wasting.3 The spectrum of care for moderately wasted children has varied widely across varying contexts, ranging from only counselling about healthy diets and medical care to dietary supplementation with specially formulated foods (SFFs) for all moderately wasted children. Guidelines for moderate wasting must balance financial and human resource costs, commodity costs, complete community coverage, competing health priorities including the management of severe wasting and the potential negative consequences of universal supplementation with SFF. The 2023 WHO guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years10 includes the first comprehensive recommendations and good practice statements (GPSs) for moderate wasting developed systematically using WHO standards and methods, based on the Grading of Recommendations, Assessment, Development and Evaluations approach.11 The guideline as a whole takes a broad view of wasting as a continuum and many of the recommendations and GPSs reasonably apply to all children with wasting.12 The guideline questions that were prioritised by the Guideline Development Group (GDG) for moderate wasting primarily focused on dietary management, with four recommendations ultimately made by the GDG around the use of SFFs for some children with moderate wasting. Table 1 Overview of recommendations and good practice statements (GPS) for infants and children 6–59 months of age with moderate wasting Recommendation or GPS number Subject Strength Certainty B6 Classification of hydration status N/A (GPS) B8 Use of ORS for rehydration Conditional Very low B11 Nutrient-dense diets for recovery and normal growth N/A (GPS) B12 Comprehensive assessment for predisposing medical and psychosocial problems N/A (GPS) B13 Individual child and social factors for prioritisation of SFFs Strong Moderate B14 Contextual factors for prioritisation of SFFs Strong Moderate B15 Preferred types of SFFs to be provided Conditional Low B16 Quantity of SFFs to be provided Conditional Very low B17 Identification and management by community health workers Conditional Very low C1 Post-exit interventions for caregivers N/A (GPS) C2 Psychosocial stimulation for children after exit from care Conditional Low GPS, good practice statement; N/A, not applicable; ORS, oral rehydration solution; SFFs, specially formulated foods.

Programme design, including targeting criteria, should consider available resources and the capacity of health, food, water, sanitation and hygiene, and social protection systems to support wasting prevention. INTRODUCTION Globally, an estimated 42.8 million children (6.6% prevalence) worldwide suffered from wasting at any given time in 2024, with severe cases accounting for 20% of deaths among children under 5 years old.1 2 Ongoing crises—including armed conflicts, food price volatility, economic instability, climate change and aid funding cuts—are expected to intensify wasting-related deaths, as poverty and food insecurity deepen.3 4 As a result, preventing child wasting is more urgent than ever. The GDG also advised against the use of micronutrient powders (MNPs) for wasting prevention and formulated two good practice statements described in the evidence gaps section below.6 The GDG reviewed evidence for several other types of interventions identified in an effectiveness systematic review focused on wasting prevention.7 No recommendations were made, however, for reasons such as limited certainty in the evidence, a lack of cost-effectiveness data and unknown impacts on equity.8 EVIDENCE GAPS In this commentary, we bring the perspectives of some of the GDG members, methodologists and WHO Steering Committee members involved in the 2023 WHO guideline, and highlight three critical evidence gaps that hinder effective wasting prevention: (1) limited evidence on the effectiveness of wasting prevention interventions, (2) poor understanding of the challenges in implementing wasting prevention programmes and (3) the absence of effective criteria for targeting wasting prevention. Despite this, the supplements (SQ-LNS) and the recommended dose were largely comparable, allowing meta-analyses to assess differential impacts by study, household and individual characteristics.9 The UN Global Action Plan on Child Wasting10 recommends multisectoral programmes that integrate actions from health, food, water, sanitation and hygiene (WASH), and social protection sectors to address the multifaceted drivers of wasting.

Introduction Over 10 million infants under 6 months of age worldwide are at risk of poor growth and development (henceforth ‘infants u6m’).1 Risks include short-term mortality and non-communicable disease in later life for survivors.2 Affected infants are especially vulnerable to all of these risks across the lifespan.3 The 2023 WHO guideline on the prevention and management of wasting and nutritional oedema represents major advances for this group.4 The 2013 guideline5 focused on infants u6m with severe wasting (low weight-for-length) and/or nutritional oedema, but the 2023 version addresses a broader population of concern including infants with: underweight (low weight-for-age); low mid-upper arm circumference (MUAC); poor growth; or underlying vulnerabilities (box 1).4 The interdependent maternal-infant dyad is now emphasised, as are interventions combining treatment and prevention roles. Source: abridged from 2023 WHO guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years Table 1 Overview of recommendations and GPSs for infants less than 6 months of age at risk of poor growth and development Recommendation or GPS number Subject Strength Certainty A1 Regular care and monitoring of mothers/caregivers and their infants N/A (GPS) A2 Criteria for admission for inpatient care, in-depth assessment or enrolment to outpatient care Conditional Low A3 Criteria for transfer from inpatient to outpatient care Strong Moderate A4 Frequency of outpatient visits and final review at 6 months of age Conditional Very low A5 Comprehensive assessment of the mother/infant pair and resolution of breastfeeding/lactation challenges N/A (GPS) A6 Decisions about supplementary milk in addition to breastfeeding N/A (GPS) A7 Breastfeeding and supplementary milks, specifically for infants less than 6 months with severe wasting and/or nutritional oedema who are admitted for inpatient care Strong Very low A8 Comprehensive assessment and support of mothers/caregivers N/A (GPS) Source: 2023 WHO guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years GPS, good practice statement; N/A, not applicable. Caseload and cost implications of the expanded weight-for-age and MUAC criteria—which will also depend on the exact intervention being applied; Which criteria (anthropometric and other) best identify infants at highest mortality/morbidity risk, and implications for subsequent management; The added value and logistical/time implications of keeping weight-for-length as an essential programme enrolment criterion; and The most effective methods and/or tools to assess breastfeeding, underlying disability and clinical admission criteria. [...]researchers should examine how staff and systems factors affect the success of breastfeeding assessment and support.