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This paper uses intersectionality to understand how race, gender, and class oppression have influenced the passing of key child welfare policies and precipitated the overrepresentation of Black chil dren in the child welfare system who are low-income. Critical discourse analysis is used to analyze relevant legislation. Results indicate that discussions related to welfare eligibility and the redefinition of poverty as neglect precipitated disproportionate representation. Using intersectionality is essential to understanding the interlocking oppressions that women, children, and families of color face within the child welfare system.

Somalia has been affected by conflict since 1991, with children aged <5 years presenting a high acute malnutrition prevalence. Cash-based interventions (CBIs) have been used in this context since 2011, despite sparse evidence of their nutritional impact. We aimed to understand whether a CBI would reduce acute malnutrition and its risk factors. We implemented a non-randomised cluster trial in internally displaced person (IDP) camps, located in peri-urban Mogadishu, Somalia. Within 10 IDP camps (henceforth clusters) selected using a humanitarian vulnerability assessment, all households were targeted for the CBI. Ten additional clusters located adjacent to the intervention clusters were selected as controls. The CBI comprised a monthly unconditional cash transfer of US$84.00 for 5 months, a once-only distribution of a non-food-items kit, and the provision of piped water free of charge. The cash transfers started in May 2016. Cash recipients were female household representatives. In March and September 2016, from a cohort of randomly selected households in the intervention (n = 111) and control (n = 117) arms (household cohort), we collected household and individual level data from children aged 6-59 months (155 in the intervention and 177 in the control arms) and their mothers/primary carers, to measure known malnutrition risk factors. In addition, between June and November 2016, data to assess acute malnutrition incidence were collected monthly from a cohort of children aged 6-59 months, exhaustively sampled from the intervention (n = 759) and control (n = 1,379) arms (child cohort). Primary outcomes were the mean Child Dietary Diversity Score in the household cohort and the incidence of first episode of acute malnutrition in the child cohort, defined by a mid-upper arm circumference < 12.5 cm and/or oedema. Analyses were by intention-to-treat. For the household cohort we assessed differences-in-differences, for the child cohort we used Cox proportional hazards ratios. In the household cohort, the CBI appeared to increase the Child Dietary Diversity Score by 0.53 (95% CI 0.01; 1.05). In the child cohort, the acute malnutrition incidence rate (cases/100 child-months) was 0.77 (95% CI 0.70; 1.21) and 0.92 (95% CI 0.53; 1.14) in intervention and control arms, respectively. The CBI did not appear to reduce the risk of acute malnutrition: unadjusted hazard ratio 0.83 (95% CI 0.48; 1.42) and hazard ratio adjusted for age and sex 0.94 (95% CI 0.51; 1.74). The CBI appeared to increase the monthly household expenditure by US$29.60 (95% CI 3.51; 55.68), increase the household Food Consumption Score by 14.8 (95% CI 4.83; 24.8), and decrease the Reduced Coping Strategies Index by 11.6 (95% CI 17.5; 5.96). The study limitations were as follows: the study was not randomised, insecurity in the field limited the household cohort sample size and collection of other anthropometric measurements in the child cohort, the humanitarian vulnerability assessment data used to allocate the intervention were not available for analysis, food market data were not available to aid results interpretation, and the malnutrition incidence observed was lower than expected. The CBI appeared to improve beneficiaries' wealth and food security but did not appear to reduce acute malnutrition risk in IDP camp children. Further studies are needed to assess whether changing this intervention, e.g., including specific nutritious foods or social and behaviour change communication, would improve its nutritional impact. ISRCTN Registy ISRCTN29521514.

A long-standing belief in the value of independence has led to an emphasis on self-sufficiency in our programming, policy, and practice responses toward youth aging out of the foster care system— an ideal that often is difficult for young people to achieve. However, a growing body of research on interdependence suggests that healthy connections to trusted adults may better help youth navigate the transition to adulthood. Semi-structured interviews conducted with 20 youth explored conceptualizations of independence in the context of emancipation. Using thematic content analysis, themes indicate contradictory and deterministic ideas about self-sufficiency and adulthood. Findings imply tensions between independence and a developmentally normative need for interdependence during the period of emerging adulthood.

A long-standing belief in the value of independence has led to an emphasis on self-sufficiency in our programming, policy, and practice responses toward youth aging out of the foster care system--an ideal that often is difficult for young people to achieve. However, a growing body of research on interdependence suggests that healthy connections to trusted adults may better help youth navigate the transition to adulthood. Semi-structured interviews conducted with 20 youth explored conceptualizations of independence in the context of emancipation. Using thematic content analysis, themes indicate contradictory and deterministic ideas about self-sufficiency and adulthood. Findings imply tensions between independence and a developmentally normative need for interdependence during the period of emerging adulthood.

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.

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.

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.

The 2010 earthquake in Haiti displaced about 1.5 million people, many of them into camps for internally displaced persons. It was expected that disruption of breastfeeding practices would lead to increased infant morbidity, malnutrition and mortality. Haiti's health ministry and the United Nations Children's Fund, in collaboration with local and international nongovernmental organizations, established baby tents in the areas affected by the earthquake. The tents provided a safe place for mothers to breastfeed and for non-breastfed infants to receive ready-to-use infant formula. Such a large and coordinated baby tent response in an emergency context had never been mounted before anywhere in the world. Baby tents were set up in five cities but mainly in Port-au-Prince, where the majority of Haiti's 1555 camps for displaced persons had been established. Between February 2010 and June 2012, 193 baby tents were set up; 180 499 mother-infant pairs and 52 503 pregnant women were registered in the baby tent programme. Of infants younger than 6 months, 70% were reported to be exclusively breastfed and 10% of the \"mixed feeders\" moved to exclusive breastfeeding while enrolled. In 2010, 13.5% of registered infants could not be breastfed. These infants received ready-to-use infant formula. Thanks to rapid programme scale-up, breastfeeding practices remained undisrupted. However, better evaluation methods and comprehensive guidance on the implementation and monitoring of baby tents are needed for future emergencies, along with a clear strategy for transitioning baby tent activities into facility and community programmes.