Undernourished children have weakened immunity and impaired cognitive function, which leads to their poor health outcomes, loss of future productivity, and low academic performance, [1] extrahealthcare expenditures and opportunity costs related to the care of sick children [2]. Consequently, under- nutrition is responsible for almost half (45%) of all deaths in under 5 children worldwide. Annually, 8 million deaths are anticipated to be caused by wasting, with severe wasting responsible for 60% of these deaths in low‐ and middle‐income countries [3].

According to the Joint Child Malnutrition Estimates, 45 million infants and children under 5 experienced wasting in 2022; an estimated 13.7 million infants and children under 5 had severe wasting and the remainder had moderate wasting [4]. The risk of wasting and nutritional edema in infants and children, particularly in high-risk contexts where health and socioeconomic indicators are at their poorest [5].

The Egyptian Demographic and Health Survey of (EDHS) 2014 revealed the prevalence of wasting among under-5 children to be 8.4% (up from the reported 7.2% in the 2008 DHS) with 3.8% having severe wasting [6]. Despite that the national prevalence of wasting in under 5 children is 3% in 2021, there is higher prevalence in some Egyptian governorates, as South Sinai 15.9%, Aswan 14.1%, Suez 10.7%, Luxor 8.8%, Qalioubiya 6.8%, Cairo 5.4%, Giza 4.8% and Assuit 4.5% [7].

During the early years of life nutrition is fundamental for child health and development [8]. The World Health Organization (WHO) recommends breastfeeding initiation within an hour of birth, exclusive breastfeeding for the first 6 months of life and breastfeeding continuation thereafter [9]. Egypt’s 2014 Demographic and Health Survey (EDHS) reported that 27% of mothers-initiated breastfeeding early (IBF) during the first hour after delivery and that only 13% were exclusively breastfeeding their child (EBF) until the age of four or five months, which is almost a 50% decline from the 2008 rates [6].Breastfeeding difficulties are of the main cofactors for the high prevalence of malnutrition.Egypt Family Health Survey 2021 reported that IBF during the first hour after delivery rise a little to 32.8% and 20.7% exclusive breastfeeding for 4-5 months of age [7].This is simple practical guideline for healthcare professionals to manage the emergency situation of refugees that are crossing from different borders of the country.   

Identification of acutely malnourished children is thus a priority for timely treatment and ultimately to avoid child illness and death.   

This guideline is intended to help and improve the health situation in Egypt in a trial to cope with the global goal to reduce wasting prevalence in high prevalence governorates to 5% by 2025 and 3% by 2030 [10,11]

➡️Purpose&Scope

These guidelines have been developed to standardize the delivery of services and to implement the guidance on the prevention, diagnosis and management of wasting and nutritional edema in infants and children less than 5 years. It provides guidance to primary health care providers, pediatricians and specially trained nurses.

The guidelines aimed to improve early case detection and referral, case management of mild, moderate and severe malnutrition. As a sequence,there will bean improvementin the physical & mental health which is usually reflected on scholastic performance & productivity with decrease the health care cost.

This version of the guideline includes recommendations and good practice statements for infants less than 6 months of age at risk of poor growth and development (within which infants with wasting and/or nutritional edema are a subset); moderate and severe wasting in infants and children 6-59 months of age and prevention of wasting.

▪️ Management of infants less than 6 months of age at risk of poor growth and development

Infants at risk of poor growth and development should include infants less than 6 months of age in any of the following categories with any of the following criteria:

✔️  Infants with poor growth based on sequential measures

• No weight gain or weight loss from one measurement to the next; or

• Downward crossing of weight-for-age centile lines; or

• Insufficient weight gain (velocity standards or grams/per specific time period).

✔️  Infants with poor anthropometry based on a single measure (if sequential measures not available)

• Weight-for-age z-score (WAZ) < -2 SD; or

• Weight-for-length z-score (WLZ) < -2 SD; or

• Nutritional edema; or

• Mid-upper arm circumference (MUAC) < 110 mm for infants between 6 weeks to less than 6 months of age.

✔️  Infants with known risk factors for poor growth and development

• Neurodevelopmental concerns; or

• Infant feeding concerns; or

• Maternal risk (physical or mental health problem(s) affecting caring practices); or

• History of hospitalization.

✔️  Infants at risk due to poor birth outcomes

• Preterm birth; or

• Low birth weight; or

• Small for gestational age.

Acute malnutrition in children under 5 years of age is defined in this guideline as having a weight-for-height or weight-for-length z-score more than 2 SD below the median of the WHO child growth standards (WHZ or WLZ < -2) or having nutritional edema. A MUAC less than 125mm can be used as an alternative measure to define acute malnutrition alongside weight-for-height and nutritional edema.

Nutritional edema is bilateral pitting edema which starts in the feet and can progress up to the legs and the rest of the body, including the face. It is pathognomonicof severe acute malnutrition. Clinical assessments for undernutrition should include an assessment for nutritional edema. Acute malnutrition may be further sub-classified to:

• Moderate wasting in infants and children 6-59 months of age

Weight-for-height or weight-length z-score greater than or equal to 3 and less than 2 SD below the WHO child growth standards median (WHZ or WLZ ≥-3 and <-2 SD) (or MUAC ≥115mm to <125mm as an alternative field measure).

• Severe wasting and nutritional edema in infants and children 6-59 months of age

Weight-for-height or weight-for-length z-score greater than 3 SD below the WHO child growth standards median (WHZ or WLZ <-3 SD) (or mid-upper arm circumference (MUAC) <115mm as an alternative field measure) and/or nutritional edema.

• Prevention of wasting and nutritional edema

It includes recommendation and good practice statements about individual and community approaches for prevention of wasting and nutritional edema. These approaches may differ greatly by setting, context, and other factors.