Methods of search:

A comprehensive search for guidelines was undertaken to identify the most relevant guidelines toconsider for adaptation. Using keywords: Management, nutritional edema, wasting, and children under 5 years.

Inclusion / exclusion criteria followed in the search and retrieval of guidelines to be adapted:

• Selecting only evidence-based guidelines (guideline must include a report on systematic literature

searches and explicit links between individual recommendations and their supporting evidence)

• Selecting only national and/or international guidelines

• Specific range of dates for publication (using Guidelines published or updated 2013 and later)

• Selecting peer reviewed publications only

• Selecting guidelines written in English language

• Excluding guidelines written by a single author not on behalf of an organization to be valid andcomprehensive, a guideline ideally requires multidisciplinary input.

• Excluding guidelines published without references as the panel needs to know whether a thoroughliterature review was conducted and whether current evidence was used in the preparation of therecommendations.

All retrieved Guidelines were screened and appraised using AGREE II instrument (www.agreetrust.org) by at least two members. The panel decided a cut-off point or rank the guidelines (any guideline scoring above 60% on the rigor dimension was retained)

After reviewing all the previous criteria the GDG & methodologists recommended using 2 guidelines:

1- WHO guideline updates on the management of severe acute malnutrition in infants and children

(2013)

2- WHO guideline on the prevention and management of wasting and nutritional edema (acute

malnutrition) in infants and children under 5 years (2023)

We did Adolopment for these guidelines: (Adoption, Adaptation, and Development)

         -          Adoption for most of the guideline recommendations.

         -          Adaptation for 2 recommendation according to GRADE criteria to be suitable to our Economic implications (Evidence to Decision (EtD) table was done)

         -          Development of Good Practice Statement

Contributors to the guideline development process:

Guideline Development Group (GDG):

The GDG for the guideline on prevention and management of wasting and nutritional oedema (acute

malnutrition) included experts with a range of technical skills and diverse perspectives in the field of clinical nutrition.

The main functions of the GDG were adolopment of WHO guidelines for wasting and undernutrition (2013& 2023), determining the scope of the guideline and guideline, reviewing the evidence, and formulatingevidence-informed recommendations in case of changing strength of recommendations.

Guideline Methodologists:

There were 6 guideline methodologists with expertise in guidelines development, GRADE and translationof evidence into recommendations. Methodologists provided orientation and overview of evidence-informed guideline development processes using the GRADE approach & also, provided AGREE IIassessment of the source guidelines in conjunction with CDG..

External Review Group:

The External Review Group for this guideline comprises 3 clinical experts who have interest and

expertise in the prevention and treatment of wasting and/or nutritional oedema in infants and children as well as representative of WHO and UNICEF Organizations.They were identified by Egyptian Pediatric Clinical Practice Guidelines Committee (EPG) as people whocan provide valuable insights during the guideline development process.

The External Review Group was asked to comment on (peer review) the final guideline to identify any criticism on the content and to comment on clarity and applicability as well as issues relating to implementation, dissemination,ethics, regulations, or monitoring, but not to change the recommendations formulated by the GDG. Themembers of the External Review Group were required to submit declarations of interest before the peerreview process.

Guideline Development Group meetings:

GDG meetings were organized virtually twice weekly. Due to the extensive scope of

the guideline, EPG Chair was responsible for the timetable and objectives of each meeting. GDG meetingswere also attended by members of the methodologists and systematic. Working rules for each contributor type were outlined by the chair at the start of eachmeeting, covering aspects such as vocal rights, voting, and evidence to decision and recommendationformulating processes.

Declarations of interests:

Prospective members of the GDG were asked to fill in and sign the standard WHO declaration of interestand confidentiality undertaking forms. All guideline members and methodologists were also asked to fillin and sign the standard WHO declaration-of-interests.

Members of the external review group will be asked to fill in and sign the standard WHO declaration-

of-interests form before the peer review process.

Evidence for the guideline:

We used the GRADE system (Grading of Recommendations, Assessment, Development and Evaluation) for assigning the quality of evidence and strength of recommendations that includes the following definitions [13]. Informed by the evidence required for the GRADE Evidence to Decision (EtD) table was done while considering changingstrength of recommendations according to availability of some resources in the recommendations (we didthis for only 2 recommendations).

Description of the interpretation of the GRADE four levels of certainty of evidence:

Table 1. Classification of the Quality of Evidence

High	We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate	We are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low	Our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.
Very Low	We have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of the effect.

 

GRADE EtD criteria and considerations that link to the strength of recommendations:

Criteria Considerations:

Benefits and harms: When a new recommendation is developed, desirable effects (benefits) need to be weighedagainst undesirable effects (risks/harms), considering any previous recommendation or

another alternative. The larger the gap or gradient in favor of the desirable effects over the

undesirable effects, the more likely that a strong recommendation will be made.

Certainty of theevidence about the effects: The higher the certainty of the scientific evidence base, the more likely that a strong will be made.

Values andpreferences: If there is no important uncertainty or variability in how much people value the mainoutcomes, it is likely that a strong recommendation will be made. Uncertainty or variability

around these values that could likely lead to different decisions, is more likely to lead to a

conditional recommendation.

Economicimplications: Lower costs (monetary, infrastructure, equipment or human resources) or greater cost-effectiveness are more likely to support a strong recommendation.

Equity and humanrights: If an intervention will reduce inequities, improve equity or contribute to the realization ofhuman rights, the greater the likelihood of a strong recommendation.

Feasibility: The greater the feasibility of an intervention to all stakeholders, the greater the likelihood ofa strong recommendation.

Acceptability: If a recommendation is widely supported by health workers and program managers andthere is widespread acceptance for implementation within the health service, the likelihood

of a strong recommendation is greater.

Table 2. Classification of the Strengths of Recommendations

Strong	The desirable effects of an intervention clearly outweigh the undesirable effects (or vice versa), so most patients should receive the recommended course of action.
	There is uncertainty about the trade-offs. The clinician and patient need to discuss the patient's values and preferences, and the decision should be individualized.

 

Developing good practice statements:

The GDG also developed good practice statements for this guideline, which are actionable messages relevant to theguideline questions. The justification for each good practice statement was carefully considered by the GDG with anemphasis that they are clearly needed. Good practice statements were developed, guided by the following GRADEcriteria:

1- Message is really necessary with regard to actual healthcare practice

2- Have large net positive consequence (relevant outcomes and downstream consequences) (GRADE EtDdomains)

3- Collecting and summarizing the evidence is a poor use of time and resources

4- Include a well-documented, clear rationale connecting indirect evidence

5- Are clear and actionable statements.

The GDG collectively drafted and finalized good practice statements with relevant justifications and remarks to helpwith their interpretation, with close support and input from the consultant and guideline methodologists.