Table 3. Recommendations

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

N

Health questions

Source Guideline

Recommendations (Quality of evidence, Strength of Recommendation)

A1

Interventions for mothers/caregivers of infants at risk of poor growth and development

In mothers/caregivers of infants less than 6 months at risk of poor growth and development, What interventions can guarantee the best health outcome for both of them?

GDG

Good practice statement

A1. Mother/caregiver and infant should be considered as inter- dependent pair.

They should receive regular care and monitoring by health professionals in the form of: 

1. Medical and anthropometric assessment for Infants less than 6 months of age at risk of poor growth and development to

 a. Achieve early detection of any acute medical problems and appropriate intervention, and

b. Enable these infants to grow and develop in a healthy way 2. Maternal/caregiver Comprehensive assessment and support are recommended to ensure maternal/caregiver physical and mental health and well-being

Admission, referral, transfer, and exit criteria for infants at risk of poor growth and development.

A2

a) In infants less than 6 months at risk of poor growth and development, what are the criteria that best inform the decision for referral to treatment in an inpatient setting?

b) In infants less than 6 months at risk of poor growth and development, what are the criteria that best inform the decision for an in-depth assessment to consider if they need inpatient admission or outpatient management?

c) In infants less than 6 months at risk of poor growth and development, what are the criteria that best inform the decision to initiate treatment in an outpatient/community setting?

WHO 2023

Conditional recommendation, Low certainty evidence

A2. a) Infants less than 6 months of age at risk of poor growth and development who have any of the following characteristics should be referred and admitted for inpatient care:

i. one or more Integrated Management of Childhood Illness (IMCI) danger signs**

ii. acute medical problems or conditions under severe classification as per IMCI***

iii. edema (nutritional)

iv. recent weight loss.

b) Infants less than 6 months of age at risk of poor growth and development who do not meet any of the criteria from part a should have an in-depth assessment to consider if they need inpatient admission or outpatient management based on clinical judgement if they have any of the following characteristics:****

1. medical problems that do not need immediate inpatient care, but do need further examination and investigation (e.g. HIV-related complications);
2. medical problems needing mid or long-term follow-up care and with a significant association with nutritional status (e.g. congenital heart disease, HIV, tuberculosis, cerebral palsy or other physical disabilities);
3. specific anthropometric criteria from the list of criteria used to identify infants at risk of poor growth and development: WAZ <-2 SD, WLZ <-3 SD, MUAC <110mm for infants less than 6 months of age, failure to gain weight based on two consecutive measurements.
4. ineffective breastfeeding (e.g. attachment, positioning, suckling reflex) or perceived breastmilk insufficiency.
5. feeding concerns for non-breastfed infants (e.g. inappropriate and unsafe use of breastmilk substitutes for replacement feeding, milk refusal);
6. any maternal-related or social issue needing more detailed assessment or intensive support (e.g. disability, depression of the caregiver, absent mother, adolescent mother, or other adverse social circumstances).

c) Infants less than 6 months of age at risk of poor growth and development who have all the following characteristics should be enrolled and managed as outpatients:

i. no danger signs or/ any of the criteria from (part a) needing inpatient admission.

ii. no criteria needing in-depth assessment (part b) or when criteria from part b are present but an in-depth assessment has been completed and determined that no inpatient admission is needed (Feeding problems that can be managed in outpatient care, diarrhea with no dehydration, respiratory infections with no signs of respiratory distress, malaria with no signs of severity)

A3

 In infants less than 6 months at risk of poor growth and development admitted for inpatient treatment, what are the criteria that best inform the decision for transfer to outpatient/community treatment?

WHO 2023

Strong recommendation for, Moderate certainty evidence

A3. Infants less than 6 months of age at risk of poor growth and development who are admitted for inpatient care can be transferred to outpatient care when:

1. there have been no danger signs for at least 48 hours prior to transfer time; and
2. all acute medical problems are resolved; and
3. nutritional edema is resolving; and
4. the infant has good appetite; and
5. documented weight gain for at least 2-3 days is satisfactory on either exclusive breastfeeding or replacement feeding; and
6. refer the infants with medical problems needing mid or long-term follow-up care and with a significant association with nutritional status to appropriate care/support services and/or the limits of inpatient care have been reached; and
7. the infant has been checked for immunizations and other routine interventions delivered or plans made for follow-up; and
8. the mothers/caregivers are linked with needed follow-up care and support (e.g. for any health, mental health or social issues identified during assessment).

A4

In infants less than 6 months at risk of poor growth and development receiving outpatient/community treatment, what are the criteria that best inform the decision for exit from outpatient/community treatment?

WHO 2023

Conditional recommendation for, Very low certainty evidence

A4. a) Infants less than 6 months of age at risk of poor growth and development can have a reduced frequency of outpatient visits when they:

i. are breastfeeding effectively or feeding well with replacement feeds, and

ii. have sustained weight gain^# for at least 2 consecutive weekly visits.

b) Infants less than 6 months of age at risk of poor growth and development should be assessed (including assessment of their anthropometry) once they reach 6 months of age to determine if they need

i. An ongoing follow-up or

ii. A referral to services for infants 6 months of age and older (including nutritional treatment/supplementation) as appropriate according to their clinical and nutritional status##

A5

Management of breastfeeding/lactation difficulties in mothers/caregivers of infants at risk of poor growth and development
In mothers/caregivers of infants less than 6 months at risk of poor growth and development who are experiencing difficulties with breastmilk intake, which interventions to manage difficulties with breastfeeding/lactation can improve breastfeeding practices and increase breastmilk intake?

WHO 2023

Good practice statement

A5. For infants less than 6 months of age at risk of poor growth and development, health care providers should conduct comprehensive assessments of the mother/caregiver-infant pair and follow best practices for the management of breastfeeding/lactation challengesand underlying factors contributing to these challenges. Preferably by lactation consultant

A6

Supplemental milk for infants at risk of poor growth and development

In infants less than 6 months at risk of poor growth and development, which criteria best determine if an infant should be given a supplemental milk (in addition to breastmilk if the infant is breastfed) and when?

WHO 2023

Good practice statement

A6. Decisions about whether an infant less than 6 months of age at risk of poor growth and development needs a supplementary milk in addition to breastfeeding must be based on

i. A Comprehensive assessmentof themedical, nutritional/ feeding needs⁺of the infant as well as,

ii. The physical and mental health of the mother/caregiver.

This applies to infants who are enrolled in outpatient care or admitted into inpatient care.

A7

In infants less than 6 months of age with severe wasting and/or nutritional edema, what is the most effective supplemental milk (donor human milk, human milk from wet nurse, commercial infant formula, F-75, F-100, or diluted F-100) and for how long should these be given?

WHO 2023

Strong recommendation for, very low certainty evidence

A7. Infants who are less than 6 months of age with severe wasting and/or nutritional edema who are admitted for inpatient care:

a) should be breastfed where possible and the mothers or female caregivers should be supported to breastfeed the infants. If an infant is not breastfed, support should be given to the mother or female caregiver to re-lactate. If this is not possible, wet nursing should be encouraged.

b) should also be provided a supplementary feed:

- supplementary suckling approaches should, where feasible, be prioritized.

- for infants with severe wasting but no edema, expressed breast milk should be given, and, where this is not possible, commercial (generic) infant formula or F-75 or diluted F-100⁺⁺may be given, either alone or as the supplementary feed together with breast milk.

- for infants with edema, commercial (generic) infant formula or F-75 should be given as a supplement to breast milk.

-c) should not be given full-strength F-100⁺⁺if they are clinically unstable less 6 month and/or have diarrhea or dehydration and/or nutritional edema

-d) should, if there is no realistic prospect of being breastfed, be given appropriate and adequate replacement feeds such as commercial (generic) infant formula, with relevant support to enable safe preparation and use, including at home when transferred from inpatient care.

A8

Antibiotics for infants at risk of poor growth and development

In infants less than 6 months at risk of poor growth and development, should an antibiotic be routinely given?

WHO 2013

Strong recommendation against, Low certainty evidence

A8. Children who are undernourished but who do not have severe wasting and/or nutritional edema should not routinely receive antibiotics unless they show signs of clinical infection.

Table 4. Recommendations

B. Management of infants and children 6-59 months with wasting and/or nutritional edema

N

Health questions

Source Guideline

Recommendations (Quality of evidence, Strength of Recommendation)

B1

Admission, referral, transfer and exit criteria for infants and children with severe wasting and/or nutritional edema.

B1. In emergency health setting how to pick up infants and children 6-59 months old with severe wasting and/or nutritional edema

GDG

Good practice statement

B1. Identification of nutritional status should be a vital component of initial assessment to pick up infants and children 6-59 months old with severe wasting and/or nutritional edema with emergency or danger signs receive immediate intervention. Others receive appropriate care as per their clinical status and classification

B2

a) In infants and children 6-59 months with wasting and/or nutritional edema, what are the criteria that best inform the decision for referral to treatment in an inpatient setting for wasting and/or nutritional edema?

b) In infants and children 6-59 months, what are the criteria that best inform the decision for in depth assessment?

c) In infants and children 6-59 months, what are the criteria that best inform the decision to initiate treatment in an outpatient/ community setting for wasting and/or nutritional edema?

WHO 2023

Conditional recommendation for, Low certainty evidence

B2. a) Infants and children 6-59 months old with severe wasting and/or nutritional edema who have any of the following characteristics should be referred and admitted for inpatient care:

i. One or more Integrated Management of Childhood Illness (IMCI) danger signs

ii. Acute medical problems

iii. Severe nutritional edema (+++)

iv. Poor appetite (failed the appetite test).

b) Infants and children 6-59 months old with severe wasting and/or nutritional edema who do not meet any of the criteria from part a but who do have any of the following characteristics are likely to benefit from an in-depth assessment to inform the decision on possible referral to inpatient: *

i. Medical problems that do not need immediate inpatient care, but do need further examination and investigation (e.g. bloody diarrhea, hypoglycemia, HIV-related complications);

ii. Medical problems needing mid or long-term follow-up care and with a significant association with nutritional status (e.g. congenital heart disease, cerebral palsy or other disability, HIV, tuberculosis).

iii. Failure to gain weight or improve clinically in outpatient care.

iv. Previous episode(s) of severe wasting and/or nutritional edema.

c) Infants and children 6-59 months old with severe wasting and/or nutritional edema who have all the following characteristics should be enrolled and managed as outpatients:

i. Good appetite (passed the appetite test); and

ii. No danger signs or any of the acute medical problems from part a ii; and

iii.No criteria needing in-depth assessment (see part b) or criteria from part b present, but an in-depth assessment has been completed and no inpatient admission needed (e.g. diarrhea with no dehydration, respiratory infections with no signs of respiratory distress, malaria with no signs of severity).

Therapeutic feeding approaches in the management of severe acute malnutrition in children who are 6–59 months of age

B3

In infants and children with severe wasting or edema, what is the inpatient therapeutic feeding approaches in management?

WHO 2013

Conditional recommendation, very low-quality evidence

B3. In inpatient settings, where ready-to-use therapeutic food is provided as the therapeutic food in the rehabilitation phase (following F-75 in the stabilization phase)

Once children are stabilized, have appetite and reduced edema and are therefore ready to move into the rehabilitation phase, they should transition from F-75 to ready-to-use therapeutic food over 2–3 days, as tolerated. The recommended energy intake during this period is 100–135 kcal/kg/day. The optimal approach for achieving this is not known and may depend on the number and skills of staff available to supervise feeding and monitor the children during rehabilitation Two options for transitioning children from F-75 to ready-to use therapeutic food aresuggested:

a. start feeding by giving ready-to-use therapeutic food as prescribed for the transition phase. Let the child drink water freely. If the child does not take the prescribed amount of ready-to-use therapeutic food, then top up the feed with F-75. Increase the amount of ready-to-use therapeutic food over 2–3 days until the child takes the full requirement of ready-to-use therapeutic food, or

b. Give the child the prescribed amount of ready-to-use therapeutic food for the transition phase. Let the child drink water freely. If the child does not take at least half the prescribed amount of ready-to-use therapeutic food in the first 12 h, then stop giving the ready-to-use therapeutic food and give F-75 again. Retry the same approach after another 1–2 days until the child takes the appropriate amount of ready-to-use therapeutic food to meet energy needs.

B4

In infants and children with complicated severe wasting or edema receiving F100 formula, When to change to ready to use therapeutic food?

WHO 2013

Conditional recommendation, very low-quality evidence

B4. In inpatient settings where F-100 is provided as the therapeutic food in the rehabilitation phase

Children who have been admitted with complicated severe acute malnutrition and are achieving rapid weight gain on F-100 should be changed to ready-to-use therapeutic food and observed to ensure that they accept the diet before being transferred to an outpatient program.

B5

If F100 or F 75 formula are not available, what formula is recommended to use?

GDG

Good practice statement

B5. If F100 or F 75 formula are not available, other commercial formula could be used to fulfil the recommended caloric and protein requirement

B6

In infants and children with severe wasting or edema who are not tolerating F-75 or F-100, which formula can be used?

GDG

Good practice statement

B6. In infants and children 6-59 months of age with severe wasting and/or nutritional edema who are not tolerating standard formula could be shifted to low lactose formulas and assessed for tolerance.

B7

Ready-to-use therapeutic food for treatment of severe wasting and/or nutritional edema.

In infants and children 6-59 months with severe wasting and/or nutritional edema, what is the optimal quantity and duration of RUTF?

WHO 2023

Conditional recommendation, Low certainty evidence

B7. In infants and children 6-59 months of age with severe wasting and/or nutritional edema who are enrolled in outpatient care, ready-to-use therapeutic food (RUTF) should be given in a quantity that will provide:

•150-185 kcal/kg/day until anthropometric recovery and resolution of nutritional edema; or

•150-185 kcal/kg/day until the child is no longer severely wasted and does not have nutritional edema, then the quantity can be reduced to provide 100-130 kcal/kg/day, until anthropometric recovery and resolution of nutritional edema

B8

In infants and children 6-59 months with severe wasting and/or nutritional edema, which formula to use if RUTF is not available?

GDG

Good practice statement

B8. If RUTF is not available, available standard formula can be used with special consideration to protein and caloric content

B9

In infants and children 6-59 months admitted for inpatient treatment of wasting and/or nutritional edema, what are the criteria that best inform the decision for transfer to outpatient/community treatment?

WHO 2023

Strong recommendation, for Moderate certainty evidence.

B9. a) Infants and children 6-59 months with severe wasting and/or nutritional edema who are admitted to inpatient care can be transferred to outpatient care when:

i.    They do not have any danger signs for at least 24-48 hours prior to transfer time; and

ii.   The medical problems that prompted their admission have resolved to the extent there is no longer requirement for inpatient care; and

iii. They do not have ongoing weight loss (among children admitted with wasting only, who did not have nutritional edema at any time); and

iv. Their nutritional edema is no longer grade +++ and is resolving; and

v. They have a good appetite.

vi. All attempts have been made to refer children with medical problems needing mid or long-term follow-up care and with a significant association with nutritional status to appropriate care/support services and/or the limits of inpatient care have been reached.

b) The decision to transfer children from inpatient to outpatient care should not be made based on anthropometric criteria such as a specific weight-for-height/length or mid-upper arm circumference. Instead, the criteria listed above should be used.

c) Upon deciding to transfer children from inpatient to outpatient care, caregivers must be linked to appropriate outpatient care with nutrition services.

d) Additional social and family factors should be identified and addressed before transfer to outpatient care to ensure that the household has the capacity for care provision

B10

In infants and children 6-59 months with severe wasting and/or nutritional edema, what is the necessity of discharge planning?

GDG

Good practice statement     

B10. Discharge planning that is timely, efficient, and holistic is vital to continuity of care between inpatient and outpatient services. This is to ensure that children are discharged from inpatient care at the appropriate time and with definitive guidance given to caregivers for ongoing nutritional, medical, and psychosocial support services.

B11

In infants and children 6-59months receiving outpatient/community treatment for wasting and/or nutritional edema, what are the criteria that best inform the decision for exit from outpatient/community treatment?

WHO 2023

Conditional recommendation, very low certainty evidence

B11. a) Infants and children 6-59 months with severe wasting and/or nutritional edema should only exit from nutritional treatment when all the following conditions are met:

i. Their weight-for-height/length z-score is equal to or greater than 2 standard deviations (SD) below the WHO child growth standards median (WHZ or WLZ ≥ -2) and their mid-upper arm circumference (MUAC) is equal to or greater than 125mm observed for at least 2 consecutive visits/measurements; and

ii. They have had no nutritional edema for at least 2 consecutive visits/measurements.

b) Percentage weight gain and absolute weight gain should not be used as exit criteria.

c) Children with medical problems needing mid or long-term follow-up care and with a significant association with nutritional status (e.g. HIV, tuberculosis, congenital heart disease, cerebral palsy) and/or additional social factors (e.g. household food insecurity, vulnerable household) have also been referred to appropriate care/support services care and the limit of care has been reached for outpatient care for severe wasting and/or nutritional edema.

B12

Identification of dehydration in infants and children with wasting and/or nutritional edema

In infants and children with moderate or severe wasting or edema, how can dehydration be identified?

GDG

Good practice statement

B12. Accurate classification of hydration** status in children with wasting and/or nutritional edema who have diarrhea or other fluid losses is vital to provide and monitor appropriate treatment and must be frequently reassessed.

B13

Rehydration fluids for infants and children with wasting and/or nutritional edema and dehydration but who are not shocked.

B12. In infants and children with severe wasting or edema and dehydration but who are not shocked, what is the effective oral rehydration therapy?

GDG

Good practice statement

B13. In infants and children 6-59 months of age with severe wasting and/or nutritional edema who are dehydrated but not in shock, low-osmolarity Oral Rehydration Solution (ORS) can be used. Rehydration Solution for Malnourished children (ReSoMal) is preferred if available

B14

 In infants and children with moderate wasting or edema and dehydration but who are not shocked, what is the effective oral rehydration therapy?

WHO 2023

Conditional recommendation, very low certainty evidence

B14. In infants and children 6-59 months with moderate wasting who are dehydrated but not in shock, low-osmolarity Oral Rehydration Solution (ORS) should be administered in accordance with existing WHO recommendations for all children apart from those with severe wasting and/or nutritional edema.

B15

Dietary management of infants and children with moderate wasting

In infants and children 6-59 months with moderate wasting, what is the appropriate dietary treatment in terms of optimal type, quantity, and duration?

WHO 2023

Good practice statement

B15. Infants and children aged 6–59 months of age with moderate wasting (defined as a weight-for-height between 2 and 3 z-scores below the WHO child growth standards median and/or a mid-upper arm circumference 115 mm or more and less than 125 mm, without edema) should have access to a nutrient-dense food fully meet their extra needs for recovery of weight and height and for improved survival, health, and development.

B16

In infants and children 6-59 months of age with moderate wasting what they should be assessed for?

WHO 2023

Good practice statement

B16. All infants and children 6-59 months of age with moderate wasting should be assessed comprehensively and treated wherever possible for medical and psychosocial problems leading to or exacerbating this episode of wasting.

B17

In infants and children 6-59 months of age with moderate wasting when they should be considered for specially formulated food with councelling?

WHO 2023

Strong recommendation for, Moderate certainty evidence

B17. Prioritizing specially formulated food (SFF) interventions with counseling, compared to counselling alone, should be considered for.

Individual child factors:

•mid-upper arm circumference (MUAC) 115-119mm

•weight-for-age z-score (WAZ) <-3 SD

•age <24 months

•failing to recover from moderate wasting after receiving other interventions (e.g. Counselling alone)

•having relapsed to moderate wasting

•history of severe wasting

•co-morbidity (medical problems needing mid or long-term follow-up care and with a significant association with nutritional status such as HIV and tuberculosis or a physical or mental disability)

Social factors:

•Severe personal circumstances, such as mother died or poor maternal health and well-being

B18

In infants and children 6-59 months of age with moderate wasting I high risk context what they should be considered for?

WHO 2023

Strong recommendation for, Moderate certainty evidence

B18. In high-risk contexts (where there is a recent or ongoing humanitarian crisis), all infants and children 6-59 months of age with moderate wasting should be considered for specially formulated foods (SFFs) along with counseling and the provision of home foods for them and their families.

B19

In infants and children 6-59 months of age with moderate wasting who need supplementation with specially formulated foods (SFFs) what is the alternative if it is not available?

WHO 2023

Conditional recommendation for, Low certainty evidence

B19. In infants and children 6-59 months of age with moderate wasting who need supplementation with specially formulated foods (SFFs), lipid-based nutrient supplements (LNS) are the preferred type. When these are not available, Fortified Blended Foods with added sugar, oil, and/or milk (improved FBFs) are preferred compared to Fortified Blended Foods with no added sugar, oil, and/or milk.

B20

Infants and children 6-59 months of age with moderate wasting who require specially formulated foods (SFFs) how to calculate the required amount?

WHO 2023

Conditional recommendation for, very low certainty evidence

B20. Infants and children 6-59 months of age with moderate wasting who require specially formulated foods (SFFs) should be given SFFs to provide 40-60% of the total daily energy requirements needed to achieve anthropometric recovery. Total daily energy requirements needed to achieve anthropometric recovery are estimated to be around 100-130 kcal/kg/day.

B21

Vitamin A supplementation in the treatment of children with severe acute malnutrition

What is the effectiveness and safety of giving vitamin A supplementation to children with severe acute malnutrition when they are receiving a WHO-recommended therapeutic diet containing vitamin A?

WHO 2013

Strong recommendation for , Low certainty evidence

B21. Children with severe wasting and/or nutritional edema should receive the daily recommended nutrient intake of vitamin A throughout the treatment period. Children with severe wasting and/or nutritional edema should be provided with about 5000 IU vitamin A daily, either as an integral part of therapeutic foods or as part of a multi-micronutrient formulation.***

Table 5. Recommendations

C. post-exit interventions after recovery from wasting and/or nutritional edema

N

Health questions

Source Guideline

Recommendations (Quality of evidence, Strength of Recommendation)

C1

Which infants and children at risk of poor growth and development or with moderate or severe wasting or edema require post-exit interventions?  If yes, which post-exit interventions are effective?

GDG

Good practice statement

C1. Mothers/caregivers after their infants and children exit from nutritional treatment should be provided with continuous counseling and education and should be kept in contact with one of presidential initiatives, civil society organizations and Ministry of Social Solidarity for social and financial support to improve overall child health and prevent relapse to wasting.

C2

In infants and children at risk of poor growth and development or with wasting and/or nutritional edema what is the role of psychosocial stimulation?

WHO 2023

Conditional recommendation for, Low certainty evidence

C2. In infants and children at risk of poor growth and development or with wasting and/or nutritional edema, psychosocial stimulation should continue to be provided by mothers/caregivers after transfer from inpatient treatment and exit from outpatient treatment, with psychosocial stimulation interventions * as part of routine care to improve child development and anthropometric outcomes.

Table 6. Recommendations

D. Prevention of wasting and nutritional edema

N

Health questions

Source Guideline

Recommendations (Quality of evidence, Strength of Recommendation)

D1

In communities with infants and children up to five years old at risk of wasting, what community characteristics increase or mitigate risk of wasting for individual children?

WHO 2023

Good practice statement

D1. In contexts where wasting and nutritional edema occur, preventive interventions should ideally be implemented through a multisectoral and multisystem approach (i.e. food, health, safe water, sanitation and hygiene, and social protection systems). These interventions should include access to healthy diets and nutrition and medical services as appropriate, counselling (breastfeeding, health and nutrition related, especially helping families use locally available nutrient-dense foods for a healthy diet), should address maternal and family needs, and should involve psychosocial elements of care to ensure healthy growth and development.

D2

In communities with infants and children up to five years at risk of wasting, what is effective community prevention interventions for prevention of wasting?

GDG

Good practice statement

D2. Infant and young child feeding counselling must be provided by comprehensively trained health professionals as part of routine care.

D3

In communities with infants and children up to five years at risk of wasting, what is the effectiveness of population-based interventions compared to targeted interventions for primary and secondary prevention of wasting?

WHO 2023

Conditional recommendation for, Low certainty evidence

D3. a) In areas of or during periods of high food insecurity, in addition to infant and young child feeding counselling, specially formulated foods (SFFs), including medium-quantity lipid-based nutrient supplements (MQ-LNS) or small-quantity lipid-based nutrient supplements (SQ-LNS), may be considered for the prevention of wasting and nutritional edema for a limited duration for all infants and children 6-23 months of age, while continuing to enable access to adequate home diets for the whole family.

b) In areas of or during periods of high food insecurity, children living in the most vulnerable households should be prioritized for SFF interventions through a targeted approach. However, when targeting is not possible, these SFFs may need to be given to all households through a blanket approach for infants and children 6-23 months of age, while continuing to enable access to adequate home diets for the whole family and providing infant and young child feeding counselling.