Deadline of submission: 20 January 2021
Background
In 2012, the World Health Assembly Resolution 65.6 endorsed a Comprehensive implementation plan for maternal, infant and young child nutrition, which specified six global nutrition targets for 2025. Appropriate infant and young child feeding, essential to fostering healthy growth, is directly related to three of these six targets: 40% reduction in the number of under-5 who are stunted, reduce and maintain childhood wasting to less than 5%, and no increase in childhood overweight; and is fundamental to achieving SDG Targets 2.2, 2.1.1, 2.2.1, and 2.2.2.
In 2003, the Pan American Health Organization developed a set of 10 Guiding principles for complementary feeding of the breastfed child[1] and in 2005 WHO developed a set of 9 Guiding principles for feeding non-breastfed children 6-23 months of age.[2] While still useful, the Guiding principles documents need to be updated, taking into consideration the scientific literature published over the past 15 years. The documents were focused primarily on the prevention of undernutrition and did not address concerns over rising rates of childhood obesity and the development of NCDs.
The Department of Nutrition and Food Safety (NFS) is in a process of updating guidance on feeding of infants and young children 6 to 23 months of age. In 2019, WHO formed a Guideline Development Group (GDG) for this purpose. In 2019-20, the GDG met several times to decide on a set of priority questions for recommendations on complementary feeding. The first set of systematic reviews are already underway (see Annex 2 for details). This new announcement requests additional reviews on separate topics.
Scope
To inform the guidance on feeding infants and young children, WHO will commission 2 additional systematic effectiveness reviews and 5 systematic qualitative reviews to retrieve, synthesize and assess the available evidence for the following priority questions.
Systematic effectiveness reviews:
9. Responsive feeding
: For infants and young children 6-23 months of age (P), do interventions that include elements of responsive feeding (I) compared to interventions that do not include those elements of responsive feeding (C) result in beneficial or harmful dietary
and health outcomes (O)?
| Population: | Children 6-23 months |
| Intervention: | Behavioural intervention with one or more of the following components of responsive feeding:
|
| Comparator: | No intervention or same intervention but without the responsive feeding elements |
| Outcomes: | Critical: a) Food acceptance b) Intake of healthy food/beverage c) Growth and body composition d) Food preference e) Nutrition intake f) Intake of unhealthy food/beverages g) ECD includes motor development, cognitive (e.g. language), social emotion Important: h) Flavour preference i) Food regulation j) Nutrient status k) Sleep l) Physical activity and play m) Dental health n) Caregiver-infant bonding |
| Study design | RCT, quasi-randomized trial |
| Variables to note during data extraction | Intermediate behavioural outcomes, e.g., soothing - not using food as a reward |
| Subgroup analyses | HIC vs LMIC |
*Notes:
Results should be categorized with respect to which intervention components the studies did nor did not include, as well as on “packages” of intervention components that are commonly grouped together. Outcomes may be assessed at any point after the intervention, including after 24 months
10. Fortified complementary foods: For infants and young children 6-23 months of age (P), is consumption of a fortified complementary food (E) compared to an unfortified version of the same complementary food (C) associated with beneficial or harmful dietary and health outcomes (O)?
| Population: | Infants and young children <24 months of age - Stratify by age group (6-8 months, 9-11 months, 12-23 months) |
| Exposure: | Consumption of a fortified complementary food (excluding milks) |
| Comparator: | Consumption of an unfortified version of the same complementary food |
| Outcomes (can be at any point later in life): | Critical: a) anaemia b) growth and body composition (e.g. stunting, wasting, overweight/obesity) c) nutrient status (e.g. iron, zinc, vitamin A) d) nutrient adequacy and excess Important: e) child development f) displacement of other foods g) morbidity h) microbiome i) taste preference |
| Subgroup analysis | HIC vs. LMIC Type of food fortified: Cereals/blended foods Sugary breakfast cereals Other Nutrients added through fortification |
| Study design | RCT, quasi-randomized trial |
Systematic qualitative reviews:
Whereas systematic reviews based on PECO questions are intended to evaluate the benefits and harms of a particular behaviour, additional criteria need to be considered in making WHO recommendations. These additional criteria include i) Values and preferences of individuals and populations affected by the recommendation, ii) Resource implications (including caregiver time considerations and costs of the foods), iii) Equity and human rights (including environmental/climate considerations), iv) Acceptability (including cultural, religious, etc), and v) Feasibility. See Annex 1 below for further information. Narrative reviews will be commissioned on these criteria related to the following issues:
3. Unhealthy foods and beverages
: Consumption in infants and children 6-23 months of age of unhealthy foods and beverages, such as ultra-processed foods high in sugar, fat, or salt. (See PECO 1 in Annex 2 for more information). In addition to the five criteria in Annex
1, this review should include discussion of:
- Use of unhealthy foods and beverages as a treat, to show love, or to have fun
- Innate taste preferences for salty or sweet foods and beverages
4. Milk consumption: Milk consumption in infants and children 6-23 months of age, including use of infant and toddler formulas, fortified milks, low-fat milk, plant-based milk. (See PECOs 2, 4, 5, & 6 in Annex 2 for more information).
5. Specialized micronutrient products
: Consumption in infants and children 6-23 months of age of specialized food products designed to address micronutrient deficiencies, including fortified complementary foods, micronutrient powders (MNPs), and small-quantity lipid-based nutrient supplements.
(See PECO 10 above and questions 11 & 12 in Annex 2 for more information). In addition to the five criteria in Annex 1, this review should include discussion of:
- cost implications of use of these products compared to unfortified ‘natural’ foods
6. Responsive feeding: Responsive feeding behaviours exhibited between infants/children 6-23 months of age and their caregivers. (See question 1 above for the components of responsive feeding).
7. Dietary diversity: Summary descriptions of the quality of complementary feeding based on dietary diversity, used both in giving advice to caregivers and in population measures. This would include summary measures of dietary diversity such as diversity scores or indexes. (See PECOs 3, 7 & 8 in Annex 2 for more information). In addition to the five criteria in Annex 1, this review should include discussion of:
- How dietary diversity has been defined in both counselling interventions and population-based indicators
- What evidence exists that more diverse diets lead to improved health outcomes
- Relative costs of different elements of a diverse complementary feeding diet, particularly fruits and vegetables and animal-source foods
Concept note and budget
Interested author(s)/teams are invited to submit a concept note (2-3 pages) by sending an email to WHO at nutrition@who.int no later than 20 January 2021. The subject heading of the email should read as, “Reviews on feeding infants and young children”.
The concept note should include a proposal containing (in a single document) the following:
- The number(s) and title(s) of the review(s) being proposed, lead author and host institution with overall responsibility for the review, and contributors. The specific competencies and contributions of each author or team member should be explicitly stated. Interested author(s)/teams must have experience with conducting complex reviews and should provide references of reviews that they have published in peer-review journals. Proposals to conduct systematic effectiveness reviews should specify experience with GRADE-PRO and ROBINS-I software and for qualitative reviews, inclusion of GRADE CERQual. Interested author(s)/teams should have members with complementary skills and competencies including knowledge of the technical area, statistical analysis and excellent writing capabilities.
- Proposed question(s) to be addressed through the review(s), outlining the background and justification for the review, the search strategy and databases to be searched, the definition of inclusion/exclusion criteria, the process of data extraction and analytical approach. This description should reflect the scope of work described below. Author(s)/teams may undertake one or more reviews. However, they need to demonstrate capacity to conduct the review(s) within the timeline above. Successful authors will be required to submit a protocol prior to performing the review.
- Budget (US $). This should outline the total amount for the review including an approximate breakdown of personnel vs. institutional/other costs. If the author/team proposes to undertake multiple reviews, the budget should specify costs for each separate review as well as the total for the package of reviews since savings may be possible when conducting multiple reviews jointly. It is expected that WHO will provide technical input on the final protocols that will govern the reviews. For the purpose of the concept note, it is not necessary to describe every detail of the review.
Timeline
- 20 January 2021 - Interested authors or teams submit concept notes and budget
- 12 February 2021 - WHO review of proposals complete and authors/teams contacted
- 26 February 2021 - Contracts agreed (subject to WHO conditions including review of declarations of interest of members of the review teams)
- 28 May 2021 - Draft reviews submitted
- 18 June 2021 - Final reviews submitted (with GRADE or GRADE CERQual tables)
1 Guiding principles for complementary feeding of the breastfed child
2 Guiding principles for feeding non-breastfed children 6-24 months of age