An executive briefing from a technical consultation between the World Health Organization, the Office of the United Nations High Commissioner for Refugees, the United Nations Children’s Fund and the World Food Programme
Background
Today, at any point in time, an average of 50 million children aged under 5 years suffer from wasting worldwide. These children are at a higher risk of death than their well-nourished and healthy peers. This risk is particularly high among the 17 million children with severe wasting. Levels of wasting have barely declined in a decade. As a result, the world is off-track to reach the global Sustainable Development Goal (SDG) target to reduce the prevalence of child wasting (Target 2.2). Preventing children from becoming wasted requires concerted actions to ensure that they are born to well-nourished mothers and have access to age-appropriate nutritious and healthy diets and care practices, as well as to health services and clean and safe environments. Yet, when prevention fails – as it has done for those 50 million children suffering from wasting now – early detection and appropriate treatment of wasting remain essential.
For decades, United Nations agencies have provided leadership in improving access to effective services for children with wasting, contributing to a decrease in the number of children dying from wasting, in both humanitarian and development contexts. In 2018, an estimated 10 million children with wasting, including 4.5 million with severe wasting, received treatment with support from the United Nations High Commissioner for Refugees (UNHCR), the United Nations Children’s Fund (UNICEF), the World Food Programme (WFP) and the World Health Organization (WHO), but more needs to be done.
Current status and the issue
Commitment to child nutrition by national governments in over 70 countries has led to the adoption of national protocols to treat wasting, based on existing WHO recommendations where available. However, in many settings, the implementation of national guidelines for the treatment of child wasting faces challenges, owing to limited resources and capacities, which hamper efforts to reach all children in need. Therefore, in addition to other efforts, UNHCR, UNICEF and WFP are collaborating with partners on simplified approaches to finding and treating child wasting.
As per WHO guidelines, children suffering from severe wasting with medical complications are treated using specialized therapeutic milk (F-75 and F-100) and those without medical complications are treated using Ready to Use Therapeutic Foods (RUTF), along with other clinical interventions. Currently, there is no WHO guideline for the management of moderate wasting, except in emergency settings. Children with moderate wasting are treated using Ready to Use Supplementary Foods (RUSF) in many settings.
Simplified approaches, rather than being a single prescriptive adaptation, include a range of adaptations to protocols and programmes that aim to improve coverage/reach and/or reduce costs. These have been particularly explored in exceptional circumstances where the potential for recovery is hindered by severe food insecurity, very weak health systems, and/or the extreme vulnerability of the population.
Response
Comprehensive actions are needed to increase access to and the effectiveness of interventions to address wasting. Simplified approaches to the treatment of child wasting have been proposed as potential contributing components when circumstances are exceptionally difficult.
Thus, on 26–27 March 2019, the nutrition teams of UNHCR, UNICEF, WFP and WHO came together to review the available evidence on simplified approaches for the early detection and treatment of wasted children; to discuss ongoing efforts, and to decide on next steps. Invited researchers presented existing evidence and preliminary results of ongoing trials comparing the nutrition outcomes of different simplified approaches. Simplifications presented varied across screening, admission and discharge criteria; strategies for the provision of specialized nutritious food during treatment (e.g. location and frequency); and the amount and type of specialized nutritious food used for treatment (e.g. use of a single product with reducing the dosage over the course of treatment).
The key conclusions from the meeting on simplified approaches are listed next.
- The preliminary findings of studies that have assessed different simplifications are promising but limited in scope and context-specific. No studies were conducted in South Asia which has the highest populations of children with wasting.
- Studies have been conducted at a relatively small scale, so the potential of simplified approaches to improve efficiencies at scale, and their ultimate impact on population-based outcomes and cost, are not yet known.
- The potential programmatic advantages of simplified protocols in exceptional circumstances warrant further investigation.
- As they currently stand, not all elements of simplified approaches align with WHO normative guidelines and the evidence available to date does not yet warrant a change in global recommendations.
Next steps
UNHCR, UNICEF, WFP and WHO under their respective mandates will:
- Support national coordination platforms to lead on the use and documentation of simplified approaches to the treatment of child wasting in exceptional circumstances, where warranted.
- Continue to support and encourage further opportunities for evidence generation for the management of children with wasting, including the potential contribution of simplified approaches to improving the coverage, effectiveness, cost and impact of treatment of child wasting in exceptional circumstances.
- Develop updated, comprehensive normative guidelines on wasting in all settings being led by WHO, and the role of specially-formulated foods for wasted children vis-a-vis family foods in the management of moderate wasting.
- Prioritize and stimulate the generation of appropriate evidence necessary to develop updated, comprehensive normative guidelines on wasting in all settings being led by WHO.
- Present a UN Global Action Plan on Wasting by the end of 2019 framing wasting in the broader context of reaching the SDGs and aligning priorities and agendas across all global partners.
The UN agencies recognize the interest generated by recent research efforts on simplified protocols. WHO, UNHCR, UNICEF, and WFP remain more committed than ever to generate a new global impetus to scale up care for children suffering from wasting.