Targeting wasting treatment and age – are we on the right track?

In our latest blog, we ask if the nutrition community are shifting their approach towards targeting wasting treatment to children under 2 years old only?

In 2020 it was estimated that 45 million children around the world were wasted¹. Only 11 million were reportedly reached with treatment in 2019 (UN 2023).  Increased international attention to the issue of wasting, recognises the need to accelerate progress on treatment (UN 2023, USAID 2022). However, given competing needs in the world of malnutrition, optimising efforts, focussing treatment on the most at risk children, and answering questions of what effective prevention looks like are all increasingly essential.

Research has estimated that a child who is severely wasted (weight-for-height z score) experiences a risk of death up to 12 times higher than a child who is not malnourished. And a moderately wasted child faces 3 times the risk (Olofin 2013). However, with a number of different anthropometric indices and cut-offs being used to identify children for different intensities of therapeutic or supplementary treatment, questions remain of whether we can better and more efficiently target services to their urgent needs. 

In order to answer some of these questions, ENN, supported by a group of global technical experts, have undertaken several analyses using unique pooled datasets of community cohorts (children followed over time with anthropometry measured and deaths recorded).  One of the benefits of this dataset is its size, enabling questions around mortality to be included; another is that they were conducted when outpatient treatment was not yet widespread, so opportunistically give us the ability to better understand mortality risk for untreated children in the community. One of these analyses explored the impact of age and sex on mortality outcomes in children who are wasted, stunted and underweight in order to re-examine the evidence base for current standard targeting of prioritising treatment for wasted children under 5 years of age (Thurstans et al 2020).

The results of this analysis are consistent with previous research (Pelletier et al 1994), in that they demonstrate a high risk of mortality associated with child wasting (both using weight-for-height and MUAC classifications). Specifically, they indicate that mortality risk in wasted children does not differ significantly according to age.  In particular, there is no difference in mortality risk between wasted children aged 6-23 months and wasted children aged 24-59 months (Thurstans et al 2020). 

Together with evidence of the increased risks of mortality associated with wasting in children under 6 months (Grijalva-Eternod et al 2017) and the development of broad protocols to address their specific needs alongside those of their mothers (MAMI 2021), the implication is that targeting of all wasted children under 5 years of age is appropriate for treatment approaches aiming to reduce mortality rates.

It is interesting therefore that key strategy documents within the nutrition community appear to be shifting their approach towards targeting wasting treatment to children under 2 years old only.  Examples of this include:

• The UNICEF Nutrition strategy 2020-2030 overall refers to children under 5 but does allude to prioritising children under 2 in the result for treating wasting in early childhood.  They state, ‘Timely and effective detection and treatment are particularly critical for children under 2 years of age who are most vulnerable to the life-threatening consequences of wasting.’ 
• UNICEF‘s acceleration plan for 2022-2023, No time to waste, outlines a strategic approach to ensure that no child dies from wasting.  Strategic result 4, outlines 10 innovations to prioritise to optimise and simplify treatment with the more severe forms of wasting.  Innovation 1 is "Focusing early detection and treatment on children under 2 years of age". 
• The UNICEF child alert on severe wasting published in May 2022 states that all stakeholders should "Prioritize resources where they will save the most lives - severely wasted children under age 2"

This apparent policy shift is concerning given the evidence that risk does not differ by age for children under 5 and which therefore doesn’t support age-based targeting of treatment.

There is not a clear rationale presented in the policy documents above, but it appears to be based on prevalence estimates i.e. there are more wasted children under 2 years of age so that is where efforts should focus. 

In March 2022, an analysis published in the eClinicalMedicine, part of the Lancet group, compared prevalence estimates between children 0-2yrs and children 2-5 yrs (Karlsson et al 2022).  Children under 2 were reported to have a wasting prevalence of 14% compared with 9% in children 2-4.  The authors state, based on this and the fact that interventions are more effective during the 1000 days from conception until age 2, that "nutrition interventions should ensure coverage of children under 2 through programmatic measures to increase detection and enrolment in wasting programs". 

The wording of this is potentially misleading. 

Whilst it doesn’t directly suggest only targeting children under 2 for wasting treatment, when read alongside the above policy documents that is a conclusion that might be drawn.  Surely higher prevalence alone is not a reason to target one group over another without consideration of risk, especially in areas where the prevalence of wasting in children over 2 is as high as 15%, as was the case in South Asia (Karlsson et al 2022).  We find ourselves reflecting that, based on our own published analysis, wasting prevalence is significantly higher in boys than girls (Thurstans et al 2020) but this should not and would not pass as a reason to target only boys. 

There is also the suggestion in the same Lancet group paper that wasting treatment is more effective in children under 2, that the "effectiveness of nutrition interventions and complementary feeding to improve child health have been found to be particularly successful at younger ages" (Karlsson et al 2022). They cite literature to support this statement which we reviewed and whilst many interventions such as those aimed at pregnant women, and interventions to support infant and young child feeding are most effective in children under 2, the evidence presented on wasting treatment refers to all children under 5 years of age and doesn’t support the conclusion of greater effectiveness in any specific age group (Keats and Das et al 2021). 

We do not dispute that children under 2 are a priority group for many interventions including preventative approaches for wasting and stunting.  Their higher susceptibility to infection and undernutrition in all its forms make them a priority group for interventions aimed at preventing wasting and other forms of undernutrition which should be targeted throughout the first 1000 days at a minimum.  Resources for nutrition services are increasingly limited and at the same time UN agencies and others are flagging increasing needs linked to climate change, food systems breakdown and the effects of Covid-19 (ALNAP 2022). In light of this, we absolutely understand that there is a need to focus on context specific and risk specific presentations rather than a one size fits all approach.  

Given the constraints that nutrition services face, the principles of equity and accountability that guide our work become even more important. They demand that targeting decisions be informed by evidence and communicated clearly to all.  A refocus towards the under two’s might result in improved coverage estimates, but this would not be a true reflection of needs.  In this case we are left feeling somewhat confused about the rationale for this refocus and concerned for the many wasted children over 2 years of age (9% of 2 to 4 year olds according to the Karlsson analysis) that are at high risk of dying.

We do not dispute that 45 million wasted children is an enormous burden to reach but let’s collectively be clear about what we are aiming for and why.

The WHO have over the last year been conducting their wasting prevention and treatment guideline review process for children under 5 years and a complementary data analysis by WHO to stratify risk in children is not limited to children under 2 years. Thus no change indicated that would focus treatment to under 2’s.

We would love to hear from others. Is the Lancet paper, alongside the policy documents referenced above being taken as evidence to underpin a focus of treatment towards under 2’s? Are countries adapting national programmes? Are NGOs and community teams changing targeting criteria, or do they continue to focus on all children under 5? How (if at all) is any of this impacting your work?

We welcome your input.