Management of wasting in children and infants

• Targeted management of moderate wasting among children 6–59 months through either targeted supplementary feeding using specially formulated and fortified foods and/or support through social protection and health counselling and education.
• Therapeutic feeding among children 6–59 months with severe wasting using therapeutic foods.
• Management of acute malnutrition in infants (MAMI).

• Interventions to manage wasting in infants and children are delivered as part of routine healthcare in most settings including through outpatient and inpatient services.
• In humanitarian contexts these interventions are often supplemented and/or strengthened by humanitarian agency support including through approaches such as ‘CMAM surge’ and/or the addition of mobile health teams to reach hard to access populations.

• WHO guidance (2023) defines the anthropometric measurements and clinical signs which categorise Severe Acute Malnutrition (SAM)/Moderate Acute Malnutrition (MAM) and outlines recommendations on use of nutritional products for each category 

  (see below).

For children over the age of six months with wasting:

• The decision of whether to refer a child with wasting to inpatient or outpatient care should be made by health workers with the training and expertise to recognise and act on the signs and symptoms of childhood illness and the complications associated with wasting.
• WHO guidance emphasises that not all children over the age of six months with MAM will need a specially formulated food (SFF) and for those who need it, SFF should only be given to supplement the home diet.
• WHO guidance also recommends evidence–informed risk factors which can be used to prioritise which children with MAM to give a SFF to supplement their home diet, based on risk factors which make them at higher risk of mortality and non–recovery than others.
• As such, children with MAM and SAM should be cared for in the appropriate programme or service and given nutritional supplementation or nutritional treatment respectively, according to the specific recommendations for either MAM or SAM.
• Children with medical problems needing mid or long– term follow–up care and with a significant association with nutritional status (for example, HIV, tuberculosis, congenital heart disease, cerebral palsy) and/or additional social factors (for example, household food insecurity, vulnerable household) should be referred to appropriate care/support services in parallel with receiving treatment and support for wasting.
• Assessment, classification and management or referral of infants and children 6–59 months of age with wasting and/ or nutritional oedema can be carried out by community health workers as long as they receive adequate training and regular supervision of their work is built into service delivery.
• Children with severe wasting and/or nutritional oedema who are discharged from treatment programmes should be periodically monitored to avoid a relapse.
• Mothers/caregivers of infants and children treated for wasting and/or nutritional oedema should be provided with interventions after their children exit from nutritional treatment/supplementation. These could include counselling and education (on infant and young child feeding practices, recognition of common childhood illnesses and appropriate health–seeking behaviours); support to provide responsive care; and safe water, sanitation and hygiene interventions to improve overall child health and prevent relapse to wasting and/or nutritional oedema.
• In infants and children with severe wasting and/or nutritional oedema, cash transfers in addition to routine care may be provided to decrease relapse and improve overall child health during outpatient care and after exit from treatment, depending on contextual factors such as cost.

For infants < 6 months at risk/with wasting:

• Infants under six months are unique. Their wellbeing is intrinsically linked to that of their mother/caregiver, being completely dependent on breastfeeding (or a breastmilk substitute ) to meet all their nutritional needs. Developmental changes from birth to six months are exponential compared to later in childhood. Younger infants are at greater risk of death than older children; with feeding practices closely linked to risk. In addition to this baseline risk, additional risk factors increase an infants’ vulnerabilities, for example being born prematurely or at low birthweight (<2500g).
• The MAMI Care Pathway provides a guide for health workers to identify, assess, classify and manage at–risk infants under six months and their mothers. When a mother and u6m infant present to a contact point, the MAMI Care Pathway guides the assessment of: danger signs, Integrated Management of Childhood Illness (IMCI) clinical signs and symptoms, growth of infant, MAMI risk– factors, infant feeding practices and maternal wellbeing. These principals of care for the management of small and nutritionally at-risk infants under six-months and their mothers are now also integrated into new WHO guidance.