1. Anthropometric assessment of infants and children presenting to primary health-care facilities
Programmatic questions
- Should primary health-care workers assess infants and children in order to identify stunting (chronic malnutrition) in addition to wasting (acute malnutrition)?
- Should primary health-care workers assess infants and children in order to identify overweight and obesity?
- Which anthropometric measures should primary health-care workers use to assess nutritional status?
Background
IMCI provides clinical algorithms that guide health workers at primary health-care facilities on the assessment and management of infants and children presenting with illnesses, including assessment and classification of nutritional status. The algorithms reflect WHO guidelines on interventions to treat the most common and serious conditions causing mortality or serious morbidity among neonates and infants and children. An underlying principle of IMCI is that an assessment provides a classification and that classifications should translate into an appropriate care and treatment response. An assessment that does not result in a classification and relevant treatment would not therefore be included.
WHO classifications of nutrition conditions in children based on anthropometry are provided in the earlier section “Definitions and key terms”. Definitions of wasting are based on weight-for-length in children under 2 years of age or weight-for-height in older children, or an assessment of the mid-upper arm circumference. The presence of bilateral oedema is a further criterion for identifying children with severe acute malnutrition. WHO definitions for overweight and obesity are also based on both weight and length/height estimates, i.e. weight-for-length/height and body mass index (BMI) but not mid-upper arm circumference.
Children with severe wasting or severe acute malnutrition have significantly increased mortality risk, though appropriate treatment significantly reduces mortality (19, 20). Children with moderate wasting and/or stunting also have increased mortality risk, although less than for severe wasting or wasting and stunting combined (21).
In an individual patient meta-analysis of 53 607 participants and 1306 deaths, the risk of all-cause mortality was elevated among children with one, two or three anthropometric deficits. In comparison with children with no deficits, the mortality hazard ratios were 3.4 (95% confidence interval [CI]: 2.6 to 4.3) among children who were stunted and underweight but not wasted; 4.7 (95% CI: 3.1 to 7.1) in those who were wasted and underweight but not stunted; and 12.3 (95% CI: 7.7 to 19.6) in those who were stunted, wasted and underweight (21).
In children, moderate acute malnutrition (moderate wasting) may be transient and experienced by children in the course of an acute illness. Moderate wasting may also be due to chronic illnesses such as tuberculosis (TB) or HIV, or can also be the result of food insecurity and inadequate dietary intake. Management of moderate wasting should include a range of essential nutrition actions such as breastfeeding promotion and support, education and nutrition counselling for families, and other activities that identify and prevent the underlying causes of malnutrition, including nutrition insecurity. Interventions to improve food insecurity include the provision of conditional or non-conditional cash transfers and support to agriculture, such as crop diversification (22). Children with moderate wasting need nutrient-rich foods to meet their extra needs for full recovery (22). In the context of food insecurity, food supplements may have a role and food programmes have been established in many humanitarian crises or other settings of chronic food insufficiency.
Historically, anthropometric assessments and nutrition classifications in IMCI focused on identifying infants and children with undernutrition because of the associated health consequences. The classification of undernutrition included in IMCI focused on assessing weight-for-age because it is simpler to measure than the length or height of children. Children whose weight-for-age was less than the third percentile were classified as “very low weight”. However, this classification did not necessarily reflect the relevant risks of morbidity and mortality. For example, one child may have a very low weight-for-age because he or she is stunted or has a history of low birth weight. In contrast, another child who is taller may have the same weight-for-age and is wasted because he or she has suffered a recent acute or serious illness. Similar considerations are relevant for children and classifications for overweight and obesity.
Therefore, with respect to both wasting and overweight and obesity, it is important to relate a child’s weight-for-age to their length/height, in order to correctly interpret their nutritional status.
In the context of the double burden of malnutrition, it is therefore important that a public health approach, such as IMCI, correctly identifies children who are at risk of clinically important undernutrition (severe or moderate wasting, or severe acute malnutrition) and also children who are at risk of overweight and obesity.
Summary of the evidence
Three reviews of relevant information were completed to contextualize the environment in which recommendations may be implemented and to assist the guideline development group to make informed decisions. Details of the review teams and references are presented in Annex 1, Annex 2a and Annex 2b.
- A meta-analysis of epidemiological anthropometric data of infants and children from different regions. This shows regional differences in rates of undernutrition and stunting in infants and children (23).
- A systematic review of the relationship between anthropometric measures in childhood and short- and long-term health outcomes (24).Note: Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tables (25) were not developed but comprehensive tables summarizing the evidence for associations between anthropometric measures in early childhood and anthropometric and health outcomes in adulthood are included in the report.
- A survey of IMCI chart booklets and clinical algorithms used in different countries, reporting current uptake and adaptations of IMCI at national level (26).
The first, an epidemiological analysis of surveys conducted in 63 low- and middle-income countries (1993–2012) (23) reported that between 0.4% and 18.6% of children (aged 6–59 months) would be classified as “very low weight”, i.e. weight-for-age more than 3 SD below the WHO child growth standards (2) (Bangladesh 14.1%, Chad 15.7%, India 18.6%, Niger 16.3%, Timor Leste 16%). The vast majority of these children are also stunted (low length/height-for-age). The proportion who were “very low weight” and also wasted varied by region. In Central and South American and Caribbean countries, 0.4–2% of stunted children were concurrently wasted, whereas in Africa and South Asia 0.5–11% were also wasted (see distributions by regions in Annex 1 (23)). The analyses highlight the regional differences in rates of undernutrition and stunting in infants and children, and the importance of correct classification of nutritional status for individual-based recommendations.
The second, a systematic review (24), analysed data from 52 studies (36 cohorts or longitudinal studies) that reported data on the association of anthropometric measures during infancy and childhood and the risk of developing obesity in later life (childhood, adolescence or adulthood). A meta-analysis using a random-effects model showed a significant inverse association of correlation coefficients. The pooled analysis of BMI showed a decreasing trend when tracked from early childhood (3–6 years) to mid childhood (9–11 years; r = 0.79, 95% CI: 0.71 to 0.87), adolescence (12–18 years; r = 0.66, 95% CI: 0.53 to 0.78), adulthood (19–40 years; r = 0.39, 95% CI: 0.29 to 0.50) and late adulthood (>40 years; r = 0.26, 95% CI: 0.18 to 0.34); mid childhood (9–11 years to adolescence (12–18 years; r = 0.81, 95% CI: 0.73 to 0.88), adulthood (19–40 years; r = 0.58, 95% CI: 0.50 to 0.66). BMI tracking showed similar trends in low- and middle-income countries and high-income countries. Thirteen studies showed that high BMI in childhood or adolescence was associated with a high risk of overweight or obesity in later life. The majority of the studies predicted a high risk of becoming overweight or obese with higher weight status during infancy and childhood.
Rapid weight gain in infancy and childhood was also strongly associated with the risk of overweight or obesity in adolescence or adulthood. Evidence from cohort studies showed that children who gained excess weight in “mid-child years” (age 4 years in four of the birth cohorts and age 8 years in one birth cohort) are at significant risk of obesity, diabetes and cardiovascular disease in adult life (27).
Eleven articles (including two consortia) from 13 cohorts discussed the associations of various anthropometric measures during infancy or childhood and cardiovascular morbidity and mortality in later life.
Four cohort studies showed that higher BMI during childhood was associated with cardiovascular disease morbidity and mortality during adult life. One cohort study (Helsinki Birth Cohort) showed that lower BMI during early childhood was associated with higher risk of cardiovascular disease during adult life. However, this finding was not consistent across all cohort studies. Two cohort studies, one each from Great Britain and the United States of America, did not find any association between childhood BMI and adult cardiovascular disease. The pooled results from three British cohorts found a significant relationship between being persistently overweight throughout childhood until adult life and coronary artery disease in later life. Pooled results from three historical British birth cohorts attributed minimal risk for ischaemic heart disease when childhood BMI was high. One cohort study (Helsinki) showed that lower weight and/or shorter length at 1 year of age increased the morbidity and mortality due to cardiovascular disease in adult life. Low weight-for-age at 1 year may have been due to low birth weight or being small for gestational age.
Findings regarding associations between childhood weight and height and systolic and diastolic blood pressure were not consistent. Among 29 283 subjects in 12 cohorts, 9 studies reported positive associations between BMI in childhood (2–12 years) and adolescence (12–18 years) and raised adult systolic and diastolic blood pressure measured between 19 and 50 years. One study, however, reported no association after adjusting for adult BMI.
In summary, there were strong correlations between high weight-for-length/height/BMI (and other markers of adiposity such as skinfold thickness) in early to mid-childhood and the prevalence of obesity, cardiovascular disease and diabetes in adolescents and adults (24).
The third review was a brief survey carried out by WHO in 2015 for the purpose of this guideline process (26), which found that anthropometric assessment of infants and children in the national IMCI chart booklet had been updated in 19 countries. In these versions, the combination of measurement most frequently included to assess nutritional status was weight-for-age + weight-for-length/height + mid-upper arm circumference, whereas in previous versions only assessments of weight-for-age were included. Clinical signs were used more frequently than anthropometric measurements to define acute malnutrition; “visible severe wasting” is still being used as a criterion in 39 countries despite no longer being recommended by WHO since 2013.
A separate growth-monitoring programme is carried out in 39 countries, mostly together with routine immunizations. Growth monitoring is most commonly performed in children below the age of 5 years. The anthropometric measurement used most frequently for growth monitoring was weight-for-age, then weight-for-length/height and length/height-for-age. Data on coverage of growth monitoring among children (up to 12 months of age) were available in 23 countries; high coverage of growth monitoring (80–100%) was reported in 12 countries (26).
Best practice statement
With respect to anthropometric assessment of infants and children presenting to primary health-care facilities, a statement on best practice was agreed.
Justification/remarks
The guideline development group considered that the statement did not constitute a recommendation that could be supported by comparative clinical studies. Instead, they considered it is self-evident that a child with acute undernutrition or who is overweight or obese must be identified, in order for appropriate interventions to be provided. No evidence was presented regarding the ability of health workers to effectively measure and interpret length/height and weight measurements to appropriately classify children. While growth monitoring is a common part of child health services, it is often challenging to do accurately (28, 29).
The group agreed, however, that they should make a formal statement that assessment of anthropometric status is important and provides the critical background against which several other important care and treatment decisions would be made. The group therefore decided that it was appropriate to formulate and present a best practice statement.
The group noted that using weight alone to inform clinical decisions leads to significant misclassification of nutritional status. One way to minimize this misclassification would be to standardize measurement of length/height in the context of IMCI. With this information, health workers would be able to provide appropriate nutrition counselling, e.g. information about food quality, and avoid inappropriate guidance such as advising parents whose children are underweight but of low length/height (therefore normal weight-for-length/height) to eat more.
An evidence base on health outcomes associated with reduced weight-for-length/height is available but there is no evidence on the impact of performing the assessment in routine conditions. Some members of the guideline development group felt that measuring length/height is not useful unless it is done properly. Also, it may not always be possible to measure length/height, and it could be an extra task carried out at the expense of some other health-worker activity.
Countries in the WHO Region of the Americas measure length/height routinely. Implementation was done with sensitization and advocacy for its importance, which has helped to put it into practice.
The arguments in favour of a recommendation were that if there were a recommendation to measure length/height routinely, then the strategy for implementation, including training, would be established.
Suggesting a “best practice” was considered to give flexibility to countries and reflect that measuring length/height may not always be possible.
Implementation considerations
Considerable initial training and feedback will be required to establish good measurement processes at health-care facilities.
Research priorities
A better understanding of the use and feasibility of biomarkers present in childhood to predict obesity and the risk of cardiovascular disease or diabetes mellitus in adolescence and adulthood.
2. Care of infants and children with acute or chronic malnutrition presenting to primary health-care facilities
Programmatic questions
- Should primary health-care workers counsel caregivers of, or otherwise intervene among, infants and children who are moderately wasted?
- Should primary health-care workers counsel caregivers of, or otherwise intervene among, infants and children who are stunted?
Background
Children with a history of low birth weight, or acute or chronic undernutrition, are at increased risk of morbidity and mortality during childhood (21) and are also at increased risk of overweight, obesity and cardiovascular disease in later life (30). They are also at greater risk of metabolic syndrome, including type 2 diabetes mellitus (31). The basis for the additional risk is not fully understood; however, it is thought that infants born with low birth weight have adapted to an in-utero environment in which fetal nutrition is suboptimal, such that their energy needs in infancy and childhood are reduced (32, 33). However, later, if presented with high-energy diets containing sugar or fat, these children may gain excess adipose tissue without gaining additional lean tissue or achieving improved linear growth (34). This concept is sometimes referred to as the developmental origins of health and development. Infants who experience moderate degrees of wasting and become stunted for whatever reason, may similarly have altered energy requirements in early childhood.
For these reasons, there is a potential, inadvertent risk of promoting overweight and obesity, or inappropriate gains in adipose tissue, if high-energy food supplements are given in response to stunting in childhood populations, or as part of efforts to treat or prevent moderate wasting.
The management of children presenting with moderate wasting is further complicated by the range of conditions that may decrease normal dietary intake or increase catabolic, physiological processes that can cause wasting. Acute illnesses may cause a child to lose their appetite and experience transient losses in weight. As such, children who experience moderate wasting may fully recover both nutritionally and functionally, as long as they receive adequate, high-quality nutrient-dense foods (22). If illnesses are severe or recurrent, then acute wasting may follow. Chronic infections such as TB or HIV infection may increase metabolic demands and also result in acute wasting. If appropriate anti-tuberculous or antiretroviral treatment is not given, then these children may experience severe wasting and are at high risk of death. Moderate wasting may also be the result of food insecurity and prolonged periods of inadequate dietary intake. In crisis settings, where there is a high prevalence of wasting or food insecurity (7), at community or household level, family food programmes may be implemented to avert increased infant and child mortality.
IMCI has historically emphasized dietary counselling as part of routine care of all infants and children presenting to primary health-care facilities with an illness. When the nutritional status of a child is normal, a mother is encouraged and reminded of good infant and child feeding practices, including exclusive and continued breastfeeding, appropriate complementary foods and family foods (see Figs. 1 and 2). If a child is found to have severe acute malnutrition, he or she is assessed for complications and either treated with therapeutic foods as an outpatient or admitted for additional treatment if found to have signs of sepsis. There has been no explicit guidance for health workers when they identify a child with moderate wasting and stunting.
Summary of the evidence
Note: The summary of evidence presented next reflects the terminology used by authors of the original scientific publications.
Counselling of caregivers of children with moderate wasting
One randomized controlled trial (RCT) reported on outcomes related to the effect of counselling and education to caregivers versus no education (36). The study methods were poorly described and hence the risk of bias is unclear. The authors investigated the effect of a home-based nutrition-education programme versus no education on the growth and psychological performance of moderately underweight (≤72% of expected weight-for-age without oedema or ≤79% of expected weight-for-age with oedema) children aged 7–36 months. The nutrition-education programme was provided to the mothers for a few months. The authors did not report on the short-term outcomes of the investigation, but instead on the growth and psychological functioning of the children 3 years later. The counselling did not address breastfeeding practices in younger children. There were no statistically significant differences in physical growth or psychological functioning of the children whose mothers had or had not received the nutrition-education programme.
Counselling of caregivers of children who are stunted but not wasted
No studies were identified that reported on the effectiveness of providing nutrition counselling to caregivers of children with stunting but no wasting.
Supplementary foods for young children (<24 months) who are severely underweight with moderate wasting
Short-term outcomes: Hossain and colleagues (37) evaluated the effect of supplementary foods plus standard care and counselling compared to standard care and counselling without supplementary foods among 162 children, aged 12–13 months, who presented with “very low weight”. Of these children, 81% were moderately wasted (z-scores, mean weight-for-age ± SD, −3.8 ± 0.1; length-for-age −3.5 ± 1.0; weight-for-length −2.7 ± 0.8); 67% were severely stunted; and 27% were moderately stunted. Despite weight and height gains, the children were still severely underweight at the end of the treatment period (see Table 1).
Table 1
Effect of supplementary foods and counselling on growth outcomes compared with counselling alone (37).
Long-term outcomes: No evidence was identified on the long-term effect of providing supplementary food to children with moderate wasting on outcomes such as the development of overweight and obesity or the development of, and/or risk factors for, cardiovascular disease or diabetes during adolescence or adulthood.
Supplementary foods for young children (<24 months) with moderate wasting and stunting
Short-term outcomes: Nikiema and colleagues (38) evaluated outcomes in 1974 stunted children aged 6–24 months presenting with moderate wasting, randomized to receive either 3 months of supplementation with fortified corn–soy blend or ready-to-use supplementary food, or child-centred counselling only. After 3 months of supplementation, children in the supplementation arm had some increase in weight and length (see Table 2). There were no outcome data for growth or mortality at later time points.
Table 2
Effects of supplementary food on growth outcomes compared with counselling alone (38).
No evidence was identified on the benefits or harms of providing supplementary food for children older than 24 months of age presenting with moderate wasting.
Long-term outcomes: No evidence was identified on the long-term effect of providing supplementary food to children with moderate wasting on outcomes such as the development of overweight and obesity or the development of, and/or risk factors for, cardiovascular disease or diabetes, during adolescence or adulthood.
Supplementary foods for children who are stunted but not wasted
Six studies reported on the effect of providing supplementary foods to children with stunting but who were not wasted.
Young children less than 24 months of age
Short-term outcomes: Four studies (39–42) in moderately stunted children aged 6–24 months contributed to a meta-analysis of outcomes assessed after 3 months of supplementary foods (see Table 3). There was significant heterogeneity between the studies. The supplementary foods provided to children were quite different between studies: high-energy milk-based supplements/milk and soy-fortified spread/lipid-based supplements/corn–soy blend.
Table 3
Outcomes assessed after 3 months of supplementary foods in children aged 6–24 months.
One study (43) provided evidence for the effect of providing moderately stunted children aged 6–24 months with 6 months of supplementary food (see Table 4).
Table 4
Outcomes assessed after 6 months of supplementary foods in children aged 6–24 months.
One study (44) provided outcome data on height, collected 3 months after a 3-month supplementation period in moderately stunted children aged 6–24 months. There was no statistically significant difference in length between the supplemented and non-supplemented children with moderate stunting (n = 82; mean difference = +2.3 cm, 95% CI: −0.86 cm to 5.46 cm; P = 0.15).
Long-term outcomes: There were no data on whether providing supplementary food to moderately underweight young children with moderate stunting improves linear growth, or has an impact on blood pressure or measures of body fat in late childhood (age 7–8 years) (45). Providing supplementary food to moderately underweight children with moderate stunting did not lead to any improvement in linear growth measured in adolescence (45). However, increased BMI in childhood is correlated with increased BMI in both adolescence and adulthood (24).
Children aged 24–59 months
Short-term outcomes: Among children aged 24–59 months, two studies provided outcome data at several time points during and after the supplementation period (n = 148 and 65) (43, 46). After 3 months of supplementation in children aged 36–59 months with moderate stunting, the supplemented children were significantly taller than the non-supplemented children (n = 148; mean difference = 2.4 cm, 95% CI: 0.1 cm to 4.7 cm; P = 0.04) (46). After 6 months of supplementation, the supplemented children were significantly taller than the non-supplemented children (46) (n = 148; mean difference = 2.4 cm, 95% CI: 0.1 cm to 4.7 cm; P = 0.04). Walker et al. (43) provided supplementary food for 24 months to children aged 18–42 months with moderate stunting. After 12 months of supplementary food, the supplemented children were statistically significantly taller than the non-supplemented children (43) (n = 65; mean difference = 1.3 cm; 95% CI: 0.0 cm to 2.6 cm; P = 0.04). However, after 24 months of supplementary food, there was no significant difference between the length/height of the supplemented and non-supplemented children (43) (n = 63; mean difference = 1.2 cm, 95% CI: −0.8 cm to 3.2 cm; P = 0.23).
Available outcome data from the two studies (43, 46) measured at the same time points are summarized in Table 5.
Table 5
Summary of outcome data comparing moderately stunted but not wasted children (24–59 months) who received or did not receive supplementary foods (43, ).
Best practice statement and Recommendation
With respect to counselling, a statement on best practice was agreed.
With respect to supplementary foods among children presenting to primary health-care facilities with either moderate wasting or stunting, two recommendations were agreed.
Justification/remarks
Counselling for moderate wasting and stunting
The deliberations of the guideline development group were constrained because there was only one RCT examining the effect of counselling, and this was not directly relevant to the population in question; nor did the RCT address breastfeeding practices, which may be relevant in younger populations of children. However, the group was satisfied that the benefits of providing nutrition counselling to caregivers of children with moderate wasting outweighed any risk. Extending counselling beyond young children to the group up to 5 years of age was regarded as a benefit.
The guideline development group considered that offering counselling to caregivers of stunted children may have unintended consequences, especially if the quality of counselling is inadequate or misdirected. Specifically, the group noted that counselling may infer that caregivers of children who are stunted should give additional energy-dense foods or products in response to chronic malnutrition. The evidence available does not show any sustained improvement in length/height-for-age over time in response to counselling or provision of supplementary foods for a limited period. The guideline development group noted, however, that giving additional energy to children who are stunted may increase adiposity and the likelihood of overweight/obesity both in childhood and in later years.
Nearly all caregivers are likely to value nutrition counselling in most settings, and health workers generally accept it as part of their interaction with clients. This counselling may contribute to children catching up weight after an illness.
The guideline development group acknowledged, however, that some nongovernmental organizations engaged in humanitarian work have opted to provide supplementary food products. The WHO Essential nutrition actions (22) recognize that children with moderate wasting need adequate nutrient-dense foods to meet their extra needs for nutritional and functional recovery. Also, caregivers of children with moderate wasting may benefit from nutrition counselling and other interventions to improve food security, including the provision of conditional or non-conditional cash transfers and support to agriculture such as crop diversification. However, the efficacy of individual interventions and the detailed nature of a full package of care required to achieve full nutritional and functional recovery are not clear, owing to the lack of evidence.
Some participants were concerned with the resources required. However, counselling of some kind is already in place in most settings; the issue will be to enhance and improve it.
The group concluded that health workers should address nutritional risks through counselling of caregivers of children presenting to a health facility. The recommendation was conditional, owing to the lack of relevant evidence.
Supplementary foods for moderate wasting
In reaching a recommendation, the guideline development group was concerned that most of the evidence was based on a single trial from some time ago, and thus the overall quality of the evidence was low. The group considered that there would be major variability in acceptability, values and preferences in terms of whether providing supplementary foods would be appropriate or even feasible, depending on the local context, especially whether the household or the community was food insecure. In some cases, families might worry about the quality of supplementary foods compared to identifying approaches for improving the quality and adequacy of local family foods.
The group also acknowledged there is a range of supplementary foods available, some of which are high in energy content while others have lower energy content but perhaps have a higher micronutrient content. The lack of data contrasting the benefit of these respective types of supplementary foods compared to no intervention limited discussions among the guideline development group.
The resources required for providing supplementary foods, even only for children presenting to primary health-care facilities, were assessed as being major. The needs would be not only for the food itself, but also for distribution, storage, staff training, etc. There was some preference expressed for home-made supplements, but some of the same issues might apply, depending on the context.
The group concluded against routinely providing supplementary feeding to moderately wasted children presenting to primary health-care facilities. It noted that exceptions could be made in the face of local food insecurity.
Supplementary foods for stunting
In reaching a recommendation, the guideline development group considered that the quality of the evidence from the systematic review was low. There was no strong evidence that supplementary feeding changes the outcomes of interest, and the review showed no impact on stunting over longer durations. At the same time, supplementary food may increase weight gain in stunted children, with long-term consequences.
The group noted that there is broad experience in implementing supplementary feeding schemes in various settings, so it is clearly feasible given adequate resources. However, whether resources would be forthcoming, and whether these would detract from other needs, were major questions raised by the guideline development group, especially noting the numbers of children globally who are stunted. Providing a supplement only for stunted children aged from 6 to 24 months was one option considered. However, there is no evidence to support this specific approach for children who are stunted, nor is there evidence for any differential effects on linear growth according to the type of supplementary food, i.e. high versus low energy, or by micronutrient profile. Another difficulty would be focusing the intervention to reach the most vulnerable, and to avoid accentuating inequalities.
While a generally acceptable intervention, it was noted that some families in different settings would prefer to receive cash. In many places, the provision of a food supplement or cash could be done as a community intervention, and not solely for children attending a primary health-care facility and cared for through IMCI. To this end, improving linkages between health-facility services and community-based programmes may be advantageous.
Given the evidence and balance of other factors, the guideline development group recommended against the provision of supplementary foods for stunted children. Because of the wide variation in acceptability and the low quality of evidence, the recommendation made was conditional.
Implementation considerations
- While counselling may appear to be a straightforward intervention to implement, the benefits that might be obtained are entirely dependent on the content and quality of the counselling. This would, in part, depend on the investments available for human resources and training.
- WHO provides relevant training courses to improve both the content and quality of nutrition-related counselling for this population. National programmes or adapted training courses should be consistent with, and of the same quality as, WHO training courses.
- Maintaining the quality of counselling over time requires continuing support to staff on the ground. The issue of sustainability of quality services should be considered at the time when an intervention is launched.
Research priorities
Nutritional counselling
- What are effective ways of communicating nutrition messages in low-resource settings.
- What are the most effective approaches for the delivery and content of nutrition counselling for caregivers of stunted children?
- What is the most effective approach for dietary counselling and what is the impact on catch-up growth in sick children with moderate acute malnutrition?
- How can reported barriers to counselling be overcome?
Supplementary foods
- What is the effect of different types and durations of supplementary foods, including low-energy supplements, on linear growth in children who are stunted, presenting with or without an illness?
Interventions
- What is an effective package of interventions to achieve nutritional and functional recovery of children with moderate wasting or stunting?
- What is the effect of providing different types and durations of supplementary foods in food-insecure settings on linear growth in children?
- What is the effect of zinc supplementation on linear growth in children living in food-insecure or low-resource settings?
3. Care of children who are overweight or obese presenting to primary health-care facilities
Programmatic questions
- Should primary health-care workers counsel caregivers of children who are overweight or obese regarding nutrition or other dietary measures?
- Should primary health-care workers counsel caregivers of children who are overweight or obese regarding physical activity?
- Should primary health-care workers refer children who are obese?
Background
The epidemic of child and adolescent overweight and obesity is affecting all regions of the world and not just those of relative affluence. Lifestyle changes, including shifts towards unhealthy diets and reduced physical activity, are affecting the status of child health as much as adult health. The patterns emerging today in child overweight and obesity will impact on the health of populations for the next 50–60 years and will probably have major economic and human-resource consequences for health systems (4).
Poverty and poor diets are some of the drivers of obesity. Obesity and increased rates of overweight are commonly seen in lower socioeconomic groups, owing to the expense associated with more healthy foods. Urbanization and increased motorized transportation and availability of fast foods contribute to the social determinants of the epidemic being witnessed in many transitioning economies and countries.
The Global strategy for infant and young child feeding (9) aims to improve breastfeeding and infant and young child feeding practices. It highlights the importance of compliance with, and implementation of, the International Code and subsequent relevant World Health Assembly resolutions, in order to protect breastfeeding and infant and young child feeding practices from unethical marketing practices and commercial pressures. It noted, even in 2003, the associations between poor early-infant and child feeding practices and the increasing incidence of child obesity and potential lifelong adverse health consequences. However, it does not specifically address the identification of children at risk of overweight and obesity, nor does it provide guidance on care and management.
IMCI focuses on children presenting to primary health-care facilities with an illness. It serves as an approach for delivering proven effective infant and child interventions. It aims to provide clinical guidance to cover the most serious childhood illnesses typically seen at first-level health facilities. In most countries, the clinical algorithms address diarrhoeal diseases, pneumonia, undernutrition, malaria and fever/meningitis. To date, the generic WHO IMCI has not addressed the challenge of overweight and obesity, though some countries and regions have started their own adaptation.
In response to the changing epidemiology of child health, and to provide guidance on mitigating risk factors for noncommunicable diseases in later life, IMCI needs to adapt and include appropriate guidance related to overweight and obesity.
Summary of the evidence
A new systematic review of relevant evidence was not commissioned for this area of care, as several systematic reviews had recently been published. Instead, a systematic overview of systematic reviews was conducted, to identify meta-analyses published between 2010 and 2015 that would provide relevant evidence. GRADE profiles were prepared from the relevant reviews.
The search strategy for the reviews, criteria for eligible reviews, Prisma diagram showing the final selection of eligible studies, and GRADE profiles are included in Annex 3.
Nutrition counselling of caregivers of children who are overweight or obese
One systematic review was identified (48) that provided indirect evidence regarding the question, “Should primary health-care workers counsel caregivers of children who are overweight or obese regarding nutrition or other dietary measures?” This was an update of a previous Cochrane review (49) that summarized interventions for the prevention of obesity in children. Peirson et al. (48) searched five databases up to August 2013 for eligible studies. Randomized trials of behavioural interventions relevant to primary care (diet, exercise and lifestyle) for preventing overweight and obesity in healthy normal or mixed-weight children or youth aged 0–18 years were included, if 12-week post-baseline data were provided for BMI, BMI z-score, or prevalence of overweight or obesity. In total, 90 studies were included, all with mixed-weight populations. Of these, there were 15 RCTs that assessed dietary interventions alone, including but not limited to nutrition counselling.
Overall, among the 90 studies evaluating dietary and/or exercise and/or lifestyle interventions, compared with controls, any combination of dietary/exercise or lifestyle interventions showed a small but significant effect on BMI and BMI z-score (standardized mean difference (SMD) = −0.07, 95% CI: −0.10 to −0.03; I2 = 74%), a reduction in BMI (mean difference = −0.09 kg/m2, 95% CI: −0.16 to −0.03; I2 = 76%) and a reduced prevalence of overweight and obesity (risk ratio [RR], RRintervention − RRcontrol = 0.94, 95% CI: 0.89 to 0.99; I2 = 0%; number needed to treat 51, 95% CI: 29 to 289). Little evidence was available on harms. There was variability across efficacious interventions, although many of the interventions were short term (68% were 12 months or less in duration), involved school-aged children and were delivered in educational settings. The authors concluded that, overall, behavioural prevention interventions (dietary and/or exercise and/or lifestyle) are associated with small improvements in weight outcomes in mixed-weight populations of children and adolescents.
Subgroup analyses (15 studies, 11 568 children) show that in children aged 0–18 years who were exposed to dietary interventions (including but not limited to nutrition counselling) alone, the SMD for BMI was −0.08 kg/m2 (95% CI: −0.17 kg/m2 to +0.01 kg/m2) than among children who did not receive such interventions.
Among children younger than 5 years (17 studies, 6930 children) who were exposed to dietary and/or exercise and/or lifestyle interventions, the SMD for BMI was −0.06 kg/m2 (95% CI: −0.15 kg/m2 to +0.02 kg/m2) than among children who did not receive such interventions.
The authors (47) rated the quality of the evidence for both of these subgroups as very low, owing to risk of bias, indirectness, inconsistency, imprecision or reporting bias among the studies included in the review. Other reviews identified addressed the elements of PICO only indirectly and either did not include RCTs, did not provide relevant subgroup data and/or failed to provide some form of evidence assessment.
Physical-activity counselling of caregivers of children who are overweight or obese
One systematic review was identified that provided indirect evidence regarding the question, “Should primary health-care workers counsel caregivers of children who are overweight or obese regarding physical activity?”. Peirson et al. (48), included 18 RCTs (15 902 children) that reported the effect of counselling on physical activity. This systematic review summarized preventive interventions that investigated the effect of dietary, exercise (including but not limited to counselling on physical activity), lifestyle and/or a combination of these interventions on BMI or BMI z-score in children and adolescents (0–18 years of age). Subgroup analyses based on intervention type (diet, exercise, diet plus exercise or lifestyle) showed that the effect was only significant for programmes of diet plus exercise compared with control conditions (mean difference = −0.15 kg/m2, 95% CI: −0.25 to −0.03 kg/m2). Additionally, among children (0–18 years of age) who were exposed to exercise interventions alone, the SMD for BMI was −0.08 kg/m2 (95% CI: −0.16 to 0.00 kg/m2; P < 0.001) compared to children who did not receive such interventions. Among children aged less than 5 years who were exposed to dietary and/or exercise and/or lifestyle interventions, the SMD for BMI was −0.06 kg/m2 (95% CI: −0.15 to 0.02; P = 0.001) compared to children who did not receive such interventions.
Peirson and colleagues (48) assessed that the evidence was of very low quality, owing to risk of bias, indirectness, inconsistency, imprecision or reporting bias. Other systematic reviews by Mura and colleagues (50), Kelley et al. (51) and Cesa et al. (52) included RCTs, but did not provide an assessment of the quality of the evidence and were therefore not considered.
Referral of infants and children who are obese
No systematic review was identified that directly addressed the question, “Should primary health care workers refer children who are obese?”. Four systematic reviews indirectly addressed the question (53–56). Both the National Institute for Health and Care Excellence (NICE) (53) and Peirson and colleagues (54) provided a formal assessment of the quality of the evidence, and so both reviews were used to inform the evidence for this question. Black et al. (55) summarized studies of all designs assessing bariatric surgery for obese children and adolescents. Boland and colleagues (56) summarized RCTs and case-studies assessing the pharmacological management of obesity in paediatric patients. However, neither of these two reviews (55, 56) included a formal assessment of the quality of the evidence and they were therefore not further considered.
A systematic review commissioned by NICE to inform guideline development contains two meta-analyses (53). The first meta-analysis of 12 studies, of which two examined referral to specialist centres with staff experienced in assessment and management of obese children, suggests that interventions that involve specialist medical referral to a programme, compared to self-referral, referral by a general doctor or school, or a mixture of referral methods show greater improvements in BMI z-scores at the end of the intervention (SMD = −0.41 (95% CI: −0.64 to −0.17). The second meta-analysis of 15 studies, three of which examined specialist medical referral, also provides strong evidence that the effect is sustained at 6 months or more post-intervention (SMD = −0.30, 95% CI: −0.49 to −0.11). Although the authors of the systematic review reported the quality of the evidence to be high (strong evidence), it was downgraded by the guideline development group to moderate quality, because of its indirectness.
A review of treatment by Peirson and colleagues (54) included RCTs aimed at behavioural and non-behavioural (pharmacotherapy and surgery) treatment of overweight and obese children aged 0–18 years. Subgroup analyses of combined pharmacological (orlistat) and behavioural (diet, exercise, lifestyle) interventions showed a reduction in BMI and BMI z-score from baseline to the end of the intervention period (2 studies including 562 children; SMD= −0.43, 95% CI: −0.6 to −0.25; I2 = 0%). The review authors judged the quality of the evidence for this outcome to be moderate.
Recommendations
With respect to children who are overweight or obese and presenting to primary health-care facilities, three recommendations were agreed.
Justification/remarks
It should be first noted that these recommendations do not represent comprehensive guidance on assessment and management of all children at risk of overweight and obesity. They do, however, start by addressing one population – children presenting to primary health-care facilities – for which there is already a system for training and clinical management (IMCI) that is implemented in many countries.
Nutrition counselling of caregivers of children who are overweight or obese
All members of the guideline development group agreed with the recommendation and its “conditional” strength. While agreeing that counselling of caregivers of these children would be helpful, it was less clear whether counselling alone would have a significant impact. The evidence base regarding the content of effective counselling is limited and the prevalence of overweight/obesity in different countries is variable; the return, therefore on time and investment may be quite different according to setting. For these reasons, it was considered that a decision to implement counselling as part of routine services at primary health-care facilities would have to be context specific.
With respect to the systematic reviews and evidence summary, one member of the guideline development group stated that it would have been helpful to know how long follow-up was for the interventions, and whether there had been language restrictions on the search strategy. The Secretariat explained that the strategy was not restricted by language, but noted that the review by Peirson and colleagues (48) only covered publications in English and French.
It was noted that the evidence was constrained by the strategy of the Peirson review (48). Other reviews might consider different interventions that might be more or less effective. It was also noted that the term “counselling” included a wide range of styles and methods, and the content of counselling was not considered.
All members of the guideline development group agreed that the recommendation should be conditional because of the lack of high-quality evidence on the effectiveness of providing training on counselling, uncertainty in terms of equity, and variability in values and preferences.
Physical-activity counselling of caregivers of children who are overweight or obese
Members of the guideline development group agreed with the draft recommendation, while noting similar constraints as for counselling on nutrition, i.e. a limited evidence base on the effectiveness of counselling, and uncertainty on the optimal content of counselling, including the frequency and variable prevalence of overweight/obesity in different settings. It was noted that counselling for diet and physical activity should go together (as in the WHO Global strategy on diet, physical activity and health and Global recommendations on physical activity for health (57, 58)), and not be considered separately. The national adaptation of this strategy should take the context into account for determining specific interventions, and should be seen in the overall context of promoting an agenda for healthy growth and development. It should encourage, enable and facilitate children to engage in physical activity and exploration for cognitive development, at levels appropriate for different ages. This is not specialized “exercise”, but usual and healthy activity. Counselling on physical activity has benefits for all children, including those with nutrition problems.
It was noted in the discussion that some of the studies included in the review involved actual programmes of physical activity, and not just counselling. The studies appeared to be so varied that it was difficult to draw a general conclusion from them.
Referral of infants and children who are obese
It was agreed that all obese children and their caregivers should be assessed and a comprehensive care plan should be developed to address underlying risk factors, promote weight reduction and healthy practices, and provide psychosocial support. In order to mitigate possible serious medical complications associated with obesity, such as hypertension and diabetes, assessment should include screening for early indicators of metabolic syndrome, e.g. raised blood pressure for age, or hyperglycaemia/insulin resistance or signs of hyperlipidaemia. However, there was discussion as to where the assessment and development of a care-management plan should be done.
Some members of the guideline development group thought that only obese children with complications such as comorbidities, or from high-risk families, needed referral. However, the group noted the diversity of settings in which recommendations may be implemented and agreed that it could not be assumed that all primary health-care facilities would have sufficient staff to undertake full and satisfactory assessments.
It was also noted that, in some countries, the large number of obese children aged under 5 years would make it impractical for them all to be referred. In some settings, community-based or private paediatricians may be available to assess and manage children, avoiding the need to refer to a specialist centre.
In settings where there is limited experience in assessing the underlying factors and the ability of a family to implement a comprehensive care plan for an individual child, the guideline development group considered it better to refer the child and family to a facility where such experience would be available. In time, such capacity may become available at primary health-care facilities.
The group agreed, however, that if comorbidities can be excluded and a comprehensive management plan developed, then subsequent follow-up could occur at the primary health-care facilities.
It was considered that national health authorities would make these decisions when adapting and implementing the recommendation.
It was noted that some of the interventions in the systematic reviews included interventions, such as bariatric surgery, that are not recommended for children under 5 years of age. However, the recommendation only refers to referral itself and does not address the subsequent interventions. The guideline development group was also concerned that most of the studies in the systematic reviews were conducted in high-income settings and included only older children.
Finally, it should be noted that WHO is currently developing recommendations for the treatment of obese children and adolescents.
Implementation considerations
- The content of counselling packages for both nutrition and physical activity should reflect local dietary practices and food availability. Packages should be field-tested for acceptability to families and also for ease and feasibility of use by health workers. They should also include positive health messages for the entire family and not be restricted to the child only.
- Staff at primary health-care facilities need to be trained to assess weight and length/height and how to determine weight-for-length/height. When staff identify a child as obese, they also need to recognize that checking the child’s blood pressure and blood sugar are important. Depending on the capacity of staff at primary health-care facilities, a management plan for weight management and dealing with medical complications will be needed. This may be undertaken at a primary health-care facility or may require referral to specialist services at another centre. After a management plan is developed, it may be possible to follow up children at primary health-care facilities, depending on local resources and capacity.
- These referral systems for children with obesity should be clarified when the recommendation is being implemented at primary health-care facilities. Low availability, or lack, of services may be a significant constraint. Resources required at primary health-care facilities to provide treatment recommended by a referral centre should be allocated in advance. It was noted this may include paediatric sphygmomanometers and facilities to treat insulin-dependent diabetes.
Research priorities
Dietary counselling for caregivers of infants and children who are overweight or obese
- How does the context in which recommendations are implemented, e.g. less-resourced settings versus more-resourced settings influence the outcome of dietary counselling?
- What is the quality and type of nutrition counselling currently provided versus what is needed?
- What equity-related issues, in the short and long term, influence the outcome of dietary counselling?
- How can diet-specific counselling at health facilities be linked to multi-sector approaches for improving other health activities including increased physical activity.
Physical activity among infants and children who are overweight or obese
- An evaluation of the effect of appropriate physical activity in small children for the prevention of overweight/obesity.
- Evidence on how to implement interventions in younger children and their families including multisectoral approaches for improving diet and physical activity.
- How to frame the language from the health worker to the caregiver, noting the need to differentiate normal physical activity from “exercise”, and to convey the correct message to caregivers.
Referral of infants and children who are obese
- What are the long-term effects of combined interventions and the importance of referring obese children aged less than 5 years to a specialist setting?
- What is the optimal management of these children in the long term?
- How to identify which obese children aged less than 5 years require more specific attention.
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NLM Citation
Guideline: Assessing and Managing Children at Primary Health-Care Facilities to Prevent Overweight and Obesity in the Context of the Double Burden of Malnutrition: Updates for the Integrated Management of Childhood Illness (IMCI). Geneva: World Health Organization; 2017. Evidence and recommendations.