South Asia and child wasting – unravelling the conundrum
By Harriet Torlesse and Minh Tram Le
Each annual release of the Joint Malnutrition Estimates by United Nations Children’s Fund (UNICEF), World Health Organization (WHO) and World Bank Group confirms the same situation. That the epicentre of the global wasting crisis lies in South Asia. That the number of wasted (25.1 million) and severely wasted (7.7 million) children in South Asia is more than double the next highest region of sub-Saharan Africa (UNICEF, WHO and World Bank, 2020). And that this is not just a function of population size - the prevalence of child wasting (14.8%) and severe wasting in South Asia (4.5%) are also double the prevalence in sub-Saharan Africa (Figure 1).
And yet these numbers are failing to provoke the scale and quality of response needed from national governments and the development and humanitarian community. There has been virtually no progress in reducing the prevalence of child wasting in South Asia in the last 10 years, and less than 5% of severely wasted children in South Asia are accessing treatment – one of the lowest coverage levels of any child health or nutrition intervention in the region.
The high prevalence of child wasting, combined with the lack of access to treatment services, have far-reaching consequences for child survival, growth and development in the region. Severely wasted children are up to 11 times more likely to die than well-nourished children, and those who survive may experience poor linear growth, stunting and associated developmental delays, with consequences for human capital and economic growth (UNICEF, 2019). In fact, it is likely that the high prevalence of wasting explains in part why the prevalence of stunting (33.2%) is also higher in South Asia than any other region.
With the COVID-19 pandemic posing even greater threats to children’s nutrition in South Asia (Roberton et al, 2020; Headey et al, 2020), there is a critical need to rethink and recharge the response to the wasting challenge in the region. This requires a more nuanced understanding of the context-specific drivers of wasting, the barriers and bottlenecks that are holding back progress, and the opportunities to make better use of the resources that are available and that could be mobilised. This article examines the context of child wasting in South Asia, the current status of the policy and programme response in countries, the immense challenges brought on by the COVID-19 pandemic, and what is needed to transform progress.
Child wasting in South Asia
Until the advent of the COVID-19 pandemic, the high prevalence of wasting persisted against a backdrop of relatively strong economic growth in South Asian countries; albeit with widening inequalities and inequities. The World Bank classifies only Afghanistan as a low-income country, the Maldives as upper-middle income and all other countries in the region as lower-middle income. Some countries in the region are affected by conflict and recurrent natural disasters; however, the overwhelming majority of wasted (and stunted) children live in a development context.
Almost all of South Asia’s wasted children are in five countries: India, Pakistan, Bangladesh, Afghanistan and Nepal. The national wasting prevalence hovers just below 10% in Afghanistan, Bangladesh and the Maldives, exceeds 10% in Nepal, and exceeds 15% in Pakistan, Sri Lanka and India (Figure 2). No country is on track to achieve the World Health Assembly target to maintain wasting below 5% by 2025 or below 3% by 2030 (Development Initiatives, 2020). In fact, the 2020 Global Nutrition Report found that there is “no progress or a worsening situation” in Afghanistan, India, Sri Lanka, the Maldives and Pakistan.
The context of child wasting in South Asia has several unique characteristics compared to other regions where the wasting prevalence is also high, such as sub-Saharan Africa. They include the very high prevalence and incidence of wasting at birth and in early life, the more prolonged periods of wasting that children experience in the first two years of life, the higher prevalence of concurrent stunting and wasting, and the relatively low post-neonatal mortality rate. It is important to understand these issues, because they influence the policy discourse on wasting prevention and treatment in the region.
The prevalence of wasting in South Asia is higher at birth than any other time in early childhood, which suggests that poor maternal nutrition and/or health are key drivers of wasting in the region (Ashorn et al, 2018). South Asia has the highest prevalence of low birth weight (27%) in the world; almost double that of sub-Saharan Africa (14%), the next highest region (UNICEF and WHO, 2019). One in five women are thin (body mass index <18.5 kg/m2) and one in 10 women has a short stature (<145 cm) (Goudet et al, 2018), both of which are risk factors for child wasting in South Asian countries (Harding et al, 2018b). This is also much higher than in sub-Saharan Africa. In East and Southern Africa, an estimated 12.5% of women are thin and only 2.5% have a short stature, while in West and Central Africa 11% of women are thin.1 Adolescent pregnancy is common in South Asia (11%), particularly in Afghanistan (20%) and Bangladesh (24%), although it is not as high as in sub-Saharan Africa (26%).2
Two recent studies examined longitudinal datasets of child wasting and stunting from South Asia, Africa and Latin America (Mertens et al, 2020a and 2020b). They found that South Asia has the highest prevalence of wasting at birth (19% in South Asia, compared to 8% in Africa), and the highest prevalence and incidence of wasting at all ages up to 24 months. Seasonality had a larger influence on wasting at birth in South Asia than in Africa. In fact, mean weight-for-length z-score at birth varied by almost a full standard deviation, depending on the month a child was born. This suggests that there are seasonal influences on food security in South Asia that impact on intrauterine growth restriction or preterm birth. In both South Asia and sub-Saharan Africa, the longitudinal analysis found that the highest incidence of wasting occurred in the first three months of age, even after excluding episodes of wasting at birth. Children who were wasted in their first six months of life were more likely to suffer wasting and stunting in later life. Early wasting also increased the risk of death by 24 months, with “persistent” wasting under six months of age (defined by the authors as at least 50% of child measurements wasted), severe underweight under six months of age, and concurrent wasting and stunting most strongly associated with death.
These findings call for much greater attention to preventing wasting at birth and during the first six months of life in order to reduce the prevalence and caseload of wasting and its associated mortality and development risks. South Asia outperforms all other regions on exclusive breastfeeding; however, the stakes are high for the 43% of infants less than six months old who are not exclusively breastfed, particularly those born small or preterm. In addition, only 40% of newborns in South Asia benefit from early initiation of breastfeeding (compared to 52% in sub-Saharan Africa)3 at a time of life when they are most vulnerable to wasting. By two years of age, the longitudinal analysis found that half (50%) of children in South Asia had experienced at least one wasting episode, compared with only 28% in Africa. One of the likely contributing factors is the poor quality of children’s diets in South Asia: only 12% of children aged 6-23 months consume diets that meet minimum acceptable standards.4
The same analysis revealed a higher proportion of children who were “persistently” wasted in the first two years (7% vs. 2%) in South Asia, and the highest proportion of concurrent wasting and stunting in this region, peaking at 7-8% in children 18-24 months (2% in Africa). Concurrent wasting and stunting is a highly vulnerable state that carries a similar mortality risk to severe wasting (McDonald et al, 2013; Myatt et al, 2018). In the past there has been a tendency to address wasting and stunting in isolation – often with wasting considered a humanitarian problem and stunting a development concern. However, it is apparent that these two conditions are closely related, with repeated or prolonged periods of wasting resulting in linear growth failure and stunting.
Wasting and stunting share several common predictors in South Asian countries (maternal undernutrition and poor health, low birth weight, and poor diets in infancy and early childhood) and often affect the same child (Harding et al, 2018b; Torlesse and Aguayo, 2018). Indeed, low birth weight is a predictor of being concurrently wasted and stunted in South Asia, while in India poor complementary feeding is also associated with the co-occurrence of stunting and wasting (Harding et al, 2018b). These findings call for integrated programming that brings the wasting and stunting agendas together to address both forms of undernutrition across the lifecycle.
Some researchers argue that the mortality risks of severe wasting may be lower in South Asia than other regions because post-neonatal mortality rates are relatively low in the region, despite the high prevalence of wasting and severe wasting (UNICEF, 2018). However, the analysis of longitudinal data by Mertens et al (2020b) found that early growth failure, persistent wasting and concurrent wasting – all common conditions in South Asia – were associated with increased mortality.
More research is needed to understand the relationship between mortality and wasting in South Asia, how it is affected by the context, and its implications for policies and programming. What is clear is that the mortality risks are not low enough to ignore, and even if more children survive wasting and severe wasting in South Asia, there are potentially long-term deleterious consequences for linear growth, cognition and learning.
Studies in India have also reported that severely wasted children without medical complications respond more slowly to treatment than in Africa (Prost et al, 2019); perhaps because they are younger, have more severe wasting episodes, or have different body morphologies which mean that weight-for-length cut-offs capture different severities of wasting across different populations (Post et al, 2001). These findings may reflect regional differences in wasting aetiology, but also require further investigation.
Policy and programme response to child wasting in South Asia
Nutrition is currently high on the political agenda in South Asia and most countries are implementing multi-sector national nutrition plans to meet global nutrition targets. However, wasting has not attracted sufficient attention in the design and implementation of these plans, as is evident in the slow progress to prevent wasting and the very low coverage of services to treat severely wasted children. In countries that are members of the Scaling Up Nutrition (SUN) Movement (Afghanistan, Bangladesh, Nepal, Pakistan, Sri Lanka and selected states in India), this may stem from the primary focus of the movement on stunting reduction. Indeed, there has been a tendency in some countries to separate, rather than integrate and align, efforts to address stunting and wasting.
In addition, South Asia has not attracted the same level of donor support or non-governmental organisational presence to address wasting as sub-Saharan Africa. The transition of South Asian countries to middle-income status, and the concentration of donor support to humanitarian crises in sub-Saharan Africa and the Middle East, may partly explain why South Asia’s immense wasting challenge has received disproportionately low attention from donors and the global nutrition community. While this could be viewed as an opportunity to build strong government leadership and ownership of the wasting agenda in South Asia, unresolved questions on how countries can afford to deliver interventions at scale, particularly for wasting treatment, is a drag on progress.
Here we describe the current policy and programme response in the six countries with the highest wasting burdens (Afghanistan, Bangladesh, India, Nepal, Pakistan and Sri Lanka). We focus predominantly on the treatment of wasting (Table 1 and Box 1), because preventive actions have received relatively more attention by governments and partners in most country contexts (with the possible exception of Afghanistan and Pakistan), thanks to the global, regional and country efforts to reduce stunting. That said, we recognise that the prevention of wasting should be the first priority in order to lower the number of children requiring treatment, and because children who recover from wasting have a higher risk of poor growth and neurocognitive development (Black et al, 2013). In particular, the evidence calls for intensified action in South Asian countries to improve the nutrition of women and their infants during the 500 days between conception and six months postpartum. There is also need to improve complementary feeding, as practices in the region are very poor and better diets could reduce the incidence of wasting after six months. Maternal nutrition is further explored in this edition of Field Exchange5 and in a recent edition of the ENN publication Nutrition Exchange which examined actions to improve the diets of young children in South Asia.6
Only three countries (Afghanistan, Nepal and Pakistan) have national policies and guidelines for the treatment of wasting that are largely in line with the 2013 WHO recommendations (WHO, 2013), including the use of ready-to-use therapeutic foods (RUTF) to treat uncomplicated cases of severe wasting at community level. The programmes in these three countries began as humanitarian responses and are at various stages of integrating treatment into routine health services, but coverage is severely constrained by a lack of funding, particularly for RUTF. Afghanistan is largely dependent on short-term humanitarian funding (Food for Peace, United States Government (FFP/USG)), and this has enabled the country to achieve up to 50% coverage of children with severe wasting – the highest in the region but still far short of universal coverage. Further, this coverage is fragile, as attempts to leverage multi-year and/or development funding have not been successful. Ideally, the funding for procurement of RUTF should be included in the government’s Basic Health Service Package (BHSP) in Afghanistan; however, concerns regarding the size of the budget line has meant there has been no agreement to date. In Pakistan, both FFP/USG (for humanitarian needs only) and the government fund RUTF, although the programme is severely underfunded and coverage is therefore very low (<5%). In Nepal, the government now has a budget line for RUTF and is poised to take over financial support from the European Union and UNICEF, but again the needs outstrip financial resources and coverage remains below 5%. None of these three countries has included RUTF in its essential medicines list, and the funding gaps to bring these services to scale have not been quantified, although work is underway to address these gaps.7
Both India and Bangladesh have inpatient services to treat severe wasting. However, neither country has fully adopted WHO recommendations on the management of severe wasting, including the treatment of uncomplicated cases at community level using RUTF formulations that meet WHO specifications. In Bangladesh, the reliance on inpatient treatment severely constrains access to treatment as the opportunity costs of inpatient care are high, particularly for vulnerable families. The one exception is the response to the Rohingya crisis in Cox’s Bazaar, where community-based management of severe wasting with RUTF is in place. In India, some states are implementing community-based management of severe wasting using a range of nutrition products that are financed by the government and (in a few states) by philanthropic foundations.8 In addition, take-home rations (for children aged 6-35 months) or mid-day meals (for children aged 3-6 years) are provided by the government-financed Integrated Child Development Services (ICDS) in India; children who are severely underweight receive a double ration (de Wagt et al, 2019). Sri Lanka has both inpatient and outpatient management of severe wasting, also largely funded by government, but services are only provided up to the district level, again constraining access to treatment.
Public officials and academics in Bangladesh and India raise a number of concerns regarding global recommendations on how child wasting is managed. One is on RUTF, including the cost of managing severely wasted children with RUTF at scale; the cost-effectiveness, given the relatively low post-neonatal mortality rate; the suitability of the product for South Asian children, in particular its nutrient content and cultural appropriateness; the existence of alternative food products, such as the food rations provided by the ICDS in India, that cater to severely underweight children; the relatively stronger health-service platforms in countries (compared with sub-Saharan Africa) that enable children to be detected and referred to inpatient care if needed; and the epidemiology of wasting (which, the officials and academics argue, calls for a rebalance of efforts to prevent maternal malnutrition and infant wasting in the first six months). We do not examine these arguments in this article, except to say that there is an urgent need to convene the academic community to build a stronger evidence base that can objectively inform policies and programmes to treat severe wasting in South Asia and to inform the global normative guidance; which, as acknowledged by WHO (2013), is largely based on evidence from sub-Saharan Africa.
It is important to balance the policy discourse on wasting in the region, which should encompass much more than the ‘product’ used to treat severe wasting. In the context of South Asia, we must examine the continuum of care from pregnancy to child to bring down the numbers of wasted children requiring treatment, and from the early detection of wasting to treatment and prevention of relapse. We are currently missing opportunities to identify wasted children because some countries in the region are not using mid-upper arm circumference (MUAC) as a screening tool and instead rely on weight-for-height only, which is challenging to measure at community level. Recent evidence that weight-for-age may identify children at high risk of death (Mertens et al, 2020b) is encouraging as growth monitoring is implemented in all countries. Community-based systems and services to treat wasting are still often delivered vertically and in isolation from interventions that prevent stunting and wasting, and more integrated approaches are needed. In some countries, such as Afghanistan, services to manage moderate wasting are not systematically linked to services treating severe wasting. Elsewhere, there is often a lack of services to aid the recovery of moderately wasted children, including caregiver counselling, and prevent deterioration to severe wasting. It is essential to address the disjoint in approaches and design services in a way that enables a comprehensive, child-centred approach across the continuum of care from prevention to treatment.
For infants less than six months of age, countries across the region have integrated the care of low-birth-weight infants into neonatal services at health facilities. A greater concern is the continuity of care when these infants are discharged into the community (or for children born at home) and the early identification and care of infants who are or who become nutritionally vulnerable in early infancy. All six countries have national guidelines for the inpatient care of wasting in infants less than six months of age, but no country currently has national programmes to manage nutritionally at-risk infants and their mothers at community level. However, India is providing home-based care for children born with low birth weight,9 and Afghanistan, Bangladesh and India are actively exploring how to introduce programmes to manage nutritionally at-risk infants and their mothers at community level. Outstanding issues are how best to identify these nutritionally vulnerable infants and how to ensure their mothers receive support, given the service entry point is often centred on paediatric care.
Many of these issues were raised during the regional conference convened by the South Asia Association for Regional Cooperation (SAARC) and UNICEF on “Stop Stunting – No Time to Waste” in 2017.10 This landmark event brought together countries from across South Asia to discuss and agree actions to scale up the care and treatment of severely wasted children. The conference concluded with a Call to Action11 to guide policy and programming action to reduce child wasting, which was endorsed by the SAARC Ministers of Health later the same year. The central premise of this Call to Action is that the prevention of wasting and stunting is the priority in all contexts, development and humanitarian, given the very high prevalence and burdens in the region and costs of these conditions to children, families and nations. But, when children become wasted, it is essential that they are identified early and treated, which is best achieved through a combination of community-based treatment for those without medical complications and facility-based treatment for those with medical complications.
This Call to Action remains relevant and we expect it to be reflected as the region and high-burden countries move forward under the Framework for Action of the United Nations Global Action Plan on Wasting (hereafter referred to as the “GAP Framework”) to develop country Roadmaps for Action towards the Sustainable Development Goal target on wasting.12 These country Roadmaps for Action will be developed under the leadership of national governments and will identify a set of priority actions needed to accelerate progress on the prevention and treatment of wasting. These actions should be integrated into broader, multi-sector national nutrition policies, strategies and plans at the earliest opportunity to ensure appropriate linkages with actions to prevent all forms of malnutrition.
Child wasting and COVID-19
Since early 2020, the COVID-19 pandemic has upended the lives of millions across the region (Ingram, 2020). The massive loss of jobs and income, combined with disruptions in the production, transportation and sale of affordable foods, have severely impacted the ability of vulnerable households to feed their families. For example, a study conducted among urban poor households in Bangladesh in April 2020 found that 75% experienced a fall in income, 28% experienced a fall in food expenditure, and 24% were no longer able to consume three meals a day (PPRC & BIGD, 2020). Social protection systems are unable to meet the growing needs of impoverished families, which are likely to persist for many months following the removal of lockdown measures.
The impact on child wasting is deeply concerning. Estimates released in July 2020 suggest that, in the absence of timely action, an additional 6.7 million children will become wasted globally, an increase of 14.3%, and more than 10,000 children will die each month as a result. (Headey et al, 2020).1 Worryingly, the authors predict that South Asia will be most affected – of the predicted additional 6.7 million wasted children, 3.9 million (58%) will be in South Asia. It is challenging to obtain actual data on nutritional status at this time as these measurements require physical contact with a child; however, Afghanistan has continued to measure children at health facilities and recorded a 13% increase in number of wasted children between January (690,000) and May (780,000) alone.13
Overwhelmed health systems have struggled to continue providing essential services to prevent and treat wasting and to reassure families to use them. In countries across the region, preventive nutrition services (e.g., nutritional care of women during antenatal care, support and counselling on breastfeeding and complementary feeding, and vitamin A supplementation) were often the first to be deprioritised following lockdown measures. A study conducted in nine hospitals in Nepal found that the percentage of newborns who were breastfed within one hour of birth decreased by 3.5% during the early weeks of lockdown (Ashish et al, 2020). Fear of the contagion meant that some women in maternity facilities and isolation centres were separated from their breastfeeding infants, severely compromising the initiation and continuation of breastfeeding. Wasting treatment services were closed or considerably reduced to free up staff time and space to treat COVID-19 patients. For example, by May 2020 data from routine information systems showed that inpatient admissions for severe wasting were over 40% lower in Afghanistan and 75% lower in Bangladesh compared to May 2019, and outpatient services ground to a halt in Nepal.
However, by June 2020, most countries were reversing the downward trend in admissions for severe wasting. Country, regional and global nutrition communities have truly come together to identify pragmatic solutions to enable the delivery of essential nutrition services to continue. Ministries of health across the region reprioritised and resumed essential nutrition services as soon as measures were in place to do so as safely as possible. Many have adapted global guidance on the nutritional care of children in the context of the COVID-19 pandemic to their country contexts, including guidance on the treatment of wasting. They have introduced a range of programmatic adaptations to enable the continuation of services to prevent and treat wasting while minimising the risks of COVID-19 transmission (Box 2).
While essential nutrition services have since been able to resume in most settings, they are not yet back to prior capacity. Thousands of children have slipped into wasting as a result of the indirect impacts of the pandemic and have missed out on treatment when they needed it most. As countries continue to grapple with the pandemic, and the threat of further lockdown measures and economic hardship continues, it is essential that governments and their partners take action to prevent more children from becoming wasted, and to treat those that do.
In July 2020 the heads of UNICEF, the Food and Agriculture Organization (FAO), the World Food Programme (WFP) and WHO issued a global Call for Action to protect children’s right to nutrition in the face of the COVID-19 pandemic. They identified actions that should be taken and tracked immediately to protect children’s right to nutrition. These included actions to:
- Safeguard and promote access to nutritious, safe, and affordable diets;
- Invest in improving maternal and child nutrition through pregnancy, infancy and early childhood;
- Reactivate and scale up services for the early detection and treatment of child wasting; and
- Expand social protection to safeguard access to nutritious diets and essential services.
The challenge now is to realise these actions in practice. This will require substantial investments from governments, donors, the private sector and the United Nations at a time of economic downturn, when the mismatch between needs and financial resources (of both donors and governments) is likely to be considerable. There is, therefore, an urgent need to contextualise this Call to Action according to each country setting in the region to focus resources on actions most likely to mitigate the impact of the pandemic on children’s nutrition.
Reimagining care for wasted children in South Asia
The response to wasting in South Asia is clearly not commensurate with the magnitude of the problem. Global normative guidance on the treatment of severe wasting has been adopted in Afghanistan, Nepal and Pakistan, but the shortage of financial resources to cover the cost of RUTF and meet both development and humanitarian needs sustainably is a key barrier to scale. Meanwhile, there are no national programmes to treat severe wasting at community level in Bangladesh, India and Sri Lanka. In these countries, there are aspects of the global normative guidance for community-based management of acute malnutrition that some stakeholders consider inappropriate for their country contexts; yet evidence-based alternatives have not been identified. While there has been relatively greater emphasis on preventive interventions, the prevalence and incidence of wasting remains persistently high in early life because too many mothers are thin, short and young, and there is insufficient care for nutritionally vulnerable infants. This failure to prevent wasting and treat those who become wasted is robbing the opportunities of this generation’s children to survive, grow, develop and thrive.
At the same time, South Asia offers a wealth of capacity and opportunities to think and do things differently, and to help drive innovative approaches that may not only inform policies and programmes to prevent and treat child wasting in South Asian countries, but benefit other regions, too.
Government leadership and ownership of the prevention and treatment of child wasting should be at the core of all efforts. Government leadership is critical in all contexts – development and humanitarian – and at all levels. We must do more to bring leaders’ attention to the harmful consequences of inaction on wasting and to the potential returns on investing public resources. However, countries should not address wasting in isolation. Instead, they should ensure that actions to prevent and treat wasting (including those identified in country Roadmaps for Action as part of the operationalisation of the GAP Framework) are embedded in multi-sector nutrition strategies and plans.
The challenges are too immense for governments to act alone; nor can they rely on humanitarian funding to treat children, given its short-term horizon and failure to cater to the needs of the majority of wasted children who live in a development context. The development community should also pay proportionate attention to South Asia in terms of technical assistance and funding to unravel the most pressing challenges. This includes leveraging the global health as well as nutrition communities. A crucial step in leveraging financial resources for wasting prevention and treatment is to understand the costs involved.
Preventive actions should be positioned at the centre of national efforts to reduce the number of wasted children. Greater priority must be given in South Asia to improving the nutritional and health care of women before and during pregnancy to prevent low birth weight and for their own health and wellbeing; to strengthening the nutritional care for low-birth-weight infants and their mothers, both at facility and community level; to improving breastfeeding and complementary feeding practices in the first two years of life; and to identifying and referring children who become wasted. The health system plays a primary role in delivering these nutrition interventions, but convergent actions by the food, social protection and water and sanitation systems are also needed to improve the access of vulnerable households to safe, nutritious and affordable diets and the capacity of caregivers to care for their children during the crucial early years. We still have much to learn on how to deliver services that prevent wasting, so preventive actions should be coupled with knowledge generation to iteratively learn what works and how.
We must strengthen the integration of the care of wasted children into the health system across a continuum of care that spans the prevention and treatment of moderate and severe wasting. For some countries, this needs to begin with policy consensus on evidence-based approaches to treat wasting at community level. In all contexts, interventions to prevent and treat wasting should be considered a part of the essential healthcare package and be appropriately reflected in policies, plans, budgets, health workers’ pre-service training, supply-chain management, and health management information systems.
Finally, we need to continue to build the evidence base on the epidemiology of child wasting in South Asia and on effective models of care across the prevention and treatment continuum. We must clearly define and target the evidence gaps that are stifling policy and programme action. In particular, implementation research is needed to examine the effectiveness of alternative models and innovative approaches to care for wasted children that build on existing systems and service-delivery platforms and which have genuine potential for scale. There is also a need for open forums to discuss the evidence and its interpretation, and to drive consensus-based and evidence-driven policy and programme decisions.
We truly believe that there is immense need and potential for research and the ongoing evidence debates in South Asia to contribute to both regional and global efforts to optimise and innovate sustainable and scalable approaches to care for children with wasting. To this end, the UNICEF Regional Office for South Asia (ROSA) has formed a Technical Advisory Group (TAG), comprising leading regional and global experts, to examine the existing evidence from South Asia and to help address the evidence gaps that are blocking solutions for South Asia’s children.14 The TAG will also advise on the implications of new evidence for the design of policies and programmes in South Asia, and global operational and normative guidance.
As countries continue to grapple with the COVID-19 pandemic and its knock-on effects on livelihoods, income and services, we must accept that business cannot continue as usual for South Asia’s wasted children. The crisis may, in fact, be the long overdue catalyst that forces national government and developments partners to rethink how we focus resources to prevent and treat child wasting in South Asia. Now, more than ever, we must identify what will be most impactful at a time of multiple needs and how to effectively reach the region’s most vulnerable children, and greatly enhance our efforts to secure both domestic and external financial resources. It is time to bring greater visibility to child wasting in South Asia and to build the commitment of national and international actors to more purposefully resolve the challenges that are holding back progress.
1 Unpublished estimates prepared by UNICEF East and Southern Africa Regional Office (does not include data from South Sudan, Somalia and Angola) and UNICEF West and Central Africa Regional Office.
2 Percentage of women aged 20-24 years who gave birth before 18 years of age. Data available from https://data.unicef.org/topic/child-health/adolescent-health
3 UNICEF database on infant and young child feeding available from: https://data.unicef.org/resources/dataset/infant-young-child-feeding/
4 See preceding footnote.
5 See views article in this edition entitled “Improving Maternal Nutrition in South Asia: Implications for Childhood Wasting Prevention Efforts”.
6 Nutrition Exchange South Asia: Young Children’s Diets in South Asia. June 2020, Issue 2. Available from: www.ennonline.net/nex/southasia
7 See news item in this edition entitled “Tackling child wasting: a review of costing tools and an agenda for the future”.
8 See field article in this edition entitled “Community management of acute malnutrition in Rajasthan, India”.
9 See field article in this edition entitled “Managing at risk mothers and infants under six months in India – no time to waste”.
11 See Call to Action in the report summary in this edition entitled “Report of the South Asia ‘Stop stunting: No time to Waste’ conference”.
12 See views article in this edition entitled “UN Global Action Plan (GAP) Framework for Child Wasting and the Asia and Pacific Region”.
14 See news article in this edition entitled “South Asia Technical Advisory Group on Wasting”.
Ashish, K. C., Kinney, M. V., Avinash, K. S., Moinuddin, M., Basnet, O., …Malqvist, M. (2020). Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: a prospective observational study. Lancet Global Health, https://doi.org/10.1016/ S2214-109X(20)30345-4.
Ashorn, P., Hallamaa, L., Allen, L. H., Ashorn, U., Chandrasiri, U., … Dewey, K. G. (2018). Co-causation of reduced newborn size by maternal undernutrition, infections, and inflammation. Maternal and Child Nutrition, 14, e12585.
Black, R. E. et al. (2013). Maternal and child undernutrition and overweight in low-income and middle-income 347 countries. Lancet, 382, 427–451.
de Wagt, A., Rogers, E., Kumar, P., Daniel, A., Torlesse, H. & Guerrero, S. (2019). Continuum of care for children with wasting in India: Opportunities for an integrated approach. Field Exchange 60.
Development Initiatives (2020). 2020 Global Nutrition Report: Action on Equity to End Malnutrition. Bristol, UK: Development Initiatives.
Goudet, S., Murira, Z. & Torlesse, H. (2018). Effectiveness of programme approaches to improve the coverage of maternal nutrition interventions in South Asia. Maternal & Child Nutrition, 14(Suppl 4), e12699.
Harding K.L., Aguayo, V. M. & Webb, P.(2018a). Birthweight and feeding practices are associated with child growth outcomes in South Asia. Maternal and Child Nutrition, 14(S4): e12650.
Harding, K.L., Aguayo, V. M. & Webb, P. (2018b). Factors associated with wasting among children under five years old in South Asia: Implications for action. PLoS ONE 13(7): e0198749.
Headey, D., Heidkamp, R., Osendarp, S., Ruel, M., Scott, N., …, on behalf of the Standing Together for Nutrition consortium (2020). Impacts of COVID-19 on childhood malnutrition and nutrition-related mortality. Lancet. https://doi.org/10.1016/S0140-6736(20)31647-0
Ingram, S. (2020). Lives Upended: How COVID-19 Threatens the Futures of 600 Million South Asian Children. Kathmandu: UNICEF Regional Office for South Asia.
McDonald, C.M., Olofin, I., Flaxman, S., Fawzi, W. W., Spiegelman, D., … Nutrition Impact Model Study (2013). The effect of multiple anthropometric deficits on child mortality: meta-analysis of individual data in 10 prospective studies from developing countries. American Journal of Clinical Nutrition, 97(4), 896–901.
Mertens, A., Benjamin-Chung, J., Colford, J. M., Coyle, J., van der Laan, M., … ki Child Growth Consortium (2020a). Causes and consequences of child growth failure in low- and middle-income countries. Preprint available at https://doi.org/10.1101/2020.06.09.20127100
Mertens, A., Benjamin-Chung, J., Colford, J. M., Hubbard, A. E., van der Laan, M., … ki Child Growth Consortium (2020b). Child wasting and concurrent stunting in low- and middle-income countries. Preprint available at https://doi.org/10.1101/2020.06.09.20126979
Myatt, M., Khara, T., Schoenbuchner, S., Pietzsch, S., Dolan, C., … Briend, A. (2018). Children who are both wasted and stunted (WaSt) are also underweight and have a high risk of death. Archives of Public Health, 76, 28. https://doi.org/10.1186/s13690-018-0277-1
Post, C. L. & Victora, C. G. (2001). The low prevalence of weight-for-height deficits in Brazilian children is related to body proportions. Journal of Nutrition, 131, 1290–1296.
PPRC & BIGD (2020). Livelihoods, Coping and Support During the COVID-19 Crisis. Dhaka: Power and Participation Research Centre and BRAC Institute of Governance and Development.
Prost, A., Nair, N., Copas, A., Pradhan, H., Saville, N., … Sachdev, H.S. (2019). Mortality and recovery following moderate and severe acute malnutrition in children aged 6–18 months in rural Jharkhand and Odisha, eastern India: A cohort study. PLoS Med, 16(10), e1002934.
Roberton, T., Carter, E. D., Chou, V. B., Stegmuller, A. R., Jackson, … Walker, N. 2020). Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. The Lancet.
Torlesse, H. & Aguayo, V. (2018). Aiming higher for maternal and child nutrition in South Asia. Maternal & Child Nutrition, 14(Suppl 4), e12739.
UNICEF & WHO (2019). UNICEF-WHO Low Birthweight Estimates: Levels and Trends 2000–2015. Geneva: World Health Organization.
UNICEF (2018). Wasting in South Asia: Consultation on Building the Evidence Base for the Policy and Programme Response. UNICEF Regional Office for South Asia: Kathmandu, Nepal.
UNICEF (2019). Stunting, Hidden Hunger and Human Capital in South Asia. Kathmandu: UNICEF Regional Office for South Asia.
UNICEF, WHO & World Bank (2020). Levels and Trends in Child Malnutrition: Key Findings of the 2020 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization.
WHO (2013). Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children. Geneva: World Health Organization.
Figure 1: Prevalence of wasting and severe wasting by region (2019 estimates)
Source: UNICEF, WHO and World Bank Joint Malnutrition Estimates, 2020 edition.
Figure 2: Prevalence of wasting and severe wasting in South Asian countries
Source: Afghanistan National Nutrition Survey (NNS) 2013, Bangladesh Multiple Indicator Cluster Survey (MICS) 2019, Bhutan NNS 2015, India Comprehensive National Nutrition Survey 2016-7, Maldives DHS 2016, Nepal MICS 2019, Pakistan NNS 2017-8, Sri Lanka DHS 2016; South Asia UNICEF, WHO and World Bank Joint Malnutrition Estimates, 2020 edition.
AFG = Afghanistan; BGD = Bangladesh; BHU = Bhutan; IND = India; MDV = Maldives; NPL = Nepal; PAK = Pakistan; LKA = Sri Lanka
Table 1: National policies and strategies to care for severely wasted children
Box 1: Treatment of severe wasting in South Asian counties
Afghanistan: Child wasting is a priority in the National Public Nutrition Strategy and the Afghanistan Food Security Nutrition agenda. The community-based programme for the management of child wasting is part of the Basic Package of Health Services (BPHS) and Essential Package of Hospital Services (EPHS). While ready-to-use therapeutic food (RUTF) procurement remains reliant on humanitarian funding, the treatment of severe wasting is otherwise well integrated into the health system, and this has enabled significant scale-up of services (coverage of up to 50% of severely wasted children). The country is currently working on the simplification of the national protocol and will pilot the use of ‘family MUAC’ (mid-upper arm circumference) and reduced dosage of RUTF in selected provinces in response to shortages of funding for RUTF.
Bangladesh: Bangladesh has national guidelines for both facility and community-based management of severe wasting. However, only inpatient services are provided at facility level as treatment with commercial RUTF is not permitted (except for the Rohingya response in Cox’s Bazaar) and no alternative has been identified. As a result, the coverage of treatment services remains persistently low. Researchers in Bangladesh are seeking to test the effectiveness of locally prepared RUTF recipes that comply with World Health Organization (WHO) specifications. Given the high prevalence of low birth weight and wasting in early life, the country has piloted an innovative approach for the management of infants and mothers at risk of wasting at community level.
India: In India the inpatient management of child wasting is provided in nutrition rehabilitation centres (NRCs), following the 2013 guideline on facility-based management of severe acute malnutrition. More recently, there has been experience in integrating inpatient management of child wasting in inpatient paediatric services, which could be a more scalable approach. A draft guideline for the community-based management of acute malnutrition (CMAM) was developed in 2017, but as yet has not been released. There are ongoing scientific and policy debates on the aetiology of wasting in India and how best to manage severe wasting (including opposition by some coalitions to the use of commercial RUTF to treat severe wasting) that have not been resolved. This lack of consensus is delaying the introduction and scale-up of services to manage severe wasting at community level. However, 13 out of 29 states are expanding or planning to expand the management of wasted children from NRCs to communities, using different approaches and strategies, including local alternatives to RUTF in some states.
Nepal: Community-based management of acute malnutrition (CMAM) was introduced in Nepal in 2008 in response to the floods in Terai. Since then, the country has gradually scaled up coverage by including CMAM in its first (2013-17) and second (2018-22) Multi-Sectoral Nutrition Plans. The scale-up of the CMAM programme in Nepal is a positive example of how the management of child wasting has been transformed from a humanitarian to a development programme, integrated into health services, but with the capacity to expand in the event of emergencies. The programme is owned and led by the government, with technical support provided by the national coordination group on nutrition composed of UN agencies and non-governmental organisations. Currently, the programme covers 28 out of 77 districts, but only reaches an estimated <5% of Nepal’s severely wasted children.
Pakistan: Pakistan’s 2013 guidelines on CMAM are currently under revision. The country introduced the CMAM approach during the 2005 emergency response to the Azad Kashmir earthquake. Since then, Pakistan has been working to expand from a humanitarian-focused programme to development programming for the prevention and treatment of child wasting. This involves integrating services into the health system, a process that is still underway, and ensuring appropriate linkages with national initiatives to reduce stunting.
Sri Lanka: Sri Lanka has a national guideline for the management of severe wasting that includes community-based management with RUTF (BP100). However, the outpatient treatment of severe wasting has only been decentralised to the district-hospital level. Only paediatricians are authorised to prescribe therapeutic food, which restricts access, particularly for severely wasted children living far from district hospitals.
Box 2: Programmatic adaptations to services to prevent and treat COVID-19 in South Asian countries
- Use of ‘family MUAC’ or ‘mother’s MUAC’ to enable family members to screen their children for acute malnutrition using mid-upper arm circumference tapes.
- Increase the spacing of beds for children in inpatient settings.
- Reduce the frequency of outpatient follow-up visits for children with severe wasting.
- Provide counselling to women and caregivers on dietary intake during pregnancy, breastfeeding and complementary feeding through remote mechanisms (e.g., WhatsApp and phone helplines).
- Orient and train health workers on programmatic adaptations through WhatsApp and other remote platforms.
Preposition supplies of nutrition commodities to mitigate against supply-chain breaks.
More like this
View this article as a pdf A warm welcome to our 63rd edition of Field Exchange, focused on child wasting in South Asia. The idea for this issue came out of a meeting in New...
View this article as a pdf By Zivai Murira and Harriet Torlesse Zivai Murira is Nutrition Specialist at United Nations Children's Fund (UNICEF) Regional Office for South Asia...
View this article as a pdf Click here to listen to an interview with one of the authors on the ENN podcast channel Summary of research1 What we know: Cross-sectional,...
Lire ce blog en francais Over the years the scope of ENN's work has expanded beyond a focus on humanitarian contexts to encompass a broader set of issues around drivers of...
Research Summary 1 Poor nutrition in early life threatens the growth and development of children, which has a knock-on effect on the sustainable development of nations. This...
View this article as a pdf Research snapshot1 Child wasting has received much less policy attention in South Asia than stunting, despite the region being home to over half...
View this article as a pdf One of the major challenges in improving access for children to services to effectively prevent and treat child wasting in South Asia is evidence....
View this article as a pdf Report summary1 In May 2017 the first three-day South Asia regional 'Stop Stunting' conference was convened by the South Asian Association for...
View this article as a pdf By Harriet Torlesse, Roland Kupka, Warren T K Lee, Britta Schumacher and Angela de Silva Harriet Torlesse is the Regional Advisor Nutrition at the...
View this article as a pdf Lisez cet article en français ici We are delighted to mark our 60th edition of Field Exchange with an issue dedicated to the continuum of...
Research snapshot1 The largest proportion of wasted children globally is found in Southeast Asia, yet this is not fully recognised as a public health problem and the coverage...
FEX: Factors associated with wasting among children under five years old in South Asia: Implications for action
View this article as a pdf Research snapshot1 The continued high prevalence and burden of child wasting in South Asia is an urgent policy priority. The region's progress...
FEX: Wasting in South Asia: Consultation on building the evidence base on the policy and programme response
A one-day consultation was held in New York on 16 November 2018 to examine the evidence on wasting in South Asia and guide the direction of future collaborative efforts of the...
FEX: One UN for nutrition in Afghanistan - Translating global policy into action: A policy shift to tackle wasting
View this article as a pdf Click here to listen to an interview with Dr. Jamil Bawary, Integrated Management of Acute Malnutrition (IMAM) Officer, Ministry of Health...
View this article as a pdf Lisez cet article en français ici By Arjan de Wagt, Eleanor Rogers, Praveen Kumar, Abner Daniel, Harriet Torlesse and Saul Guerrero Arjan...
View this article as a pdf In its first-ever regional issue, Nutrition Exchange has partnered with the United Nations Children's Fund (UNICEF) Regional Office of South Asia...
View this article as a pdf Click here to listen to more information on the work being done in Pakistan on the ENN podcast channel By Saba Shuja, Eric Alain Ategbo, Yasir...
Unlocking the power of maternal nutrition to improve nutritional care of women in South Asia View this article as a pdf Zivai Murira is the Nutrition Specialist at UNICEF...
View this article as a pdf Report summary1 The lives and futures of children across South Asia are threatened by the COVID-19 crisis. While they may be less susceptible to...
View this article as a pdf Research snapshot1 South Asia has the greatest burden of wasted and stunted children of any region in the world. These children are more likely to...
Reference this page
Harriet Torlesse and Minh Tram Le (2020). South Asia and child wasting – unravelling the conundrum. Field Exchange 63, October 2020. p7. www.ennonline.net/fex/63/southasiachildwasting