Prognostic evidence synthesis and equity considerations informed recommendations for higher-risk children with moderate wasting in a WHO guideline

2024 Prague [Global Evidence Summit]

Bendabenda J¹, Daniel A¹, de Polnay K¹, Foroutan F², Grummer-Strawn L¹, Jemutai J³, McCaul M⁴, Naude C⁴, Rayner D⁵, Weise Prinzo Z¹

¹Department of Nutrition and Food Safety, Food and Nutrition Action in Health Systems Unit, World Health Organization, Geneva, Switzerland

²Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Ted Rogers Center for Heart Research, Toronto General Hospital, Toronto, Ontario, Canada

³Independent Consultant, Kilifi, Kenya

⁴Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa

⁵Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada

Background:

Globally, nearly 5% of children (31 million) per year experience moderate wasting, a serious form of malnutrition. Specially formulated foods (SFFs) are potentially effective interventions for these children, but costs prohibit scale-up to all affected children in most settings. The Global Action Plan on Child Wasting aims to accelerate progress toward wasting targets (SDG 2.2; Global Nutrition Targets 2025). In response, the World Health Organization (WHO) partnered with Cochrane and GRADE methodologists to address prioritized guidance gaps, which included SFFs for children with moderate wasting.

Objectives:

To support a WHO Guideline Development Group (GDG) in developing recommendations on prioritization of children with moderate wasting for SFFs, applying equity considerations

Methods:

Using an evidence-to-decision framework, the GDG considered and made judgements on the effectiveness of SFFs for children with moderate wasting based on a commissioned systematic review of randomized controlled trials. A prognostic factor systematic review was commissioned to identify specific risk factors reliably associated with higher risk for the prioritized outcomes in children with moderate wasting. To filter risk factors and facilitate meaningful GDG judgements, 3 criteria were applied. Firstly, we only considered factors in which we had moderate or high certainty (GRADE for prognostic studies) in their association with the respective outcomes. Secondly, if multiple outcomes were examined for a certain factor, the directionality of associations had to be consistent. Lastly, we only considered factors with a meaningful impact on children’s prognosis (absolute risk difference of 10% or more).

Results:

The GDG agreed that SFFs for children with moderate wasting have moderate desirable effects (moderate-certainty evidence). Prognostic evidence synthesis and factor filtering identified individual child, social, and contextual factors reliably associated with the prioritized outcomes. The GDG used this evidence to formulate 2 recommendations for the use of SFFs for specific higher-risk children with moderate wasting deemed vulnerable and more likely to benefit from the provision of greater attention and resources.

Conclusions:

This prognostic factor filtering process incorporating certainty of evidence, consistency, and meaningful absolute risk difference thresholds, used with the effectiveness evidence, enabled the GDG to make 2 equity-focused recommendations on prioritizing SFFs for higher-risk children with moderate wasting.