Article type
Abstract
Background: The Global Action Plan on Child Wasting aims to accelerate progress toward wasting targets (SDG 2.2; Global Nutrition Targets 2025). The World Health Organization (WHO) partnered with Cochrane and GRADE methodologists to address prioritized guidance gaps, including updating 3 recommendations from 2013 on severe wasting and/or nutritional edema, very serious forms of malnutrition. These related to criteria for when to admit a child to inpatient care, transfer from inpatient to outpatient, and safely exit a child from nutritional treatment. The 2013 recommendations were strong, low-certainty recommendations based on indirect evidence and expert opinion.
Objectives: To support a WHO Guideline Development Group (GDG) to update 3 recommendations from 2013, informed by synthesized prognostic evidence and expert experience for a 2023 WHO guideline on wasting and nutritional edema
Methods: A prognostic factor systematic review was commissioned to identify factors reliably associated with higher risk for prioritized outcomes, which were mapped to relevant decision points along the care pathway for severe wasting and/or nutritional edema shown in Figure 1. These factors could reinforce existing criteria or be added to criteria in the 2013 recommendations. The GDG established minimally important absolute risk thresholds for the outcomes, defined as the smallest change in their prognosis that most health workers would regard as meaningful. The GDG evaluated every factor above these thresholds with moderate or high certainty (GRADE for prognostic studies), agreeing on factors making clinical sense. This informed consensus on the strength and certainty of the updated recommendations by the GDG.
Results: The prognostic factor systematic review identified individual child, social, and contextual factors for the prioritized outcomes. The GDG used this evidence as the basis for discussions, decisions, and consensus for recommendations, bearing in mind its indirectness. There were challenges with the consensus process for the strength and certainty, requiring extensive discussion to reach agreement. Key GDG discussion points were clearly documented, with selected points in Table 1.
Conclusions: This was a unique approach to updating the recommendations on admission, referral, transfer, and exit criteria that enabled the GDG to consider best available evidence on risk differences for prioritized outcomes in combination with clinical reasoning and frontline experience.
Objectives: To support a WHO Guideline Development Group (GDG) to update 3 recommendations from 2013, informed by synthesized prognostic evidence and expert experience for a 2023 WHO guideline on wasting and nutritional edema
Methods: A prognostic factor systematic review was commissioned to identify factors reliably associated with higher risk for prioritized outcomes, which were mapped to relevant decision points along the care pathway for severe wasting and/or nutritional edema shown in Figure 1. These factors could reinforce existing criteria or be added to criteria in the 2013 recommendations. The GDG established minimally important absolute risk thresholds for the outcomes, defined as the smallest change in their prognosis that most health workers would regard as meaningful. The GDG evaluated every factor above these thresholds with moderate or high certainty (GRADE for prognostic studies), agreeing on factors making clinical sense. This informed consensus on the strength and certainty of the updated recommendations by the GDG.
Results: The prognostic factor systematic review identified individual child, social, and contextual factors for the prioritized outcomes. The GDG used this evidence as the basis for discussions, decisions, and consensus for recommendations, bearing in mind its indirectness. There were challenges with the consensus process for the strength and certainty, requiring extensive discussion to reach agreement. Key GDG discussion points were clearly documented, with selected points in Table 1.
Conclusions: This was a unique approach to updating the recommendations on admission, referral, transfer, and exit criteria that enabled the GDG to consider best available evidence on risk differences for prioritized outcomes in combination with clinical reasoning and frontline experience.