Nutrition News for Africa

Abstract November 09

Dietary management of moderate malnutrition

Andr Briend and Zita Weise Prinzo, guest editors. Food and Nutrition Bulletin, Volume 30, Number 3: S265-S474, 2009
Introduction
The World Health Organization (WHO) convened a meeting in Geneva, Switzerland from 30 September to 3
October 2008 to address a range of issues concerning the dietary management of children with moderate malnutrition.
Moderate malnutrition includes both moderate wasting (defined as a weight-for-height between 3 and 2 Z-scores of the
WHO child growth standards) and moderate stunting (defined as a height-for-age between -3 and -2 Z-scores of the WHO
standards). In contrast to the situation for severe malnutrition, recommendations for the management of children with
moderate malnutrition have changed very little during the past 30 years. The general objectives of the meeting in Geneva were
to: 1) identify areas of consensus on the nutrient needs, dietary formulations and related counseling for children with moderate
malnutrition, which can be translated into evidence-based global guidelines; and 2) identify knowledge gaps that should be
addressed by research. Four background papers were prepared for the consultation, as summarized below; and these papers
have now been published as a special supplement of the Food and Nutrition Bulletin.
Nutrient content of diets suitable for feeding moderately malnourished children
The consensus opinion of the meeting participants was that the nutritional requirements of moderately malnourished
children probably fall between the nutritional requirements of healthy children and those of children with severe malnutrition
during the phase of catch-up growth. The first background paper systematically reviews the estimated macro- and
micronutrient requirements of moderately malnourished children (1). The nutrient intakes of these children need to be
adequate to allow wasted children to synthesize the lean tissue deficits and to allow stunted children to achieve both
accelerated linear growth and associated accrual of lean tissue. Research is needed to assess whether diets adequate for treating
moderately wasted children will also be adequate to treat stunted children.
Foods and ingredients suitable for use in moderately malnourished children
The second background paper provides an extensive description of the individual foods and ingredients of mixed diets
that are used most commonly to feed children with moderate malnutrition (2). The meeting participants agreed that the
addition of animal-source foods to plant-based diets helps to promote the recovery of moderately malnourished children.
Diets providing substantial quantities of animal-source foods, including dairy products, provide high-quality protein and
bioavailable micronutrients and contain lower levels of anti-nutritional factors. Research is needed to assess the minimum
quantities and types of animal-source foods that are needed in the diets of children with moderate malnutrition.
Dietary counseling for moderately malnourished children
Dietary counseling is an integral component of the treatment regimen for children with moderate malnutrition.
Ashworth and Ferguson (3) reviewed current counseling practices and concluded that dietary recommendations are often too
vague and therefore unlikely to be effective. The review concluded that when dietary counseling is done well, it can be
effective in treating moderate malnutrition. Thus, it is important for programs to focus on improving the quality of dietary
counseling, including breastfeeding support and promotion and improved general feeding practices, even when food

supplements are provided. Training of health care providers in dietary counseling is essential for achieving better outcomes of
nutritional therapy.
Food supplements used to treat moderate malnutrition in children
The fourth background paper (4) reviewed specialized, processed food supplements that are now available for the
treatment of moderate malnutrition. Most supplementary feeding programs supply fortified blended foods, such as corn-soy
blend and wheat-soy blend, in combination with sugar and oil. Besides the recent improvements made to these fortified
blended foods, other products such as lipid-based nutrient supplements (LNS) and ready-to-use foods (RUFs) have become
available. The working group concluded that there is an urgent need to develop clear terminology for the different specialized
foods used to treat malnutrition and guidelines on the composition of these products, and to gather evidence on their efficacy
and effectiveness. Participants suggested that it is appropriate to use new products in programs for feeding moderately
malnourished children, only when the new food meets the theoretical needs of these children and can be expected to have an
impact on growth, morbidity and micronutrient status at least equal to that of existing specialized products. Programs using
new products should be carefully monitored and evaluated.
Conclusions of the meeting
It was agreed that moderate malnutrition is a pathological process that requires special dietary treatment. There is a
need to develop specific recommendations for adequate dietary intakes of energy and all nutrients for children with moderate
wasting and moderate stunting. Although there are too many uncertainties at present to be able to propose an optimal diet for
all children with moderate malnutrition, there is sufficient information available to improve the current situation and start a
process of continuous evaluation and improvements of possible treatment options for moderate malnutrition (5).
NNA Editors' comments*
Many countries have now developed national protocols for identifying and treating children with moderate and severe
acute malnutrition (6), although few programs specifically address the situation of moderately stunted, non-wasted children.
The background papers prepared for the aforementioned meeting on moderate malnutrition provide a wealth of information
for developing local treatment guidelines for children with either form of moderate malnutrition (i.e., wasting or stunting).
However, many national programs lack the capacity to formulate population-specific treatment regimens, and many food
insecure households lack the resources to implement these guidelines. Thus, many countries and households will continue to
depend on donated food blends or raw commodities, some of which may be less than ideal according to the conclusions of
these recent reviews. The reviews provide minimum standards for such therapeutic products, and these tentative
recommendations should be considered by international agencies, national governments, and non-governmental organizations
in developing programs to treat moderately malnourished children. Additional research is needed to confirm the suitability of
these recommendations and to compare the impact and cost-effectiveness of different treatment regimens. Moreover,
information is needed on the responsiveness of stunting to these proposed dietary regimens, and whether the same
recommendations should be applied for moderately malnourished children with either wasting or stunting.
* These comments have been added by the editorial team and are not part of the cited publication.

References
1.

Golden MH. Proposed recommended nutrient densities for moderately acute malnourished children. Food and
Nutrition Bulletin 2009;30:S-267-S342.

Helen Keller International

Nutrition News for Africa

www.hki.org

2.

Michaelsen KF, Hoppe C, Roos N, et al. Choice of foods and ingredients for moderately acute malnourished children
6 months to 5 years of age. Food and Nutrition Bulletin 2009;30:S343-S404.

3.

Ashworth A, Ferguson E. Dietary counseling in the management of moderate malnourishment in children. Food and
Nutrition Bulletin 2009;30:S405-S433.

4.

de Pee S, Bloem MW. Current and potential role of specially formulated foods and food supplements for preventing
malnutrition among 6- to 23-month-old children and for treating moderate malnutrition among 6- to 59-month-old
children. Food and Nutrition Bulletin 2009;30:S434-S465.

5.

Briend A, Prinzo ZW. Dietary management of moderate malnutrition: Time for a change. Food and Nutrition Bulletin
2009;30:S265-S266.

6.

Brown KH, Nyirandutiye DH, Jungjohann S. Management of children with acute malnutrition in resource-poor
settings. Nature Reviews Endocrinology 2009;5:597-603.

Helen Keller International

Nutrition News for Africa

www.hki.org