How WHO Identifies High-Risk Children for Special Foods in Moderate Wasting Care

WHO’s 2025 brief explains how global research evidence and systematic risk-factor analysis guide decisions on which moderately wasted children should receive specially formulated foods, ensuring support reaches those at highest risk. It emphasizes targeted, equity-focused intervention over universal supplementation to improve recovery and prevent deterioration.

The World Health Organization’s 2025 technical brief, supported by research contributions from WHO’s Nutrition and Food Safety Department, BMJ Best Practice, the GRADE Working Group, and academic public health institutes involved in the systematic reviews, explains in clear detail how experts developed criteria for identifying which infants and young children with moderate wasting should receive specially formulated foods (SFFs). This brief accompanies the 2023 global guideline on wasting and nutritional oedema and serves as a transparent account of the evidence, reasoning, and public health considerations that shaped WHO’s final recommendations.

Why Universal Supplementation Isn’t the Answer

The document begins by reaffirming that all children aged 6–59 months with moderate wasting, defined as weight-for-height between –2 and –3 z-scores or MUAC between 115 and 125 mm, require nutrient-dense diets and full medical and psychosocial assessment. Yet, it stresses that while some children recover through counselling and improved feeding alone, available research cannot reliably predict who will not. Universal SFF provision risks displacing breastfeeding and home diets, imposes significant financial burdens, and may undermine programme scalability. These constraints make targeted prioritization both a practical necessity and an equity imperative.

Who Should Be Prioritized for Supplementation

WHO offers strong recommendations for children who should receive SFFs alongside counselling. Individual risk factors include MUAC of 115–119 mm, a weight-for-age z-score below 3, being under two years old, failure to recover after counselling alone, relapse into moderate wasting, a history of severe wasting or co-morbidities such as HIV, tuberculosis, or disabilities. Social vulnerabilities, most notably maternal death or severe maternal illness, also heighten risk and justify prioritization. Each of these factors is tied to significantly higher probabilities of deterioration into severe wasting, non-response, or mortality. Crucially, WHO stresses that one factor alone is sufficient; children are not expected to meet multiple criteria.

High-Risk Contexts and the Case for Broader Coverage

The brief expands its recommendation when population-level vulnerability is extreme. In high-risk contexts, including humanitarian crises, widespread food insecurity, poor water and sanitation conditions, low socioeconomic status, or high seasonal prevalence of wasting, WHO advises that all moderately wasted children be considered for SFFs. These environments accelerate deterioration and threaten survival, making broad supplementation a protective public-health measure. The document notes that such crises may arise from climate-related disasters, disease outbreaks, conflict, persecution, or displacement, and that risk levels vary across seasons and regions.

How WHO Chose the Risk Factors

A major section of the brief details the evidence-gathering process. The Guideline Development Group reviewed randomized controlled trials comparing SFFs with counselling alone and judged the benefits of SFFs to be moderate, with moderate certainty. Although resource demands are substantial, the GDG found SFFs acceptable and likely to enhance equity. WHO then commissioned a prognostic-factor systematic review focused on outcomes such as recovery, deterioration, mortality, and sustained improvement. Only factors supported by moderate or high certainty, consistent direction of associations, and an absolute risk difference of at least 10% were included. The document shows that MUAC 115–119 mm and WAZ below 3 were consistent predictors across studies, whether or not children received supplementation. Additional risks among supplemented children included HIV, young age, food insecurity, and poor water and sanitation. Among unsupplemented children, illness in the weeks before admission, twin status, low maternal work capacity, and unimproved drinking water were key predictors. These overlaps confirmed that the vulnerabilities reflected genuine underlying risks rather than programme effects.

The brief also presents conditional recommendations on product type and dosage. Lipid-based nutrient supplements, such as RUSF or RUTF, are preferred, while improved fortified blended foods remain acceptable alternatives. Children should receive SFFs providing 40–60% of their daily energy requirement, allowing flexibility across programme contexts, especially during food shortages.

The document emphasizes that implementation must be shaped by local feasibility, acceptability, and equity considerations. It reinforces the importance of directing resources towards children most likely to deteriorate and encourages national programmes to share their operational experiences to strengthen global learning on addressing moderate wasting.