Type of Paper: Review
Purpose: In 2008, the World Health Organization (WHO) organized a meeting on the nutrient needs and the dietary management of moderate malnutrition in children under 5 years of age. This paper was written as a background paper for the meeting and was included in the special issue on the Dietary Management of Moderate Malnutrition in the Food and Nutrition Bulletin. The purpose of this paper was to define the Recommended Nutrient Intakes (RNIs) for children with moderate malnutrition who live in poor environments.
- Moderate malnutrition is defined as having a z-score between -2 and -3 according to the WHO child growth standards for either weight-for-height (moderate wasting) or height-for-age (moderate stunting).
- The prevalence of moderate malnutrition in children ages 6 to 59 months is as follows:
- 5% to 15% of children are moderately wasted (low weight-for-height). The peak prevalence is between 6 and 24 months of age.
- 20% to 40% are moderately stunted (low height-for-age) by the age of 2 years.
- RNIs have been established for healthy children who are living in clean environments, and these RNIs may not be adequate for children with moderate malnutrition who live in drastically different environments. For instance, in the developing world children live in environments characterized by being unhygienic, including contaminated water and food, having recurrent infections, being exposed to smoke pollution form cooking fires, and eating a limited variety of foods restricted to those that are grown locally.
- There are no internationally agreed-upon RNIs for children with moderate malnutrition, partly due to the lack experimental evidence in children.
- However, the dietary intakes of children with moderate malnutrition need to:
- Support catch-up growth in weight and height and restore tissue that may have been lost.
- The accelerated growth rate will require a more nutrient-dense diet.
- Prevent death from nutritional disease.
- Strengthen resistance to infection and protect against hostile/stressful environments.
- Protection in stressful environments may require higher nutrient intakes.
- Promote recovery from any prior illness.
- Promote normal physical and mental development.
- Children with moderate malnutrition may have deficiencies in multiple nutrients, and all nutrients (not just calories) need to be replenished.
Recommended Nutrient Intakes (RNIs):
- RNIs for moderately malnourished children are defined for 30 essential nutrients (please refer to the full text of the paper for individual RNIs).
- The RNIs for moderately malnourished children are assumed to be between the RNIs for normal, healthy children and the RNIs for severely malnourished children.
- Two sets of dietary requirements are given to support rehabilitation from moderate malnutrition:
- Requirements using a variety of locally available foods. This is the preferable recommendation, but may not be feasible.
- Requirements using special, complementary, supplementary, or rehabilitation foods.
- The factors that were considered for defining the RNIs included:
- The amount of tissue needed to be synthesized to reach normal body composition.
- The time available for recovery.
- The composition of tissue (i.e., percent body fat compared to lean tissue) that is needed.
- The degree of any particular nutrient deficiency or excess (due to adaptations of being malnourished).
- Any disruptions in nutrient availability (e.g., poor intestinal absorption or ongoing nutrient losses).
Moderately malnourished children have a higher risk for illness and dying than healthy children, but do not suffer from life-threatening severe acute malnutrition. The RNIs for moderately malnourished children are between those recommended for healthy children and those recommended for severely malnourished children. All nutrients (not just calories) need to be restored for healthy recovery of moderate malnutrition.
Golden MH. Proposed recommended nutrient densities for moderately malnourished children. Food Nutr Bull. 2009;30:S267-342.