Marie McGrath

Background/Objectives: Worldwide, millions of infants under 6 months are at increased risk of poor growth and development, illness, and death. We investigated the coherence of global policy characteristics, vulnerability, and continuity of care, which guides the care of vulnerable infants under 6 months and their mothers. Methods: We conducted a scoping review according to PRISMA-ScR guidance. We included English publications with no time limit, applicable to low- and middle-income countries, sourced through Google Scholar, contacts, WHO and UNICEF databases, global networks, and agency websites. The search was conducted from August 2023 to February 2024. We identified 34 documents for review. We categorised policies into guidelines, namely, WHO evidence-based recommendations and multi-source guidance documents with implementation details. We consolidated 49 vulnerability descriptors into 28 vulnerability factors and four sub-groups. We did not assess policy quality. Results: We found rich but fragmented global policy guidance. Multiple terminologies create superficial differences and mask important ones. Growth appraisal was mostly limited to nutrition-oriented guidance and was lacking in health-centric documents. Continuity of care lacked scope and depth. WHO policies are out of sync with each other and the latest evidence on mortality risk markers. WHO procedures need to accommodate non-UN documents to leverage existing guidance potential. A living policy system to manage evidence-to-policy processes and policy interactions is needed. The WHO-INTEGRATE evidence for decision frameworks could help country-led adaptations, system-sensitive global support, and WHO methodological development. Conclusions: There are immediate opportunities for interdisciplinary policy cooperation. Action is urgently needed to secure coherent evidence-based policies for equitable and effective care.

Introduction: Tackling malnutrition in infants aged under 6 months (u6m) is a major global priority yet evidence around this vulnerable group is weak. We aimed to support the rollout of new 2023 WHO guidelines by examining the burden of infant malnutrition and potential programme caseloads with new enrolment criteria.Methods: Secondary analysis of Demographic and Health Survey (DHS) datasets. We calculated the number of underweight (low weight-for-age), wasting (low weight-for-length), stunting (low length-for-age) and low birth weight (LBW) infants. We assessed data quality by recording extreme or missing values. We calculated the population-weighted prevalence of anthropometric deficit and extrapolated to all low- and middle-income countries (LMICs). We regressed being underweight and wasti on infant, maternal and household characteristics using logistic regression.Results: We analysed 56 DHS surveys. There were more extreme (flagged) values for length-based measures (7.5% flagged for weight-for-length, 3.8% for length-for-age) than for weight-for-age (0.6% flagged). Overall, 17.4% of infants (95% CI: 16.9 to 18.0) were underweight, 15.5% (15.0–16.0) were wasted, 19.9% (19.3–20.5) were stunted and 15.0% (14.5–15.5) were LBW. This corresponds to an estimated burden in LMICs of 10.3 million underweight infants (4.1 million severely underweight), 9.2 million wasted (4.0 million severely wasted), 11.8 million stunted (5.4 million severely stunted) and 8.9 million LBW infants. Overlap of the indicators varied markedly in different regions/countries. Numerous factors were associated with both underweight and wasting; associations tended to be stronger and have greater biological plausibility with being underweight.Conclusion: Malnutrition in infants u6m is a major problem in LMICs. Local epidemiology should inform case identification in contextualised care services across health and nutrition. Data quality and stronger associations with health and social characteristics support the use of underweight as a key enrolment criterion. Since vulnerability may be due to or exacerbated by multiple factors, management must go beyond feeding support to address wider infant, maternal and mental health and social circumstances through integrated, multidisciplinary care systems.

Introduction Millions of infants worldwide are born vulnerable or become so in the first six months of life. These infants are at risk of poor growth and development, immediate and long-term ill-health, and increased mortality. The wellbeing of infants is intimately connected with the nutrition and health of their mothers, necessitating combined care. Methods We conducted a scoping review to investigate the nature and coherence of global policy guidance on the care of vulnerable infants u6m and their mothers, using the MAMI Care Pathway as a framework. Our iterative methodology identified 83 global policy documents, of which 34 (13 guidelines and 21 guidance documents) addressed vulnerable infants under 6 months and their mothers. Results We first summarized common characteristics of policy guidance documents. Next, we identified 28 key vulnerability factors (descriptors) and grouped them into small and sick newborns, nutritional status of the infant, infant (breast)feeding difficulties and illness, and maternal lactation difficulties and illness. Finally, we identified 11 care dimensions whose coverage varied across the policies. Congenital illness was the most frequently identified vulnerability marker, followed by low birth weight, preterm birth, breastfeeding problems, maternal physical health, and maternal absence or death. The markers least often identified were the mother’s adolescent and anthropometry status and infant mental health. Infant growth was included in only three of 13 priority guidelines. Continuity of care was implied but lacked detail. Policies often focused on specific infant conditions rather than combined individual needs, and few addressed maternal aspects. Discussion Vulnerable infants under 6 months come in many forms. Multiple descriptors obscure what exists and what is missing in global policy guidance that impedes care continuity and cross-sector collaboration. Resourceful and innovative amalgamation of global guidance is needed at country level for feasible, efficient, and coherent person-centred delivery of care. KEY MESSAGES What is already known on this topic. Extensive global policy guidance exists for managing vulnerable infants under 6 months of age. However, the lack of clear coherence across policies and implementation strategies risk duplicating efforts and missing opportunities. The focus often remains on infants rather than mothers, and on specific conditions rather than personal needs. Diverse descriptors of vulnerability and unpredictable content make it challenging to navigate and apply policy guidance effectively. What this study adds. This scoping review unearthed consequential gaps. Guidance on vulnerable newborns lacks details on follow-up care beyond the early postnatal period. Infant growth as a marker of vulnerability is missing in key guidance. Maternal health is poorly covered. How this study might affect research, practice, or policy. Identified common ground in policy guidance present opportunities to align efforts to implement them using a person-centred lens. Policy coherence requires institutional commitment and accountability, connecting disciplines and country leadership to demystify and contextualise existing practices.

Many infants are born vulnerable or become vulnerable in the first 6 months of life, putting them at risk of poor growth and development, long-term ill-health, and increased mortality. Many policies and practitioners aim to integrate care across services for at-risk mother infant pairs, but this is challenging in practice given individual, setting, and policy complexities. The MAMI Care Pathway, an integrated care pathway approach, frames and guides implementation of WHO nutrition and health guidelines within health and nutrition systems. Local contextualization is a pre-requisite for evidencing national policy uptake of relevant global recommendations. To gain insight into such contextualization, we undertook three in-depth country case studies to investigate planning, implementation, adoption, and scalability of the approach with practitioners in Pakistan, South Sudan, and Yemen. Our mixed methods using theoretical frameworks explored planning, implementation, normalization, and sustainable scalability of the care pathway. We explored healthcare workers’ perspectives through in- and cross-country reflective learning discussion. Initiatives were prompted by perceived but unmeasured need. Planning and starting implementation required substantial time and stakeholder consultation. Healthcare workers needed skills to perform existing tasks (reflecting shortfalls in routine care capacity and quality) as well as new ones (e.g. maternal mental health). Shifting from disease-focused to person-centred care required (and did not always get) buy-in from healthcare workers (where it was not embedded in service duties and pay), and from communities and mothers to adopt it (practical and competing priorities). It was possible to be system-supportive and scale-sensitive in emergency contexts. Identified commonalities in implementation realities heighten transferable learning potential. Health system strengthening is needed for impactful scale. A paradigm shift towards person-centred care is needed in policy framing and implementation guidance. Deeper localized case study development is a critical type of evidence to inform policy navigation, development and practice. TEASER KEY MESSAGE Reflective learning from adapting, implementing, and normalizing the MAMI Care Pathway in Pakistan, South Sudan, and Yemen health systems highlighted the need for system-supportive, scale-sensitive approaches and financial and technical support to align with national policies and implementation realities. KEY MESSAGES Infants born vulnerable or becoming vulnerable early in life risk poor growth and development, ill-health, and mortality. Integrated care for at-risk mother-infant pairs is the goal of many policies but is challenging in practice. Case studies in Pakistan, South Sudan, and Yemen investigated the process of adapting, implementing, and normalizing the integrated MAMI Care Pathway approach by putting WHO guidelines on outpatient care of at-risk infants and their mothers into practice to inform feasible, sustainable care. The cases in these diverse contexts demonstrated that system strengthening, and early healthcare provider engagement were crucial for impactful and sustainable scale of the MAMI Care Pathway approach. Identifying commonalities in implementation realities enhance transferable learning. Embedding a sustainable approach in existing health services requires financial and technical support aligning with national health policies, planners, and implementation. Achieving comprehensive care also demands investment in routine service capabilities. A paradigm shift toward person-centred care is needed in policy and implementation guidance. Deeper localized case studies are critical evidence to inform policy navigation, development, and practice.

An integrated care pathway to manage small and nutritionally at‐risk infants under 6 months (u6m) and their mothers (MAMI Care Pathway) is consistent with 2023 WHO malnutrition guidelines and is being tested in a randomised controlled trial (RCT) in Ethiopia. To optimise trial implementation, we investigated contextual fit with key local stakeholders. We used scenario‐based interviews with 17 health workers and four district managers to explore perceived feasibility. Eighteen policymakers were also surveyed to explore policy coherence, demand, acceptability, evidence needs, opportunities and risks. The Bowen feasibility framework and an access to health care framework were adapted and applied. Health workers perceived the MAMI Care Pathway as feasible to implement with support to access services and provide care. The approach is acceptable, given consistency with national policies, local protocols and potential to improve routine care quality. Demand for more comprehensive, preventive and person‐centred outpatient care was driven by concerns about unmet, hidden and costly care burden for health services and families. Inpatient care only for severe wasting treatment is inaccessible and unacceptable. Support for routine and expanded components, especially maternal mental health, is needed for successful implementation. Wider contextual factors may affect implementation fidelity and strength. Policymakers cautiously welcomed the approach, which resonates with national commitments, policies and plans but need evidence on how it can work within varied, complex contexts without further system overstretch. A responsive, pragmatic randomised controlled trial will generate the most useful evidence for policymakers. Findings have informed trial preparation and implementation, including a realist evaluation to contextualise outcomes.

An integrated care pathway to manage small and nutritionally at-risk infants under 6 months (u6m) and their mothers (MAMI Care Pathway) is consistent with 2023 WHO malnutrition guidelines and is being tested in a randomised controlled trial (RCT) in Ethiopia. To optimize trial implementation, we investigated contextual fit with key local stakeholders. We used scenario-based interviews with 17 health workers and four district managers to explore perceived feasibility. Eighteen policymakers were also surveyed to explore policy coherence, demand, acceptability, evidence needs, opportunities and risks. The Bowen feasibility framework and an access to healthcare framework were adapted and applied. Health workers perceived the MAMI Care Pathway as feasible to implement with support to access services and provide care. The approach is acceptable, given consistency with national policies, local protocols and potential to improve routine care quality. Demand for more comprehensive, preventive and person-centred outpatient care was driven by concerns about unmet, hidden and costly care burden for health services and families. Inpatient care for all severe wasting treatment is inaccessible and unacceptable. Support for routine and expanded components, especially maternal mental health, is needed for successful implementation. Wider contextual factors may affect implementation fidelity and strength. Policymakers cautiously welcomed the approach, which resonates with national commitments, policies and plans but need evidence on how it can work within varied, complex contexts without further system overstretch. A responsive, pragmatic RCT will generate the most useful evidence for policymakers. Findings have informed trial preparation and implementation, including a realist evaluation to contextualise outcomes.

Introduction Evidence gaps limit management of small and/or nutritionally at-risk infants under 6 months and their mothers, who are at higher risk of death, illness, malnutrition and poor growth and development. These infants may be low birth weight, wasted, stunted and/or underweight. An integrated care model to guide their management (MAMI Care Pathway) is being tested in a randomised controlled trial in Ethiopia. Evaluating the extent to which an innovation is consistent with national policies and priorities will aid evidence uptake and plan for scale. Methods and analysis This review will evaluate the extent to which the MAMI Care Pathway is consistent with national policies that relate to the care of at-risk infants under 6 months and their mothers in Ethiopia. The objectives are to describe the range and characteristics, concepts, strategic interventions, coherence and alignment of existing policies and identify opportunities and gaps. It will be conducted in accordance with the JBI methodology for scoping reviews (PRISMA-ScR). Eligible documents include infant and maternal health, nutrition, child development, food and social welfare-related policies publicly available in English and Amharic. The protocol was registered on the Open Science Framework Registry on 20 June 2022 (https://osf.io/m4jt6). Grey literature will be identified through government and agency websites, national and subnational contacts and Google Scholar, and published policies through electronic database searches (MEDLINE, EMBASE and Global and Health Information). The searches will take place between October 2023 and March 2024. A standardised data extraction tool will be used. Descriptive analysis of data will be undertaken. Data will be mapped visually and tabulated. Results will be described in narrative form. National stakeholder discussions will inform conclusions and recommendations. Ethics and dissemination Ethical approval is not required as data consist solely of publicly available material. Findings will be used to evidence national and international policy and practice.

Skilled staff are essential for successfully managing child malnutrition, especially when dealing with small, nutritionally at-risk infants aged under 6 months. Training and patient management tools provide healthcare workers with core knowledge, skills, and support. To inform more effective future approaches and support the rollout of new WHO wasting prevention/treatment guidelines, we aimed to map and understand globally available training and patient management tools. In a mixed-methods study, we searched the literature to identify different training packages and management tools and conducted semi-structured key informant interviews with staff working in a variety of internationally organizations and settings. Data were analyzed using a phenomenological approach. We found 14 different training packages targeting different settings, including inpatient, outpatient, and humanitarian contexts. Curricula varied, especially around breastfeeding and maternal assessment, mental health, and nutritional status. Key informants (n = 9) reported gaps regarding counseling skills, time for practice, and how to effectively provide mental health counseling. Training delivery was highly dependent on resources and setting. In conclusion, future training should consider setting-specific needs, opportunities, and limitations. Emphasis on breastfeeding-support skills, mental health support, and counseling skills is needed. Enhanced practical sessions, refresher trainings, and ongoing monitoring and support are vital to ensure sustained high-quality services.

Malnutrition is a leading cause of preventable deaths in infants and children. To benefit from treatment and prevention programmes, malnourished children must first be identified. Low weight-for-age is an anthropometric indicator of malnutrition which is gaining much recent attention because it is particularly effective at identifying children at highest risk of death. However, assessing weight-for-age can be challenging. We aimed to evaluate a novel, low-cost weight-for-age slide chart and compare its performance against two traditional methods. We conducted a cross-over diagnostic study comparing a new “MAMI” slide-chart against traditional growth charts and look-up tables. Participants were health and public health professionals working or studying in the UK. Each acted as their own control, using all three methods but in random order. Under timed conditions, they evaluated hypothetical scenarios, arranged in a random sequence. Each tool’s diagnostic accuracy and response rate were compared. User preferences were also recorded. Sixty-two participants took part. Diagnostic accuracy was highest for the MAMI chart: 79%(351/445) correct assessments. Accuracy using look-up tables was 70%(308/438). Growth charts performed worst: 61%(217/353) correct (p-value<0.01). The mean number of scenarios (±SD) correctly identified by each participant in 4-minutes was 3.5(±2.19) using growth charts; 4.97(±2.50) using look-up tables; 5.66(±2.69) using MAMI charts (ANOVA, p-value<0.01). This translates to approximately 53, 75 and 85 correct assessments per participant in an hour for the respective tools. No statistically significant differences were found with participants’ years of experience or profession type. Most participants, 43/62(69%), preferred the MAMI chart and reported it to be easier and faster to use than traditional tools. We conclude that weight-for-age assessment is quicker and more accurate using the newly-developed MAMI slide chart as opposed to traditional methods. It should be further field tested in other settings since the potential to improve the efficiency and effectiveness of treatment programmes is great.

Background: There is increasing global focus on malnutrition in infants aged under 6 months (u6m) but evidence on how best to identify and manage at-risk individuals is sparse. Our objectives were to: explore data quality of commonly used anthropometric indicators; describe prevalence and disease burden of infant u6m malnutrition; compare wasting and underweight as measures of malnutrition by determining the strength and consistency of associations with biologically plausible risk factors. Methods: We performed a cross-sectional secondary analysis of Demographic and Health Survey (DHS) datasets, focussing on infants u6m. We calculated underweight (low weight-for-age), wasting (low weight-for-length), stunting (low length-for-age), and concurrent wasting and stunting. We explored data quality by recording extreme (flagged, as per standard criteria) or missing values. We calculated the population-weighted prevalence of each type of malnutrition and extrapolated the burden to all low- and middle-income countries (LMICs). We explored associations between infant, maternal and household risk factors with underweight and wasting using logistic regression models. Results: We analysed 54 DHS surveys. Data quality in terms of refusals and missingness was similar for both weight and length. There were more extreme (flagged) values for length-based measures (6.1% flagged for weight-for-length, 4.8% for length-for-age) than for weight-for-age (1.0% flagged). Overall, 20.1% of infants (95% CI: 19.5, 20.7) were underweight, 21.3% (95% CI: 20.7, 22.3) were wasted, 17.6% (95% CI: 17.0, 18.2) were stunted, and 2.0% (95% CI: 1.8, 2.2) were concurrently wasted and stunted. This corresponds to an estimated burden in LMICs of 23.8m underweight infants, 24.5m wasted infants, 21.5m stunted infants and 2.2m concurrently wasted and stunted. Logistic regression models showed that numerous risk factors were associated with wasting and underweight. Effect sizes of risk factors tended to be stronger and more consistently associated with underweight compared to wasting. Conclusion: Malnutrition in infants u6m is a major problem in LMICs. This is true whether assessed by underweight, wasting or stunting. Our data build on other evidence suggesting that underweight may be a better anthropometric case definition than wasting: data quality is better when length is not involved; biologically plausible risk factors are better reflected by an infant being underweight. Future research, ideally from intervention trials, should further explore how best to identify malnourished (small and nutritionally at-risk) infants u6m. For now, treatment programmes should note that many factors might underlie problems in this age group: services should thus consider how to address maternal health and wider social circumstances as well as caring for infants themselves.