key: cord-0872277-78ml024l authors: Thacker, Naveen; Namazova-Baranova, Leyla; Mestrovic, Julije; Carrasco-Sanz, Angel; Vural, Mehmet; Giardino, Ida; Indrio, Flavia; Ferrara, Pietro; Pettoello-Mantovani, Massimo title: Child malnutrition during the Coronavirus disease 2019pandemic date: 2022-02-10 journal: J Pediatr DOI: 10.1016/j.jpeds.2022.02.010 sha: 6e1c85dc1bd7aad74613299d9885e90dec148114 doc_id: 872277 cord_uid: 78ml024l nan In the period before the onset of the coronavirus 2019 disease (Covid-19) pandemic, the number of people suffering from malnutrition had escalated worldwide, despite the efforts made by leading international organizations to mitigate this phenomenon 1 . During the pre-pandemic period, the World Health Organization (WHO) and the World Bank reported impressive data from Asia and Africa, where 381 and 250 million people were undernourished in 2019, respectively, followed by Latin America and the Caribbean (48 million) 2 . In some areas of the world, the combined effect of conflict, climate crisis, and socioeconomic fragility threatens to have serious repercussions on the nutritional status of populations, particularly in children . In the period 2015-19, malnutrition accounted for nearly half of the total number of child deaths worldwide (5.2 million in 2019) with significant costs in economic and human capital development terms 3, 4 . This situation was further exacerbated by the onset of the Covid-19 pandemic. According to an EPA-UNEPSA analysis 4, 5, 6 , the Covid-19 pandemic is expected to cause major health and nutrition effects worldwide 7 (Table; available at www.jpeds.com). Before the pandemic, an estimated 144 million children under age 5 (21.3% of the total) had chronic malnutrition (stunting), 47 million (6.9%) had acute malnutrition (wasting) and 38 million (5.6%) were overweight, with the prevalence increasing in this group from 4.9% in 2000. Chronic malnutrition exacerbated by the pandemic threatens to seriously impair the mental, physical and cognitive development of children, who may experience difficulty learning, entering the workforce, and poor social interaction within their communities 8,9 . The definition of childhood malnutrition has evolved in accordance with the principles, definition, and dimensions of New Nutrition Science 11 and has progressively integrated the concepts of the 1978 Alma Ata Declaration 12 . Therefore, after being considered a biological deficiency of micro-and macro-nutrients, malnutrition is now viewed as a broad condition that includes social, environmental, and economic determinants. A consistent theoretical and research work now links social factors to children's nutritional status 11 . This includes undernutrition related conditions (protein-energy malnutrition) due to insufficient intake of energy and other nutrients; deficiency diseases due to insufficient intake of one or more specific nutrients including vitamins or minerals, and overnutrition related conditions (overweight and obesity) due to excessive consumption of energy and other nutrients. The burden of malnutrition is unacceptably high. As outlined by the World Bank, the costs of undernutrition must consider several socio-economic determinants, including the significant impact of lost national productivity and economic growth. The cost to the global economy and society is calculated to be approximately $3 trillion per year in the form of lost productivity, ranging from 3 to 16% of GDP in low-income environments. the Consortium of Global Experts, estimated an economic productivity loss equivalent to $29 billion globally by the end of 2022 as a result of additional malnutrition burdens attributable to the COVID-19 pandemic 13 . Sound programs supported by appropriate investments, however, can mitigate and prevent such losses, if strategic interventions focusing of child health will include malnutrition. For example, J o u r n a l P r e -p r o o f ensuring optimal nutrition in the critical 1,000-day window between the start of a woman's pregnancy and her child's second birthday. Food quality plays an important role and income, is not the only determinant of stunting, as food insecurity, poorly diversified diets, high rates of infectious diseases, inadequate child nutrition, and other causal factors, including nursing practices, poor sanitation and hygiene, can also contribute. Poor food quality and financial crises, as well as conflict, natural disasters, and the COVID-19 pandemic, have worsened malnutrition in many regions 2, 3 . Several changes had taken place during the pre-pandemic years, and significant transitions in global nutrition are now influencing the lifestyles of children and families in diverse social contexts globally. Rapid changes in food production systems and availability, environmental and living conditions are visible in many lowand middle-income countries (LMICs). Although these changes could be seen as a positive socioeconomic factor, in many cases they have also stimulated a rapid increase in the burden of overweight and obesity, which were previously considered a disorder of wealthy countries 5, 13 . Over the past 30 years, overweight rates have increased faster in LMICs than in high-income countries, and many regions of the world have seen some increase in the prevalence of overweight children under age five. In 2020, 38.9 million children under age 5 were affected by overweight and obesity, which are now insidiously pervasive conditions even in countries where child undernutrition is endemic 2,3,11 . Overall, overweight and obesity are currently estimated to cost $2 trillion in economic and social expenditures globally and in the post-pandemic years we may expect the causative conditions and costs to further expand 2 . experiences from previous outbreaks suggest that these phenomena have profound humanitarian effects, affecting the most vulnerable groups who are already exposed to various forms of frailty and malnutrition; this includes women, children, migrants, refugees, and people with disabilities. Data analysis from WHO and the World Bank 2,3 show that globally by the end of 2022, at least 70 to 140 million people could be hungry due to increased poverty as a result of the economic downturn triggered by COVID-19 2,3,16 . nearly two-thirds of urban households (62%) have difficulty accessing meat, dairy products, fruits, vegetables and cereals. In most cases (52%), this was linked to unsustainable price increases 17 . In addition to the disruption of basic health services, the main factors through which COVID-19 is driving severe malnutrition for millions of people include loss of income due to unemployment, wage retrenchment, and rising food prices. These factors are compounded by the growing impact of blockades and restrictions on food production and supply, weakening social safety nets, the suspension of school feeding programs and the unfortunate general increase in political instability and conflict over the management of natural resources such as water 18 . A report by Save the Children shows that in a sample of 37 countries, 9 out of 10 households lost more than half their income during the pandemic and will have difficulty accessing health services 19 and 8 in 10 households reported difficulty in purchasing food. In addition, the economic impacts of the pandemic on households are expected to cause an increase in negative socioeconomic response mechanisms that will cause a general increase in child labor. The impact on education during the pandemic period also contributed to a worsening of child feeding conditions 20 . the closure of school refectories puts at risk those children for whom eating at school represents the only opportunity to receive a full meal each day. Poverty, climate change and conflict continue to slow the fight against maternal and child malnutrition and the achievement of the WHO 2030 targets 21 . This pathway is now further compromised by the COVID-19 pandemic that affects exposes the most vulnerable sections of the world's population to a range of devastating health and socio-economic consequences 22, 23 . Although children account for a small proportion of COVID-19 deaths, it is estimated that reducing levels of essential and routine health services by about half could result in 45% increase in child mortality 24 . The choices that governments and all stakeholders are making in response to child malnutrition and to the COVID-19 emergency will have critical consequences for mothers and children 25 . Given the projected increase in maternal and child mortality, it is important to develop policies that respond to the immediate needs generated by the pandemic, but also look to future generations 26 The State of Food Security and Nutrition in the World The World Bank and Nutrition Joint child malnutrition estimates Global Emergencies in Child Health: Challenges and Solutions-Viewpoint and Behavioral and Emotional Disorders in Children during the COVID-19 Epidemic Integrating and rationalizing public healthcare services as a source of cost containment in times of economic crises The principles, definition and dimensions of the new nutrition science Johns Hopkins alliance for a Healthier World. Health for all: the role of food, nutrition and the Alma Ata declaration The potential impacts of the COVID-19 crisis on maternal and child undernutrition in low and middle income countries pdf?c=1637595983. (Accessed Don't let children be the hidden victims of COVID-19 pandemic Implications of the COVID-19 Pandemic for Pediatric Primary Care Practice in Europe Sustainable Development Goals (SDGs) Child Abuse and Neglect and its Psycho-Physical and Social Consequences: A Review of the Literature Internet Addiction: Starting the Debate on Health and Well-Being of Children Overexposed to Digital Media Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study Caring for Infants and Children Following Alternative Dietary Patterns Femicide and murdered women's children: which future for these children orphans of a living parent Fostering Resilience in Children: The Essential Role of Healthcare Professionals and Families Looking at the Future, Learning from the Past: Current Activities and Upcoming Goals of the European Paediatric Association, the Union of National European Paediatric Societies and Associations