Invisible Pursuit: A Scoping Review of Global Policy for Continuity of Care of Vulnerable Infants Under 6 Months and Their Mothers in Low- and Middle-Income Countries
Abstract
Highlights
- Fragmented global policy guidance masks important synergies and gaps that hinder interdisciplinary continuity of care.
- Anthropometric markers of risk are lacking in health-oriented guidance, which weakens risk-differentiated paediatric care.
- There are immediate opportunities for interdisciplinary policy cooperation in global and country guidance development processes underway.
- A managed living guideline system would improve accessibility, coherence, and content of global policy for vulnerable infants under 6 months and their mothers.
Abstract
1. Introduction
- What are the characteristics of global policy guidance related to vulnerable infants u6m and their mothers?
- How is vulnerability in infants u6m and their mothers described?
- How is continuity of care for vulnerable infants u6m and their mothers conceptualised?
- What are emerging considerations for developing policy that addresses vulnerable infants u6m and their mothers?
2. Materials and Methods
2.1. Approach
2.2. Definitions, Terminologies, and Frameworks
2.3. Eligibility Criteria
2.4. Information Sources
2.5. Search Strategy
2.6. Selection of Sources

2.7. Data Charting Process and Characteristics
2.8. Vulnerability
2.9. Continuity of Care
2.10. Data Items
2.11. Synthesis of Results
2.12. Sharing of Results
3. Results
3.1. Search Results
3.2. Characteristics
3.2.1. Sources
3.2.2. Publication Dates and Updates
3.2.3. Conditions
3.2.4. Target Audience
3.2.5. Target Population
3.2.6. Vulnerability Descriptor for Infants
3.2.7. Vulnerability Descriptor for Mothers
3.2.8. Sector
3.2.9. Level of Care
3.2.10. Care Service
3.3. Vulnerability Factors
3.3.1. Anthropometry and Growth
3.3.2. Feeding
3.3.3. Maternal
3.3.4. Illness
3.3.5. Combination of Risk Markers
3.4. Continuity of Care
4. Discussion
4.1. Policy Content
4.1.1. Characteristics
4.1.2. Vulnerability of Infants
4.1.3. Vulnerability of Mothers
4.1.4. Continuity of Care
4.2. Policy Processes
4.3. Ways Forward
4.3.1. Toward a Living Policy System
4.3.2. Handling Complexity Within Policy Guidance
4.3.3. Investing in Policy Cooperation
4.3.4. Shared Problems May Spark Collective Solutions
4.3.5. Strengths and Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Data Availability Statement
Acknowledgments
Conflicts of Interest
Abbreviations
| AGREE | Appraisal of Guidelines for Research and Evaluation |
| BMJ | British Medical Journal |
| CBM | Christian Blind Mission |
| CCC | Clinical Care in Crises |
| ENN | Emergency Nutrition Network |
| ETAT | emergency triage, assessment and treatment |
| GRADE | Grading of Recommendations Assessment, Development and Evaluation |
| IMCI | Integrated Management of Childhood Illness |
| LBW | low birth weight |
| LMICs | low- and middle-income countries |
| MAMI | Management of small and/or nutritionally at-risk infants under 6 months and their mothers |
| MUAC | mid-upper arm circumference |
| NGO | Non-governmental organisation |
| PAHO | Pan American Health Organization |
| PCC | population, concept, and context |
| PRISMA-ScR | Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews |
| UN | United Nations |
| u6m | under six months of age |
| WAZ | weight-for-age z score |
| WHO | World Health Organization |
| WHZ | Weight-for-height z score |
References
- Mertens, A.; Benjamin-Chung, J.; Colford, J.M., Jr.; Coyle, J.; van der Laan, M.J.; Hubbard, A.E.; Rosete, S.; Malenica, I.; Hejazi, N.; Sofrygin, O.; et al. Causes and consequences of child growth faltering in low-resource settings. Nature 2023, 621, 568–576. [Google Scholar] [CrossRef]
- Martorell, R.; Zongrone, A. Intergenerational influences on child growth and undernutrition. Paediatr. Perinat. Epidemiol. 2012, 26 (Suppl. S1), 302–314. [Google Scholar] [CrossRef]
- Kerac, M.; James, P.T.; McGrath, M.; Brennan, E.; Cole, T.; Opondo, C.; Frison, S. Malnutrition in infants aged under 6 months: Prevalence and anthropometric assessment—Analysis of 56 low- and middle-income country DHS datasets. BMJ Glob. Health 2025, 10, e016121. [Google Scholar] [CrossRef] [PubMed]
- Blencowe, H.; Krasevec, J.; de Onis, M.; Black, R.E.; An, X.; Stevens, G.A.; Borghi, E.; Hayashi, C.; Estevez, D.; Cegolon, L.; et al. National, regional, and worldwide estimates of low birthweight in 2015, with trends from 2000: A systematic analysis. Lancet Glob. Health 2019, 7, e849–e860. [Google Scholar] [CrossRef] [PubMed]
- Lawn, J.E.; Ohuma, E.O.; Bradley, E.; Idueta, L.S.; Hazel, E.; Okwaraji, Y.B.; Erchick, D.J.; Yargawa, J.; Katz, J.; Lee, A.C.C.; et al. Small babies, big risks: Global estimates of prevalence and mortality for vulnerable newborns to accelerate change and improve counting. Lancet 2023, 401, 1707–1719. [Google Scholar] [CrossRef] [PubMed]
- World Health Organization. WHO Handbook for Guideline Development, 2nd ed.; WHO: Geneva, Switzerland, 2014. [Google Scholar]
- World Health Organization. Constitution of the World Health Organization. 1946. Available online: https://www.who.int/about/governance/constitution (accessed on 2 July 2025).
- WHO. WHO Guidelines Approved by the Guidelines Review Committee, in Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children; World Health Organization: Geneva, Switzerland, 2013. [Google Scholar]
- World Health Organization. Improving the Quality of Care for Maternal, Newborn and Child Health: Implementation Guide for National, District and Facility Levels; World Health Organization: Geneva, Switzerland, 2022. [Google Scholar]
- World Health Organization. WHO Recommendations for Care of the Preterm or Low Birth Weight Infant; World Health Organization: Geneva, Switzerland, 2022. [Google Scholar]
- World Health Organization. Integrated Management of Childhood Illness: Distance Learning Course; Chart booklet; WHO: Geneva, Switzerland, 2014. [Google Scholar]
- World Health Organization. Integrated Management of Childhood Illness: Management of the Sick Young Infant Age up to 2 Months: Facilitator Guide and Chart Booklet; World Health Organization: Geneva, Switzerland, 2019. [Google Scholar]
- Akl, E.A.; Meerpohl, J.J.; Elliott, J.; Kahale, L.A.; Schünemann, H.J.; Agoritsas, T.; Hilton, J.; Perron, C.; Akl, E.; Hodder, R.; et al. Living systematic reviews: 4. Living guideline recommendations. J. Clin. Epidemiol. 2017, 91, 47–53. [Google Scholar] [CrossRef]
- Pai, M.; Bandara, S.; Kyobutungi, C. Shifting power in global health will require leadership by the Global South and allyship by the Global North. Lancet 2024, 404, 1711–1713. [Google Scholar] [CrossRef]
- Greenhalgh, T.; Thorne, S.; Malterud, K. Time to challenge the spurious hierarchy of systematic over narrative reviews? Eur. J. Clin. Investig. 2018, 48, e12931. [Google Scholar] [CrossRef]
- Peters, M.D.J.; Marnie, C.; Colquhoun, H.; Garritty, C.M.; Hempel, S.; Horsley, T.; Langlois, E.V.; Lillie, E.; O’Brien, K.K.; Tunçalp, Ӧ.; et al. Scoping reviews: Reinforcing and advancing the methodology and application. Syst. Rev. 2021, 10, 263. [Google Scholar] [CrossRef]
- Arksey, H.; O’Malley, L. Scoping studies: Towards a methodological framework. Int. J. Soc. Res. Methodol. 2005, 8, 19–32. [Google Scholar] [CrossRef]
- Peters, M.D.J.; Marnie, C.; Tricco, A.; Pollock, D.; Munn, Z.; Alexander, L.; McInerney, P.; Godfrey, C.; Khalil, H. Updated methodological guidance for the conduct of scoping reviews. JBI Evid. Implement. 2021, 19, 3–10. [Google Scholar] [CrossRef] [PubMed]
- Tricco, A.C.; Lillie, E.; Zarin, W.; O’Brien, K.K.; Colquhoun, H.; Levac, D.; Moher, D.; Peters, M.D.J.; Horsley, T.; Weeks, L.; et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Ann. Intern. Med. 2018, 169, 467–473. [Google Scholar] [CrossRef] [PubMed]
- McGrath, M.; Woldie, M.; Berhane, M.; Abera, M.; Hailu, E.; Rana, R.; Lanyero, B.; Grijalva-Eternod, C.; Abdissa, A.; Girma, T.; et al. Mapping the range of policies relevant to care of small and nutritionally at-risk infants under 6 months and their mothers in Ethiopia: A scoping review protocol. BMJ Open 2023, 13, e069359. [Google Scholar] [CrossRef] [PubMed]
- Greenhalgh, T.; Papoutsi, C. Studying complexity in health services research: Desperately seeking an overdue paradigm shift. BMC Med. 2018, 16, 95. [Google Scholar] [CrossRef]
- Downey, J.; Harris, N.; Rybczynska-Bunt, S.; Golder, E.; Shearn, K.; Bradley, N. Reflecting on Reflexivity in Realist Evaluation: A Call to Action. Int. J. Qual. Methods 2024, 23, 16094069241284206. [Google Scholar] [CrossRef]
- World Health Organization. Health Systems Strengthening Glossary; WHO: Geneva, Switzerland, 2011. [Google Scholar]
- MAMI Global Network; ENN; LSHTM. MAMI Care Pathway Package, Version 3. 2021. Available online: https://www.ennonline.net/resource/mami/mami-care-pathway-package-version-3 (accessed on 15 May 2025).
- MAMI Global Network. Available online: https://www.ennonline.net/network/mami-global-network (accessed on 8 June 2025).
- World Health Organization. WHO Institutional Repository for Information Sharing (IRIS). Available online: https://iris.who.int/ (accessed on 13 January 2023).
- UNICEF. UNICEF Data (Resource) Repository. Available online: https://data.unicef.org/resources/resource-type/publications/ (accessed on 13 January 2023).
- Emergency Nutrition Network; MAMI Global Network. Global Policy Guidance on Care of Vulnerable Infants Under Six Months and Their Mothers. Tableau public. Available online: https://www.ennonline.net/fex/75/en/global-policy-guidance-on-care-of-vulnerable-infants (accessed on 15 May 2025).
- Ahmed, T.; Ali, W.; Argaw, A.; Bahl, R.; Bailey, J.; Baqui, A.; Becquey, E.; Berkley, J.A.; Brown, K.; Chisti, M.J.; et al. Infant-level and child-level predictors of mortality in low-resource settings: The WHO Child Mortality Risk Stratification Multi-Country Pooled Cohort. Lancet Glob. Health 2025, 13, e843–e858. [Google Scholar] [CrossRef]
- The AGREE Research Trust. Appraisal of Guidelines for Research and Evaluation (AGREE). Available online: https://www.agreetrust.org/ (accessed on 8 June 2025).
- Brouwers, M.C.; Kho, M.E.; Browman, G.P.; Burgers, J.S.; Cluzeau, F.; Feder, G.; Fervers, B.; Graham, I.D.; Grimshaw, J.; Hanna, S.E.; et al. AGREE II: Advancing guideline development, reporting and evaluation in health care. CMAJ 2010, 182, E839–E842. [Google Scholar] [CrossRef]
- McGrath, M.; Wrottesley, S.V.; Brennan, E.; Samnani, A.; Deconinck, H. Invisible pursuit: Global policy guidance on care of vulnerable infants under 6 months and their mothers, a scoping review. Emerg. Nutr. Netw. (ENN) 2024, 10, m9. [Google Scholar]
- World Health Organization. WHO Guideline on the Prevention and Management of Wasting and Nutritional Oedema (Acute Malnutrition) in Infants and Children Under 5 Years; World Health Organization: Geneva, Switzerland, 2023. [Google Scholar]
- World Health Organization. WHO Consolidated Guidelines on Tuberculosis. Module 5: Management of Tuberculosis in Children and Adolescents; World Health Organization: Geneva, Switzerland, 2022. [Google Scholar]
- World Health Organization. Consolidated Guidelines on HIV Prevention, Testing, Treatment, Service Delivery and Monitoring: Recommendations for a Public Health Approach; World Health Organization: Geneva, Switzerland, 2021. [Google Scholar]
- World Health Organization. Guideline: Infant Feeding in Areas of Zika Virus Transmission; World Health Organization: Geneva, Switzerland, 2021. [Google Scholar]
- Pan American Health Organization. Evidence-Based Clinical Practice Guidelines for the Follow-Up of At-Risk Neonates; Pan American Health Organization: Washington, DC, USA, 2021. [Google Scholar]
- World Health Organization. Improving Early Childhood Development: WHO Guideline; World Health Organization: Geneva, Switzerland, 2020. [Google Scholar]
- World Health Organization. Counselling of Women to Improve Breastfeeding Practices; WHO: Geneva, Switzerland, 2018. [Google Scholar]
- World Health Organization. Paediatric Emergency Triage, Assessment and Treatment (ETAT); WHO: Geneva, Switzerland, 2016. [Google Scholar]
- World Health Organization. Guideline: Managing Possible Serious Bacterial Infection in Young Infants When Referral Is Not Feasible; WHO: Geneva, Switzerland, 2015. [Google Scholar]
- World Health Organization. WHO Recommendations on Interventions to Improve Preterm Birth Outcomes; WHO: Geneva, Switzerland, 2015. [Google Scholar]
- World Health Organization. Guidelines on Basic Newborn Resuscitation; WHO: Geneva, Switzerland, 2012. [Google Scholar]
- World Health Organization. Recommendations for Management of Common Childhood Conditions: Evidence for Technical Update of Pocket Book Recommendations: Newborn Conditions, Dysentery, Pneumonia, Oxygen Use and Delivery, Common Causes of Fever, Severe Acute Malnutrition and Supportive Care; WHO: Geneva, Switzerland, 2012. [Google Scholar]
- World Health Organization. WHO Recommendations on Maternal and Newborn Care for a Positive Postnatal Experience; World Health Organization: Geneva, Switzerland, 2022. [Google Scholar]
- World Health Organization. WHO Recommendations on Home-Based Records for Maternal, Newborn and Child Health; World Health Organization: Geneva, Switzerland, 2018. [Google Scholar]
- World Health Organization. Guideline: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services; World Health Organization: Geneva, Switzerland, 2017. [Google Scholar]
- World Health Organization. WHO Recommendations on Maternal Health: Guidelines by the WHO Guidelines Review Committee; World Health Organization: Geneva, Switzerland, 2017. [Google Scholar]
- World Health Organization. Guideline: Assessing and Managing Children at Primary Health-Care Facilities to Prevent Overweight and Obesity in the Context of the Double Burden of Malnutrition; WHO: Geneva, Switzerland, 2017. [Google Scholar]
- World Health Organization. WHO Recommendations on Newborn Health; WHO: Geneva, Switzerland, 2017. [Google Scholar]
- World Health Organization. Guidelines on Optimal Feeding of Low Birthweight Infants in Low-and Middle-Income Countries; WHO: Geneva, Switzerland, 2011. [Google Scholar]
- World Health Organization. Pocket Book of Primary Health Care for Children and Adolescents: Guidelines for Health Promotion, Disease Prevention and Management from the Newborn Period to Adolescence; World Health Organization, Regional Office for Europe: Copenhagen, Denmark, 2022. [Google Scholar]
- World Health Organization. WHO Operational Handbook on Tuberculosis. Module 5: Management of Tuberculosis in Children and Adolescents; World Health Organization: Geneva, Switzerland, 2022. [Google Scholar]
- World Health Organization. Guide for Integration of Perinatal Mental Health in Maternal and Child Health Services; World Health Organization: Geneva, Switzerland, 2022. [Google Scholar]
- UNICEF; University of Pretoria. Feeding Preterm and Low-Birthweight Newborns: A One-Stop Resource Document for Developing Country-Specific Implementation Guidelines, Protocols, Standard Operating Procedures and Job Aids; UNICEF: New York, NY, USA, 2022. [Google Scholar]
- UNICEF. Integrating Early Detection and Treatment of Child Wasting into Routine Primary Health Care Services: A Resource Guide to Support National Planning; UNICEF: New York, NY, USA, 2022. [Google Scholar]
- SPOON. Screening Children for Feeding Difficulties—Guidelines for Healthcare Professionals; SPOON: Portland, OR, USA, 2022. [Google Scholar]
- SPOON. Identifying Feeding Difficulties in Infants—Guidelines for Healthcare Professionals; SPOON: Portland, OR, USA, 2022. [Google Scholar]
- World Health Organization. Protecting, Promoting and Supporting Breastfeeding: The Baby-Friendly Hospital Initiative for Small, Sick and Preterm Newborns; WHO: Geneva, Switzerland, 2020. [Google Scholar]
- Ngabireyimana, E.; Mutaganzwa, C.; Kirk, C.M.; Miller, A.C.; Wilson, K.; Dushimimana, E.; Bigirumwami, O.; Mukakabano, E.S.; Nkikabahizi, F.; Magge, H. A retrospective review of the Paediatric Development Clinic implementation: A model to improve medical, nutritional and developmental outcomes of at-risk under-five children in rural Rwanda. Matern. Health Neonatol. Perinatol. 2017, 3, 13. [Google Scholar] [CrossRef]
- Foster, A.M.; Evans, D.P.; Garcia, M.; Knaster, S.; Krause, S.; McGinn, T.; Rich, S.; Shah, M.; Tappis, H.; Wheeler, E. The 2018 Inter-agency field manual on reproductive health in humanitarian settings: Revising the global standards. Reprod. Health Matters 2017, 25, 18–24. [Google Scholar] [CrossRef]
- World Health Organization. Oxygen Therapy for Children: A Manual for Health Workers; WHO: Geneva, Switzerland, 2016. [Google Scholar]
- World Health Organization. Caring for Newborns and Children in the Community: Planning Handbook; WHO: Geneva, Switzerland, 2015. [Google Scholar]
- World Health Organization. Integrated Management of Childhood Illness (Chart Booklet); World Health Organization: Geneva, Switzerland, 2014. [Google Scholar]
- World Health Organization. Hospital Care for Mothers and Newborn Babies Quality Assessment and Improvement Tool; WHO: Geneva, Switzerland, 2014. [Google Scholar]
- Christian Blind Mission. Recognising Impairments at Birth, Fact Sheet and Manual; CBM: Bensheim, Germany, 2014. [Google Scholar]
- World Health Organization. Pocket Book of Hospital Care for Children; WHO: Geneva, Switzerland, 2013. [Google Scholar]
- Christian Blind Mission. Cerebral Palsy, Factsheet and Manual; CBM: Bensheim, Germany, 2012. [Google Scholar]
- World Health Organization. Managing Newborn Problems: A Guide for Doctors, Nurses, and Midwives; World Health Organization: Geneva, Switzerland, 2003. [Google Scholar]
- World Health Organization. Kangaroo Mother Care: A Practical Guide; World Health Organization: Geneva, Switzerland, 2003. [Google Scholar]
- World Health Organization. Early Essential Newborn Care: Clinical Practice Pocket Guide; World Health Organization: Geneva, Switzerland, 2022. [Google Scholar]
- Holt International. The Child Nutrition Program: Community Resource Manual; Holt International: Eugene, OR, USA, 2022. [Google Scholar]
- SPOON. Count Me In; Brief; SPOON: Portland, OR, USA, 2021. [Google Scholar]
- World Health Organization; UNICEF. Ensuring Competency of Direct Care Providers to Implement the BFHI: Competency Verification Toolkit; WHO: Geneva, Switzerland, 2020. [Google Scholar]
- World Health Organization; UNICEF. Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services: The Revised Baby-Friendly Hospital Initiative 2018 Frequently Asked Questions; WHO: Geneva, Switzerland, 2020. [Google Scholar]
- World Health Organization; UNICEF. Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services: The Revised Baby-Friendly Hospital Initiative 2018 Implementation Guidance; WHO: Geneva, Switzerland, 2020. [Google Scholar]
- World Health Organization. Essential Nutrition Actions: Mainstreaming Nutrition Through the Life-Course; WHO: Geneva, Switzerland, 2019. [Google Scholar]
- World Health Organization. Network for Improving Quality of Care for Maternal, Newborn and Child Health-Quality of Care for Maternal and Newborn—A Monitoring Framework for Network Countries; WHO: Geneva, Switzerland, 2019. [Google Scholar]
- Holt International. Feeding and Positioning Manual: Guidelines for Working with Babies and Children Including “Child Nutrition Program: Community Flipbook”; Holt International: Eugene, OR, USA, 2019. [Google Scholar]
- World Health Organization; World Bank Group. Delivering Quality Health Services: A Global Imperative for Universal Health Coverage; WHO: Geneva, Switzerland, 2018. [Google Scholar]
- World Health Organization. Global Reference List of 100 Core Health Indicators (Plus Health-Related SDGs); WHO: Geneva, Switzerland, 2018. [Google Scholar]
- UNICEF; World Health Organization. Nurturing Care for Early Childhood Development: A Framework for Helping Children Survive and Thrive to Transform Health and Human Potential; WHO: Geneva, Switzerland, 2018. [Google Scholar]
- World Health Organization. Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors; WHO: Geneva, Switzerland, 2017. [Google Scholar]
- World Health Organization. Network for Improving the Quality of Care for Maternal, Newborn and Child Health: Implementation Guidance; WHO: Geneva, Switzerland, 2017. [Google Scholar]
- IFE Core Group. IYCF in Emergencies: Operational Guidance for Emergency Relief Staff and Programme Managers; IFE: Oxford, UK, 2017. [Google Scholar]
- World Health Organization. Interagency List of Priority Medical Devices for Essential Interventions for Reproductive, Maternal, Newborn and Child Health; WHO: Geneva, Switzerland, 2016. [Google Scholar]
- World Health Organization. Integrated Management of Pregnancy and Child Birth. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice; WHO: Geneva, Switzerland, 2015. [Google Scholar]
- Action Contre La Faim. Baby Friendly Spaces Holistic Approach for Pregnant, Lactating Women and Their Very Young Children in Emergency; Action Contre la Faim-France: Paris, France, 2014. [Google Scholar]
- Christian Blind Mission. Primary Health: Preventing Impairment and Disability, Fact Sheet and Manual. CBM Prevention Toolkit “How to Improve the Health and Development of Your Child”; CBM: Bensheim, Germany, 2012. [Google Scholar]
- UNICEF; OMS; UNESCO; UNFPA; PNUD; ONUSIDA; PAM; Banque Mondiale. Facts for Life; UNICEF: New York, NY, USA, 2010. [Google Scholar]
- World Health Organization. Acceptable Medical Reasons for Use of Breast-Milk Substitutes (BMS); WHO: Geneva, Switzerland, 2009. [Google Scholar]
- Walt, G.; Gilson, L. Reforming the health sector in developing countries: The central role of policy analysis. Health Policy Plan 1994, 9, 353–370. [Google Scholar] [CrossRef]
- Kitila, S.B.; Feyissa, G.T.; Olika, A.K.; Wordofa, M.A. Maternal Healthcare in Low- and Middle-Income Countries: A Scoping Review. Health Serv. Insights 2022, 15, 11786329221100310. [Google Scholar] [CrossRef]
- James, P.T.; Wrottesley, S.V.; Lelijveld, N.; Brennan, E.; Fenn, B.; Menezes, R.; Mates, E. Women’s Nutrition: A Summary of Evidence, Policy and Practice Including Adolescent and Maternal Life Stages; ENN: Oxford, UK, 2022. [Google Scholar]
- Lelijveld, N.; Brennan, E.; Wrottesley, S.V.; Akwanyi, B.; James, P.T. Nutrition of Women and Adolescent Girls in Humanitarian Contexts: Current State of Play; ENN: Oxford, UK, 2022. [Google Scholar]
- Dib, S.; Fewtrell, M.; Wells, J.C.K. Maternal capital predicts investment in infant growth and development through lactation. Front. Nutr. 2023, 10, 1272938. [Google Scholar] [CrossRef] [PubMed]
- Fuller, S.; Dent, N.; Deconinck, H.; McGrath, M. Supporting Mothers of Vulnerable Infants Under Six Months: Inviting Conversation and Collaboration; Emergency Nutrition Network (ENN): Oxford, UK, 2025. [Google Scholar]
- Haggerty, J.L.; Reid, R.J.; Freeman, G.K.; Starfield, B.H.; Adair, C.E.; McKendry, R. Continuity of care: A multidisciplinary review. BMJ 2003, 327, 1219–1221. [Google Scholar] [CrossRef] [PubMed]
- Mwangome, M.; Ngari, M.; Bwahere, P.; Kabore, P.; McGrath, M.; Kerac, M.; Berkley, J.A. Anthropometry at birth and at age of routine vaccination to predict mortality in the first year of life: A birth cohort study in BukinaFaso. PLoS ONE 2019, 14, e0213523. [Google Scholar] [CrossRef]
- Vogel, J.P.; Dowswell, T.; Lewin, S.; Bonet, M.; Hampson, L.; Kellie, F.; Portela, A.; Bucagu, M.; Norris, S.L.; Neilson, J.; et al. Developing and applying a ‘living guidelines’ approach to WHO recommendations on maternal and perinatal health. BMJ Glob. Health 2019, 4, e001683. [Google Scholar] [CrossRef]
- Agarwal, A.; Hunt, B.J.; Stegemann, M.; Rochwerg, B.; Lamontagne, F.; Siemieniuk, R.A.C.; Agoritsas, T.; Askie, L.; Lytvyn, L.; Leo, Y.-S.; et al. A living WHO guideline on drugs for covid-19. BMJ 2020, 370, m3379. [Google Scholar] [CrossRef]
- Lamontagne, F.; Stegemann, M.; Agarwal, A.; Agoritsas, T.; Siemieniuk, R.; Rochwerg, B.; Bartoszko, J.; Askie, L.; Macdonald, H.; Al-Maslamani, M.; et al. A living WHO guideline on drugs to prevent covid-19. BMJ 2021, 372, n526. [Google Scholar] [CrossRef]
- Punton, M.; Isabel, V.; Leavy, J.; Michaelis, C.; Boydell, E. Reality Bites: Making Realist Evaluation Useful in the Real World; CDI Practice, Paper 22; IDS: Brighton, UK, 2020. [Google Scholar]
- Askie, L.; Bartolomeos, K.; Farrar, J.; Sheikh, M. A continuous improvement agenda for WHO’s normative and standard-setting functions. Bull. World Health Organ. 2024, 102, 682–682a. [Google Scholar] [CrossRef]
- World Health Organization. Clinical Care in Crises. L4 Mobile Reference App. 2024. Available online: https://www.who.int/tools/CCC/l4-mobile-reference-app (accessed on 3 June 2025).
- World Health Organization. Clinical Management of COVID-19: Living Guideline. 2023. Available online: https://app.magicapp.org/summary/guideline_6915.html (accessed on 3 June 2025).
- Rehfuess, E.A.; Rehfuess, E.A.; Stratil, J.M.; Scheel, I.B.; Portela, A.; Norris, S.L.; Baltussen, R. The WHO-INTEGRATE evidence to decision framework version 1.0: Integrating WHO norms and values and a complexity perspective. BMJ Glob. Health 2019, 4, e000844. [Google Scholar] [CrossRef]
- Stratil, J.M.; Paudel, D.; Setty, K.E.; Menezes de Rezende, C.E.; Monroe, A.A.; Osuret, J.; Scheel, I.B.; Wildner, M.; Rehfuess, E.A. Advancing the WHO-INTEGRATE Framework as a Tool for Evidence-Informed, Deliberative Decision-Making Processes: Exploring the Views of Developers and Users of WHO Guidelines. Int. J. Health Policy Manag. 2022, 11, 629–641. [Google Scholar] [CrossRef] [PubMed]
- Norris, S.L.; Rehfuess, E.A.; Smith, H.; Tunçalp, Ö.; Grimshaw, J.M.; Ford, N.P.; Portela, A. Complex health interventions in complex systems: Improving the process and methods for evidence-informed health decisions. BMJ Glob. Health 2019, 4 (Suppl. S1), e000963. [Google Scholar] [CrossRef] [PubMed]
- Regis, C.; Foucault, G.; Denis, J.L.; Larouche, P.; Cohen, M. Challenges for impact evaluation of WHO’s normative output. Bull. World Health Organ. 2024, 102, 683–683a. [Google Scholar] [CrossRef]
- Taylor, L. WHO to cut budget by a fifth following Trump withdrawal. BMJ 2025, 389, r651. [Google Scholar] [CrossRef]
- Saluja, K.; Reddy, K.S.; Wang, Q.; Zhu, Y.; Li, Y.; Chu, X.; Li, R.; Hou, L.; Horsley, T.; Carden, F.; et al. Improving WHO’s understanding of WHO guideline uptake and use in Member States: A scoping review. Health Res. Policy Syst. 2022, 20, 98. [Google Scholar] [CrossRef]
- World Health Organization. Risk Stratification Analyses for Programmes and Research in Newborn and Child Health: Meeting Report, Geneva, Switzerland, 12–14 March 2024; WHO: Geneva, Switzerland, 2025. [Google Scholar]
- World Health Organization. Evidence, Policy, Impact. WHO Guide for Evidence-Informed Decision-Making; WHO: Geneva, Switzerland, 2021. [Google Scholar]
- Ashorn, P.; Ashorn, U.; Muthiani, Y.; Aboubaker, S.; Askari, S.; Bahl, R.; Black, R.E.; Dalmiya, N.; Duggan, C.P.; Hofmeyr, G.J.; et al. Small vulnerable newborns-big potential for impact. Lancet 2023, 401, 1692–1706. [Google Scholar] [CrossRef]
- Shiffman, J. Four Challenges That Global Health Networks Face. Int. J. Health Policy Manag. 2017, 6, 183–189. [Google Scholar] [CrossRef] [PubMed]
| Vulnerablilty Factors | Guideline Documents * | Guidance Documents | All Policy Documents | |||
|---|---|---|---|---|---|---|
| n = 28 | n = 13 | (%) | n = 21 | (%) | n = 34 | (%) |
| Poor birth outcomes | ||||||
| Congenital illness | 7 | (54) | 15 | (71) | 22 | (65) |
| Low birth weight (LBW) ** | 7 | (54) | 14 | (67) | 21 | (62) |
| Preterm ** | 7 | (54) | 13 | (62) | 20 | (59) |
| Disability or congenital abnormality | 5 | (38) | 12 | (57) | 17 | (50) |
| Birth trauma or complications | 5 | (38) | 7 | (33) | 12 | (35) |
| Preterm morbidity | 4 | (31) | 11 | (52) | 15 | (44) |
| Small for gestational age | 3 | (23) | 5 | (24) | 8 | (24) |
| Low anthropometry or poor growth | ||||||
| Low anthropometry (low WAZ **, low WLZ, or low MUAC) | 3 | (23) | 7 | (33) | 9 | (26) |
| Poor growth (weight loss or stagnant or insufficient weight gain) | 3 | (23) | 12 | (57) | 15 | (44) |
| Nutritional oedema | 3 | (23) | 6 | (29) | 9 | (26) |
| Risk factors related to the infant | ||||||
| Breastfeeding difficulties | 7 | (54) | 14 | (67) | 21 | (62) |
| Illness | 7 | (54) | 11 | (52) | 18 | (53) |
| Not breastfed ** | 4 | (31) | 13 | (62) | 17 | (50) |
| Neurodevelopment concerns | 4 | (31) | 11 | (52) | 15 | (44) |
| Hospitalisation history | 1 | (8) | 5 | (24) | 6 | (18) |
| Mental health | 0 | (0) | 3 | (14) | 3 | (9) |
| Risk factors related to the mother | ||||||
| Physical health | 6 | (46) | 15 | (71) | 21 | (62) |
| Breastfeeding conditions | 5 | (38) | 12 | (57) | 17 | (50) |
| Mental health | 5 | (38) | 11 | (52) | 16 | (47) |
| Social or contextual factors affecting care and feeding practices | 3 | (23) | 11 | (52) | 14 | (41) |
| Birth complication | 3 | (23) | 6 | (29) | 9 | (26) |
| Adolescent | 2 | (15) | 7 | (33) | 9 | (26) |
| Absent or died | 2 | (15) | 5 | (24) | 7 | (21) |
| Multipara | 1 | (8) | 6 | (29) | 7 | (21) |
| Primipara | 1 | (8) | 2 | (10) | 3 | (9) |
| Anaemia | 0 | (0) | 3 | (14) | 3 | (9) |
| Birth spacing | 0 | (0) | 2 | (10) | 2 | (6) |
| Low MUAC | 0 | (0) | 2 | (10) | 2 | (6) |
| Category of Vulnerability | Guideline Documents (>50% Coverage) | Guidance Documents (>50% Coverage) |
|---|---|---|
| Poor birth outcomes | Congenital illness Low birth weight Preterm | Congenital illness Low birth weight (LBW) Preterm Disability and/or congenital abnormality Preterm morbidity |
| Low anthropometry or poor growth | No | Poor ponderal growth |
| Risk factors related to the infant | Breastfeeding difficulties Illness | Breastfeeding difficulties Not breastfed Illness Neurodevelopment concerns |
| Risk factors related to the mother | No | Physical health Breastfeeding conditions Mental health Social or contextual factors |
| Title of Document | Condition | Care Across Time, Services, and Levels of Care | Integrated Care Pathway | Comprehensive Person-Centred Care | Early Childhood Development | Mother, Father, and Family Support | Community Participation | Embeddedness (Mainstream) | Local Health System Support | M&E | Wider Multisectoral Support | Organisational Capacities |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Guidelines (blue) | ||||||||||||
| 2023 WHO Guideline on the prevention and management of wasting and nutritional oedema in infants and children under 5 years | Poor growth and development | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - | ✔️ | - | - | ✔️ | - |
| 2022 WHO Consolidated guidelines on tuberculosis in children and adolescents | Tuberculosis | ✔️ | ✔️ | ✔️ | - | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - | - |
| 2022 WHO Recommendations for care of the preterm or low-birth-weight infant | Preterm and LBW | - | ✔️ | - | - | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ |
| 2021 WHO-PAHO Evidence-based clinical practice guidelines for the follow-up of at-risk neonates | Newborn care | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - | - | - | ✔️ | - | - |
| 2021 WHO Guideline: Infant feeding in areas of Zika virus transmission | Zika virus | - | - | - | - | ✔️ | - | ✔️ | - | - | - | - |
| 2021 WHO Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring | HIV | ✔️ | ✔️ | ✔️ | - | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ |
| 2020 WHO Improving early childhood development | ECD | ✔️ | n/a | n/a | ✔️ | ✔️ | - | - | ✔️ | ✔️ | - | - |
| 2018 WHO Guideline: Counselling of women to improve breastfeeding practices | Breastfeeding | ✔️ | ✔️ | ✔️ | - | ✔️ | - | ✔️ | ✔️ | ✔️ | - | ✔️ |
| 2016 WHO Paediatric emergency triage, assessment and treatment (ETAT) | Critically ill child | - | - | - | - | - | - | - | ✔️ | ✔️ | - | - |
| 2015 WHO Recommendations on interventions to improve preterm birth outcomes | Preterm | - | - | - | - | ✔️ | - | ✔️ | ✔️ | ✔️ | - | - |
| 2015 WHO Guideline: Managing possible serious bacterial infection in young infants when referral is not feasible | Ill child | ✔️ | - | - | - | - | - | ✔️ | ✔️ | ✔️ | - | - |
| 2012 WHO Recommendations for management of common childhood conditions | Ill child | - | - | - | - | - | - | ✔️ | ✔️ | - | - | - |
| 2012 WHO Guidelines on basic newborn resuscitation | Newborn resuscitation | - | - | - | - | - | - | ✔️ | - | ✔️ | - | - |
| Guidance (green) and manuals (yellow) | ||||||||||||
| 2022 WHO Guide for integration of perinatal mental health in maternal and child health services | Perinatal mental health | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ |
| 2022 UNICEF, University of Pretoria Feeding preterm and low-birth-weight newborns | Preterm and LBW | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - | - | - | - |
| 2022 WHO-Europe Pocketbook of primary healthcare for children and adolescents | Ill child | - | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - | ✔️ | ✔️ |
| 2022 SPOON Identifying feeding difficulties in infants—guidelines for healthcare professionals | Feeding difficulties | ✔️ | - | - | - | - | - | ✔️ | - | - | - | - |
| 2022 SPOON Screening children for feeding difficulties—guidelines for healthcare professionals | Feeding difficulties | ✔️ | - | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - | - | - |
| 2022 UNICEF Integrating early detection and treatment of child wasting into routine primary healthcare services | Wasting | ✔️ | n/a | n/a | - | - | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ |
| 2022 WHO Operational handbook on tuberculosis. Module 5: Management of tuberculosis in children and adolescents | Tuberculosis | n/a | ✔️ | ✔️ | - | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - |
| 2021 ENN, LSHTM, MAMI Care Pathway Package, Version 3 (guiding framework) | Small and nutritionally at-risk infant and mother | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ |
| 2020 WHO, UNICEF The Baby-Friendly Hospital Initiative for small, sick and preterm newborns | Breastfeeding | - | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - |
| 2020 Partners in Health, UNICEF Early Childhood Development Support for High-Risk Infants | Preterm and LBW | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - | ✔️ | - | - | ✔️ | - |
| 2019 WHO Integrated Management of Childhood Illness of the sick young infant aged up to 2 months. Chart booklet | Ill child | ✔️ | ✔️ | ✔️ | - | ✔️ | - | ✔️ | - | ✔️ | - | - |
| 2018 IASC Field Manual on Reproductive Health in Humanitarian Settings | Reproductive health | ✔️ | ✔️ | ✔️ | - | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ |
| 2016 WHO Oxygen therapy for children | Ill child | n/a | ✔️ | - | - | ✔️ | - | ✔️ | ✔️ | ✔️ | - | - |
| 2015 WHO, UNICEF, USAID Caring for newborns and children in the community: planning handbook for programme managers and planners | Newborn care | n/a | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - | - |
| 2014 WHO-Europe Hospital care for mothers and newborn babies: quality assessment and improvement tool | Newborn care | ✔️ | ✔️ | ✔️ | - | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - | ✔️ |
| 2014 WHO Integrated Management of Childhood Illness—Chart booklet | Ill child | n/a | ✔️ | ✔️ | - | ✔️ | - | ✔️ | - | - | - | - |
| 2014 Christian Blind Mission (CBM) Recognising impairments at birth | Newborn care | n/a | ✔️ | ✔️ | ✔️ | - | - | ✔️ | ✔️ | - | - | - |
| 2013 WHO Pocketbook of hospital care for children | Ill child | n/a | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - | ✔️ | - | - |
| 2012 CBM Cerebral Palsy | Cerebral palsy | n/a | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - | - | - |
| 2003 WHO Kangaroo mother care: a practical guide | Newborn care | n/a | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | ✔️ | - |
| 2003 WHO Managing newborn problems | Newborn care | n/a | ✔️ | - | ✔️ | ✔️ | ✔️ | - | ✔️ | - | - |
| Dimensions of Care | Guideline Documents (n = 13) | Guidance Documents (n = 21) | Summary Appraisal * |
|---|---|---|---|
| Care across time, services, and levels of care | 7 | 10 | Gaps in continuity across time, primarily for follow-up after discharge from a particular service or when infants ‘age out’ of the service without adequate referral mechanisms; gaps in continuity between services and levels of care, e.g., linking facility- and community-based care. |
| Integrated care pathway | 6 | 18 | Strong focus on addressing one or more condition(s), without integration into a broader care pathway that assesses and responds to maternal and infant risks and monitors progress/links to follow-up care, particularly at other levels of the health system (primary care/outpatient/community levels). |
| Comprehensive person-centred care | 5 | 17 | Guidelines centred on the condition rather than the person (mother or infant) and a lack of comprehensive assessment and care for both mother and infant together. |
| Early childhood development | 3 | 12 | Limited contextualisation within a framework that supports early child development, with a focus on the identification and management of one or more condition(s) rather than on a holistic approach to ensuring optimal growth and development. |
| Mother, father, and family support | 9 | 18 | Primary focus on supporting the mother in feeding and care practices for the infant, including targeted counselling for mothers and other caregivers/family members in some cases. Lack of inclusion of broader aspects of support, particularly for the mother’s own health and social circumstances. |
| Community participation | 3 | 15 | Limited aspects of community participation in care/organisation of care, particularly for guidelines. |
| Integration and embeddedness (mainstream) | 10 | 21 | Focus on mainstreaming of guidance into routine care but lacking detail on how to embed services across levels of the health system (particularly primary care/outpatient/community). |
| Local health system support | 9 | 14 | Emphasis on integration into existing health systems and services, particularly for guidelines. More limited reference to the how, including steps such as situational analysis needs assessment and planning/budgeting for the necessary infrastructure, resources, and capacity development. |
| Monitoring and evaluation | 10 | 13 | A need for monitoring and evaluation frameworks often mentioned but lacking in detail. |
| Wider multisectoral support | 3 | 9 | Minimally mentioned, with only one guideline emphasising the need for linkages to other services and systems (social assistance/protection, food, water, and sanitation) and two making brief mentions of policies/services outside of the health system. Greater presence in manuals and guidance documents but still low overall presence, along with a lack of detail when included. |
| Organisational capacities | 3 | 6 | Largely missing, except for a few examples that included best practice statements for, or the need to align with, emergency preparedness plans or humanitarian response strategies. |
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© 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
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McGrath, M.; Deconinck, H.; Wrottesley, S.V.; Kerac, M.; Smythe, T. Invisible Pursuit: A Scoping Review of Global Policy for Continuity of Care of Vulnerable Infants Under 6 Months and Their Mothers in Low- and Middle-Income Countries. Children 2025, 12, 1328. https://doi.org/10.3390/children12101328
McGrath M, Deconinck H, Wrottesley SV, Kerac M, Smythe T. Invisible Pursuit: A Scoping Review of Global Policy for Continuity of Care of Vulnerable Infants Under 6 Months and Their Mothers in Low- and Middle-Income Countries. Children. 2025; 12(10):1328. https://doi.org/10.3390/children12101328
Chicago/Turabian StyleMcGrath, Marie, Hedwig Deconinck, Stephanie V. Wrottesley, Marko Kerac, and Tracey Smythe. 2025. "Invisible Pursuit: A Scoping Review of Global Policy for Continuity of Care of Vulnerable Infants Under 6 Months and Their Mothers in Low- and Middle-Income Countries" Children 12, no. 10: 1328. https://doi.org/10.3390/children12101328
APA StyleMcGrath, M., Deconinck, H., Wrottesley, S. V., Kerac, M., & Smythe, T. (2025). Invisible Pursuit: A Scoping Review of Global Policy for Continuity of Care of Vulnerable Infants Under 6 Months and Their Mothers in Low- and Middle-Income Countries. Children, 12(10), 1328. https://doi.org/10.3390/children12101328

