As the COVID-19 pandemic continues to spread and persist, disrupting economies, food, health, and social protection systems, hard-won global progress on child nutrition and health are at risk. Marie Ruel and Derek Headey, writing on behalf of the Standing Together for Nutrition Research group, quantify the potential scale of child mortality and malnutrition impacts under COVID-19. To address this crisis and its possibly severe long-term consequences, four UN agencies have outlined five actions countries should take to protect children’s nutrition and health.—John McDermott, series co-editor and Director, CGIAR Research Program on Agriculture for Nutrition and Health (A4NH).

In a pair of commentaries published in The Lancet in August, we and our colleagues in the Standing Together for Nutrition Consortium (STfN) and the leaders of four UN agencies called for immediate action to address the escalating problems of child malnutrition and excess mortality triggered by the COVID-19 pandemic. Although child mortality from the virus itself is low compared to other age groups, the social, economic, and health systems crises it has prompted pose a serious threat to young children’s nutrition, health, and survival in low- and middle-income countries (LMICs).

As disruptions to economies and food and health systems continue, their negative impacts are multiplying: IFPRI estimates from April 2020 suggest that an additional 140 million people could fall into extreme poverty, while the World Food Program predicts that up to 265 million people could be food insecure by the end of 2020 without intervention. At the household level, this means that incomes are plummeting, food security is deteriorating, and nutritious diets are growing increasingly out of reach for the most vulnerable populations in LMICs. Making matters worse are the pandemic-induced interruptions to health, nutrition, and social protection services. Early estimates from UNICEF showed that coverage of essential maternal and child nutrition and health services had dropped by roughly 30% on average since the outbreak, and even stopped completely under some lockdowns. Although social protection programs, including cash and food transfers, are being modified or scaled up in many countries, they are struggling to meet the skyrocketing demand resulting from job and income losses.

The combination of increased poverty and food insecurity and gaps in essential health and nutrition services means that the number of children suffering from malnutrition, especially wasting (thinness, a form of acute malnutrition), will rise and along with it, the risk of mortality from infectious diseases. Before the pandemic, some 47 million children under age 5, mostly in Africa and South Asia, were moderately or severely wasted; without rapid mitigation, child wasting and related mortality are expected to increase in 2020 and beyond.

How many additional children could become malnourished or die as a result of the COVID-19-related health and economic crises?

To stimulate a rapid response to protect nutrition and prevent dramatic rises in child wasting and mortality, a group of researchers from the STfN consortium planned a set of analyses to assess the scope and depth of the problem. We took a multipronged approach to model the combined effects of the COVID-19-triggered health and economic crises on child wasting and mortality. We used macroeconomic projections of changes in per capita gross national income (GNI) resulting from the economic crisis; analyzed 177 rounds of Demographic and Health Surveys from 52 LMICs to assess how these types of GNI shocks would affect child wasting; and used the Lives Saved Tool to generate country-specific projections of child mortality due to increases in wasting and disruptions to nutrition services like vitamin A supplementation, complementary feeding interventions, and treatment of severe acute malnutrition.

The results were grim. We found that a 10% decrease in GNI per capita on average in LMICs could lead to a 14% increase in the prevalence of child wasting—that is, roughly 6.7 million more children under age 5 suffering from wasting in 2020 than there would have been without the pandemic. When we factor in a hypothetical 25% reduction in coverage of health and nutrition services (likely an underestimate), the projected number of additional child deaths is roughly 128,605.

What could these trends look like at the national level? In India, for example, which before the pandemic was home to more than 23 million wasted children, an estimated 10% reduction in GNI could lead to an additional 3.4 million children with moderate or severe wasting in 2020 and with a much greater risk of death. And in Mexico, a country that had largely eliminated wasting over past decades, a resurgence could occur and lead to more than 177,041 new cases of moderate or severe wasting.

It is important to note that the dramatic increases in severe wasting and associated mortality tell only part of the story. The children who survive may suffer from long-lasting and largely irreversible impacts—ranging from repeated infections to impaired cognition and even blindness (from severe vitamin A deficiency)—that will affect them, their families, and their societies for decades.

The road ahead

Although the health crisis may start winding down in 2021 if effective vaccines become available, the social and economic crises are expected to linger for much longer. The STfN team is currently assessing other longer-term nutrition impacts, including maternal anemia during pregnancy, birth outcomes, child stunting (a more chronic manifestation of malnutrition), and the percentage of the population that cannot afford a healthy diet. The team is also modeling the impacts of the crisis on the nutrition financing landscape for the next five years; estimating the cost of inaction for society; and using optimization tools to analyze how funding could be allocated at the national level across a range of health and nutrition interventions to minimize damage on child nutrition, health, and mortality.

The Call to Action signed by four UN institutions urges national governments to adopt five actions across health, food, and social protection systems to prevent COVID-19 from triggering an intergenerational hunger and malnutrition crisis.

1. Safeguard and promote access to nutritious, safe, and affordable diets
2. Invest in improving maternal and child nutrition through pregnancy, infancy, and early childhood
3. Reactivate and scale-up services for the early detection and treatment of child wasting and maintain and expand other nutrition services
4. Maintain the provision of nutritious and safe school meals for vulnerable children
5. Expand social protection to safeguard access to nutritious diets and essential services

The challenges ahead are immense. But we do know that by acting now, we can reduce the impact on young children and perhaps spare them from lifelong consequences that could cripple their ability to learn, leave them vulnerable to chronic diseases, and prevent them from realizing their full physical, cognitive, health, and productive potential.

Marie Ruel is Director of IFPRI’s Poverty, Health, and Nutrition Division (PHND); Derek Headey is a Senior Research Fellow with PHND. The analysis and opinions expressed in this piece are solely those of the authors. The work on this study was supported by a grant from the Children’s Investment Fund Foundation (CIFF).

The Standing Together for Nutrition “research group” includes Jonathan Kweku Akuoku (World Bank), Robert Black (Johns Hopkins Bloomberg School of Public Health), Augustin Flory (Results for Development), Lawrence Haddad (Global Alliance for Improved Nutrition), Rebecca Heidkamp (JHU Bloomberg School of Public Health), Saskia Osendarp (Micronutrient Forum), Nick Scott (Burnet Institute), Meera Shekar (World Bank), Neff Walker (JHU Bloomberg School of Public Health).