Guidance for Systematic Integration of Undernutrition in Attributing Cause of Death in Children

Abstract

Minimally invasive tissue sampling (MITS) is increasingly being used to better understand causes of death in low-resource settings. Undernutrition (eg, wasting, stunting) is prevalent among children globally and yet not consistently coded or uniformly included on death certificates in MITS studies when present. Consistent and accurate attribution of undernutrition is fundamental to understanding its contribution to child deaths. In May 2020, members of the MITS Alliance Cause of Death Technical Working Group convened a panel of experts in public health, child health, nutrition, infectious diseases, and MITS to develop guidance for systematic integration of undernutrition, as assessed by anthropometry, in cause of death coding, including as part of the causal chain or as a contributing condition, in children <5 years of age. The guidance presented here will support MITS and other researchers, public health practitioners, and clinicians with a systematic approach to assigning and interpreting undernutrition in death certification.

Keywords: Undernutrition; cause of death; child mortality surveillance; minimally invasive tissue sampling; severe wasting.

Figure 1.

Codes from the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10).

Figure 2.

Wasting or stunting in a child aged 1–59 months with no history of low birth weight (LBW), small for gestational age (SGA), or prematurity.

Figure 3.

Moderate or severe wasting in children with a history of low birth weight (LBW), prematurity, or small for gestational age (SGA). As indicated in objective 1, severe wasting should be included in part 1 unless it is clearly not associated with the cause of death, in which case it should be listed in part 2. As indicated in objective 1, moderate wasting should be included in part 2 unless it is clearly associated with the cause of death, in which case it should be included in part 1. For severe or moderate wasting with birth weight (BW) for gestational age (GA) (BW-for-GA) below the 10th centile and concurrent prematurity, guidelines from the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) for coding prematurity should be followed. ^aAlternatively was weight-for-age centile at death (corrected for GA) unchanged or better/higher than BW-for-GA centile? ^bTo allow for comparisons when GA is unknown, when BW is <2500g, LBW should also be included in part 2 (unless it was clearly associated with another condition in the causal chain, in which case it should be included in part 1).