Malnourished children don't only suffer from lack of food. Their nutrition, health, and risk of dying are influenced by underlying diseases and their caregiver’s social and home environments.


Healthy parents and caregivers make for healthier children. Look after your own health, including what you eat, stress, and sleep routines, and seek medical care for your own health issues.

Background  |  Findings from the CHAIN Study  |  What the CHAIN results mean  |  CHAIN Information


Childhood wasting (defined as low weight-for-height) is a known risk factor for both inpatient and post discharge death. An inadequate supply of food (food insecurity) is only one cause of wasting. Chronic medical conditions, including genetic and congenital syndromes, sickle cell disease, tuberculosis and HIV can also cause wasting, as can frequent acute illness such as malaria, pneumonia, and diarrhoea. In addition, adverse social situations, caregiver depression and household instability are also associated with childhood wasting.

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Findings from the CHAIN cohort

CHAIN has found that caregivers expend a lot of time and money seeking care and advice from multiple sources prior to bringing their child to the hospital for admission. Caregivers often visit and talk with pharmacists, local clinics, friends, family and/or traditional healers. They may avoid hospitals until a child is very sick because of fear of costs of travel or admission and other household responsibilities.

After arriving at the hospital, caregivers were often met by clinicians who were frustrated that the child was not brought sooner. Caregivers also noted that hospital staff sometimes suggested that if a child was wasted it was because the caregiver had not been adequately feeding their child. Caregivers often felt stigmatized by healthcare workers, which discouraged them from seeking medical services. This sentiment is expressed in this quote from a Kenyan caregiver:

“I met the doctor, and I told him/her to look at my child, and s/he started asking me [in front of every- body], ‘do you even take the time to feed this child?’ I told her/him yes, ‘then comparing your child with other children, are they of the same size?’ Ah, I walked out and came back home.”

Among severely wasted children in CHAIN, more than half were from households who reported having reasonable access to food. This suggests that wasting in these children is often not related to lack of available food. Even among caregivers who did report moderate or high food insecurity, more than a third of the children were not wasted. CHAIN found that in addition to food insecurity and other nutritional issues, background medical conditions were equally important to the development of wasting.

Many of the factors that lead to wasting, including underlying medical conditions, maternal employment status and caregiver mental health are also directly related to mortality. Wasting should not be viewed as exclusively caused by food insecurity or lack of dietary diversity. It is important to understand the complex relationships between medical factors, household and social factors and nutritional factors in order to optimally manage children with, or at risk of, wasting.

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What the CHAIN results mean

Hospital staff may stigmatize the caregivers of severely and moderately wasted children and often incorrectly assume that the primary cause of wasting is always food insecurity. As a result, the experiences of these caregivers during hospitalization often leads them to become less likely to seek care in the future. Clinicians, researchers, and policy makers should remember that wasting is the result of many factors, including social, medical, and nutritional challenges. Failing to identify and treat or support all these underlying causes leaves children at continued risk of mortality, recurrent illness, and impaired neurodevelopment. 

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  1. Zakayo SM, Njeru RW, Sanga G, et al. Vulnerability and agency across treatment-seeking journeys for acutely ill children: how family members navigate complex healthcare before, during and after hospitalisation in a rural Kenyan setting. Int J Equity Health. 2020;19(1):136. Published 2020 Aug 10. doi:10.1186/s12939-020-01252-x


CHAIN is continuing to examine laboratory markers of mortality mechanisms and risks to better identify new treatments that can be tested in clinical trials. CHAIN investigators are working in Kenya, Malawi, Uganda, Burkina Faso, Bangladesh and Pakistan. The project is coordinated from the KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya, and the Department of Global Health, University of Washington, Seattle, USA. Collaborating centres are in the UK, USA, Canada and the Netherlands. CHAIN is supported by the Bill & Melinda Gates Foundation as a grant to the Centre for Tropical Medicine & Global Health, University of Oxford, UK.

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Acute Care   |  Discharge   |  Leaving Against Medical Advice   |  Stigma and Wasting

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