Severe acute malnutrition (SAM) places children at significant risk of mortality. Outpatient treatment programs are effective but there is a need to increase treatment coverage and reduce costs of treatment. Reducing the dosage of therapeutic food products and/or reducing visitation required by caregivers may be beneficial but evidence is limited on the treatment outcomes and costs of these approaches.
This study will compare two dosage options (full vs reduced dosages) of the World Health Organization protocol for the treatment of SAM and high-risk moderate acute malnutrition (HR-MAM) to each other and to the Kenya national protocol (which involves reducing dosage, changing treatment product, and reducing visitation schedule during the course of the treatment once the SAM child reaches the criteria for moderate acute malnutrition before recovery), in terms of treatment performance and cost. We will conduct a cluster-randomized controlled trial including 45 facilities in Samburu, West Pokot, and Wajir sub-counties. Children 6-59 months old being admitted into outpatient treatment programs for SAM or HR-MAM will be enrolled. Outcomes will be recovery, default, death, transfer, and non-response rates; treatment adherence; mean amount of therapeutic products needed for recovery; mean length of stay; and anthropometry at discharge. We will conduct a costing study in which we will estimate the costs per child admitted into treatment and cost per treated child recovered. We will estimate the non-inferiority of each of the two WHO protocol dosage options (full vs reduced) compared to the Kenya national protocol, and of the two WHO protocol options compared to each other (full vs reduced). Enrollment will begin in early 2026, and continue for 10 months. We will also conduct an observational sub-study documenting outcomes on children with MAM but who are not considered high risk in a sub-set of study facilities.
Evidence generated from the study will identify the optimal treatment strategy for better treatment performance and lower cost, providing policymakers in Kenya and across the globe with high-quality evidence to inform policy change.
6-59.9 months of age at admission into treatment
For SAM: WHZ <-3 or MUAC <115 mm or presence of bilateral oedema, absence of clinical complications, pass the appetite test
For high-risk MAM: -3 ≥ WHZ <-2 or 115mm ≥ MUAC <125 mm, and one or more of the following factors: MUAC of 115-119 mm, weight-for-age z-score (WAZ) < -3, age < 24 months, failing to recover from MAM after receiving other interventions (e.g. counselling, nutrient dense diet), relapse, history of SAM, co-morbidity (medical problems needing mid- or long-term follow-up care, and with a significant association with nutritional status, such as HIV, tuberculosis, or a physical or mental disability)
Accompanied by caregiver or legal guardian
SAM requiring hospitalization (presence of clinical complications, failure to pass the appetite test, or presence of bilateral pitting edema)
Enrolled in MAM or SAM treatment program before implementation of the treatment protocols to which the facilities were randomized
Presence of physical abnormalities that make measurement of anthropometry impossible
Caregiver has intention to move out of the study area within the next 3 months
Parallel
WHO-reduced
Other interventionChildren will receive the full, weight-based dosage of RUTF (150-185 kcal/kg/day) until the resolution of severe wasting, followed by a shift to reduced dosage (100-130 kcal/kg/day) until recovery. Treatment visits will be weekly until recovery.
WHO-full
Other interventionChildren will receive the continuous full, weight-based dosage of 150-185 kcal/kg/day until recovery. Visits will be weekly until recovery.
Kenya-IMAM
Other interventionChildren will receive the Kenya Integrated Management of Acute Malnutrition protocol for treatment. In this protocol, children will receive the weight-based dosing RUTF during treatment while they meet the SAM criteria (150-185 kcal/kg/day) and then 1 sachet RUSF for SAM children meeting the MAM criteria on the recovery period. Visits will be weekly during the SAM phase, and bi-weekly during the MAM phase.
Anthropometric recovery
The number of discharges considered cured (WHZ ≥ -2 and MUAC ≥ 125 mm and absence of bilateral edema for two consecutive visits, within 12 weeks of enrollment in the program) divided by the total number of discharges recorded.
Non-response
the number of children who failed to meet recovery criteria after 4 months in the program, divided by the total number of children admitted into treatment
Transfer
the number of children transferred to inpatient care or outpatient therapeutic care during the course of treatment, divided by the total number of children admitted into treatment
Default rate
the number of children who were absent from three consecutive weekly visits during treatment, divided by the total number of children admitted into treatment
Relapse
admission for a new episode of either MAM or SAM within 2 months of recovery from a previous episode.
Amount of product needed for recovery
number of sachets of RUTF or RUSF provided to children during the course of treatment among children who reached anthropometric recovery
Mortality
the number of children who died during the treatment course, divided by the total number of children admitted into treatment
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International Food Policy Research Institute
Lead sponsor
Kenyatta University
Collaborator
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