Transactions of The Royal Society of Tropical Medicine and Hygiene, Sep 17, 2021
The title read 'mo' instead of 'months'. The full, correct title is: 'The management of moderate ... more The title read 'mo' instead of 'months'. The full, correct title is: 'The management of moderate acute malnutrition in children aged 6-59 months in low-and middle-income countries: a systematic review and meta-analysis'. The captions of Figures 2, 3, and 4 had errors in the descriptions of D + L and M-H. The corrected text in all three captions should read: D + L, DerSimonion and Laird random effects estimates; M-H, Mantel-Haenszel fixed effects estimates.
Child undernutrition and later-life non-communicable diseases (NCDs) are major global health issu... more Child undernutrition and later-life non-communicable diseases (NCDs) are major global health issues. Literature suggests that undernutrition/famine exposure in childhood has immediate and long-term adverse health consequences. However, many studies have theoretical and methodological limitations. To add to the literature and overcome some of these limitations, we adopted a life course perspective and used more robust methods. We investigated the association between exposure to the 1959–1961 Chinese famine and later-life NCDs and if this association depends on: life stage at exposure, famine severity, and sex. We conducted a secondary data analysis of a large-scale, nationally representative, longitudinal study—the China Health and Retirement Longitudinal Study (2011–2018, 11,094 participants). We measured famine exposure/severity using self-reported experience, life stage using age at exposure, and health using the number of NCDs. We performed Poisson growth curve models. We obtaine...
Background: Anthropometric measurements, including mid-upper arm circumference (MUAC), are used f... more Background: Anthropometric measurements, including mid-upper arm circumference (MUAC), are used for monitoring and evaluating children's nutritional status. Evidence is limited on optimal nutritional assessment for children with disabilities, who are at high risk for malnutrition. Aim: This study describes MUAC use among children with disabilities. Methods: Four databases (Embase, Global Health, Medline, and CINHAL) were searched from January 1990 through September 2021 using a predefined search strategy. Of the 305 publications screened, 32 papers were included. Data included children 6 months to 18 years old with disabilities. Data including general study characteristics, methods for MUAC measurement, terminology, and measurement references were extracted into Excel. Due to heterogeneity of the data, a narrative synthesis was used. Results: Studies from 24 countries indicate that MUAC is being used as part of nutritional assessment, but MUAC measurement methods, references, an...
Adolescent pregnancy is associated with poor foetal growth and development which increase the ris... more Adolescent pregnancy is associated with poor foetal growth and development which increase the risk of childhood wasting and underweight. However, evidence on how young maternal age affects childhood anthropometry beyond the neonatal period is limited. This systematic review and meta-analysis examined associations between adolescent pregnancy and child wasting and underweight and explored potential underlying social and biological factors. Peer-reviewed literature published in English since 1990 was systematically searched. Eligible studies presented data on wasting and/or underweight in children (≤59 months) born to adolescent mothers (10-19, or ≤24 years where applicable) from low- and middle-income countries. Data extraction used a predefined extraction sheet. Both meta-analysis and qualitative synthesis were performed. Of 92 identified studies, 57 were included in the meta- analysis. The meta-analysis showed that children born to adolescent versus adult mothers were at a higher r...
Background: To improve global child health, efficacious interventions are important but real-worl... more Background: To improve global child health, efficacious interventions are important but real-world effectiveness is crucial; this requires translating technical guidance into frontline clinical and patient care practices. Patient management ‘tools’ are frequently used for this purpose, guiding healthcare workers to deliver quality care. Ahead of an update to a patient management tool for small and nutritionally at-risk infants under six months of age (C-MAMI Tool, V2), we reviewed how others have done this in the past. Our aim was to ensure an evidence-based development process to optimise future success and impact. Methods: We investigated five patient management tools: Integrated Care Pathways (ICPs), Integrated Management of Childhood Illness (IMCI), Paediatric Early Warning Systems (PEWS), Growth Monitoring (GM), and Emergency Triage Assessment and Treatment (ETAT). Searches were run in PubMed and examined evidence on the development, uptake, and effectiveness of these tools. Re...
ABSTRACTIntroductionChild undernutrition and later-life non-communicable diseases (NCDs) are majo... more ABSTRACTIntroductionChild undernutrition and later-life non-communicable diseases (NCDs) are major global health issues. Existing literature suggests that undernutrition/famine exposure in childhood has immediate and long-term adverse health consequences. However, many existing studies have theoretical and methodological limitations. To add to the literature and overcome some of these limitations, we adopted a life course perspective and used more robust methods to investigate the association between exposure to the 1959-1961 Chinese famine and later-life NCDs and if this association depends on: life stage (age) at exposure, severity of exposure, and sex.MethodsSecondary data analysis of the China Health and Retirement Longitudinal Study (2011-2018,Nparticipants=11,094). We measured famine exposure and severity using self-reported experience, life stages using age at exposure, and health using the number of NCDs. We performed Poisson growth curve models.ResultsFirst, compared with u...
Background: Child wasting is highly prevalent, with around 49.5 million children under five years... more Background: Child wasting is highly prevalent, with around 49.5 million children under five years affected globally. More evidence is needed to inform the scale up of effective treatment of wasted children worldwide. The aim of this study was to identify and prioritise the main outstanding research questions relating to the treatment of wasting to inform future research agendas. Methods: A research prioritisation exercise was undertaken using the Child Health and Nutrition Research Initiative method. Research gaps were identified from multiple sources, grouped in themes and condensed into a list of 53 research areas by a group of experts. An online survey was developed and circulated globally to individuals working in the global nutrition sector. Participants evaluated each research area according to four agreed criteria. Research areas were then ranked according to an overall research priority score. Results: A total of 394 individuals from 63 countries participated in the survey. ...
There is limited information on the feeding practices of 9.42 million children living within inst... more There is limited information on the feeding practices of 9.42 million children living within institution-based care (IBC) worldwide. Poor feeding practices can predispose or exacerbate malnutrition, illness and disability. Here we describe the feeding practices of children living within IBC based on a retrospective analysis of records from 3335 children, 0-18 years old, participating in Holt International's Child Nutrition Program (CNP), from 36 sites in six countries. Data analysed included demographic information on age, sex, feeding practices, disabilities and feeding difficulties. Descriptive statistics were produced. A generalised linear model explored associations between feeding difficulties and disability and 2 × 2 tables examined feeding difficulties over time. An additional set of feeding observations with qualitative and quantitative data was analysed. At baseline, the median age of children was 16 months (0.66-68 months) with 1650/3335 (49.5%) females. There were 757/3335 (22.7%) children with disabilities; 550/984 (55.9%) were low birth weight; 311/784 (39.7%) were premature; 447/3113 (14.4%) had low body mass index and 378/3335 (11.3%) had feeding difficulties. The adjusted risk of having a
BackgroundRapid catch-up growth after prenatal undernutrition is associated with increased risk o... more BackgroundRapid catch-up growth after prenatal undernutrition is associated with increased risk of non-communicable diseases (NCDs) in high-income countries. Severe malnutrition treatment programmes in low- and middle-income countries promote rapid post-malnutrition growth (PMGr) as desirable. Our aim was to explore patterns of PMGr during and in the year following treatment, and describe associations with survival and NCD risk seven years post-treatment.MethodsSecondary data analysis from a cohort of children treated for severe malnutrition in Malawi in 2006/7. Six definitions of PMGr were derived based on a variety of timepoints, weight, weight-for-age z-score (WAZ) and height-for-age z-score (HAZ). Three categorisation methods included: no categorisation, quintiles, and latent class analysis (LCA). Associations with mortality risk, and with eight NCD indicators were analysed visually using scatter plots and boxplots, and statistically using simple and multivariable linear regress...
ObjectivesThe aim of this study is to fill a key information gap on the nutrition-related epidemi... more ObjectivesThe aim of this study is to fill a key information gap on the nutrition-related epidemiology of orphaned and vulnerable children living within institution-based care (IBC) across six countries.DesignA retrospective analysis with Shewhart control charts and funnel plots to explore intersite and over time variations in nutritional status.SettingWe conducted a retrospective analysis of records from Holt International’s Child Nutrition Programme from 35 sites in six countries; Mongolia, India, Ethiopia, Vietnam, China and the Philippines.ParticipantsDeidentified health records from Holt International’s online nutrition screening database included records from 2926 children, 0–18 years old. Data were collected from 2013 to 2020 and included demographic and health information.ResultsAt initial screening, 717 (28.7%) children were anaemic, 788 (34.1%) underweight, 1048 (37.3%) stunted, 212 (12.6%) wasted, 135 (12%) overweight or obese and 339 (31%) had small head circumference. M...
Background: Many small and malnourished infants under 6 months of age have problems with breastfe... more Background: Many small and malnourished infants under 6 months of age have problems with breastfeeding and restoring effective exclusive breastfeeding is a common treatment goal. Assessment is a critical first step of case management, but most malnutrition guidelines do not specify how best to do this. We aimed to identify breastfeeding assessment tools for use in assessing at-risk and malnourished infants in resource-poor settings. Methods: We systematically searched: Medline and Embase; Web of Knowledge; Cochrane Reviews; Eldis and Google Scholar databases. Also the World Health Organization (WHO), United Nations International Children’s Emergency Fund (UNICEF), CAse REport guidelines, Emergency Nutrition Network, and Field Exchange websites. Assessment tool content was analysed using a framework describing breastfeeding ‘domains’ (baby’s behaviour; mother’s behaviour; position; latching; effective feeding; breast health; baby’s health; mother’s view of feed; number, timing and l...
Transactions of The Royal Society of Tropical Medicine and Hygiene, 2021
The title read 'mo' instead of 'months'. The full, correct title is: 'The management of moderate ... more The title read 'mo' instead of 'months'. The full, correct title is: 'The management of moderate acute malnutrition in children aged 6-59 months in low-and middle-income countries: a systematic review and meta-analysis'. The captions of Figures 2, 3, and 4 had errors in the descriptions of D + L and M-H. The corrected text in all three captions should read: D + L, DerSimonion and Laird random effects estimates; M-H, Mantel-Haenszel fixed effects estimates.
Purpose: Children living with disabilities (CLWD) are at high risk of malnutrition but have long ... more Purpose: Children living with disabilities (CLWD) are at high risk of malnutrition but have long been marginalised in malnutrition treatment programmes and research. The 2013 World Health Organization (WHO) guidelines for Severe Acute Malnutrition (SAM) mention disability but do not contain specific details for treatment or support. This study assesses inclusion of CLWD in national and international SAM guidelines. Methods: National and international SAM guidelines were sourced online and via direct enquiries. Eight scoping key informant interviews were conducted with experts involved in guideline development to help understand possible barriers to formalising malnutrition guidance for CLWD. Results: 71 malnutrition guidelines were reviewed (63 national, 8 international). Only 4% (3/71) had a specific section for CLWD, while the remaining lacked guidance on consistently including CLWD in programmes or practice. Only one guideline mentioned strategies to include CLWD during a nutriti...
IntroductionSevere acute malnutrition (SAM) and disability are major global health issues. Althou... more IntroductionSevere acute malnutrition (SAM) and disability are major global health issues. Although they can cause and influence each other, data on their co-existence are sparse. We aimed to describe the prevalence and patterns of disability among a cohort of children with SAM.MethodsA longitudinal cohort study in Malawi followed SAM survivors up to 7 years postdischarge. Clinical and anthropometric profiles were compared with sibling and community controls. Disability at original admission was identified clinically; at 7-year follow-up a standardised screening tool called ‘the Washington Group Questionnaire’ was used.Results60/938 (6.4%) of admissions to SAM treatment had clinically obvious disability at admission. Post-treatment mortality was high, with only 11/60 (18%) surviving till 7-year follow-up. SAM children with a disability at admission had 6.99 (95% CI 3.49 to 14.02; p<0.001) greater risk of dying compared with children without disability. They were also older, less ...
Background Malnutrition underlies 3 million child deaths worldwide. Current treatments differenti... more Background Malnutrition underlies 3 million child deaths worldwide. Current treatments differentiate severe acute malnutrition (SAM) from moderate acute malnutrition (MAM) with different products and programs. This differentiation is complex and costly. The Combined Protocol for Acute Malnutrition Study (ComPAS) assessed the effectiveness of a simplified, unified SAM/MAM protocol for children aged 6-59 months. Eliminating the need for separate products and protocols could improve the impact of programs by treating children more easily and cost-effectively, reaching more children globally. Methods and findings A cluster-randomized non-inferiority trial compared a combined protocol against standard care in Kenya and South Sudan. Randomization was stratified by country. Combined protocol clinics treated children using 2 sachets of ready-to-use therapeutic food (RUTF) per day for those with mid-upper arm circumference (MUAC) < 11.5 cm and/or edema, and 1 sachet of RUTF per day for those with MUAC 11.5 to <12.5 cm. Standard care clinics treated SAM with weight-based RUTF rations, and MAM with ready-to-use supplementary food (RUSF). The primary outcome was nutritional recovery. Secondary outcomes included cost-effectiveness, coverage, defaulting, death, length of stay, and average daily weight and MUAC
Transactions of The Royal Society of Tropical Medicine and Hygiene, Sep 17, 2021
The title read 'mo' instead of 'months'. The full, correct title is: 'The management of moderate ... more The title read 'mo' instead of 'months'. The full, correct title is: 'The management of moderate acute malnutrition in children aged 6-59 months in low-and middle-income countries: a systematic review and meta-analysis'. The captions of Figures 2, 3, and 4 had errors in the descriptions of D + L and M-H. The corrected text in all three captions should read: D + L, DerSimonion and Laird random effects estimates; M-H, Mantel-Haenszel fixed effects estimates.
Child undernutrition and later-life non-communicable diseases (NCDs) are major global health issu... more Child undernutrition and later-life non-communicable diseases (NCDs) are major global health issues. Literature suggests that undernutrition/famine exposure in childhood has immediate and long-term adverse health consequences. However, many studies have theoretical and methodological limitations. To add to the literature and overcome some of these limitations, we adopted a life course perspective and used more robust methods. We investigated the association between exposure to the 1959–1961 Chinese famine and later-life NCDs and if this association depends on: life stage at exposure, famine severity, and sex. We conducted a secondary data analysis of a large-scale, nationally representative, longitudinal study—the China Health and Retirement Longitudinal Study (2011–2018, 11,094 participants). We measured famine exposure/severity using self-reported experience, life stage using age at exposure, and health using the number of NCDs. We performed Poisson growth curve models. We obtaine...
Background: Anthropometric measurements, including mid-upper arm circumference (MUAC), are used f... more Background: Anthropometric measurements, including mid-upper arm circumference (MUAC), are used for monitoring and evaluating children's nutritional status. Evidence is limited on optimal nutritional assessment for children with disabilities, who are at high risk for malnutrition. Aim: This study describes MUAC use among children with disabilities. Methods: Four databases (Embase, Global Health, Medline, and CINHAL) were searched from January 1990 through September 2021 using a predefined search strategy. Of the 305 publications screened, 32 papers were included. Data included children 6 months to 18 years old with disabilities. Data including general study characteristics, methods for MUAC measurement, terminology, and measurement references were extracted into Excel. Due to heterogeneity of the data, a narrative synthesis was used. Results: Studies from 24 countries indicate that MUAC is being used as part of nutritional assessment, but MUAC measurement methods, references, an...
Adolescent pregnancy is associated with poor foetal growth and development which increase the ris... more Adolescent pregnancy is associated with poor foetal growth and development which increase the risk of childhood wasting and underweight. However, evidence on how young maternal age affects childhood anthropometry beyond the neonatal period is limited. This systematic review and meta-analysis examined associations between adolescent pregnancy and child wasting and underweight and explored potential underlying social and biological factors. Peer-reviewed literature published in English since 1990 was systematically searched. Eligible studies presented data on wasting and/or underweight in children (≤59 months) born to adolescent mothers (10-19, or ≤24 years where applicable) from low- and middle-income countries. Data extraction used a predefined extraction sheet. Both meta-analysis and qualitative synthesis were performed. Of 92 identified studies, 57 were included in the meta- analysis. The meta-analysis showed that children born to adolescent versus adult mothers were at a higher r...
Background: To improve global child health, efficacious interventions are important but real-worl... more Background: To improve global child health, efficacious interventions are important but real-world effectiveness is crucial; this requires translating technical guidance into frontline clinical and patient care practices. Patient management ‘tools’ are frequently used for this purpose, guiding healthcare workers to deliver quality care. Ahead of an update to a patient management tool for small and nutritionally at-risk infants under six months of age (C-MAMI Tool, V2), we reviewed how others have done this in the past. Our aim was to ensure an evidence-based development process to optimise future success and impact. Methods: We investigated five patient management tools: Integrated Care Pathways (ICPs), Integrated Management of Childhood Illness (IMCI), Paediatric Early Warning Systems (PEWS), Growth Monitoring (GM), and Emergency Triage Assessment and Treatment (ETAT). Searches were run in PubMed and examined evidence on the development, uptake, and effectiveness of these tools. Re...
ABSTRACTIntroductionChild undernutrition and later-life non-communicable diseases (NCDs) are majo... more ABSTRACTIntroductionChild undernutrition and later-life non-communicable diseases (NCDs) are major global health issues. Existing literature suggests that undernutrition/famine exposure in childhood has immediate and long-term adverse health consequences. However, many existing studies have theoretical and methodological limitations. To add to the literature and overcome some of these limitations, we adopted a life course perspective and used more robust methods to investigate the association between exposure to the 1959-1961 Chinese famine and later-life NCDs and if this association depends on: life stage (age) at exposure, severity of exposure, and sex.MethodsSecondary data analysis of the China Health and Retirement Longitudinal Study (2011-2018,Nparticipants=11,094). We measured famine exposure and severity using self-reported experience, life stages using age at exposure, and health using the number of NCDs. We performed Poisson growth curve models.ResultsFirst, compared with u...
Background: Child wasting is highly prevalent, with around 49.5 million children under five years... more Background: Child wasting is highly prevalent, with around 49.5 million children under five years affected globally. More evidence is needed to inform the scale up of effective treatment of wasted children worldwide. The aim of this study was to identify and prioritise the main outstanding research questions relating to the treatment of wasting to inform future research agendas. Methods: A research prioritisation exercise was undertaken using the Child Health and Nutrition Research Initiative method. Research gaps were identified from multiple sources, grouped in themes and condensed into a list of 53 research areas by a group of experts. An online survey was developed and circulated globally to individuals working in the global nutrition sector. Participants evaluated each research area according to four agreed criteria. Research areas were then ranked according to an overall research priority score. Results: A total of 394 individuals from 63 countries participated in the survey. ...
There is limited information on the feeding practices of 9.42 million children living within inst... more There is limited information on the feeding practices of 9.42 million children living within institution-based care (IBC) worldwide. Poor feeding practices can predispose or exacerbate malnutrition, illness and disability. Here we describe the feeding practices of children living within IBC based on a retrospective analysis of records from 3335 children, 0-18 years old, participating in Holt International's Child Nutrition Program (CNP), from 36 sites in six countries. Data analysed included demographic information on age, sex, feeding practices, disabilities and feeding difficulties. Descriptive statistics were produced. A generalised linear model explored associations between feeding difficulties and disability and 2 × 2 tables examined feeding difficulties over time. An additional set of feeding observations with qualitative and quantitative data was analysed. At baseline, the median age of children was 16 months (0.66-68 months) with 1650/3335 (49.5%) females. There were 757/3335 (22.7%) children with disabilities; 550/984 (55.9%) were low birth weight; 311/784 (39.7%) were premature; 447/3113 (14.4%) had low body mass index and 378/3335 (11.3%) had feeding difficulties. The adjusted risk of having a
BackgroundRapid catch-up growth after prenatal undernutrition is associated with increased risk o... more BackgroundRapid catch-up growth after prenatal undernutrition is associated with increased risk of non-communicable diseases (NCDs) in high-income countries. Severe malnutrition treatment programmes in low- and middle-income countries promote rapid post-malnutrition growth (PMGr) as desirable. Our aim was to explore patterns of PMGr during and in the year following treatment, and describe associations with survival and NCD risk seven years post-treatment.MethodsSecondary data analysis from a cohort of children treated for severe malnutrition in Malawi in 2006/7. Six definitions of PMGr were derived based on a variety of timepoints, weight, weight-for-age z-score (WAZ) and height-for-age z-score (HAZ). Three categorisation methods included: no categorisation, quintiles, and latent class analysis (LCA). Associations with mortality risk, and with eight NCD indicators were analysed visually using scatter plots and boxplots, and statistically using simple and multivariable linear regress...
ObjectivesThe aim of this study is to fill a key information gap on the nutrition-related epidemi... more ObjectivesThe aim of this study is to fill a key information gap on the nutrition-related epidemiology of orphaned and vulnerable children living within institution-based care (IBC) across six countries.DesignA retrospective analysis with Shewhart control charts and funnel plots to explore intersite and over time variations in nutritional status.SettingWe conducted a retrospective analysis of records from Holt International’s Child Nutrition Programme from 35 sites in six countries; Mongolia, India, Ethiopia, Vietnam, China and the Philippines.ParticipantsDeidentified health records from Holt International’s online nutrition screening database included records from 2926 children, 0–18 years old. Data were collected from 2013 to 2020 and included demographic and health information.ResultsAt initial screening, 717 (28.7%) children were anaemic, 788 (34.1%) underweight, 1048 (37.3%) stunted, 212 (12.6%) wasted, 135 (12%) overweight or obese and 339 (31%) had small head circumference. M...
Background: Many small and malnourished infants under 6 months of age have problems with breastfe... more Background: Many small and malnourished infants under 6 months of age have problems with breastfeeding and restoring effective exclusive breastfeeding is a common treatment goal. Assessment is a critical first step of case management, but most malnutrition guidelines do not specify how best to do this. We aimed to identify breastfeeding assessment tools for use in assessing at-risk and malnourished infants in resource-poor settings. Methods: We systematically searched: Medline and Embase; Web of Knowledge; Cochrane Reviews; Eldis and Google Scholar databases. Also the World Health Organization (WHO), United Nations International Children’s Emergency Fund (UNICEF), CAse REport guidelines, Emergency Nutrition Network, and Field Exchange websites. Assessment tool content was analysed using a framework describing breastfeeding ‘domains’ (baby’s behaviour; mother’s behaviour; position; latching; effective feeding; breast health; baby’s health; mother’s view of feed; number, timing and l...
Transactions of The Royal Society of Tropical Medicine and Hygiene, 2021
The title read 'mo' instead of 'months'. The full, correct title is: 'The management of moderate ... more The title read 'mo' instead of 'months'. The full, correct title is: 'The management of moderate acute malnutrition in children aged 6-59 months in low-and middle-income countries: a systematic review and meta-analysis'. The captions of Figures 2, 3, and 4 had errors in the descriptions of D + L and M-H. The corrected text in all three captions should read: D + L, DerSimonion and Laird random effects estimates; M-H, Mantel-Haenszel fixed effects estimates.
Purpose: Children living with disabilities (CLWD) are at high risk of malnutrition but have long ... more Purpose: Children living with disabilities (CLWD) are at high risk of malnutrition but have long been marginalised in malnutrition treatment programmes and research. The 2013 World Health Organization (WHO) guidelines for Severe Acute Malnutrition (SAM) mention disability but do not contain specific details for treatment or support. This study assesses inclusion of CLWD in national and international SAM guidelines. Methods: National and international SAM guidelines were sourced online and via direct enquiries. Eight scoping key informant interviews were conducted with experts involved in guideline development to help understand possible barriers to formalising malnutrition guidance for CLWD. Results: 71 malnutrition guidelines were reviewed (63 national, 8 international). Only 4% (3/71) had a specific section for CLWD, while the remaining lacked guidance on consistently including CLWD in programmes or practice. Only one guideline mentioned strategies to include CLWD during a nutriti...
IntroductionSevere acute malnutrition (SAM) and disability are major global health issues. Althou... more IntroductionSevere acute malnutrition (SAM) and disability are major global health issues. Although they can cause and influence each other, data on their co-existence are sparse. We aimed to describe the prevalence and patterns of disability among a cohort of children with SAM.MethodsA longitudinal cohort study in Malawi followed SAM survivors up to 7 years postdischarge. Clinical and anthropometric profiles were compared with sibling and community controls. Disability at original admission was identified clinically; at 7-year follow-up a standardised screening tool called ‘the Washington Group Questionnaire’ was used.Results60/938 (6.4%) of admissions to SAM treatment had clinically obvious disability at admission. Post-treatment mortality was high, with only 11/60 (18%) surviving till 7-year follow-up. SAM children with a disability at admission had 6.99 (95% CI 3.49 to 14.02; p<0.001) greater risk of dying compared with children without disability. They were also older, less ...
Background Malnutrition underlies 3 million child deaths worldwide. Current treatments differenti... more Background Malnutrition underlies 3 million child deaths worldwide. Current treatments differentiate severe acute malnutrition (SAM) from moderate acute malnutrition (MAM) with different products and programs. This differentiation is complex and costly. The Combined Protocol for Acute Malnutrition Study (ComPAS) assessed the effectiveness of a simplified, unified SAM/MAM protocol for children aged 6-59 months. Eliminating the need for separate products and protocols could improve the impact of programs by treating children more easily and cost-effectively, reaching more children globally. Methods and findings A cluster-randomized non-inferiority trial compared a combined protocol against standard care in Kenya and South Sudan. Randomization was stratified by country. Combined protocol clinics treated children using 2 sachets of ready-to-use therapeutic food (RUTF) per day for those with mid-upper arm circumference (MUAC) < 11.5 cm and/or edema, and 1 sachet of RUTF per day for those with MUAC 11.5 to <12.5 cm. Standard care clinics treated SAM with weight-based RUTF rations, and MAM with ready-to-use supplementary food (RUSF). The primary outcome was nutritional recovery. Secondary outcomes included cost-effectiveness, coverage, defaulting, death, length of stay, and average daily weight and MUAC
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