State of the evidence 2021 - Modifications aiming to optimize acute malnutrition management in children under five

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Acute malnutrition impacts almost 50 million children under five each year(1), with the COVID-19 pandemic putting an additional 6.7 million children at risk (2). Children suffering from acute malnutrition are at significantly higher risk of morbidity and mortality (3,4). Community-based management of acute malnutrition (CMAM) has brought malnutrition treatment closer to home, increasing both coverage and access with high levels of effectiveness compared to inpatient, facility-based treatment. However, challenges remain in meeting the needs of all acutely malnourished children worldwide. For example, less than 20% of children with severe acute malnutrition (SAM) have access to treatment (5).

To address these challenges, organizations and governments have implemented “simplified approaches”, which Action Against Hunger USA defines as: a range of modifications and innovations to standard CMAM protocols with the aim of simplifying and streamlining operations, maximizing coverage, reducing overall costs, and optimizing cost-effectiveness. Furthermore, the COVID-19 pandemic presented unparalleled challenges to service continuity in the management of acute malnutrition, reducing children’s access to treatment. Addressing these concerns drove further implementation of these modifications and innovations, led by UNICEF and Global Nutrition Cluster guidance (6,7).

While many innovations have been tested to optimize CMAM service delivery, this summary focuses on those six modifications included in the global operational guidance on management of acute malnutrition in children aged 6-59 months in the context of COVID-19. These six CMAM protocol modifications – often discussed under the umbrella of “simplified approaches” – include:

  1. Family MUAC

  2. Reduced frequency of follow-up visits during treatment

  3. Modified admission and discharge criteria to treatment programs

  4. Combined treatment/protocol of MAM and SAM

  5. Modified (or reduced) dosage of therapeutic or supplementary foods during treatment

  6. Acute malnutrition treatment by community health workers (CHWs)

This summary assesses the current state of evidence on each approach in tabular form, providing: the definition and objectives; evidence of effectiveness; operational considerations (e.g., training, staffing, and logistics); cost considerations and evidence on cost-effectiveness; operational successes and challenges; and areas for future research and learning. This document is not intended to endorse any particular approach. Rather, it aims to objectively present the state of the existing evidence on each approach, so as to inform decision-making among practitioners looking to further test, refine and implement such approaches. The search was conducted in December 2020 and document finalized in May 2021.

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