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.

Inclusion Criteria:

• 6-59.9 months of age at admission into treatment

• Child admitted to the national treatment program according to the following criteria:

  • 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

• Caregiver or legal guardian consents to participate

Exclusion Criteria:

• 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

All data will be fully anonymized and de-identified. No names, GPS coordinates, dates of birth or other identifying data will be stored in the databases.

At the time of publication of scientific articles presenting primary results, the fully anonymized databases will become a public good and will be made available to the scientific community, government, and partners.

At the time of publication of scientific articles presenting primary results.