Moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) are public health conditions affecting 55 million and 20 million children worldwide, respectively, mostly in developing countries where humanitarian emergencies are more likely to occur. Children with MAM are defined as those with a weight-for-height z-score (WHZ) score between -3 and -2. Children with SAM are defined as having a WHZ d -3 and/or bilateral edema. Typically children with MAM receive food rations, often blended flours, without much attention to concurrent medical conditions and have low recovery rates after 1 year of <50%. Children with non- complicated SAM are treated separately with ready-to-use therapeutic food (RUTF). The purpose of the research is to integrate the operation of outpatient treatment of MAM and non- complicated SAM with one protocol during humanitarian emergencies to improve the recovery rate and program coverage, helping to alleviate malnutrition in more sick children. The research approach involves the use of one food (RUTF) for treatment of both MAM and SAM. Diagnosis and distribution of food will be conducted at one location for both MAM and SAM. Mid-upper arm circumference (MUAC), which is simpler for local staff to use and steadily increases as children improve, will be used as both diagnosis and discharge criteria for MAM and SAM. As children progress through the program, the RUTF ration will be decreased. Children will be discharged from the program when they reach MUAC >12.5 cm, and they will receive a six-week supply of a micronutrient-rich supplement to be added to their regular diet. Ten sites in Sierra Leone, a post-emergency location, will be used for a primary study to develop the approach to the integrated treatment of MAM and SAM;1800 children in total will participate. The integrated protocol (five sites) will be compared to the standard protocol (five sites). An intervention to promote breastfeeding will be carried out by use of the Care Group model, a peer counseling system. Primary outcomes are recovery rate, program coverage, and breast milk intake. Recovery will be assessed by program cured discharge rate and by relapse rate. Follow-up will be conducted for six months to determine relapse. Coverage is assessed by the Simplified LQAS (Lot Quality Assurance Sampling) Evaluation of Access and Coverage (SLEAC) method. Effectiveness of breastfeeding counseling will be assessed by quantification of breast milk intake with stable isotopes. An operational validation trial will be carried out in Chad to test the integrated approach to treatment of MAM and SAM in a humanitarian emergency.
