State of the evidence: Simplified approaches

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Action Against Hunger USA. (2021). State of the Evidence 2021: Modifications Aiming to Optimize Acute Malnutrition Treatment in Children Under Five. New York. Available from: https://www.actionagainsthunger.org/publication/2021/08/state-evidence-2021-modifications-aiming-optimize-acute-malnutrition-management

While community-based management of acute malnutrition (CMAM) has increased programme coverage and access to treatment, significant challenges remain in meeting the needs of all malnourished children worldwide. Simplified approaches are a range of modifications and innovations to standard CMAM protocols that aim to simplify and streamline operations, maximise coverage, reduce overall costs, and optimise cost-effectiveness. This report assesses the current state of evidence of six modifications based on a review of peer-reviewed publications and grey literature resources, including operational data and case studies.

1. Family mid-upper-arm circumference (MUAC) is one of the most widely implemented approaches. It aims to improve early detection and referral by empowering caregivers to detect acute malnutrition in their own children, at the household level, by measuring MUAC and assessing oedema themselves. However, robust evidence is lacking regarding programme effectiveness and cost-effectiveness on improving early treatment, identifying and referring clinical danger signs, handling moderate acute malnutrition (MAM) cases if treatment is unavailable, and best practices to ensure an effective programme design.
2. Reduced frequency of follow-up visits aims to increase access to services and uptake by reducing the travel burden for caregivers, while prioritising resources for high-risk children who may return for more frequent visits. While this approach is widely implemented, evidence is limited. Available evidence indicates adequate MUAC and weight gain.
3. Modified admissions and discharge criteria includes a range of modifications to admissions and discharge protocols. The most common modification is using only MUAC and oedema for admissions and discharge criteria, which often includes an increase in MUAC thresholds for admissions to capture children otherwise admitted by weight-for-height z scores (WHZ). MUAC- and oedema-only programming is based on the suggestion that an increased MUAC threshold is more appropriate than combining MUAC and WHZ to identify children at the highest risk of death, given the associations between MUAC and mortality and the operational simplicity of MUAC. There is a large body of evidence for MUAC- and oedema-only programming, with more limited evidence for expanded MUAC thresholds within this approach.  
4. Combined treatment/protocol for severe acute malnutrition (SAM) and MAM incorporates treatment across the full spectrum of acute malnutrition via one unified programme in one location. This approach can (but does not always) use one nutritional product. The evidence base consists of several studies with varied research designs which, to date, indicate that combined protocols are non-inferior to standard protocols, are more cost-effective, and may enable earlier treatment.
5. Modified or reduced dosage of therapeutic or supplementary foods aims to optimise the dosage for recovery to improve cost-effectiveness, programme coverage, impact, and efficiency. The evidence base comprises a few studies with varying degrees of rigour. The existing evidence largely finds that overall programme recovery rates using modified dosages were non-inferior to those using weight-based dosages. However, some secondary outcomes and sub-analyses found differences across groups.
6. Acute malnutrition treatment by community health workers (CHW) shifts most or all treatment components for children with acute malnutrition (without medical complications) to a community setting to improve programme coverage and early access to treatment, lower default rates, and to reduce treatment-seeking costs for caregivers. There is a robust evidence base supporting CHW-led SAM treatment. However, questions remain regarding the effectiveness of CHW-led MAM treatment, cost-effectiveness, long-term quality of care, and optimal training and incentives.