For uncomplicated cases of acute malnutrition treatment for children between ages 6-59 months, different treatment protocols are in place for those categorized as severely malnourished and as moderately malnourished. In certain contexts, the treatment locations are even physically separate, with severely acutely malnourished (SAM) children who successfully recover to moderately acutely malnourished (MAM) being referred to a different location to continue treatment. Additionally, some locations are hard to access because of insecurity and poor road infrastructure, making it extremely difficult to run MAM and/or SAM programs. We at the IRC have recognized the challenges in this system, and have been testing a treatment protocol that allows for these children to be treated in the same location, using the streamlined Combined Protocol.
The Combined Protocol as we define it has several characteristics different from the widely used global guidelines for acute malnutrition treatment. One, severe and moderate acutely malnourished children can receive care in the same place under a single protocol, meaning the severe children are retained in the treatment program not just until they recover to the moderate zone, but until they are fully recovered. Two, the current treatment protocol uses different products to treat SAM and MAM children respectively, but this protocol uses a single product of Ready-to-Use Therapeutic Food (RUTF) to treat both. Three, the dosage schedule is simplified, where SAM children receive 2 RUTF sachets per day on a weekly basis, while the MAM children receive 1 RUTF sachet per day on a biweekly basis. Four, the diagnosis and malnutrition categorization is done prioritizing the mid-upper arm circumference (MUAC) measure, rather than the usual procedure of using both MUAC measure and the weight-for-height Z-score.
Karaan Clinic, located in Mogadishu, Somalia, runs an Outpatient Therapeutic Program (OTP, where SAM children are treated) but has been implementing the Combined Protocol under an R2HC-funded study since January 2018. The Somalia Ministry of Health and the Somalia Nutrition Cluster have already recognized the challenges of having SAM and MAM treatments being in physically separate places and are leading a process of consolidating the physical location of the malnutrition treatment programs. This consolidation process has not reached Karaan Clinic yet, and in the meantime under the standard treatment protocol, the SAM children who recover to MAM at Karaan Clinic were being referred to a Therapeutic Supplementary Feeding Program clinic (TSFP, where MAM children are treated) that is approximately 3km away. No routine monitoring systems are currently in place to track referral completion of these children, but we understand anecdotally that many caregivers were not completing this referral due to reasons such as distance to the TSFP and belief that the child has sufficiently recovered when being discharged from the OTP. Because of that, we suspect that there has been low referral completion, which in turn likely contributes to MAM children relapsing back into the SAM zone quickly.
So far under the Combined Protocol, Karaan Clinic is seeing very high adherence to the malnutrition treatment schedule, from SAM to MAM to full recovery. It appears that allowing caregivers to continue treatment in the same location has led to negligible dropout rates, with a high proportion of SAM children reaching full recovery. While the final results are not yet ready, the high recovery rate we are seeing thus far leads us to believe that this protocol can be safely adopted, particularly in contexts where implementers of nutrition treatment programs are facing major logistical challenges in operating SAM and MAM treatment programs. Several countries including Somalia already have nutrition stakeholders adopting similar strategies under conditions of logistical difficulty. These decisions have been made primarily on practical need. The hope is for our study to add evidence that this protocol is scientifically sound and to contribute to the discussion of whether such streamlined protocols should be more widely allowed in logistically difficult contexts, if not in all contexts of high acute malnutrition burden.
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