Effectiveness of community-based treatment programs for treatment of uncomplicated severe acute malnourished children aged 6–59 months using locally produced nutrient dense foods: protocol for a multicentric longitudinal quasi-experimental study
Authors: Kumar Praveen , Sinha Rajesh Kumar , Daniel Abner , Shah Hemang , Sriswan Raja , Kokane Arun , Mohapatra Aditya , Kashyap Vivek , Goel Anil Kumar , Kumar Virendra , Kiran Asha , Arlappa N. , Joshi Ankur , Nayak Rashmi Ranjan , Singh Manjula , Salasibew Mihretab , Ghosh Samik , Pawar Sameer Manikrao , Mishra Preetu , Tiwari Khyati , Bhattacharjee Sourav , Saiyed Farhat , Patel Tarun Shrikrishna , Nayak Pritish Kumar , Sahoo Sanjay Kumar , Prajapati Mahendra , Sinha Shikha , de Wagt Arjan 
Published: December 2021

Abstract
Background
Severe acute malnutrition (SAM) is a major underlying cause of mortality among children. Around one third of the world’s acutely malnourished children live in India. The WHO recommends community-based management of acute malnutrition (CMAM) for managing children with SAM. In India, different states are implementing community-based SAM treatment programme, hereinafter called CSAM, using varieties of locally produced nutrient dense food items with different nutrient compositions. The study will assess the effectiveness of these state specific CSAM interventions.

Methods
The longitudinal quasi-experimental study will be undertaken in two purposively selected blocks of one district each in the four intervention states and one comparison state. From each state, 200 SAM children identified using weight-for-length/height z-score (WHZ) < − 3 criteria will be enrolled in the study. Their anthropometric data and skinfold thickness will be taken on admission, at sixth week and at discharge by trained field investigators. Other child details, incidence of morbidity and socio-economic details will be collected on admission. To assess food consumption pattern including consumption of locally produced nutrient dense food supplements, dietary assessment, using 24-h dietary recall will be conducted on admission, at sixth week and at discharge. In addition, body composition parameters will be assessed for a sub-set of children using bio-electrical impedance analysis on admission and at discharge to analyse changes in total body water, fat-free mass, and fat mass. Post discharge, all study participants will be followed up monthly until 6 months. Atleast 10% of the sample will be checked for quality assessment.
The study’s primary outcome is cure rate defined as children attaining WHZ ≥ -2. Secondary outcomes include mean weight gain, mean length of stay, body composition parameters, relapse and mortality rates. Additionally, process evaluation and cost effectiveness analysis will be conducted.

Discussion
There is a shortage of robust evidence regarding the effectiveness of locally produced nutrient dense food supplements provided as part of the CSAM intervention in India. This study will contribute to evidence on effective strategies to manage children with uncomplicated SAM in India. The study protocol has all necessary ethical approvals. Written informed consent will be obtained from caregivers of the children.

Trial registration
The study is registered with Clinical Trial Registration of India (Registration No.: CTRI/2020/09/028013) Date of registration 24/09/2020.