Treatment of Acute Malnutrition in Outpatient Care Services in Venezuela: a Prospective Cohort Research

The goal of this observational study is to compare the effectiveness, safety, and efficiency of the simplified protocol, which includes the following three modifications: a) use of a single treatment product (RUTF), b) reduced dose, c) expanded cut-offs, with the standard protocol based on the 2023 World Health Organization (WHO) guidelines for the prevention and treatment of acute malnutrition in children aged 6 to 59 months, in outpatient care services of the states of Bolívar, Capital District, La Guaira, and Miranda of Venezuela.

The main question it aims to answer is:

What is the effectiveness, safety, and efficiency of the simplified protocol, which includes these three modifications (use of a single treatment product (RUTF), reduced dose, expanded cut-offs) when compared to a standard protocol that is based on the 2023 WHO guidelines for the prevention and treatment of acute malnutrition in children aged 6 to 59 months in the outpatient care services of the states of Bolívar, Capital District, La Guaira, and Miranda of Venezuela? This prospective cohort, longitudinal study will be conducted in 4 states, treating children aged 6-59 months diagnosed with uncomplicated AM, defined as WHZ \<-2 or mid-upper-arm circumference (MUAC) \<125mm or bilateral edema. Children will be prospectively followed for 16 weeks or until their recovery.

Researchers will compare the simplified protocol cohort with the standard protocol cohort to determine which one has the best effectiveness, safety, and efficiency indicators in the Venezuela context.

The effectiveness of the treatment will be measured by the recovery rate, duration of the treatment, and changes in anthropometry (weight, height, and arm circumference). Other treatment effects will also be measured, including how many are admitted to the hospital, death, and relapse rates from the nutritional program. An economic evaluation component will be incorporated. Total costs will be aggregated and presented as costs per child treated and per child recovered.

The general objective of the study is to compare the effectiveness, safety, and efficiency of the simplified protocol, which includes the following three modifications: a) use of a single treatment product (RUTF), b) reduced dose, c) expanded cut-offs, with the standard protocol based on the 2023 WHO guidelines for the prevention and treatment of acute malnutrition in children aged 6 to 59 months in outpatient care services in the states Bolívar, Capital District, La Guaira, and Miranda of Venezuela.

This will be a multicentric and prospective cohort study assessing the Simplified Protocol with the Standard Protocol, among children with uncomplicated acute malnutrition. Children will be prospectively followed until their recovery or for a maximum of 16 weeks.

The study will be implemented in 4 Venezuelan states chosen based on their acute malnutrition prevalence and operational constraints.

The protocol will be implemented by health professionals from each institution, duly previously trained in applying the study protocol.

Eligibility Criteria:
Inclusion Criteria:

* Simplified protocol cohort

  * MUAC \<125 mm or
  * Weight-Height/length Z Score \<-2 or
  * Mild bipedal pitting oedema.

And all the following:

* No medical complications
* Positive appetite test.

  * Standard protocol cohort

SAM:

* MUAC \<115 mm or
* Weight-Height/length Z Score \<-3 or
* Mild bipedal pitting oedema

And all the following:

* No medical complications
* Positive appetite test

MAM (Although MAM cases are not traditionally included, in this study they will be incorporated if they meet the following criteria):

* MUAC ≥ 115 mm to \< 125 mm or
* Weight-Height/length Z Score ≥ -3 to \< -2 and
* No nutritional oedema

And at least one the following:

* Failing to recover from moderate wasting after receiving other interventions (counselling alone).
* Having relapsed to moderate wasting
* History of severe wasting
* Households' low socioeconomic status (Determined by Graffar-Mendez-Castellanos method)
* Co-morbidity (HIV, tuberculosis, or a physical or mental disability that does not jeopardize the anthropometric measurements)

Exclusion Criteria:

* Both cohorts:

  * Congenital malformations that make anthropometric measurements impossible.
  * Family that intends to leave the study area before four months.
  * Presence of medical condition requiring referral for hospitalization. Presence of medical condition requiring referral for hospitalization.