BRIGHT-SAM: BRaIn development, Growth and HealTh in children with Severe Acute Malnutrition Severe acute malnutrition (SAM) remains common among young children in low-income countries. In the past few decades the introduction of ready-to-use therapeutic foods (RUTF) into community-based SAM management has revolutionised SAM treatment by broadening access, improving outcomes, reducing hospital stays, and reducing costs. However, currently used RUTF products have formulations which do not result in optimal status of essential fatty acids (EFAs) which are required for brain and cognitive development. SAM is associated with impaired cognitive development in children, even many years after their nutritional recovery. Recommendations for SAM management include provision of caregiver education in stimulating their child (psychosocial (PS) intervention) as this has been shown to improve cognitive development in children with SAM. This component of SAM management often receives little attention during hospital treatment and has not been integrated into community SAM management. Currently, tested PS interventions, which show benefit to development of children with SAM, are too intensive and costly for scaling up and PS interventions used more broadly in the community for all children have shown some, but limited benefit.   Our working hypothesis, which we later want to test in a large clinical trial, is that both RUTF with improved EFA balance and a short, focussed PS intervention delivered while children are receiving RUTF, are required for promoting cognitive development of children with SAM. In the current study we need to adapt both these interventions for use in Tanzania. An appropriate RUTF formulation for testing in a trial has been developed by Nutriset, the company which currently provides RUTF globally, but we need to determine the acceptability of this new formulation to Tanzanian children with SAM and their caregivers. We will work with local health care staff, agencies interested in child development, and caregivers of children with SAM to develop a PS intervention based on the World Health Organization recommendations and on what is currently being used locally. We will then pilot both the novel RUTF and the PS intervention developed, among 100 children with SAM, to determine EFA status at recruitment and 8 weeks after recruitment and child development and brain function at 16 weeks after recruitment. Cognitive development will be measured by the Malawi Developmental Assessment Tool (MDAT) which is well validated in Africa and has been adapted for use with Tanzanian children as well as by a novel eye-tracking tool which is simple and potentially feasible for large scale field research. We will also test 100 non-malnourished children not given RUTF or the PS intervention in order to determine local normal EFA status, child development and cognitive function. Within the pilot study we will investigate contextual factors such as family socioeconomic status and structure, urban versus rural residence, child HIV status, and maternal mental health to see how these affect the delivery of the interventions and the child's response to them.    The project has several components, in addition to development and piloting of the two interventions, which will assist in planning the future clinical trial: determination of the variability in the MDAT, eye-tracking measures of cognitive function, and blood EFA profile which will aid calculation of the number of children needed for a trial; determination of the contextual factors which need to be considered in the trial; engagement with local health care staff managing SAM and providers of child development interventions in order to ensure that our interventions are appropriate and locally owned. Local understanding, appropriateness and ownership of the interventions will also benefit scale-up of the interventions if they prove beneficial to children in the future large trial. The Global Challenges Research Fund (GCRF) supports cutting-edge research to address challenges faced by developing countries. The fund addresses the UN sustainable development goals. It aims to maximise the impact of research and innovation to improve lives and opportunity in the developing world.