A Simplified Approach to Treating Acute Malnutrition

ComPAS research project holds promise for providing same recovery in malnourished children, at a lower cost

Around the world, about 50 million children under five years old suffer from acute malnutrition, the deadliest form of hunger. Fortunately, we can treat these children – in fact, about 90% of malnourished children who complete a full course of treatment are cured.

Still, despite the advances we’ve made to reach more children through community-based approaches and effective treatments, 75% of the world’s malnourished children cannot access treatment, leaving millions at risk of death from hunger-related causes each year. 

Why? Many malnourished children live in extremely remote and challenging contexts and resources are limited. Furthermore, while the global humanitarian aid community is designed to serve the most vulnerable, the system is complex with room to streamline, simplify and optimize its procedures in order to bring effective treatment to more children in need.  

Current policies and practices divide acute malnutrition into two separate categories—severe and moderate. Severely and moderately malnourished children are treated with different products, different protocols, supported by different UN agencies, and often at different locations.  

The current system is especially complicated and confusing for families with malnourished children. Health facilities are few and far between – forcing parents and caregivers to make frequent and long journeys to get their children treatment. As a child gets better, moving from a severe condition to a more moderate one, children switch to a different therapeutic food product and protocol and their caregiver must often visit another clinic, at a separate location, to access that treatment. Too often, children slip through the cracks and fail to fully recover.

It doesn’t have to be this way. The world needs better ways to deal with hunger – and we’re creating them.

Combined Protocol for Acute Malnutrition Protocol Study

A child is treated for malnutrition at a ComPAS facility.

Photo: Anne Salter
for Action Against Hunger & IRC,

Together with the International Rescue Committee and the London School of Hygiene & Tropical Medicine, Action Against Hunger conducted the Combined Protocol for Acute Malnutrition Study (ComPAS) – one of the first trials to use one diagnostic criteria, one product, and one protocol to treat both categories of acute malnutrition: severe and moderate. Approaching moderate and severe acute malnutrition as a continuum, rather than two separate health conditions, eliminates the need for different treatment products and protocols, potentially allowing for more cost-effective treatment, freeing up resources to treat more children. 

ComPAS results, released on July 9, 2020, showed that this innovative protocol tested in South Sudan and in Kenya, was just as safe and effective as the current protocols while costing approximately 12% less per child. By improving value for money without compromising quality of care, it may be possible to reach millions more malnourished children each year with lifesaving treatment.

More specifically, ComPAS results suggest:

  • Acutely malnourished children could benefit from treatment in one program with one product – rather than having separate programs, according to the level of severity of their condition. Combined treatment could simplify operations, streamline program logistics and staff training, and enable a more holistic continuum of care, potentially helping to prevent moderately malnourished children from deteriorating to severe acute malnutrition, the deadliest form of the condition. 
  • It is possible to safely reduce the amount of the specially formulated product used to treat an acutely malnourished child. An optimal dosage must strike the right balance between safely meeting individual energy needs and preserving critical resources that could allow more children to receive life-saving malnutrition treatment.
  • Key simplifications may also improve the availability of treatment, including:
    • Simplified diagnosis using one criterion - a child’s Mid-Upper Arm Circumference (MUAC) measurement - in place of the current process, which requires a child’s height, weight, and MUAC measurements. 
    • Simplified dosage determination for low-literacy community health workers using a simple 2:1 ratio – with two packages of product per day for a severely malnourished child and one per day for a moderately malnourished child - instead of the current process, which relies on a complex tables of weight-based dosages.

ComPAS research is an important step towards a cost-effective and simplified treatment regimen for acute malnutrition. While more research is needed to learn which simplifications work best, in which contexts, and at what level of cost-savings, we are encouraged and optimistic about these results.

Frequently Asked Questions

The current approach to treating acutely malnourished children is complex. How did it come to be this way and what are you doing to improve it?  

The current system was set up decades ago, out of necessity. It focused on the most urgent issue: finding safe and effective treatment for a child suffering from severe malnutrition, to ensure they did not succumb to the quick and deadly effects on this condition. 

After Action Against Hunger and others invented the formulas used to successfully treat malnourished children in hospitals, we saw that further innovations were needed to reach the millions of children who need this lifesaving care.

In recent decades, great effort has been taken to further innovate to reach the millions of children who need this lifesaving care. Our work has focused on developing and then implementing safe, evidence-based approaches that improve our ability to better meet high demand, such as moving treatment from hospitals to a community-based approach, which provides treatment closer to the vulnerable children who need it most.  

However, our job is not done. Even with these advances, just 25% of the world’s malnourished children are reached by the current approaches to treatment, leaving millions at risk of death from hunger-related causes each year. Further innovation is urgently required to optimize our approach, so that we can reach even more children, with the same limited resources.

Research like ComPAS, which focuses on innovative ways to simplify and streamline the current approach, represents another key milestone on the road to reaching all acutely malnourished children in need of lifesaving treatment with the highest quality of care possible in complex and challenging environments.

A malnourished child is treated at an Action Against Hunger health center in South Sudan.

Photo: Lys Arango
for Action Against Hunger,
South Sudan

How will this new approach mean more malnourished children will receive lifesaving care?

We believe a streamlined approach that improves the efficiency of the system (e.g. streamlining staff and logistics, optimizing dosages, etc.) while providing the same quality of care, will allow us to reduce the overall cost to treat each malnourished child. By reducing the cost per child cured, we could translate these cost savings (which ComPAS found to be approximately 12%) directly into the expansion of our support to reach more malnourished children with lifesaving care.

Where was this study conducted? Will this approach work outside of these areas?

ComPAS was intentionally conducted in two very different settings - a rural, conflict-affected area of South Sudan and an urban area of Kenya - as a means of boosting the generalizability of trial results.

We are cautiously optimistic that the ComPAS protocol and the simplifications it contains could achieve similar impacts in new contexts beyond those covered in this first trial. Our study is an important step forward, but more research is needed to confirm results in other contexts.

In our pursuit to continue this line of innovation, Action Against Hunger plans to test optimized approaches in variety of additional settings, including regions beyond East Africa, communities that are both food secure and food insecure, and more.

One of the simplifications studied by ComPAS included using one criterion for diagnosing malnutrition - a child's mid-upper arm circumference (MUAC) - using a simple measuring band.

Photo: Lys Arango
for Action Against Hunger,
South Sudan

This approach was tested before the COVID-19 pandemic began. Could the impact of the coronavirus affect this approach in the future?

If anything, the pandemic has made simplified and streamlined approaches, like ComPAS, even more relevant. Experts fear that the spread of COVID-19 will dramatically increase the number and severity of cases of acute malnutrition in children. However, current practices require close physical interaction and frequent travel to often-crowded health centers, both of which may unwittingly increase the potential spread of the virus and/or discourage life-saving health-seeking behaviors. 

We need simple, easy-to-use and cost-effective treatment approaches – like those identified within ComPAS – to reduce the burdens on health systems and health care workers and to ensure that essential health services can continue to be safely delivered. This will enable more children to be treated and increases the likelihood we can use this approach at the community level.

Action Against Hunger leads a COVID-19 Management of Acute Malnutrition Adaptations Tracking project, funded by USAID. In collaboration with key stakeholders, such as UNICEF and the US Centers for Disease Control, we are monitoring and analyzing the adoption of important programmatic adaptations for detection and treatment of acute malnutrition amid the current crisis in order to consolidate learning and identify key next steps for a post-COVID world. 

If ComPAS is an important first step, what's next?

ComPAS’ promising results and the unprecedented opportunity for innovation presented by the COVID-19 pandemic provide reason to accelerate operational research that applies this (or a similar, optimized approach) in a variety of resource-strapped, high-burden settings globally. In particular:

  • We must learn if and how the optimal diagnostic criteria and dosage might vary in different contexts.  
  • We need to learn more about cost saving throughout the larger system for managing acute malnutrition in operational settings.
  • We must determine the operational and physiological impacts of expanding treatment of moderate acute malnutrition (MAM) and if there are additional cost savings through the prevention of severe acute malnutrition (SAM).

Where can I read more about ComPAS?

You can find the final, peer-reviewed results in PLOS ONE (Stage 1, published on June 3, 2020) and PLOS MED (Stage 2, published on July 9, 2020), and you can also learn more in our press release about the study.

To learn more about the work of Action Against Hunger’s research team, click here.

A mother and child at a ComPAS treatment facility.

Photo: Anne Salter
for Action Against Hunger & IRC,

Action Against Hunger is leading a global movement to end hunger in our lifetimes. It innovates solutions, advocate for change, and reach 25 million people every year with proven hunger prevention and treatment programs. As a nonprofit that works across 50 countries, its 8,300 dedicated staff members partner with communities to address the root causes of hunger, including climate change, conflict, inequity, and emergencies. It strives to create a world free from hunger, for everyone, for good.