Outpatient treatment of severe acute malnutrition: response to
treatment with a reduced schedule of therapeutic food distribution1,2
Sheila Isanaka,3–5* Stephen R Kodish,3 Fatou Berthé,6 Ian Alley,5 Fabienne Nackers,5 Kerstin E Hanson,7 and
Rebecca F Grais4,5
3
Departments of Nutrition and 4Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA; and 5Epicentre and 6Epicentre Niger,
and 7Médecins Sans Frontières, Operational Center Paris, Paris, France
ABSTRACT
Background: Community-based management of severe acute mal-
nutrition (SAM) has been shown to be safe and cost-effective, but
program coverage remains low. Treatment models that maintain
high levels of clinical effectiveness but allow for increased coverage
are still needed. A reduced schedule of follow-up, in which children
receive clinical follow-up and therapeutic foods on a monthly rather
than weekly basis, may be one alternative.
Objective: We aimed to describe the safety and feasibility of a
monthly distribution of ready-to-use therapeutic food (RUTF) in
the treatment of uncomplicated SAM, in terms of clinical response
to treatment and household RUTF use.
Design: We conducted a nonrandomized pilot intervention study in
which 115 children eligible for outpatient treatment of SAM were
provided a monthly ration of RUTF. Anthropometric measurements
were taken weekly for 4 wk to monitor treatment response. Un-
announced household spot checks were conducted over 4 wk to
assess household use of RUTF and storage practices.
Results: Adequate weight and midupper arm circumference (MUAC)
gain were found throughout the 4-wk follow-up period. Observed
mean 6 SD weight gain from admission was 9.8 6 6.8 g $ kg21 $ d21
in week 1 and 4.2 6 2.1 g $ kg21 $ d21 by week 4. Unplanned
household spot checks found an average surplus of RUTF sachets com-
pared with the number expected based on the date of distribution and
recommended dosing throughout the 4 wk of follow-up. The frequency
at which more than the recommended dose was used (i.e., deviance
of .2 sachets between available and expected stocks) was 4% and 22%
of households visited in week 1 and week 4, respectively.
Conclusion: Adequate treatment response and RUTF use in the
outpatient treatment of SAM was maintained over 4 wk of
follow-up with a monthly schedule of RUTF distribution. This study
was registered at clinicaltrials.gov as NCT02994212. Am J
Clin Nutr 2017;105:1191–7.
Keywords: ready-to-use therapeutic food, RUTF, severe acute
malnutrition, SAM, community-based management of acute
malnutrition, CMAM, treatment response, household utilization
INTRODUCTION
Since 2007, the community-based management of acute
malnutrition has become the standard of care for the management
Am J Clin Nutr 2017;105:1191–7. Printed in USA. Ó 2017 American Society for Nutrition
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of severe acute malnutrition (SAM)8 (1). Today’s community-
based model represents a historic shift away from exclusive
inpatient care in the clinical management of SAM, wherein the
majority of children with SAM presenting without clinical
complications and sufficient appetite benefit from outpatient
care, and inpatient management is reserved for stabilization of
complicated cases. Outpatient care, including either weekly or
biweekly clinical follow-up at a health facility, was made pos-
sible in part by the development of ready-to-use therapeutic
foods (RUTFs). RUTFs are energy-dense pastes that provide all
of the macro- and micronutrients needed for recovery from
SAM, and they can be safely administered at home. The shift to
outpatient care places increased responsibility on caregivers to
supervise therapeutic feeding at home, but adequate weight gain,
high recovery (i.e., .80%), and low mortality (i.e., 1–5%) have
nevertheless been achieved across various settings (2–7).
Although community-based management of SAM can be cost-
effective (8–10), program coverage remains exceedingly low:
globally, only 7–13% of children with SAM received treatment
in 2012 (11). New treatment models that maintain high levels of
clinical effectiveness but allow for increased coverage are still
needed. A reduced schedule of follow-up, in which children
receive clinical follow-up and RUTF on a monthly rather than
weekly or biweekly basis, may be one alternative. A monthly
schedule of follow-up has the potential to reduce the burden on
caregivers associated with frequent visits to a health facility,
reduce program costs through improved efficiency associated
with larger patient volumes, and offer greater operational flex-
ibility to provide treatment in contexts in which security or
geography do not allow frequent visits. Such changes could be
1
Funding for this study was provided by Médecins Sans Frontières
Operational Center Paris.
2
Supplemental Figure 1 is available from the “Online Supporting Mate-
rial” link in the online posting of the article and from the same link in the
online table of contents at http://ajcn.nutrition.org.
*To whom correspondence should be addressed. E-mail: sheila.isanaka@
epicentre.msf.org.
8
Abbreviations used: MSF, Médecins Sans Frontières; MUAC, midupper
arm circumference; RUTF, ready-to-use therapeutic food; SAM, severe acute
malnutrition; WHZ, weight-for-height z score.
Received November 3, 2016. Accepted for publication March 10, 2017.
First published online April 12, 2017; doi: 10.3945/ajcn.116.148064.
1191
1192 ISANAKA ET AL.
expected to reduce barriers to program uptake and make more
resources available, allowing programs to reach more children in
need. A reduced schedule of follow-up, however, could in-
fluence individual response to treatment. Between monthly
visits, adequate nutritional recovery would largely depend on
caregivers’ abilities to manage a larger household RUTF stock
and adhere to treatment instructions over a longer period.
Task shifting has been shown to be effective in clinical settings
other than childhood malnutrition, such as in HIV care and
treatment (12). However, there is limited experience in how
increased responsibility placed on caregivers and a reduced
schedule of follow-up would influence individual treatment re-
sponses in the context of SAM treatment. To inform the safety
and feasibility of a reduced monthly schedule of follow-up in the
treatment of uncomplicated SAM, we conducted a non-
randomized pilot intervention study to assess the response to
treatment and household use of RUTF in a series of children with
SAM under a monthly schedule of RUTF distribution.
METHODS
Study site and subjects
The study was carried out in the Madarounfa Health District of
the Maradi region of south-central Niger along the Nigerian
border. The area is rural and largely representative of the Sahel
region, where subsistence agriculture and animal husbandry are
the primary livelihoods (13). Acute childhood malnutrition is
endemic, with seasonal peaks from May until October because of
food shortages and infectious illnesses. The study period (July to
November) specifically coincided with a period of decreasing
food security before the annual harvest and an increased risk of
malaria during the rainy season in this setting. In collaboration
with the Ministry of Health of Niger, Médecins Sans Frontières
(MSF) has supported pediatric care in the Madarounfa Health
District since 2001. In 2014, the MSF-supported therapeutic
feeding program treated .13,000 children with SAM, with 94%
recovery, 2% default, ,1% nonresponse, and 3% mortality.
Study enrollment was conducted at 2 outpatient nutritional
treatment sites. Study inclusion criteria included the following: 1)
being eligible for new admission to treatment of uncomplicated
SAM, and 2) being resident within 15 km of the study health
center. In accordance with the national protocol, a child was eli-
gible for outpatient SAM treatment if he or she was aged between 6
and 59 mo; had a weight-for-height z score (WHZ) ,23 according
to the 2006 WHO Growth Standards (14) and/or a midupper arm
circumference (MUAC) ,115 mm; had sufficient appetite ac-
cording to a test feeding of RUTF; and was free of clinical com-
plications requiring hospitalization, including severe edema (15).
Study exclusion criteria included any child who had previously
defaulted from previous SAM treatment (i.e., missed 2 consec-
utive weekly visits), was considered a relapse (i.e., readmitted
within 3 mo of previous discharge), or was not accompanied by a
parent or legal guardian $18 y of age.
Parents or legal guardians were provided information re-
garding the study objectives and procedures and provided written
informed consent for their child’s participation before the start of
any study activities. The study was approved by the Comité
Consultatif National d’Ethique, Niger, and the Comité de Pro-
tection des Personnes, Ile-de-France XI.
Standard care
All children received standard care for outpatient treatment of
uncomplicated SAM, as per MSF and government of Niger
guidelines. At the time of admission, children received RUTF
(14 sachets/wk for those who weighed ,8 kg, and 21 sachets/wk
for those who weighed $8 kg in the routine nutrition program)
and routine medicines (i.e., vitamin A, amoxicillin, and anti-
helminthic treatment, and, if appropriate, measles vaccination
and antimalarial treatment) to treat and prevent complications.
Follow-up in the outpatient nutritional program was conducted
on a weekly basis at the health center. At each visit, a physical
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exam and anthropometric assessment were conducted. Anthro-
pometric measurements [weight to the nearest 100 g, length (for
children ,24 mo of age) or standing height (for children
$24 mo of age) to the nearest 0.1 cm, and MUAC to the nearest
0.1 cm] were assessed with the use of standard techniques (16).
Nutritional recovery was determined at or after 3 wk if a child
had a WHZ $22 in 2 consecutive visits and a MUAC
$115 mm, no acute complication or edema for $7 d, and
completed all antibiotic and antimalaria treatment at the time of
discharge. Children were transferred to the hospital in the event
of any clinical complication requiring inpatient management or
weight loss .5% between 2 consecutive visits or lack of weight
gain after 3 wk. Caregivers were instructed to return to the
health center for any health concerns between scheduled study
visits, and treatment was provided free of charge.
Study procedures
At admission, study nurses collected background information
from participating caregivers, including maternal age and edu-
cational status, child feeding practices and vaccination history,
and household socioeconomic status, with the use of standardized
questionnaires.
For study participants, a 4-wk supply of RUTF (56 sachets/4 wk
for those weighing ,8 kg and 84 sachets/4 wk for those
weighing $8 kg) was provided on admission. Sachets distrib-
uted in the monthly ration were individually marked by unique
identifiers to distinguish study and nonstudy sachets, which
could coexist within a single household as a result of inter-
household sharing. A plastic bucket was provided to facilitate
transport and storage at home. Oral instructions were given for
recommended storage conditions and appropriate use at home,
advising caregivers to keep RUTF in the provided bucket or
another cool, dry place away from direct sunlight.
At the end of each admission visit, participants were accom-
panied to their home to record the location of their residence.
Participants returned to the health center on a weekly basis for a
minimum of 4 wk for physical exams and anthropometric as-
sessments, but no additional RUTF or instructions were provided
during those visits. Although treatment programs eventually
adopting a reduced RUTF distribution schedule may not have
required weekly clinical follow-up, weekly follow-up was ensured
in this pilot study as a safety precaution in light of this new
distribution model. In addition, after baseline consent, un-
announced spot checks were made weekly by research members at
the participant’s home. Information on availability of the marked
RUTF sachets and conditions of at-home RUTF storage was
collected with the use of standardized observation checklists.
 WEIGHT GAIN WITH MONTHLY RUTF DELIVERY 1193
A primary objective of the study was to assess the safety of a TABLE 1
monthly distribution of RUTF, for which the risk was thought to Baseline characteristics of participants1
be most acute early in treatment, when weight gain and energy Characteristic Value
needs were greatest. Therefore, study follow-up ceased after
Maternal
4 wk. Participants not yet eligible for discharge as per program
Caregiver participants, n 115
guidelines after 4 wk returned to the standard weekly distribution Age, y 29.6 6 8.0
of RUTF rations until discharge and in accordance with national Ever attended school (not including Quranic school) 12 (10.4)
guidelines. Ever attended the nutritional program before 63 (54.8)
Child
Age, mo 18.4 6 8.6
Statistical analysis
Sex, F 65 (56.5)
To estimate the proportion of caregivers adherent to the rec- WHZ 23.0 6 0.6

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ommendations of the monthly RUTF ration at 4 wk with a
precision of 610%, assuming a 50% risk, a = 0.05, and 15%
loss to follow-up, the minimum sample size was 114 caregivers
and children. Participant characteristics, including maternal
characteristics and child anthropometric status, were summa-
rized with the use of means 6 SDs for continuous measures and
proportions for discrete measures. Response to treatment in re-
covered children was summarized with the use of mean 6 SD
weight gain (grams per kilograms per day) and MUAC gain
(millimeters per day) from admission until program discharge
#4 wk from admission, as well as the count and proportion of
children with .5% weight loss or the development or worsening
of nutritional edema.
RUTF use was assessed with weekly spot-check data as the
deviance between the number of marked RUTF sachets available
and the number of sachets expected, based on the time since
admission and prescribed dose of RUTF per child.
All data were double-entered into EpiData 3.1. SAS statistical
software version 9.3 was used for analysis.
RESULTS
Between July and November 2014, 115 caregivers and their
children with uncomplicated SAM were included in the study
(Table 1). Caregivers were a mean of 29.6 6 8.0 y of age. Ten
percent of caregivers had ever attended school, and more than
one-half (54.8%) had previous experience in nutritional pro-
grams. The mean 6 SD age of children was 18.4 6 8.6 mo.
More than one-half of the children were enrolled with a WHZ
,23, and approximately one-third had a MUAC ,115 mm.
Follow-up in the nutritional program from admission to week 4
is shown in Table 2 and Supplemental Figure 1. Weight loss
.5% was infrequent, with 2 of 115 children (2%) receiving the
monthly RUTF ration transferred to inpatient care for weight
,23 59 (51.3)
MUAC 117.5 6 6.1
,115 34 (29.6)
HAZ 22.8 6 1.4
,23 48 (41.7)
Times previously admitted to nutritional program
0 65 (56.5)
1 32 (27.8)
$2 18 (15.7)
Values are means 6 SDs or n (%). HAZ, height-for-age z score;
1
MUAC, midupper arm circumference; WHZ, weight-for-height z score.
loss .5% during follow-up in week 3 (n = 1) and week 4
(n = 1). No child developed or increased nutritional edema, and
none died. Response to treatment under the monthly schedule of
RUTF distribution is shown in Table 3. Both adequate weight
and MUAC gains were found during the 4 wk of follow-up.
Observed mean 6 SD weight gain from admission was 9.8 6
6.8 g $ kg21 $ d21 in week 1, 7.4 6 4.0 g $ kg21 $ d21 by
week 2, 5.3 6 2.7 g $ kg21 $ d21 by week 3, and 4.2 6 2.1
g $ kg21 $ d21 by week 4. Observed mean 6 SD MUAC gain
from admission was 0.6 6 0.6 mm/d in week 1, 0.5 6 0.3 mm/d
by week 2, 0.3 6 0.2 mm/d by week 3, and 0.3 6 0.2 mm/d by
week 4.
All 115 households were visited by the study team $1 time
during follow-up, with a mean 6 SD 3.12 6 0.66 visits/
household over 4 wk. Household spot checks found a positive
mean deviance over the 4 wk of follow-up, indicating a con-
sistent average surplus of marked sachets compared with the
number expected based on the date of distribution and recom-
mended dosing (Figure 1). Among households visited in week
1, 68% of households were found with the correct RUTF use
(i.e., a deviance of 62 sachets between available and expected
stocks), 4% of households having used more than expected and

TABLE 2
Follow-up in the nutritional program #4 wk1
Week 1 Week 2 Week 3 Week 4

Undergoing follow-up 104 (90.4) 80 (69.6) 62 (53.9) 31 (26.9)

Absent from scheduled visit 5 (4.3) 6 (5.2) 10 (8.7) 3 (2.6)
Discharged as recovered at this visit 0 (0) 22 (19.1) 11 (9.6) 36 (31.3)
Total discharged as recovered 0 (0) 22 (19.1) 33 (28.7) 69 (60.0)
Transferred to inpatient care at this visit 6 (5.2) 1 (0.9) 3 (0.9) 2 (1.7)
Weight loss .5% 0 (0) 0 (0) 1 (0) 1(0)
Development or worsening of 0 (0) 0 (0) 0 (0) 0 (0)
nutritional edema
Died 0 (0) 0 (0) 0 (0) 0 (0)
1
Values are n (%). n = 115.
1194 ISANAKA ET AL.
TABLE 3
Response to treatment over 4 wk of follow-up from admission1
Monthly RUTF distribution, Weekly RUTF distribution,2
Niger 2014 Niger 2012–2014

Weight gain, g $ kg21 $ d21 MUAC gain, mm/d Weight gain, g $ kg21 $ d21 MUAC gain, mm/d

n 106 101 1199 1199

Week 1 9.83 6 6.81 0.61 6 0.56 11.10 6 7.71 0.57 6 0.49
Week 2 7.39 6 4.04 0.48 6 0.33 6.97 6 4.33 0.39 6 0.31
Week 3 5.28 6 2.66 0.33 6 0.22 5.75 6 3.11 0.35 6 0.24
Week 4 4.20 6 2.05 0.28 6 0.19 5.03 6 2.54 0.32 6 0.20
1
Values are means 6 SDs unless otherwise indicated. MUAC, midupper arm circumference; RUTF, ready-to-use

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therapeutic food.
2
From reference 17.

29% of households having used less than expected at the time of
the visit. Among households visited in week 4, the frequency of
correct use was 36% of households, with 22% having used more
and 43% having used less than expected.
Household spot checks revealed high levels of compli-
ance with adherence with suggested RUTF storage practices
throughout the 4 wk of follow-up. Study personnel observed the
monthly ration to be most often stored inside the home (range:
95.8–98.8% across weeks 1–4), with no stock stored in direct
sunlight. Most participants (range: 85.0–91.1%) used the plastic
bucket provided by the study for storage of the ration at home as
instructed.

FIGURE 1 Distribution of ready-to-use therapeutic food stocks available compared with those expected by week of follow-up: week 1 (A), week 2 (B),
week 3 (C), and week 4 (D).
 WEIGHT GAIN WITH MONTHLY RUTF DELIVERY
DISCUSSION
Among children receiving the monthly distribution of RUTF,
both weight gain and MUAC gain were satisfactory. Anthro-
pometric measurements, combined with household spot checks,
suggested largely appropriate RUTF usage over the 4-wk follow-
up period. Use of the monthly ration represented more often
under- rather than overconsumption, based on the standard dosing
recommendations, and sufficient to maintain an adequate re-
sponse to treatment. Few children experienced weight loss, and
no child developed or had worsening edema during 4 wk of
follow-up. These results represent the first clinical experience
with a monthly rather than weekly distribution of RUTF and
suggest this modality to be both safe and feasible for outpatient
management of uncomplicated SAM.
Adequate treatment response in the outpatient management
of SAM relies in large part on appropriate therapeutic feeding
at home. Experience has shown that adequate recovery from
uncomplicated SAM can be achieved with weekly and bi-
weekly follow-up and distributions of RUTF (18). A reduced
schedule of follow-up, however, would require caregivers to
manage large RUTF stocks and adhere to dosing instructions
over a longer period of time, potentially challenging the out-
patient response to treatment.
Despite the greater burden on caregivers, mean weight and
MUAC gains in our study cohort compared favorably to min-
imum global program standards (19). Observed weight and
MUAC gains were consistent with other community-based
nutritional programs in which mean weight gain varied be-
tween 3.0 and 6.8 g $ kg21 $ d21 (20) and mean MUAC gain
varied between 0.3 and 0.6 mm/d (21, 22) during recovery.
Response to treatment was also similar to those recorded in
children enrolled in a randomized trial in the same setting in
which a weekly distribution of RUTF and standard medical
care was provided (Table 3) (17). The favorable treatment re-
sponses noted in our study cohort thus suggest the clinical
safety of a monthly RUTF distribution in the management of
uncomplicated SAM.
Household use of ready-to-use products has been recognized
as an important barrier to program effectiveness (23), but data
on household use remains limited. Household spot-check data
suggest that the majority of participants correctly used the
monthly ration early in treatment, but this proportion decreased
by the end of follow-up. Because weight gain did not appear to
falter, incorrect use does not appear to be at the expense of
recovery. Anecdotal reports suggest that households may de-
crease therapeutic feeding later in treatment once a child’s
weight and clinical status is recovered. In 2010, our group
found that 65–80% of households enrolled in a large-scale
preventative program in Niger reported never sharing the
provided ready-to-use supplement (24). In 2011, only 30–51%
of households in Niger that were enrolled in a preventive
program that provided supplemental foods to young children,
household food rations, and/or cash reported not sharing the
provided supplement (25). Considering the limitations of self-
report, compliance may have been even lower. However, ac-
companying qualitative interviews with participants conducted
by an independent study team confirmed the high value placed
on RUTF by caregivers. The women perceived positive medi-
cal and nutritional impacts from the nutritional supplements on
1195
the target child, including an improvement in child health, as
well as prevention of diseases and malnutrition (C Langendorf,
Epicentre, personal communication, 2016).
Other reports describing the use of RUTFs are largely limited
to the use of small-quantity formulations (#20 g) provided in the
prevention of malnutrition (26–30). The greater perceived risk
associated with SAM, a life-threatening condition that requires
vigilant attention and care, may be an important determinant of
high compliance in our study in comparison with reports related
to the small-quantity formulations used in the context of pre-
vention. This, however, was not the case in Ethiopia, where
RUTF provided in SAM treatment was still perceived to be a
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food or commodity for selling (31, 32).
In high-burden settings, the number of children with SAM who
receive treatment may be constrained by limited human resources
and infrastructure to provide facility-based clinical follow-up.
Using a reduced frequency of follow-up in such contexts
could allow more children to access care. A recent cost analysis
of SAM treatment in Niger suggested that important economies
of scale were possible, with per-child costs decreasing as patient
volume increased because of fixed costs associated with per-
sonnel and infrastructure (33). The same cost analysis tool
suggests that a monthly schedule of follow-up, which simply
increases the number of children who receive outpatient treat-
ment by 4-fold compared with a weekly schedule of follow-up,
could reduce the cost per child treated by 52% ($166.39 com-
pared with $79.53). Although many interrelated factors con-
tribute to program coverage (e.g., physical access, opportunity
costs, and awareness of the illness and available services), only
some of these would be addressed by a reduced schedule of
follow-up. The potential cost efficiencies, coupled with our
findings supporting the safety and feasibility of monthly follow-
up, however, suggest that this approach may be a promising
model to increase program coverage and reduce costs in the
treatment of uncomplicated SAM.
Our study had several strengths. First, we assessed household
RUTF compliance by triangulating data from household spot
checks with important clinical outcomes representing response to
treatment. Doing so was, to our knowledge, a novel way to
describe household RUTF use, as well as assess the safety and
feasibility of an alternative RUTF distribution schedule. Second,
although caregivers were aware of weekly spot checks, the home
visits were conducted on unannounced days per times, lending
credibility to the findings observed. Repeated spot checks, as
used in this study, may be a more valid measure of compliance
than self-report (34), which could be subject to social desirability
and recall biases.
Limitations of the study include not being able to conduct
in-home observations of RUTF use to determine individual
intake. Directly observing household behaviors may have
presented additional information on factors that influence
compliance. However, more intrusive observations may have
been less acceptable. Because of safety concerns, a monthly
ration was distributed, but the children enrolled in the study
continued weekly follow-up at the health facility. No guidance
related to RUTF use or additional stock was provided during
weekly facility visits to reduce any undue influence from the
safety visits, but the study is not an exact representation of the
model in question because of safety considerations. In addition,
given one of the study’s objectives to assess the early safety of
1196 ISANAKA ET AL.
the monthly RUTF distribution model, study follow-up did not
continue after the initial 4 wk of treatment. The study thus does
not provide a complete understanding of this approach in terms
of overall recovery or length of stay. Finally, the generalizability
of this work may be limited. Thirty-five percent of caregivers
whose children were screened for eligibility chose not to par-
ticipate; this occurred most often with adolescent caregivers
who cited needing to inform the head of household before
agreeing to any change in standard care. Study participants may
therefore represent a subgroup in whom acceptability and ad-
herence may be higher than in the general population. In addi-
tion, Niger has an important history of therapeutic feeding
programs and RUTF, possibly providing the study population
with a unique experience and various strategies to respond to the
alternative RUTF distribution model. Findings may be different
in settings in which there is less experience with therapeutic
feeding programs and RUTF.
Future work should explore whether high household com-
pliance can be achieved and maintained over longer periods in
this context, with the goal of transferring effective household
strategies to other settings. Understanding how caregivers
manage appropriate use despite many potential barriers, in-
cluding large household size, high food insecurity, and social
pressure to share, may yield insights for the use of more flexible
service delivery models elsewhere. Implementation of a reduced
schedule of follow-up would also rely on caregivers to monitor
recovering children at home for any clinical or anthropometric
measure deterioration between monthly visits. Results are
forthcoming from another pilot study in the same setting that
assessed caregivers’ knowledge of clinical danger signs and
accuracy in MUAC measurement for such surveillance. Previous
research suggests that MUAC change can be a suitable indicator
of weight change (35), and that mothers can measure MUAC to
classify their children instead of having community health
workers do so (36).
In conclusion, we found treatment response and RUTF use to
be maintained over 4 wk when we used a reduced monthly
schedule of RUTF distribution. The reduced monthly schedule of
RUTF distribution shown here to be safe and feasible may make
more cost-effective service delivery models possible. These re-
sults lend support to a new, more flexible and efficient model for
the outpatient management of SAM. Implementation of any new
model for the delivery of outpatient management of SAM will
require appropriate training, follow-up, and community sensiti-
zation, but our findings provide promising evidence to encourage
further evaluation of this approach to increase access to care and
program coverage. Further randomized studies are ongoing to
assess the impact of monthly compared with standard weekly
follow-up on nutritional recovery, as well as overall length of stay
and weight gain.
We thank Yazi Mai Aiki Abdoulaziz; our field research center coordinator,
Aimé Makimere; and André Munger, Médecins Sans Frontières Operational
Center Paris.
The authors’ responsibilities were as follows—SI, KEH, and RFG: de-
signed the study; FB and FN: supported the data collection; IA: assisted with
data analysis; SI and SRK: were responsible for the first draft of the man-
uscript; and all authors: contributed to the interpretation of data, critically
reviewed the manuscript, decided to publish the manuscript, and read and
approved the final manuscript. None of the authors reported a conflict of
interest related to the study.
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