Treating twice as many children with the same RUTF

In the Gao region of Mali, a conflict zone, 92.9% of children with acute malnutrition recovered when village community health workers (CHWs) treated them with a simplified protocol. In clinics run by nurses with the standard protocol, 76.3% recovered ⁴. The simplified approach also used 43 fewer sachets of ready-to-use therapeutic food (RUTF) per child with severe acute malnutrition (SAM) ⁴.

Across the expanded evidence window, trials ask whether the same supply of RUTF can treat more children. Recovery results are encouraging, but reduced linear growth, incomplete attendance and outcomes in the sickest children limit a blanket conclusion.

The burden

In 2024, wasting affected an estimated 6.6% of children under 5 worldwide, or 42.8 million children. Of these, 12.2 million had severe wasting ¹. These are the latest figures from the joint estimates of UNICEF, WHO and the World Bank Group, published in July 2025 ¹.

Wasting means a child is too thin for his or her height. A wasted child has a higher risk of death, but treatment is possible ¹.

Where the children are. In 2024, 70% of all wasted children under 5 lived in Asia and more than a quarter lived in Africa ¹. More than half of all wasted children lived in Southern Asia alone ¹.

How many die. The UN inter-agency child mortality report, released in March 2026, counted more than 100,000 direct deaths from severe acute malnutrition among children aged 1–59 months ³. That figure counts only deaths where malnutrition is the direct cause. The authors of the Niger trial described below note that acute malnutrition is also a leading underlying cause of death, contributing to at least 800,000 deaths a year ⁵.

The trend. There is good news. The 2025 joint estimates report 8 million fewer wasted children than in 2012 ¹. But progress is uneven. Forty per cent of the world's children live in countries with no progress, or a worsening situation, on wasting ¹.

The numbers are an undercount. The joint estimates measure how many children are wasted at one moment. They do not count all the children who become wasted over a year, so they underestimate the annual burden ¹.

Most children are not treated. Fewer than 25% of children with SAM are admitted for treatment, according to the Niger trial authors ⁵. Programmes are chronically underfunded, and their costs are driven largely by RUTF and staff ⁵. Every sachet saved can go to a child who is not reached today.

How it works

What RUTF is. RUTF is a paste made from powdered milk, peanut paste, vegetable oils, sugar, and vitamins and minerals ¹². Each 92 g sachet gives 500 calories, and a carton holds 150 sachets, which is usually enough for a full course of treatment ¹².

How children are found. Health workers measure the mid-upper-arm circumference (MUAC) with a coloured tape. Under WHO definitions, a MUAC below 115 mm, a weight-for-height z-score below −3, or swelling of both feet (nutritional oedema) means SAM. A MUAC of 115–124 mm, or a z-score between −2 and −3, means moderate acute malnutrition (MAM) ⁵.

The standard protocol. In most countries, SAM and MAM are treated in separate programmes. They use different products (RUTF for SAM, ready-to-use supplementary food, or RUSF, for MAM), and different UN agencies supply them ⁴. The RUTF dose for SAM is set by the child's weight. In Niger, for example, the standard protocol gives 150–200 kcal per kg per day until discharge ⁵. This needs weekly weighing and a lookup table, which is hard for a CHW with little training.

What "simplified" means. The simplified protocols tested in these trials change three things:

• MUAC only. Children are admitted and discharged by MUAC and oedema alone, with no weight-for-height z-score ⁴⁵.
• One product. RUTF is used for both SAM and MAM, so there is one supply chain ⁴⁵.
• A fixed or reduced dose. Under the ComPAS protocol, a child with MUAC below 115 mm or oedema gets 2 sachets a day, and a child with MUAC 115–124 mm gets 1 sachet a day ⁵. As the child's MUAC improves, the dose goes down. The OptiMA protocol also reduces the dose as the child improves, but it uses both MUAC and weight to set the ration ⁵.

The DRC trial tested a different change: the same dose as usual for two weeks, then a cut of 22% to 50% from week 3, depending on the child's weight ⁶.

Where CHWs come in. Mali's Ministry of Health changed its primary health care policy in 2015 so that CHWs could treat acute malnutrition outside health centres ⁴. A MUAC-only, fixed-dose protocol is much easier for a CHW to follow.

What the evidence shows

2019–2020: the trials behind reduced dosing

MANGO, published in 2019, randomised 801 children with uncomplicated severe acute malnutrition in Burkina Faso. Reducing RUTF after two weeks was non-inferior for overall weight-gain velocity, and recovery did not differ significantly. However, height gain was slower by 0.2 mm per week, with a larger difference in children under one year ²⁰. The trial excluded children who failed an appetite test. Similar recovery rates do not establish that every aspect of growth is equivalent.

The 2020 ComPAS trial tested a unified protocol in 24 clinics in Kenya and South Sudan, enrolling 4,110 children. Among treatment completers, recovery was 76.3% with the combined protocol and 73.5% with standard care, meeting the non-inferiority criterion. Children admitted with severe malnutrition who recovered used 122 versus 193 sachets of ready-to-use food ²¹. Only about three-fifths completed treatment, an important limitation. These findings established the approach; the newer trials test whether it transfers to other programmes and patient groups.

The rulebook changed first: WHO 2023

In December 2023 WHO published a new guideline on the prevention and management of wasting and nutritional oedema. It replaced the 2013 SAM guideline ². It includes guidance on the optimal quantity of RUTF for severe wasting, dietary management of moderate wasting, and care after a child exits treatment ².

Mali: CHWs in a conflict zone (López-Ejeda et al., 2024)

Who and where. Action Against Hunger ran the trial with Mali's National Public Health Institute (INSP) and the Nutrition Directorate of the Ministry of Health, in the Gao region of northern Mali ⁴. The trial ran from June 2020 to June 2021, in one of the regions worst affected by armed conflict ⁴.

Design. It was a three-arm cluster randomised trial designed to test non-inferiority, with 2038 children aged 6–59 months with uncomplicated acute malnutrition ⁴. The control arm (549 children) was treated by nurses in health centres with the standard protocol. The second arm (800 children) used the standard protocol with CHWs added as providers. The third arm (689 children) used nurses and CHWs with the ComPAS simplified protocol ⁴.

Primary outcome. Recovery was 76.3% in the control arm, 81.8% in the CHW standard arm and 92.9% in the CHW simplified arm ⁴. This confirmed non-inferiority ⁴.

Secondary outcomes. Time to recovery (about 6 weeks) did not differ ⁴. Children with SAM in the simplified arm used 43 fewer RUTF sachets than in the control arm, and children with MAM used an average of 35 sachets ⁴. CHWs made discharge errors in 6% of cases with the simplified protocol and 19% with the standard protocol ⁴. SAM treatment coverage rose by 42.5% in the simplified arm, and MAM coverage rose by 13.8% ⁴.

Niger: the head-to-head test (Daures et al., 2025)

Who and where. The Alliance for International Medical Action (ALIMA) and its Nigerien partner, Bien-être de la Femme et de l'Enfant, ran the trial with the Ministry of Health of Niger in four health areas of Mirriah Health District, Zinder Region ⁵. The team included the University of Montpellier and IRD. A 2020 survey found acute malnutrition in 10.5% of children in Zinder by MUAC ⁵.

Design. It was an individually randomised, three-arm, open-label non-inferiority trial (NCT04698070), run in 2021–2022 ⁵. It compared the Niger national protocol with OptiMA and ComPAS in 1732 children with MUAC below 125 mm or oedema ⁵. The margin for non-inferiority was 10% ⁵.

Primary outcome. The primary outcome was a strict one: at 6 months, the child had to be alive, not malnourished, and free of any new episode of malnutrition ⁵. The standard protocol reached 52.9%, ComPAS 51.9% (difference 1.0%, 97.5% CI −5.5% to +7.6%) and OptiMA 49.7% (difference 3.2%, −3.3% to +9.9%) ⁵. ComPAS was non-inferior in both the intention-to-treat and per-protocol analyses. OptiMA was non-inferior only in the intention-to-treat analysis ⁵.

Secondary outcomes. There was no difference in mortality across the arms over 6 months ⁵. Over the 6-month follow-up, children received a median of 111 sachets under the standard protocol, 94 under OptiMA and 70 under ComPAS ⁵. Overall, ComPAS used 50% less RUTF and OptiMA 32% less ⁵.

Caveats. The sickest children did less well on the simplified protocols (see below). The trial was open-label, and mothers used to the standard ration may have known their child was on a smaller one ⁵.

DRC: a reduced dose in a food-insecure setting (Ntaongo Alendi et al., 2025)

Who and where. The EfRAMAS trial was run by Action Against Hunger with the Kinshasa School of Public Health, which gave ethics approval, in 14 health centres in the Bonzola and Nzaba health zones of Kasaï Oriental ⁶. Close to 94% of the children came from severely food-insecure households ⁶. Routine health staff delivered the treatment ⁶.

Design. It was an individually randomised non-inferiority trial (ISRCTN15258669) with 968 children aged 6–59 months with uncomplicated SAM, run from August 2021 to March 2022 ⁶. All children got the standard dose for two weeks. From week 3, the reduced-dose group got 22% to 50% less RUTF, depending on weight ⁶.

Primary outcome. Weight gain was 4.88 g/kg/day with the reduced dose and 5.09 g/kg/day with the standard dose (difference −0.09 g/kg/day, 95% CI −0.33 to 0.15; p = 0.46) ⁶. This was within the non-inferiority margin.

Secondary outcomes. Recovery was 64.3% vs 67.0%, relapse over 3 months 2.86% vs 2.40%, and mean length of stay 42 vs 43 days ⁶. Children received an average of 108 sachets with the reduced dose against 126 with the standard dose, a 14.3% saving on RUTF purchase ⁶.

Caveats. MUAC gain from week 3 was slightly lower with the reduced dose (−0.13 mm per week, 95% CI −0.25 to −0.01) ⁶. Children with oedema were under-represented, and the trial did not measure what children ate at home ⁶.

Ethiopia: a national platform (Maru et al., 2024)

Who and where. Jimma University ran the trial with UNICEF Ethiopia and the Nutrition Coordination Office of the Ethiopian Ministry of Health ⁷. It took place in three woredas (districts) in Oromia, Amhara and SNNP regions, from December 2021 to July 2022 ⁷.

Design. It was a cluster randomised non-inferiority trial. 58 health posts were randomised, 29 per arm, and 1032 children were analysed from 55 health posts ⁷. Health extension workers (HEWs) delivered care in both arms. In the simplified arm, children with SAM got 2 RUTF sachets a day, and children with MAM got 1 RUTF sachet a day instead of RUSF ⁷. The non-inferiority margin was 15% ⁷.

Primary outcome. In the per-protocol analysis, recovery was 97.8% with the simplified approach and 97.7% with the standard protocol ⁷. In the intention-to-treat analysis, it was 94.3% vs 92.4% ⁷.

Secondary outcomes. The RUTF cost per child with SAM fell from US$56.55 to US$42.78, about a quarter less ⁷. Two children died in the simplified arm and none in the standard arm ⁷.

Caveats. Recovery was very high in both arms under close monitoring, and the authors call for study in emergency settings ⁷.

Niger: what a CHW cure costs (Molanes-López et al., 2024)

Who and where. Action Against Hunger ran a non-randomised controlled trial from June 2018 to March 2019 in two rural communes of Mayahi district, Maradi region ⁸.

Results. Recovery was 77.2% with CHW-led treatment and 72.1% with standard treatment at health centres ⁸. The cost per child recovered was US$107.22 against US$116.52 ⁸. The extra cost per additional child recovered was US$98.01 ⁸. Families also saved: a round trip to a health post cost US$1.30 on average, against US$3.48 to a health centre in the control area ⁸.

Caveats. This was not a randomised trial.

Mali: preventing cases in the first place (Huybregts et al., 2026)

Who and where. The International Food Policy Research Institute (IFPRI) ran this trial in Koutiala health district, Sikasso region, with UNICEF, World Vision and AFRICSante (NCT04872088) ¹⁰¹⁹.

Design. It was a two-arm cluster randomised trial. In both arms, community nutrition groups screened children and gave advice to caregivers. The intervention arm added small-quantity lipid-based nutrient supplements (SQ-LNS), family MUAC screening and follow-up of referred children ¹⁰. The trial followed 2324 children from 6 months of age and 7104 children admitted to outpatient treatment ¹⁰.

Primary outcome. The intervention did not change wasting prevalence, the primary outcome ¹⁰.

Secondary outcomes. It reduced the incidence of wasting (RR 0.80, 95% CI 0.64–0.99) and of SAM (RR 0.71, 95% CI 0.57–0.89) ¹⁰. In plain terms, about 3 in 10 new SAM cases were prevented. Screening coverage rose by 37 percentage points and SAM treatment coverage by 15 percentage points ¹⁰.

Where it matters most. A UC Davis analysis ranked the 20 countries where SQ-LNS would matter most. At the top were Niger, South Sudan, Yemen, Sudan, Somalia and the DRC, and the list also includes Nigeria, Mali and Pakistan ¹¹.

Results at a glance

LimitsWhat didn't work (or the limits)

The sickest children did worse with simplified protocols in Niger. Among 1140 children with MUAC below 115 mm or oedema, recovery was 78.3% with the standard protocol, 69.4% with ComPAS and 68.1% with OptiMA ⁵. The standard protocol was superior in the intention-to-treat analysis ⁵.

The authors link the gap mainly to attendance, not to growth or death. Much of it came from children who met the recovery criteria for only one week instead of the required two: 7.7% under ComPAS and 8.2% under OptiMA, against 3.1% under the standard protocol ⁵. When one week of recovery was counted, the arms did not differ ⁵. Mortality did not differ ⁵. Still, programmes should not assume that a smaller ration is equal for every child.

Context matters. OptiMA did better than the national protocol in an earlier DRC trial, but not in Niger, where families have been used to the standard ration for more than 20 years ⁵.

Mali's trial was small at the cluster level. Of 32 treatment sites, only 12 health centres were randomised, and each intervention arm had only three health centres ⁴. Insecurity stopped data collectors from reaching sites at times, so the planned number of SAM cases was not reached ⁴. None of the arms reached the 50% coverage that SPHERE standards require in rural areas ⁴. In the standard-protocol arm, CHWs had a 32% lower recovery rate for SAM than nurses. With the simplified protocol, the gap shrank to 10% ⁴. This shows that simplification is what makes CHW treatment work, not CHWs alone.

There were no stockouts in the Mali trial, but that is not normal. District authorities made sure of supply during the study ⁴. The authors note that stockouts are one of the biggest barriers to coverage, and that supply chains to remote CHW sites are harder ⁴.

Recovery does not capture every growth outcome. The earlier MANGO trial found slower height gain with reduced dosing, especially below one year ²⁰. In the DRC, MUAC gain from week 3 onward was slightly lower with the reduced dose (−0.13 mm per week) ⁶. Recovery rates in that trial were also modest in both arms (64.3% and 67.0%) ⁶.

Prevention did not change prevalence. The Mali continuum-of-care trial cut new cases but had no effect on wasting prevalence, and no effect on recovery in outpatient treatment ¹⁰. Community groups sometimes gave SQ-LNS to wasted children instead of referring them to treatment ¹⁰.

Supervision levels did not clearly change costs. In southern Mali, the cost ranges for the three supervision levels overlapped, so the study cannot say which level is best value ⁹.

Cost and scale

The price of a course of RUTF. A carton of 150 sachets is usually enough for one child's full treatment ¹². In the southern Mali costing study, UNICEF gave a price of US$45 per carton ⁹. That means RUTF alone costs roughly US$45 per child treated with the standard protocol. In Ethiopia, the RUTF cost per child with SAM was US$56.55 with the standard protocol and US$42.78 with the simplified one ⁷.

What a cure costs in total. RUTF is only part of the cost. Staff, supervision, transport and training add the rest:

• In Mayahi, Niger, the full cost per child recovered was US$107.22 with CHWs and US$116.52 with standard care ⁸.
• In the Kayes region of southern Mali, adding SAM treatment to integrated community case management (iCCM) cost US$203.40–279.90 per child treated and US$303.90–324.90 per child cured, across three districts and three levels of supervision ⁹.

Who supplies it. UNICEF supplies nearly 80% of the world's RUTF ¹². In 2024, it delivered 86,500 tonnes, enough to treat 6.2 million children ¹³. Its supplier base grew to 23 manufacturers in 2025 ¹³. In 2025, 61% of the RUTF UNICEF bought came from countries where it is highly needed ¹³.

The gap. UNICEF states that funded demand is not enough to meet needs among the 12.2 million children with severe wasting ¹³. It calls for predictable, multi-year financing and for wasting treatment to be part of national health systems ¹³.

What simplification buys. The savings in these trials range from 14.3% of RUTF in the DRC ⁶, to about a quarter of RUTF cost in Ethiopia ⁷, to about half the RUTF in Niger ⁵. With a fixed budget, a 50% cut in RUTF per child means up to twice as many children can get a full course, if staff and supply chains can reach them.

Who delivers. In these trials, ministry staff and CHWs delivered treatment, with support from Action Against Hunger, ALIMA and UNICEF ⁴⁵⁶⁷.

What to watch

Kenya: reduced dose and fewer visits (R-SWITCH, NCT07420062). IFPRI and Kenyatta University plan to compare full and reduced doses of the WHO protocol with Kenya's national protocol, in 2274 children with SAM and high-risk MAM ¹⁴. Primary completion is expected in March 2027 ¹⁴.

Ethiopia: community groups and coverage (NCT06380504). IFPRI, the Ethiopian Public Health Association and UNICEF are testing whether existing community groups can raise SAM treatment coverage through screening, referral and follow-up ¹⁵. Primary completion is listed for September 2026 ¹⁵.

Kenya: community health promoters in Turkana (NCT06441305). IFPRI, UNICEF and Kenyatta University are testing family-led MUAC screening, weight-for-age screening and defaulter follow-up by community health promoters with smartphones ¹⁶.

Burkina Faso: reduced dose and RUTF for MAM (NCT06792370). The Institut de Recherche en Sciences de la Santé, funded by the Gates Foundation, plans to test reduced-dose RUTF for SAM and RUTF instead of RUSF for MAM in 3521 children ¹⁷. Primary completion is listed for December 2026 ¹⁷.

Chad and Niger: SQ-LNS and vaccination (OptiMAx, NCT07592260). ALIMA, the London School of Hygiene and Tropical Medicine and the health ministries of Niger and Chad are testing whether SQ-LNS for children from 6–11 months to 18 months can raise vaccination rates in Mirriah (Niger) and Ngouri (Chad) ¹⁸. It plans 20,000 children ¹⁸.

Open questions. How can programmes protect attendance for children with MUAC below 115 mm? Should recovery need two consecutive visits, or one? How acceptable are smaller rations to families ⁵?

What it means

Some simplified protocols achieve similar recovery with substantially less RUTF ⁴⁵⁷²¹. Programmes must also track attendance, relapse and linear growth, and keep referral pathways for complicated malnutrition ⁵²⁰. Food savings alone do not imply that total programme capacity doubles.

For ministries of health. The WHO 2023 guideline now gives the policy basis ². Use one product and MUAC-only criteria where possible, because this is what cut CHW discharge errors from 19% to 6% in Gao ⁴. Keep the supply chain to CHW sites stocked, because the gains depend on it ⁴.

For programme managers and clinicians. The Niger result sets a practical boundary. For children with MUAC below 115 mm or oedema, track attendance closely, follow up missed visits, and do not discharge after only one good reading ⁵.

For funders. The cost data from Niger, Mali and Ethiopia give the numbers to plan with: about US$45 of RUTF per standard course ⁹, and US$107–325 per child cured in full programme costs ⁸⁹. UNICEF asks for multi-year funding so that supply is not interrupted ¹³.

Prevention completes the picture. The Mali SQ-LNS trial shows that about 3 in 10 new SAM cases can be stopped before they start ¹⁰. When budgets shrink, prevention and leaner treatment together protect the most children.