Acute malnutrition is a critical driver of pediatric mortality that must be addressed to
achieve global child health targets. Provision of ready-to-use therapeutic foods (RUTF) and
nutritional counselling in the community is a highly effective method of preventing deaths
among malnourished children. However, UNICEF estimates that only 17% of malnourished children
receive treatment. Among children who are treated, the diagnosis of acute malnutrition is
often made late in their disease when the risk of complications and death increases from 2.5%
to 16%. Increasing the coverage and frequency of nutritional screening to identify
malnourished children earlier in the disease process is a critical step toward achieving
global child health goals.
Mid-upper arm circumference (MUAC) is the preferred community malnutrition screening tool.
Recent evidence comparing MUAC measurements taken by mothers and community health workers
showed that mothers can accurately measure their child's MUAC and identify malnutrition. Yet,
there is no pragmatic method of linking these mothers to the nutritional care that
malnourished children require. Training and supporting mothers to use MUAC tapes to monitor
their child's nutritional status through a two-way short message service (SMS) mobile health
system could dramatically increase the coverage of malnutrition screening and facilitate
rapid engagement with nutritional service where necessary.
This randomized controlled trial will test the "Maternal Administered Malnutrition Monitoring
System" (MAMMS) in western Kenya. Participants will be taught to measure their child's MUAC
at 6 or 9-month immunization visits and during 6-month follow up participants will receive
weekly SMS messages prompting them to measure and send their child's MUAC to a computer
system which will alert a health worker when a child with malnutrition is identified. This
scalable childhood growth monitoring system could enable nutrition programs in low and middle
income countries to optimize screening coverage, leading to early identification of
malnutrition, lower costs and a reduction in global under-five mortality. The study aims to:
Aim 1: Determine if MAMMS leads to earlier identification and recovery from acute
malnutrition (MUAC <12.5cm).
Hypothesis 1.1: Children randomized to MAMMS who develop acute malnutrition will be
identified earlier than children in the control arm.
Hypothesis 1.2: Children randomized to MAMMS who develop acute malnutrition will be more
likely to successfully complete nutritional rehabilitation (defined as no death, no
hospitalization, no severe acute malnutrition, and resolution of moderate malnutrition within
4 months of diagnosis) than children in the control arm diagnosed with acute malnutrition.
Aim 2: Demonstrate the accuracy of maternal administered MUAC assessments compared to trained
community health worker, and the ability of repeated maternal administered MUAC measurements
to monitor early childhood growth.
Hypothesis 2.1: Maternally measured MUAC will be strongly correlated with health worker
measured MUAC at baseline and during follow-up.
Hypothesis 2.2: A highly sensitive and specific growth trajectory that predicts moderate
acute malnutrition can be identified using maternally measured MUAC.
Aim 3: Evaluate the acceptability, feasibility, fidelity and cost per-child-treated of MAMMS
relative to standard-of-care nutrition programs.
Hypothesis 3.1: MAMMS will be acceptable and feasible to mothers and health workers.
Hypothesis 3.2: MAMMS will have a substantially lower cost-per-malnutrition case identified
than standard screening approaches.