Study selection

The search identified 2,754 records across databases, websites, expert consultation, and citation searching. After removal of 962 duplicates, 1,769 titles/abstract were screened, with 159 full texts assessed. Seventeen studies met inclusion criteria, and nine additional documents were retrieved from grey literature, including institutional websites and expert consultation, resulting in 26 studies included in the review. Fourteen potentially relevant papers could not be accessed in full. Reasons for exclusion were: wrong population (n = 72), wrong concept (n = 71), wrong language (n = 1), and duplication (n = 1). The PRISMA 2020 flow diagram summarises the process (Figure 1).

Figure 1.

PRISMA flow diagram illustrating the study selection process for the review of outpatient and community-based management of malnourished infants under six months.

Characteristics of included studies

The included studies and reports were published between 2011 and 2025, with only four appearing after the latest 2023 WHO guidelines emphasising integrated management of infants u6m. Geographically, sub-Saharan Africa and South Asia dominated the evidence base, with limited data from Latin America, the Middle East, and Southeast Asia^{(Reference Munirul Islam, Arafat, Connell, Mothabbir, McGrath and Berkley5,Reference Grijalva-Eternod, Kerac, McGrath, Wilkinson, Hirsch and Delchevalerie10,Reference Arafat, Islam, Connell, Mothabbir, McGrath and Berkley12,Reference Woeltje, Evanoff, Helmink, Culbertson, Maleta and Manary13,Reference Moore, O’Mahony, Shevlin, Hyland, Barthorp and Vallières20,Reference Kueter, Burrell, Butler, Sarwar and Rahman24–Reference Kerac, Mwangome, McGrath, Haider and Berkley44)} .

Study designs were heterogeneous. Qualitative studies (n = 7) were most common, followed by programme case studies (n = 4), mixed-methods (n = 3), and cohort studies (n = 3). Other designs included cross-sectional surveys, retrospective analyses, and systematic reviews (Table 1). This distribution highlights the limited availability of robust intervention trials. Table 2 illustrates the basic characteristics of included evidence, and details are presented in online Supplementary material 3.

Table 1.

Study designs represented in included literature

Table 2.

Basic features of included evidence

The included studies addressed a wide range of research foci, with the most common, almost half, being implementation challenges and stakeholder perceptions (n = 13), while relatively few evaluated intervention outcomes (n = 4) or examined admission criteria and risk identification (n = 4). A full thematic categorisation of study research foci is available in Table 3, where some studies contributed to more than one research focus category.

Table 3.

Distribution of included studies by research focus area

Intervention strategies and outcomes

Interventions are shifting away from hospitals toward outpatient and community settings, guided by protocols such as the MAMI Care Pathway, in line with the WHO’s 2023 recommendations^{(Reference Van Immerzeel, Deme-Ly, Diagne-Camara, Penzias, Seck and Diallo36,Reference Mee, Abera and Kerac38,Reference McGrath, Girma, Berhane, Abera, Hailu and Bathrop39)} . The most common interventions were the provision of nutritional supplements, including ready-to-use therapeutic foods (RUTF), ready-to-use supplementary foods (RUSF), and fortified cereals, alongside breastfeeding support and maternal health. RUTF, RUSF, and fortified cereals were given to individual cases when no other feasible options were available and were considered a very special situation; exclusive breastfeeding is still the key public health recommendation for this age group^{(Reference Woeltje, Evanoff, Helmink, Culbertson, Maleta and Manary13)}. In Bangladesh and Senegal, health workers and caregivers believe re-lactation and the supplementary suckling technique (SST) were generally acceptable, although these findings are based on perceptions rather than direct measurement of outcomes^{(Reference Arafat, Islam, Connell, Mothabbir, McGrath and Berkley12,Reference van Immerzeel, Camara, Deme Ly and de Jong35)} . In Senegal, primary healthcare centres were moderately prepared to manage malnourished infants (overall 70%), but readiness for infants u6m was much lower (38%), according to the latest WHO 2023 guidelines recommendation. Assessment, classification, and treatment were limited, though routine visits such as postnatal checkups and immunisations provided opportunities to enhance care^{(Reference Van Immerzeel, Deme-Ly, Diagne-Camara, Penzias, Seck and Diallo36)}.

Research across several countries included maternal mental health screenings, which were discussed as beneficial for maternal wellbeing and mother–infant interactions, and, indirectly, the baby’s growth^{(Reference Mee, Abera and Kerac38)}. In Bangladesh, community-based acute malnutrition management with nutrition counselling, child development support, and nutrient-rich foods were associated with reported improvements in recovery rate, weight gain, feeding habits, and growth^{(Reference Alim, Munirul Islam, Guesdon, Anik, Antoine and Marium37)}. Meanwhile, a study in Ethiopia reported that implementation of the MAMI Care Pathway was associated with improved breastfeeding, growth monitoring, and perceived reduction in hospital burden^{(Reference McGrath, Girma, Berhane, Abera, Hailu and Bathrop39)}.

Some studies reported outpatient care as a potential viable therapeutic option for malnourished infants u6m. In Malawi, a 79% recovery rate was reported using nutritional supplements, though infant-specific doses were not detailed^{(Reference Woeltje, Evanoff, Helmink, Culbertson, Maleta and Manary13)}. In Ethiopia, Abate et al.^{(Reference Abate, Tilahun, Kassie and Kassaw33)} saw a 65% recovery rate in outpatient settings, though coexisting illnesses made recovery harder^{(Reference Abate, Tilahun, Kassie and Kassaw33)}. A study in Bangladesh showed that 75% of infants reached catch-up growth with only minimal intervention, but a quarter still remained malnourished at six months^{(Reference Munirul Islam, Arafat, Connell, Mothabbir, McGrath and Berkley5)}. Online supplementary material 3 summarises the included literature.

Risk factors for malnutrition and recovery

Across various studies, several key risk factors for malnutrition were mentioned^{(Reference Kerac, Frison, Connell, Page and McGrath15,Reference Kerac, Ashorn, Berkley, Borg, Castro and Deconinck45)} . Moore et al. reported that weight loss, faltering growth, and a mid-upper arm circumference (MUAC) under 115 mm were useful indicators for identifying malnutrition^{(Reference Moore, O’Mahony, Shevlin, Hyland, Barthorp and Vallières20)}. Similarly, Munirul Islam et al. highlighted the crucial role of maternal health, showing clear links between low maternal body mass index (BMI) and poor infant nutrition^{(Reference Munirul Islam, Arafat, Connell, Mothabbir, McGrath and Berkley5)}.

Challenges to appropriate treatment included poor identification and treatment of at-risk infants – only 15% were properly classified in Senegal, for example – and maternal mental health issues harming mother–infant interactions and growth. In Ethiopia, unmet maternal–infant needs and socioeconomic hardships made the situation worse^{(Reference Van Immerzeel, Deme-Ly, Diagne-Camara, Penzias, Seck and Diallo36,Reference Mee, Abera and Kerac38,Reference McGrath, Girma, Berhane, Abera, Hailu and Bathrop39)} .

When it came to recovery, access to integrated nutrition counselling and micronutrient supplementation were identified as contributing factors in Bangladesh. Yet progress was often slowed by limited health services and hidden burdens of care^{(Reference Alim, Munirul Islam, Guesdon, Anik, Antoine and Marium37,Reference McGrath, Girma, Berhane, Abera, Hailu and Bathrop39)} . On the positive side, consistent monitoring, support for maternal mental health, and community-based follow-up were described to be associated with improved recovery rates and reduced caregivers’ burden in some settings^{(Reference Mee, Abera and Kerac38,Reference McGrath, Girma, Berhane, Abera, Hailu and Bathrop39)} .

Facilitators and barriers

Reported enablers of successful outpatient care included the convenience of weekly visits, reduced caregiver costs, and integration with existing child health services^{(Reference Arafat, Islam, Connell, Mothabbir, McGrath and Berkley12,Reference van Immerzeel, Diagne, Deme/Ly, Murungi, Diouf and Kerac34,Reference van Immerzeel, Camara, Deme Ly and de Jong35)} . Community engagement and follow-up improved adherence, while re-lactation support and home-based breastfeeding counselling strengthened maternal–infant bonding^{(Reference Arafat, Islam, Connell, Mothabbir, McGrath and Berkley12,Reference van Immerzeel, Diagne, Deme/Ly, Murungi, Diouf and Kerac34,Reference van Immerzeel, Camara, Deme Ly and de Jong35)} . Integration of the MAMI Care Pathway with the Integrated Management of Childhood Illness (IMCI) framework was also considered a strategy to improve coverage^{(Reference van Immerzeel, Diagne, Deme/Ly, Murungi, Diouf and Kerac34)}. Additional facilitators included policy alignment (e.g., with national guidelines in Ethiopia), non-governmental organisation (NGO) support and incentives (in Bangladesh), task-shifting and community networks (multi-country), and strong infrastructure at routine contact points (in Senegal)^{(Reference Van Immerzeel, Deme-Ly, Diagne-Camara, Penzias, Seck and Diallo36–Reference McGrath, Girma, Berhane, Abera, Hailu and Bathrop39)}. Contextual adaptation and professional motivation were also noted as enablers^{(Reference Alim, Munirul Islam, Guesdon, Anik, Antoine and Marium37,Reference Mee, Abera and Kerac38)} .

Reported barriers included limited availability of trained health workers, inconsistent admission and discharge criteria, high caseloads, and inadequate facility space and resources^{(Reference Kueter, Burrell, Butler, Sarwar and Rahman24,Reference Read and McGrath25,Reference Klomp, Kerac and Dyment28)} . Sociocultural barriers, such as maternal education level, food-sharing practices, and gender dynamics, also hindered adherence^{(Reference Klomp, Kerac and Dyment28)}. Policymakers often hesitated to recognise differences between complicated and uncomplicated cases, limiting adoption of outpatient care and favouring inpatient treatment^{(Reference Read and McGrath25)}. Additional barriers encompassed workforce shortages, training deficits, inconsistent equipment/supplies, stigma around maternal mental health, time/financial constraints for families, and ethical issues such as screening without referral capacity^{(Reference Van Immerzeel, Deme-Ly, Diagne-Camara, Penzias, Seck and Diallo36–Reference McGrath, Girma, Berhane, Abera, Hailu and Bathrop39)}. Table 4 highlights the key facilitators and barriers.

Table 4.

Summary of described facilitators and barriers in outpatient/community management of infants u6m

Perceptions and acceptability

Caregivers and community members generally perceived outpatient care as more accessible and less costly than hospitalisation^{(Reference Arafat, Islam, Connell, Mothabbir, McGrath and Berkley12,Reference Brugaletta42)} . Mothers reported that home-based care strengthened maternal–infant bonding and improved acceptance of re-lactation techniques^{(Reference van Immerzeel, Camara, Deme Ly and de Jong35)}. Health workers acknowledged feasibility but expressed concerns about insufficient training, particularly in breastfeeding counselling and maternal psychosocial support^{(Reference Kueter, Burrell, Butler, Sarwar and Rahman24,Reference Kumar, Deb, de Wagt, Gupta, Bhandari and Sareen26)} . Policymakers’ views were mixed; while many acknowledged the need for alternatives to inpatient management, reluctance stemmed from uncertainties around specific measurement cut-off points and resource shortages^{(Reference Read and McGrath25,Reference Klomp, Kerac and Dyment28)} .

Tools, training, and protocols

Specialised tools gained focus, with the C-MAMI package being the only standardised tool for infants u6m described in a study, though its implementation varied across settings^{(Reference Engler, McGrath and Kerac43)}. Another study reported that the MAMI slide chart had 79% diagnostic accuracy, higher than traditional charts at 61%, and was preferred by health workers, though more real-world testing is needed^{(Reference Monga, Sikorski, de Silva, McGrath and Kerac32)}.

Protocols followed WHO 2023 guidelines and the MAMI clinical care pathway, often alongside plans such as IMNCI/ICCM in Ethiopia and CMAM plus nutrition programmes in Bangladesh^{(Reference Van Immerzeel, Deme-Ly, Diagne-Camara, Penzias, Seck and Diallo36–Reference McGrath, Girma, Berhane, Abera, Hailu and Bathrop39)}. The tools also included screenings for maternal mental health in multiple countries, alongside providing specialised foods and micronutrients^{(Reference Alim, Munirul Islam, Guesdon, Anik, Antoine and Marium37,Reference Mee, Abera and Kerac38)} .

However, training gaps were a common issue, especially when it came to breastfeeding support and psychosocial care for mothers^{(Reference Kueter, Burrell, Butler, Sarwar and Rahman24,Reference Kumar, Deb, de Wagt, Gupta, Bhandari and Sareen26)} . These shortages extended more broadly – for instance, in Senegal there was notably low readiness, highlighting an urgent need to build capacity in using equipment and enhancing the skills of health workers^{(Reference Van Immerzeel, Deme-Ly, Diagne-Camara, Penzias, Seck and Diallo36)}. While task-shifting to less specialised staff and aid from NGOs helped to support implementation, challenges such as limited supplies and staffing shortages often made it hard to fully follow protocols^{(Reference Alim, Munirul Islam, Guesdon, Anik, Antoine and Marium37–Reference McGrath, Girma, Berhane, Abera, Hailu and Bathrop39)}.

Guidelines and policy perspectives

Identified literature revealed ongoing discussions about the best criteria for admitting and discharging patients in malnutrition programmes. Although WHO growth standards and weight-for-length Z-scores (WLZ) are still widely used, some studies suggested that MUAC could be a simpler alternative, though it needs more validation^{(Reference Kerac, Blencowe, Grijalva-Eternod, McGrath, Shoham and Cole27,Reference Hoehn, Lelijveld, Mwangome, Berkley, McGrath and Kerac30,Reference Kerac, Mwangome, McGrath, Haider and Berkley44)} . Moreover, weight-for-age Z-scores (WAZ) are also widely used as a criterion of interest because of their ability to identify high-risk infants compared to WLZ^{(Reference Hoehn, Lelijveld, Mwangome, Berkley, McGrath and Kerac30)}. In various settings, policymakers expressed concerns about whether outpatient care is practical without a clearer global consensus and stronger evidence to back it up^{(Reference Read and McGrath25,Reference Klomp, Kerac and Dyment28)} .

The WHO 2023 guidelines and MAMI Care Pathway, supporting outpatient care and mother–infant pairs, align with policies in Ethiopia and offer cost-effective integration^{(Reference Van Immerzeel, Deme-Ly, Diagne-Camara, Penzias, Seck and Diallo36–Reference McGrath, Girma, Berhane, Abera, Hailu and Bathrop39)}. However, challenges include limited capacity in Senegal, governance issues in several countries, and workforce shortages requiring local adaptation in Bangladesh^{(Reference Van Immerzeel, Deme-Ly, Diagne-Camara, Penzias, Seck and Diallo36–Reference Mee, Abera and Kerac38)}. Policymakers stressed the importance of advocating for integrated strategies to address the unmet needs within routine health services^{(Reference Alim, Munirul Islam, Guesdon, Anik, Antoine and Marium37,Reference McGrath, Girma, Berhane, Abera, Hailu and Bathrop39)} .

Synthesis of findings

Across diverse contexts, several consistent patterns emerged. Outpatient and community-based management was described as feasible and acceptable across different contexts. Breastfeeding support, maternal health, and culturally adapted interventions were frequently identified as important components of reported programmes. Tools such as the MAMI clinical care pathway, MUAC, and the MAMI slide chart (a WAZ look-up chart) showed promise for programmatic use, though further validation and contextual testing is needed. Persistent barriers included limited health system capacity, inconsistent protocols, and policy hesitancy. Collectively, the findings suggest that, while outpatient management of malnourished infants u6m is promising, broader adoption will require stronger evidence, standardised guidelines, and integration into national health systems.