Children discharged from hospital following management of complicated severe acute malnutrition (SAM) have a high risk of mortality, readmission and failed nutritional recovery. Current management approaches fail to sufficiently promote convalescence after inpatient nutritional rehabilitation. Novel interventions during the post-discharge period could enhance convalescence to help children survive and thrive.

The Co-SAM trial is an adaptive, multicountry, phase III, individually randomised clinical trial, based on the principles that (i) interacting biological and social factors drive multimorbidity in children with SAM, and (ii) both medical and psychosocial interventions may therefore ameliorate underlying causal pathways to reduce morbidity and mortality and improve recovery. Children aged 6–59 months with complicated SAM, who have stabilised and started the transition to ready-to-use therapeutic food (RUTF), will be enrolled and randomised to one of five trial arms (standard-of-care alone; antimicrobials; reformulated RUTF; psychosocial support; or a combination of all strategies). Standard-of-care, which is provided in all trial arms, includes RUTF until nutritional recovery (defined as weight-for-height Z-score >–2, mid-upper arm circumference >12.5 cm and oedema-free since the last study visit), and other management recommended in WHO guidelines. The 12-week antimicrobial package provides daily co-formulated rifampicin and isoniazid (with pyridoxine) and 3 days of azithromycin monthly. The reformulated RUTF, which incorporates medium-chain triglycerides and hydrolysed protein to increase nutrient bioavailability and reduce metabolic stress, is provided at the same dose and duration as standard RUTF. The 12-week psychosocial package includes caregiver problem-solving therapy, educational modules, peer support groups and child play. The combined arm includes all interventions. Children start their intervention package prior to hospital discharge, with follow-up data collection in study clinics at 2, 4, 6, 8, 12 and 24 weeks. The primary composite outcome is death, hospitalisation or failed nutritional recovery within 24 weeks post-randomisation. An interim analysis will allow unpromising arms to be dropped, while the final analysis will be conducted when 1266 children have completed the study. Embedded process evaluation and laboratory substudies will explore the mechanisms of action of the interventions.

The trial has been approved by ethics committees in Zimbabwe, Zambia, Kenya and UK. Dissemination will be via community advisory boards in each country; Ministries of Health; and dialogue with policymakers including UNICEF.

Clinicaltrials.gov: NCT05994742; Pan African Clinical Trials Registry: PACTR202311478928378.

Opioids are prescribed to manage pain. Approximately 1 in 20 pregnant women in Canada are prescribed opioids during the prenatal period, which may occur concurrently with other psychotropic drug use. The health implications of the independent and concurrent prenatal use of these drugs are not fully understood; however, adverse neonatal and longer-term outcomes have been suggested. This protocol describes a study to update the epidemiology of prenatal exposure to opioid and other psychotropic drug use during pregnancy, providing an enhanced understanding of the potential impacts on the mother and child to help inform decisions regarding prescription and use.

The retrospective cohort study design uses population-based administrative data from Manitoba and British Columbia, Canada, to investigate the effect of prenatal opioid and concurrent psychotropic drug use on maternal and child outcomes. All mother–child dyads from 2000/2001 to 2019/2020 (approximately 1M pairs) will be identified and assigned to exposure groups based on the number of opioid and other psychotropic drug dispensations to the mother during the prenatal period. Maternal sociodemographic characteristics, prescribing patterns, short- and long-term child health and education outcomes and maternal outcomes will be examined.

The study was approved by the University of Manitoba Human Research Ethics Board (No. HS24397 – H2020:470) and the University of British Columbia Clinical Research Ethics Board (No. H21-02262). The study will generate findings that will add to the growing body of evidence of potential short- and long-term adverse effects on children exposed to these drugs prenatally and will help to inform safe prescribing guidelines during pregnancy. Results will be published in peer-reviewed journals.