Background: Each year, an estimated 17 million children suffer from severe acute malnutrition (SAM) and 33 million from moderate acute malnutrition (MAM), with many of the most severe cases found in extremely food insecure contexts or conflict situations. Current global outpatient treatment protocols for uncomplicated SAM and MAM, adapted by most countries for use at national level, call for SAM and MAM to be managed separately, however global-level stakeholders have recently begun evaluating simplified and/or combined protocols managing acute malnutrition. Methods: This study analyzes national policy discussions and decision-making around outpatient acute malnutrition treatment for uncomplicated cases in emergency situations in Niger, Nigeria, Somalia, and South Sudan. Data collection (March-July 2018) included semi-structured in-depth interviews with 50 respondents (N = 11-15 per country) from government, funding agencies, and implementing partners, as well as 11 global and regional stakeholders. We also conducted a document analysis (N = 10-15 per country and at global level) to situate debates and evaluate current policy. Data were analyzed iteratively using thematic content analysis. Results: We find that while combined/simplified protocols for outpatient management of uncomplicated cases of acute malnutrition are being used in emergency situations in all four countries, there is widespread confusion about protocol terminology and content, stemming from a lack of coherence at the global level. As a result, national-level stakeholders express diverse, if overlapping, rationales for modifying current protocols, which vary given the intensity and scope of the emergency. Without specific global-level guidance, combined/simplified protocols are often used on an ad hoc basis, although the processes for triggering them were at least nominally controlled at the national level. Decisions about when and where to enact "exceptional"modifications to country protocols were often based on inconsistent determinations of what constitutes an "emergency."Respondents said more evidence is needed on both clinical and operational aspects of these protocols, and they awaited clear guidance from global norm-setting agencies. Conclusions: Based on these findings, global-level stakeholders should urgently improve coordination and communication around existing protocols. Standardized guidance based on the available evidence is required to clarify best practices for combined management of SAM and MAM, particularly in emergency contexts (which should be defined) and in situations of limited resources. Given the complexity of governance arrangements in conflict situations, both guidance and updates on research must be disseminated in a rational, systematic, and digestible way to the multiplicity of field actors.
