The Chemical Water Quality and Severe Acute Malnutrition (CWQ+SAM) Study

The CWQ+SAM study addresses an overlooked hazard in therapeutic feeding centres (TFCs) for children with severe acute malnutrition (SAM): the chemical quality of water used to prepare or accompany therapeutic foods and rehydration solutions (e.g., F-75, F-100, Ready-to-Use Therapeutic Food, ReSoMal). Highly mineralized or brackish groundwater, if used, can disrupt the carefully calibrated electrolyte and mineral intakes SAM patients receive during treatment, potentially contributing to adverse clinical outcomes—a concern raised after unexplained mortality clusters in TFCs in the Horn of Africa region in 2007 and 2017.

Using an adapted water quality risk assessment approach that combined field water quality data, a systematic literature review, and an expert Delphi panel, the study identified sodium, magnesium, sulphate, and nitrate/nitrite as parameters of concern. The literature review revealed a marked lack of evidence on allowable upper limits of intake for paediatric SAM patients for these parameters of concern. The expert panel confirmed the plausibility of the hypothesis that chemical water quality of water supplies used in the preparation of, or accompanying, therapeutic products can adversely affect clinical outcomes for the paediatric SAM population.

Based on the available evidence, the study proposes a practical preliminary threshold: water with electrical conductivity above 1500 µS/cm—saline or brackish to taste and indicative of high total dissolved solids—should not be used for drinking or preparing therapeutic foods and rehydration products in medical facilities treating paediatric SAM patients. Alternative water sources or reverse osmosis treatment should be used for this critical purpose in TFCs, wherever available. This finding underscores that “safe drinking water” for SAM treatment must account not only for microbiological water quality, but also for chemical water quality. Addressing this critical gap in humanitarian practice represents an important first step toward improving care and outcomes for vulnerable SAM patients, particularly in settings where malnutrition coincides with mineralized or brackish groundwater, such as in current nutritional crises in Gaza, Sudan, and the Horn of Africa region.

For more information, please see the resources below (please note that this research has not yet been peer-reviewed):

Advisory Note (ENGLISH): Chemical Water Quality & Severe Acute Malnutrition – Advisory Note_version15Oct2025

Advisory Note (ARABIC): Arabic Abstract_Advisory Note

Full Research Paper: CWQSAM_FinalPaper_version13Oct2025

Supplementary Information: 

Appendix 1_Systematic Literature Review Search Strategy

Appendix 2_CWQ+SAM Exposure Assessment Tool

Appendix 3_Expert Panel Delphi Evidence Matrix Synthesis

Appendix 4_Quality Appraisal of Level of Evidence of Water Quality and RDI Guidelines for Expert Panel Evidence Matrix

Appendix 5_ Additional Future Research Directions

Appendix 6_CWQ+SAM Water Quality Risk Thresholds

Authors:

Syed Imran Ali¹, Jennifer Turnbull², Tanya Narang¹, Matt Arnold¹, Sayo Falade¹, Jean-François Fesselet³, Saskia van der Kam³, James Orbinski¹

¹Dahdaleh Institute for Global Health Research, York University, Toronto, Canada; ²McGill University, Montreal, Canada; ³Médecins Sans Frontières, Amsterdam, Netherlands