Predictors of relapse of acute malnutrition following exit from community-based management program in Amhara region, Northwest Ethiopia: An unmatched case-control study

Rates and risk factors for relapse among children recovered from severe acute malnutrition in Mali, South Sudan, and Somalia: a prospective cohort study

BACKGROUND

Community-based management of acute malnutrition is an effective treatment model for severe acute malnutrition. However, sparse evidence exists on post-discharge outcomes and the sustainability of recovery. This study aimed to evaluate the risk and determinants of relapse following severe acute malnutrition recovery in high-burden settings.

METHODS

This multi-country prospective cohort study followed children who had recovered from severe acute malnutrition and their non-malnourished peers in parallel for 6 months in Mali (nine sites), South Sudan (six sites), and Somalia (one site). Nutritional status was assessed by research staff at nutrition clinics monthly to obtain the proportion of children exposed to severe acute malnutrition who relapsed to acute malnutrition and the relative risk of developing acute malnutrition for exposed versus non-exposed (ie, previously non-malnourished) children. Exposed children were eligible if they had been discharged from community-based management of acute malnutrition programmes while aged 6-47 months. Non-exposed children were eligible if they had not had an episode of acute malnutrition in the previous year; non-exposed children were matched to exposed children by age, sex, and community. Acute malnutrition was defined as having a mid-upper arm circumference of less than 125 mm, a weight-for-height Z score of less than -2, or nutritional oedema. The primary outcome was the cumulative incidence of acute malnutrition at 6 months in the exposed and non-exposed cohorts. Relapse was defined as an episode of acute malnutrition among exposed children during the 6-month follow-up period.

FINDINGS

Between April 9, 2021, and June 2, 2022, 2749 children were enrolled (1689 exposed and 1060 non-exposed). After 6 months, 30% (95% CI 25-34) of children previously exposed to severe acute malnutrition relapsed in Mali, 63% (95% CI 59-67) in South Sudan, and 22% (95% CI 19-25) in Somalia. Depending on the context, exposed children were 1·2-6·2 times more likely to have acute malnutrition compared with non-exposed children. Higher anthropometric measurements at discharge were protective against relapse; however, few other child-level or household-level factors at the time of discharge were associated with subsequent relapse. After discharge, children experiencing food insecurity or morbidity at time of follow-up were more likely to relapse than those who were not experiencing these factors.

INTERPRETATION

Following severe acute malnutrition recovery, children have a significant risk of relapsing within 6 months, highlighting the particular vulnerability of this population. Although the community-based management of acute malnutrition model proves highly effective in saving lives, high relapse indicates the need for additional services during and following treatment to better sustain recovery.

FUNDING

The United States Agency for International Development.

A multi-country, randomized trial of three nutritional supplements on short-term and sustained anthropometric recovery in children 6-24 months of age with moderate wasting and acute illnesses: the NUTRIMAM study protocol

BACKGROUND

Globally, moderate wasting affects approximately 33 million children. Complex bidirectional interactions exist between wasting and infection in children. Children who experience both conditions have an increased risk of adverse outcomes including progression to severe wasting and mortality. Breaking the cycle between moderate wasting and infection could help improve growth and survival in these children. The NUTRIMAM trial will aim to investigate the efficacy of a 12-week regimen of three different nutritional interventions in at-risk young children (i.e., children who are moderately wasted and have one/more acute infections) on anthropometric recovery. Further, the study will explore whether recovery can be sustained with a post-intervention package that includes counseling and food vouchers. Sustaining anthropometric recovery beyond supplement administration will have important implications for programs.

METHODS

NUTRIMAM is a multi-country, multi-center individually randomized, open-label, trial in five countries including Bangladesh, India, Mali, Pakistan, and Tanzania. A total of 6360 moderately wasted children aged 6 to 24 months with acute illness will be enrolled at health centers. Children will be randomly allocated to receive one of three dietary supplements (locally available foods, ready-to-use supplementary foods, or microbiota-directed supplementary foods) for 12 weeks. Anthropometric recovery will be assessed over this period. Participants who recover will then be re-randomized to a post-recovery support intervention comprising either counseling and food vouchers or routine standard of care for recovered children for an additional 12 weeks to determine if this intervention facilitates sustained recovery at 24 weeks.

DISCUSSION

Children who are moderately wasted and have an infection are at higher risk of adverse outcomes. There are very few clinical trials that have been performed among children with moderate wasting with infectious illnesses to investigate if it is possible to break the undernutrition-infection cycle and thereby reduce the risk of nutritional deterioration to severe wasting or mortality and decrease the risk of acute infections. The results of the trial are anticipated to fill important evidence gaps in feeding recommendations for moderately wasted children with acute illness as well as interventions to sustain anthropometric recovery in children beyond the period of the nutritional intervention.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN53213318 . Registered on April 03, 2023.

Household-level water, sanitation and hygiene factors and interventions and the prevention of relapse after severe acute malnutrition recovery: A systematic review

Severe acute malnutrition (SAM) is the most serious form of acute malnutrition and is associated with high mortality risk among children under 5. While the Community-based Management of Acute Malnutrition (CMAM) approach, recommended for treating cases of uncomplicated SAM, has increased treatment coverage and recovery outcomes, high relapse rates have been reported. Several risk factors for SAM relapse, such as insufficient food intake and high infectious disease burden in the community, have been identified. However, the role of household water, sanitation and hygiene (WASH) conditions remains unclear. This systematic review: (1) assesses the effectiveness of WASH interventions on preventing SAM relapse and (2) identifies WASH-related conditions associated with relapse to SAM among children aged 6-59 months discharged as recovered following SAM CMAM treatment. We performed electronic searches of six databases to identify relevant studies published between 1 January 2000 and 6 November 2023 and assessed their quality. After deduplication, 10,294 documents were screened by title and abstract, with 13 retrieved for full-text screening. We included three studies ranging from low- to medium-quality. One intervention study found that providing a WASH kit during SAM outpatient treatment did not reduce the risk of relapse to SAM. Two observational studies found inconsistent associations between household WASH conditions-unimproved sanitation and unsafe drinking water-and SAM relapse. Despite the paucity of evidence, the hypothesised causal pathways between WASH conditions and the risk of relapse remain plausible. Further evidence is needed to identify interventions for an integrated postdischarge approach to prevent relapse.

Acute malnutrition relapse and associated factors among 6-59 months old children treated in the community-based management of acute malnutrition in Dessie, Kombolcha, and Haik towns, Northeast Ethiopia

Introduction

Undernutrition is a major health concern in many developing countries, and is one of the main health problems affecting children in Ethiopia. Although many children experience multiple relapses following the management of severe acute malnutrition, it is scarcely studied in Ethiopia.

Methods

A community-based cross-sectional study was conducted in Dessie, Kombolcha, and Haik towns among 6-59-month-old children enrolled and discharged from community-based acute malnutrition management (CMAM). The total sample size was 318 children, and data were collected from April 15, 2021, to May 14, 2021. The data were entered into EPI data version 4.4.1 before being exported and analyzed with SPSS version 25 software. A multivariate logistic regression analysis was performed, and a 95% confidence interval and p-value <0.05 were used to identify significantly associated variables. Additionally, the weight-for-height z-score (WHZ) was generated using the WHO Anthro 3.2.2 software.

Result

The overall acute malnutrition relapse after discharge from CMAM was 35.2% (6.6% relapsed to severe acute malnutrition and 28.6% relapsed to moderate acute malnutrition). The following variables were significantly associated with the relapse of acute malnutrition: child age (AOR: 3.08, 95% CI; 1.76, 5.39), diarrhea after discharge (AOR: 2.93, 95%CI; 1.51, 5.69), have not immunized (AOR: 3.05, 95% CI; 1.14, 8.23), MUAC at discharge (AOR: 3.16, 95% CI; 1.56, 6.40), and poorest and poor wealth index (AOR: 3.65, 95% CI; 1.45, 9.18) and (AOR: 2.73, 95% CI; 1.13, 6.59), respectively.

Conclusion

Over one-third of children treated with the CMAM program reverted to SAM or MAM. The age of the child, diarrhea after discharge, lack of immunization, MUAC at discharge (<13 cm), and poor and poorest wealth index were significantly associated with acute malnutrition relapse. Therefore, adequate health education and counseling services are essential for mothers to improve child immunization coverage and maintain adequate hygiene to prevent diarrhea. In addition, further experimental research is needed to investigate the effect of MUAC at discharge on the risk of acute malnutrition relapse.

Correction: Predictors of relapse of acute malnutrition following exit from community-based management program in Amhara region, Northwest Ethiopia: An unmatched case-control study

[This corrects the article DOI: 10.1371/journal.pone.0231524.].

Time to readmission and associated factors after post treatment discharge of severe acute malnourished under-five children in Pawe General Hospital

Background

Relapse or repeated episodes is the admission of a child with the diagnosis of severe acute malnutrition (SAM) after being discharged to a status of treated and cured from a stabilizing center. A child may experience more than one episode of SAM depending on the improvement of the underlying comorbidity. Thus, this study aimed to estimate the time to readmission of SAM and associated factors for under-five children in North West Ethiopia.

Methods

An institution-based retrospective cohort study was employed in 760 files of under-five children spanning from 2014/15 to 2019/20. The data extraction tool was developed from SAM treatment guidelines and medical history sheets. Epi Data version 3.2 and STATA version 14 were used for data entry and final analysis, respectively. After checking all assumptions, the multivariable Cox Proportional Hazard model was fitted to the isolated independent predictors for time to readmission. A categorical variable with p < 0.05 was considered a risk factor for the relapse of SAM.

Result

The mean (± SD) age of participant children was 27.8 (± 16.5) months with mean (± SD) time to relapse of SAM cases were 30.4(± 21.39) weeks posttreatment discharge. The overall incidence density rate of relapse was determined as 10.8% (95% CI 8.3; 12.6). The average time (± SD) for treatment recovery from the first admission of the SAM case was 28.8(± 18.7) days. Time of readmission was significantly associated with living in rural resident (AHR 5⋅3 = 95% CI, 2⋅95, 13⋅87, p = 0.021), having HIV infection (AHR6⋅8 = 95%CI; 4.1–11.9 p = 0.001), and first admission with edema (AHR = 3.5 = 95% CI; 1.92, 6.2, p = 0.018).

Conclusion

Nearly one in every ten severely acute malnourished under-five children relapsed within a mean time to relapse 30.4(± 21.39) weeks posttreatment discharge. Time to relapse was significantly associated with being a rural resident for children, having edema during the first admission, and being HIV-infected cases. A protocol ought to be drafted for extending Supplementary Nutrition in Acute Malnutrition management program following discharge is highly needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41043-022-00308-8.

Incidence and predictors of attrition rate after children started inpatient treatments for complicated severe acute malnutrition in North West Ethiopia

BACKGROUND

Retaining children for inpatient treatment of complicated severe acute malnutrition (SAM) is a growing challenge until achieved the reference weight of a child. In Ethiopia, there is limited information regarding the time to be lost from the stabilizing centers after initiation of treatment. Thus, this study aimed to identify incidence and predictors of attrition for children suffering from SAM after started inpatient treatment in North West Ethiopia.

METHODS

A retrospective cohort study was conducted among under-five children admitted and started inpatient treatment for complicated SAM from 2015/2016 to 2020/2021. Data were entered using Epi-data version 4.2 and then exported to STATA (SE) version R-14 software for further analysis. The analysis was computed using Cox proportional hazard regression model after checking all proportional hazard assumptions. Covariates having < 0.2 of P values in the bi-variable analysis were candidates transferred to the multivariable Cox proportional hazard regression model. Finally, a statistical significance was declared at a P value of < 0.05.

RESULT

Overall, 760 files of under-five children were analyzed with a mean (± SD) age of participants 27.8 (± 16.5) months. About 6944 child-days of treatment observation were recorded with the crude incidence of attrition rate of 9.7% (95% CI 7.9-12.6). The overall median time of attrition and half-life time S(t_1/2) of survival rates was determined as 14 (IQR =  ± 7) days and 91.6% (95% CI 88.2-93.1), respectively. The attrition rate was significantly associated with cases living in rural residents (AHR = 6.03; 95% CI 2.2; 25.2), being re-admitted SAM cases (AHR = 2.99; 95% CI 1.62; 5.5), and caregivers did not have formal education (AHR = :5.6, 95% CI 2.7; 11.7) were all independent predictors for attrition from inpatient treatment.

CONCLUSIONS

Nearly one in every ten severely acute malnourished under-five children defaulted at the end of treatment observation with a median time of 14 (IQR =  ± 7) days. Living in a rural residence, being re-admitted cases, caregivers who did not have a formal education were significantly associated with the attrition rate. Hence, it is crucial to detect and control the identified causes of defaulting from treatment observation promptly. Furthermore, serious counseling during admission and nutritional provision strategies are essential for virtuous treatment outcomes.

Evaluation of the community-based outpatient therapeutic feeding program implementation for managing children with severe acute malnutrition in Northwest Ethiopia: A mixed-method evaluation protocol

BACKGROUND

Community-based outpatient therapeutic feeding program (C-OTP) in Ethiopia has been launched to manage uncomplicated severe acute malnutrition (SAM) by trained Health Extension Workers (HEWs). This program is believed to be the most effective strategy for reaching a large group of children suffering from SAM in rural and disadvantaged communities. Nonetheless, poor treatment outcomes, notably mortality and prolonged recovery time, become pressing public health problems, which could be a result of suboptimal implementation and poor service quality.

OBJECTIVES

To evaluate the implementation of C-OTP for managing uncomplicated severe acute malnutrition in the Central Gondar Zone.

METHODS

Multiple studies involving both qualitative and quantitative will be conducted. Availability of essential drugs and equipment, acceptability of the program by mothers/caregivers, health extension workers' compliance to the treatment protocol, and treatment outcome will be assessed employing different methods. Likewise, knowledge of health extension workers about SAM diagnosis and management and their skills to diagnose and manage uncomplicated malnutrition will be determined. Health extension workers, mothers/caregivers, supervisors, and healthcare administrators will be enrolled in the study. Besides, children's medical records registered between 2017 and 2020 will be reviewed to determine the treatment outcome. The data will be collected using pretested self-administered and face-to-face interviewer-administered questionnaires. Similarly, focus group discussions (FGDs), in-depth interviews, and observation checklists will be applied. Binary logistic regression analysis will be conducted, while the qualitative data will be analyzed using thematic content analysis.

DISCUSSION

Severe acute malnutrition is a public health problem that remains the underlying cause for over half of under-five mortality in Ethiopia. As a result, community-based therapeutic care has been launched in the country to address these problems and maximize population-level impact by improving treatment coverage, access, and cost-effectiveness. Despite its achievement, the program has been threatened with unfavourable treatment outcomes and a shortfall of resources. Hence, this implementation evaluation study will also identify gaps between healthcare systems and service users. The output will help programmers pass evidence-based and sound decisions to tackle the key barriers.

Burden and risk factors for relapse following successful treatment of uncomplicated severe acute malnutrition in young children: Secondary analysis from a randomised trial in Niger

This study aimed to quantify the burden of relapse following successful treatment for uncomplicated severe acute malnutrition (SAM) and to identify associated risk factors in rural Niger. We used data from 1490 children aged 6−59 months discharged as recovered from an outpatient nutritional programme for SAM and followed for up to 12 weeks after admission. Postdischarge SAM relapse was defined as weight‐for‐height Z‐score <−3, mid‐upper arm circumference (MUAC) <115 mm or bipedal oedema after having been discharged as recovered. Postdischarge hospitalisation was defined as admission to inpatient SAM treatment or hospitalisation for any cause after having been discharged as recovered. We used multivariate log‐binomial models to identify independent risk factors. After programmatic discharge, 114 (8%) children relapsed to SAM and 89 (6%) were hospitalised. Factors associated with SAM relapse were discharge during the lean season (relative risk [RR] = 1.80 [95% confidence interval [CI] = 1.22−2.67]) and larger household size (RR = 1.56 [95% CI = 1.01−2.41]), whereas older child age (RR = 0.94 [95% CI = 0.88−1.00]), higher child MUAC at discharge (RR = 0.93 [95% CI = 0.87−1.00]) and maternal literacy (RR = 0.54 [95% CI = 0.29−0.98]) were protective factors. Discharge during the lean season (RR = 2.27 [95% CI = 1.46−3.51]) was independently associated with postdischarge hospitalisation. Future nutritional programmes in the context of Niger may consider modification of anthropometric discharge criteria or the provision of additional home support or follow‐up during the lean season as potential interventions to prevent relapse. More research including postdischarge follow‐up is needed to better understand the sustainability of treatment outcomes after discharge and the type of intervention that may best sustain recovery over time. Clinical Trial Registration: ClinicalTrials.gov number, NCT01613547.

Following successful discharge from a community‐based nutritional programme for severe acute malnutrition (SAM) treatment in rural Niger, the prevalence of SAM relapse was 8% and the prevalence of postdischarge hospitalisation was 6% within 12 weeks from admission.

Factors associated with SAM relapse were child age at programme admission, child mid‐upper arm circumference (MUAC) at discharge, discharge from the nutritional programme during the lean season, and maternal literacy.

Anthropometry at discharge was a primary risk factor for relapse. MUAC at discharge performed better than weight‐for‐height Z‐score (WHZ) in classifying SAM relapse cases. ‘Optimal’ cut‐offs, defined using the Liu method which maximises the product of the sensitivity and specificity, were MUAC of 121 mm with 66% sensitivity and 67% specificity and WHZ of −1.38 with 54% sensitivity and 57% specificity.

Future programmes may consider additional support or follow‐up of children at high risk of postdischarge relapse or hospitalisation, including those discharged during the lean season. Modification of current anthropometric discharge criteria may also be explored as an actionable target to further reduce the risk of relapse.

The Role of Food Insecurity and Dietary Diversity on Recovery from Wasting among Hospitalized Children Aged 6-23 Months in Sub-Saharan Africa and South Asia

Background: Current guidelines for the management of childhood wasting primarily focus on the provision of therapeutic foods and the treatment of medical complications. However, many children with wasting live in food-secure households, and multiple studies have demonstrated that the etiology of wasting is complex, including social, nutritional, and biological causes. We evaluated the contribution of household food insecurity, dietary diversity, and the consumption of specific food groups to the time to recovery from wasting after hospital discharge. Methods: We conducted a secondary analysis of the Childhood Acute Illness Network (CHAIN) cohort, a multicenter prospective study conducted in six low- or lower-middle-income countries. We included children aged 6−23 months with wasting (mid-upper arm circumference [MUAC] ≤ 12.5 cm) or kwashiorkor (bipedal edema) at the time of hospital discharge. The primary outcome was time to nutritional recovery, defined as a MUAC > 12.5 cm without edema. Using Cox proportional hazards models adjusted for age, sex, study site, HIV status, duration of hospitalization, enrollment MUAC, referral to a nutritional program, caregiver education, caregiver depression, the season of enrollment, residence, and household wealth status, we evaluated the role of reported food insecurity, dietary diversity, and specific food groups prior to hospitalization on time to recovery from wasting during the 6 months of posthospital discharge. Findings: Of 1286 included children, most participants (806, 63%) came from food-insecure households, including 170 (13%) with severe food insecurity, and 664 (52%) participants had insufficient dietary diversity. The median time to recovery was 96 days (18/100 child-months (95% CI: 17.0, 19.0)). Moderate (aHR 1.17 [0.96, 1.43]) and severe food insecurity (aHR 1.14 [0.88, 1.48]), and insufficient dietary diversity (aHR 1.07 [0.91, 1.25]) were not significantly associated with time to recovery. Children who had consumed legumes and nuts prior to diagnosis had a quicker recovery than those who did not (adjusted hazard ratio (aHR): 1.21 [1.01,1.44]). Consumption of dairy products (aHR 1.13 [0.96, 1.34], p = 0.14) and meat (aHR 1.11 [0.93, 1.33]), p = 0.23) were not statistically significantly associated with time to recovery. Consumption of fruits and vegetables (aHR 0.78 [0.65,0.94]) and breastfeeding (aHR 0.84 [0.71, 0.99]) before diagnosis were associated with longer time to recovery. Conclusion: Among wasted children discharged from hospital and managed in compliance with wasting guidelines, food insecurity and dietary diversity were not major determinants of recovery.

Determinants of wasting among children aged 6-59 months in North-East Ethiopia: a community-based case-control study

OBJECTIVE

Childhood acute malnutrition, in the form of wasting defined by Weight-for-Height Z-Scores, is a major public health concern. It is one of the main reasons for the death of children in developing countries like Ethiopia. Accordingly, this study aimed to assess determinants of wasting among children aged 6-59 months in Meket district, North Wollo zone, North-East Ethiopia.

SETTING

The study was conducted among communities in Meket district, North Wollo zone, North-East Ethiopia.

PARTICIPANTS

A total of 327 (109 cases and 218 controls) children aged 6-59 months participated in the study. Children from 6 months to 59 months of age who match the definition of case/wasted/ and control/not wasted were eligible for the study. However, children who had physical deformities which make anthropometric measurements inconvenient were excluded from the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcome measure was wasting.

RESULT

The mean ages of the cases and controls were 21.77±11.41 months and 20.13±11.39 months, respectively. Factors that were significantly associated with wasting were: maternal decision making on the use of household money (adjusted odd ratio (AOR)=3.04, 95% CI 1.08 to 7.83), complementary feeding started in a month (AOR=3.02, 95% CI 1.097 to 6.97), food diversity score (AOR=2.64, 95% CI 1.64 to 5.23), frequency of complementary feeding (AOR=6.68, 95% CI 3.6 to 11.25) and history of acute respiratory infections (ARIs) 2 weeks preceding the survey (AOR=3.21, 95% CI 1.07 to 7.86).

CONCLUSION

Our result implies that the right time to introduce complementary foods, the frequency of feeding and also the amount of food consumed were some of the crucial factors that needed to be changed in child nutrition to reduce wasting. Furthermore, within the framework of our study, the empowerment of women in the decision-making process and the prevention of ARI should be seen as a necessary benchmark for acute malnutrition.

Barriers to Management of Moderate Acute Malnutrition Among Children Aged 6 to 59 Months in Damot Pulassa, Wolaita, South Ethiopia: A Phenomenological Study of Mothers and Health Service Providers

BACKGROUND

Management of children with moderate acute malnutrition (MAM) needs to improve to reduce the transition from MAM to severe acute malnutrition (SAM).

OBJECTIVE

This study aimed to assess barriers to management of MAM among children aged 6 to 59 months in Damot Pulassa, Wolaita, South Ethiopia.

METHOD

This descriptive phenomenological design used 6 focus group discussions with mothers or caregivers of children aged 6 to 59 months and 10 in-depth interviews with health service providers. Data were analyzed using Colaizzi's descriptive phenomenological method.

RESULT

Six themes were identified: Possible reasons for MAM; identification of a child with MAM; management services of MAM; maternal-level barriers; service provider-level barrier; and suggestions to improve the service. Shortage of food and money, selling out of self-produced food without having sufficient reserves at home, large household size, shame on having children with malnutrition, occasional house-to-house screening for MAM, family-initiated screening, leaving the management responsibility of children with MAM to the family, no provision of supplementary food, and lack of repeated follow-up visits were the main obstacles for managing MAM.

CONCLUSION

Maternal-level barriers and service provider-level barriers affect the management of MAM negatively in Damot Pulassa, Wolaita. Children with MAM living in the area ineligible for food supplementation could deteriorate to SAM. The provision of nutrition counseling to the mothers of children with MAM without food supplementation placed children with MAM at increased risk of negative outcomes. Thus, the government should give more attention and facilitation in promoting supplementary food into the existing management of MAM.

Clinical and growth outcomes of severely malnourished children following hospital discharge in a South African setting

Background

Data on outcomes of children with severe acute malnutrition (SAM) following treatment are scarce with none described from any upper-middle-income country. This study established mortality, clinical outcomes and anthropometric recovery of children with SAM six months following hospital discharge.

Methods

A prospective cohort study was conducted in children aged 3–59 months enrolled on discharge from two hospitals in the Tshwane district of South Africa between April 2019 and January 2020. The primary outcome was mortality at six months. Secondary outcomes included relapse rates, type(s) and frequency of morbidities experienced and the anthropometric changes in children with SAM following hospital discharge. Standard programmatic support included nutritional supplements.

Results

Forty-three children were enrolled with 86% of participants followed up to six months. Only a third of the participants had normal anthropometry at hospital discharge–a quarter still had ongoing SAM. There were no deaths, although four children (9%) were re-hospitalised including two for complicated SAM. Mean weight-for-length z-scores (WLZ) and wasting rates improved at one month but deteriorated by three months. At three months, six children (14%) either had ongoing or relapsed SAM–a SAM incidence rate of 20 per 1000 person-months despite more than half of the participants still receiving nutritional supplements at the time. Risk factors associated with persistent malnutrition at three months included a low WLZ on admission (relative risk [RR] 3.3, 95% confidence interval [95%CI] 1.2–9.2), being discharged from hospital before meeting WHO SAM treatment discharge criteria (RR 5.3, 95%CI 1.3–14.8) or having any illness by three months (RR 8.6, 95%CI 1.3–55.7).

Conclusion

Post-discharge mortality and morbidity was lower than in other less resourced settings. However, anthropometric recovery was poorer than expected. Modifying discharge criteria, optimising the use of available nutritional supplements and better integration with community-based health and social services may improve outcomes for children with SAM post-hospitalisation.

Spatial Variations and Determinants of Acute Malnutrition Among Under-Five Children in Ethiopia: Evidence from 2019 Ethiopian Demographic Health Survey

Background and aims:

Childhood acute malnutrition, in the form of wasting defined by a severe weight loss as a result of acute food shortage and/or illness. It is a critical public health problem that needs urgent attention in developing countries, like Ethiopia. Despite its variation between localities, the risk factors and its geospatial variation were not addressed enough across the various corner of the country. Therefore, the current study was undertaken to assess spatial variation and factors associated with acute malnutrition among under-five children in Ethiopia.

Methods:

A total weighted sample of 4 955 under-five children were included from the 2019 Demographic and Health Survey. Getis-Ord spatial statistical tool used to identify the hot and cold spot areas of severe and acute malnutrition. A multilevel multivariable logistic regression model using was used to examine predictors of acute malnutrition. In the multivariable multilevel analysis, Adjusted Odds Ratio with 95% CI was used to declare significant determinants of acute malnutrition among children.

Result:

Among 4 955 under-five children, 7% of them were wasted and 1% of them were severely wasted in Ethiopia during the 2019 national demographic survey. The distribution was followed some spatial geo-locations where most parts of Somali were severely affected (RR = 1.46, P37 value <0.001), and the distribution affected few areas of Afar, Gambella, and Benishangul Gumz regions. Factors that significantly associated with childhood wasting were: gender(male)1.9 (1.3–2.7), age (above 36 months) 0.5 (0.2–0.9), wealth index(richest) 0.5 (0.2–0.8), and water source (unimproved source) 1.5 (1.0–2.3).

Conclusions:

Our finding implies, the distribution of childhood wasting was not random. Regions like Afar, Somali, and pocket areas in Gambella and SNNP should be considered as priority areas nutritional interventions for reducing acute malnutrition. The established socio-demographic and economic characteristics can be also used to develop strategies.

Comparison of Mid-Upper-Arm Circumference and Weight-For-Height Z-Score in Identifying Severe Acute Malnutrition among Children Aged 6-59 Months in South Gondar Zone, Ethiopia

Children with severe acute malnutrition (SAM) are identified for admission to outpatient therapeutic programs using mid-upper-arm circumference (MUAC) or weight for height (WHZ). However, MUAC and WHZ do not identify the same children, and such observed differences might have programmatic implications of missed nutrition therapy if only MUAC is used to identify children with SAM. The objective of the study was to assess any difference in prevalence and degree of agreement between MUAC and WHZ in identifying SAM affected children. A cross-sectional study was conducted in South Gondar Zone, Ethiopia, among 17 districts, with 3 districts and 10 health centers with their clustered health posts selected randomly. A total of 2,040 children were recruited, and data were collected using a parent questionnaire then entered into EpiData and analyzed using SPSS v 20. A total of 1,980 respondents (97.1%) were interviewed, all of whom were female and rural residents. Children's mean age in months was 23.2 (SD ± 9.7), and 54% were male children. The prevalence of SAM based on MUAC <11.5 cm was 11.2% (95% CI: 9.9–12.7) and 11.0% (95% CI: 9.7–12.5) based on WHZ <−3. The agreement between MUAC and WHZ was good (k = 0.729). The proportion of children with SAM identified using both MUAC and WHZ was 61.2%. The prevalence of SAM identified using both MUAC and WHZ was comparable. A substantial degree of agreement between MUAC and WHZ was observed to diagnose SAM. Therefore, MUAC can be used as an appropriate tool in identifying children with SAM for admission into the outpatient therapeutic program (OTP) in the study area.

Incidence of relapse following a new approach to simplifying and optimising acute malnutrition treatment in children aged 6-59 months: a prospective cohort in rural Northern Burkina Faso

The present study aimed to determine the 3-month incidence of relapse and associated factors among children who recovered under the Optimising treatment for acute MAlnutrition (OptiMA) strategy, a MUAC-based protocol. A prospective cohort of children successfully treated for acute malnutrition was monitored between April 2017 and February 2018. Children were seen at home by community health workers (CHWs) every 2 weeks for 3 months. Relapse was defined as a child who had met OptiMA recovery criteria (MUAC ≥ 125 mm for two consecutive weeks) but subsequently had a MUAC < 125 mm at any home visit. Cumulative incidence and incidence rates per 100 child-months were estimated. Multivariable survival analysis was conducted using a shared frailty model with a random effect on health facilities to identify associated factors. Of the 640 children included, the overall 3-month cumulative incidence of relapse was 6⋅8 % (95 % CI 5⋅2, 8⋅8). Globally, the incidence rate of relapse was 2⋅5 (95 % CI 1⋅9, 3⋅3) per 100 child-months and 3⋅7 (95 % CI 1⋅9, 6⋅8) per 100 child-months among children admitted with a MUAC < 115 mm. Most (88⋅6 %) relapses were detected early when MUAC was between 120 and 124 mm. Relapse was positively associated with hospitalisation, with an adjusted hazard ratio (aHR) of 2⋅06 (95 % CI 1⋅01, 4⋅26) for children who had an inpatient stay at any point during treatment compared with children who did not. The incidence of relapse following recovery under OptiMA was relatively low in this context, but the lack of a standard relapse definition does not allow for comparison across settings Closer follow-up with caretakers whose children are admitted with MUAC < 115 mm or required hospitalisation during treatment should be considered in managing groups at high risk of relapse. Training caretakers to screen their children for relapse at home using MUAC could be more effective at detecting early relapse, and less costly, than home visits by CHWs.

Relapse and regression to severe wasting in children under 5 years: A theoretical framework

Systematic reviews have highlighted that repeated severe wasting after receiving treatment is likely to be common, but standardised measurement is needed urgently. The Council of Research & Technical Advice for Acute Malnutrition (CORTASAM) released recommendations on standard measurement of relapse (wasting within 6 months after exiting treatment as per recommended discharge criteria), regression (wasting within 6 months after exiting treatment before reaching recommended discharge criteria) and reoccurrence (wasting after 6 months of exit from treatment as per recommended discharge criteria). We provide a theoretical framework of post-treatment relapse and regression to severe wasting to guide discussions, risk factor analyses, and development and evaluations of interventions. This framework highlights that there are factors that may impact risk of relapse and regression in addition to the impact of contextual factors associated with incidence and reoccurrence of severe wasting more generally. Factors hypothesised to be associated with relapse and regression relate specifically to the nutrition and health status of the child on admission to, during and exit from treatment and treatment interventions, platforms and approaches as well as type of exit from treatment (e.g., before reaching recommended criteria). These factors influence whether children reach full recovery, and poorer nutritional and immunological status at exit from treatment are more proximate determinants of risk of severe wasting after treatment, although post-treatment interventions may modify risks. The evidence base for many of these factors is weak. Our framework can guide research to improve our understanding of risks of relapse and regression and how to prevent them and inform programmes on what data to collect to evaluate relapse. Implementation research is needed to operationalise results in programmes and reduce post-treatment severe wasting at scale.

Frequency of relapse for severe acute malnutrition and associated factors among under five children admitted to health facilities in Hadiya Zone, South Ethiopia

BACKGROUND

Severe acute malnutrition is a common cause of morbidity and mortality among under five children in Ethiopia. A child may experience more than one episode of SAM depending on the improvement of the underlying factors. However, there is no study that determined the frequency of relapse of SAM cases after discharge in Ethiopia.

OBJECTIVE

To identify the frequency of relapse and associated factors among children discharged after undergoing treatment for SAM in Hadiya Zone, South, Ethiopia.

METHODS

An institution based retrospective cohort study was done among children admitted to health posts for treatment of SAM from 2014/2015-2019/2020 under-five children's after discharge in health post for severe acute malnutrition in the last five years in Hadiya zone, SNNPR, Ethiopia. Both first admission data and relapse data were abstracted from the records of the SAM children from Aguste 1-30 /2020 Using a data collection format. Data were coded and edited manually, then doubly entered into Epi-Data statistical software version 3.1 and then exported to SPSS for windows version 26. After checking all the assumptions finally Negative binomial regression for poison has been used. All tests were two sided and P values <0.05 were used to declare statistical significance.

RESULTS

In the last five year there were the proportion of relapsed cases were 9.6%, 95% CI: (7.7%, 11.7%) On multivariable negative binomial regression model, after adjusting for background variables relapse of severe acute undernutrition was significantly associated with having edema during admission with (IRR = 2.21, 95% CI:1.303-3.732), being in the age group of 6-11 months (IRR = 4.74,95% CI:1.79-12.53), discharge MUAC for the first admission (P = 0.001, IRR = 0.37, 95% CI:0.270-0.50) increase the risk of incidence rate ratio(IRR) relapse case of severe acute under nutrition.

CONCLUSION

Frequency of SAM relapse was positively associated with age, having edema during admission, while it was negatively associated with discharge MUAC. The results imply the need for reviewing the discharge criteria taking into account the recovery of MUAC as a marker for lean tissue accretion, especially in edematous children and those in the younger age.