Relapse after severe acute malnutrition: A systematic literature review and secondary data analysis

Abstract

The objectives of most treatment programs for severe acute malnutrition (SAM) in children focus on initial recovery only, leaving post-discharge outcomes, such as relapse, poorly understood and undefined. This study aimed to systematically review current literature and conduct secondary data analyses of studies that captured relapse rates, up to 18-month post-discharge, in children following recovery from SAM treatment. The literature search (including PubMed and Google Scholar) built upon two recent reviews to identify a variety of up-to-date published studies and grey literature. This search yielded 26 articles and programme reports that provided information on relapse. The proportion of children who relapsed after SAM treatment varied greatly from 0% to 37% across varying lengths of time following discharge. The lack of a standard definition of relapse limited comparability even among the few studies that have quantified post-discharge relapse. Inconsistent treatment protocols and poor adherence to protocols likely add to the wide range of relapse reported. Secondary analysis of a database from Malawi found no significant association between potential individual risk factors at admission and discharge, except being an orphan, which resulted in five times greater odds of relapse at 6 months post-discharge (95% CI [1.7, 12.4], P = 0.003). The development of a standard definition of relapse is needed for programme implementers and researchers. This will allow for assessment of programme quality regarding sustained recovery and better understanding of the contribution of relapse to local and global burden of SAM.

Keywords: community-based management of acute malnutrition; outpatient therapeutic programme; post-discharge outcomes; relapse; severe acute malnutrition; wasting.

Figure 1

Relapse rates presented in literature according to the duration of follow‐up after discharge from treatment of SAM. AM: acute malnutrition; SAM: severe acute malnutrition. When relapse rates were disaggregated between those who met discharge criteria and those who did not, rates of those who met discharge criteria were included. However, it was not always clear if all children included in the relapse rates were discharged as recovered. Also, some studies included relapse to AM where others included only relapse to SAM. Lastly, rates also vary between those that are point prevalence or cumulative; thus, relapse rates in Figure 1 are not fully comparable. Data measured: † fortnightly, ‡ monthly, § quarterly, ‖ varied, ¶ readmission/unclear, and †† once at endpoint. * Studies with relapse defined as relapse to AM (including MAM or SAM). Such studies that report relapse back to MAM or SAM are those where children are discharged at a point in which they are deemed “not malnourished” and therefore a “relapse” to MAM is indeed a true regression in nutritional status