Relapse Burden of Severe Acute Malnutrition Post‐Recovery Using SPHERE Performance Indicators: A Systematic Review and Meta‐Analysis

TL;DR

This study finds that nearly one in five children in Ethiopia relapse into severe acute malnutrition after recovery, exceeding expected performance standards.

Contribution

The study provides a systematic review and meta-analysis of relapse rates using SPHERE indicators in Ethiopia.

Findings

The pooled national relapse burden was 19.4% with high heterogeneity (I² = 98.78%).

MUAC ≥ 125 mm as a discharge criterion and household food insecurity were significant predictors of relapse.

The Amhara region had a higher relapse burden (26.9%) compared to the Southern region (10.52%).

Abstract

In Ethiopia, factors including persistent regional conflicts, comorbidities, and caregivers' self‐discharge (ranging from 2.5% to 36.5%) from treatment centers increase the risk of readmission. This study aimed to estimate the relapse burden of SAM utilizing SPHERE performance indicators through a systematic review and meta‐analysis (SRMA).

Following the PRISMA guideline, we retrieved 1276 published articles from PubMed, Scopus, ScienceDirect, Web of Science, African Journals Online, and Google Scholar. Article quality was assessed using the JBI checklist. The pooled relapse burden was estimated using weighted inverse variance random‐effects meta‐regression. Heterogeneity was evaluated using Cochran's Q test and I² statistics. Subgroup analyzes and sensitivity tests were conducted to explore potential publication bias.

Eight studies comprising 4,878 participants were included, of which 958 cases were readmitted for SAM re‐treatment. The male‐to‐female ratio was 47.2% to 52.8%. The pooled national relapse burden was 19.4% (95% CI: 10.69 to 28.78, I² = 98.78%). Aggregating treatment outcome indicators using SPHERE performance standards yielded recovery, attrition, and death rates of 79.17%, 4.15%, and 5.84%, respectively. Subgroup analysis indicated a higher relapse burden in the Amhara region (RB = 26.9%) compared to the Southern region (RB = 10.52%). Random‐effects meta‐regression identified MUAC ≥ 125 mm as a discharge criterion (Pooled HR 3.6) and household food insecurity (Pooled HR = 6.33) as significant predictors for SAM relapse.

This review found that nearly one in every five children under five is readmitted for SAM re‐treatment. The relapse burden and loss to follow‐up rates exceeded the expected national‐level SPHERE performance indicators. Therefore, the use of MUAC indices for recovery discharge criteria should be reconsidered and re‐standardized. Comprehensive nutrition education, household food aid, and continued follow‐up are strongly recommended for children who have been treated and declared cured of severe acute malnutrition.

PROSPERO CRD42024520816.

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