# Levels and determinants of child wasting relapse: a prospective cohort study from Somalia

## TL;DR

This study tracks how often children in Somalia who recovered from severe malnutrition relapse, finding that factors like initial health status and location affect relapse rates.

## Contribution

The study provides the first detailed analysis of SAM relapse rates and risk factors in Somalia using a prospective cohort design.

## Key findings

- SAM relapse rates increased over time, reaching 26% by six months post-discharge.
- Children with lower initial weight-for-height z-scores had a higher risk of relapse.
- Cash assistance programs were associated with a reduced risk of relapse.

## Abstract

Understanding the rates and determinants of severe acute malnutrition (SAM) relapse is crucial for stakeholders in Somalia, where evidence is limited. This study aimed to assess SAM relapse rates and associated risk factors among children discharged from outpatient therapeutic programmes (OTP) in the Bay and Hiran regions of Somalia.

We conducted a prospective cohort study of 160 children aged 7–53 months discharged as recovered from OTP SAM treatment between August–September 2023. Children were followed monthly for six time points post-discharge. Anthropometric measurements, morbidity data, and household information were collected. Survival analysis was used to calculate cumulative incidence of SAM relapse, defined by weight-for-height z-score (WHZ)<−3 standard deviation (SD) or mid-upper arm circumference (MUAC)<11.5 cm or oedema. Cox proportional hazard models identified factors associated with relapse.

Cumulative incidence of SAM relapse at Time 1 (T1) = 5.2% (95% confidence interval (CI) = 2.5, 10.6%), T2 = 14.3% (95% CI = 9.4, 21.5%) and T6 = 26.0% (95% CI = 19.3, 34.5%) by WHZ and 13.2% (95% CI = 8.8, 19.5%) by MUAC. The relapse rate for combined SAM and moderate acute malnutrition by WHZ at T1 = 26.9% (95% CI = 19.5, 36.3%), T2 = 36.2% (95% CI = 28.0, 46.1%) and T6 = 50.1% (95% CI = 41.0, 60.0%). Weight-for-height z-score (WHZ)-based relapse was higher in rural areas (31.4% vs. 22.7% urban, P = 0.285) and among children with WHZ<−3 SD at admission (37.4% vs. 21.2%, P = 0.029). Mid-upper arm circumference (MUAC)-based relapse was higher in urban areas (20.8% vs. 4.1% rural, P = 0.002), among younger children (19.7% vs. 5.5% > 2 years, P = 0.009), and internally displaced persons (21.8% vs. 5.8% non-internally displaced persons, P = 0.003). Factors significantly associated with increased relapse risk included WHZ<−3 SD at admission (adjusted hazard ratio (HR) = 2.22; 95% CI = 1.04, 4.72) and longer OTP stay (adjusted HR = 1.02 per day; 95% CI = 1.00, 1.04). Participation in a cash assistance programme was protective (adjusted HR = 0.44; 95% CI = 0.22, 0.90).

Severe acute malnutrition (SAM) relapse rates in Somalia are considerable, with varying patterns by anthropometric indicator, region, and demographic factors. Cash assistance programme offers a promising complementary intervention. These findings can inform targeted interventions and policy changes to reduce relapse and improve long-term outcomes for children recovering from SAM in Somalia and similar contexts.

The cluster-RCT associated with this cohort study is registered at ClinicalTrials.gov, ID: NCT06642012.