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

ABSTRACT Background 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 programs (OTP) in the Bay and Hiran regions of Somalia. Methods We conducted a prospective cohort study of 160 children aged 7-53 months discharged as recovered from OTP SAM treatment between August and September 2023. Children were followed monthly for 6 timepoints 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 SD or mid-upper arm circumference (MUAC) <11.5cm or oedema. Cox proportional hazard models identified factors associated with relapse. Results Cumulative incidence of SAM relapse at T1=5.2% (CI: 2.5-10.6%)), T2=14.3% (9.4-21.5%) and T6 was 26.0% (CI: 19.3-34.5%) by WHZ and 13.2% (CI: 8.8-19.5%) by MUAC. The relapse rate for combined SAM and MAM by WHZ at T1=26.9% (CI: 19.5-36.3%), T2=36.2% (CI: 28.0-46.1%) and T6=50.1% (CI: 41.0-60.0%). WHZ-based relapse was higher in rural areas (31.4% vs 22.7% urban, p=0.285) and among children with WHZ <-3SD at admission (37.4% vs 21.2%, p=0.029). 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 IDPs (21.8% vs 5.8% non-IDPs, p=0.003). Factors significantly associated with increased relapse risk included WHZ <-3 SD at admission (adjusted HR: 2.22, CI: 1.04-4.72) and longer OTP stay (adjusted HR: 1.02 per day, CI: 1.00-1.04). Participation in a cash assistance program was protective (adjusted HR: 0.44, CI: 0.22-0.90). Conclusions SAM relapse rates in Somalia are considerable, and varies by indicators, regions, and demographics. cash assistance shows promise for improving outcomes. Registration The cluster-RCT associated with this cohort study is registered at ClinicalTrials.gov , ID: NCT06642012 .