Incidence of severe acute malnutrition after treatment: A prospective matched cohort study in Sokoto, Nigeria

Abstract

Severe acute malnutrition (SAM) among children in Nigeria is tackled through the outpatient therapeutic programme (OTP) of the Community‐based Management of Acute Malnutrition (CMAM) programme. CMAM is evidently effective in resolving SAM, but little evidence exists on the remaining risk of SAM relapse for children discharged as cured from the OTP. We aimed to measure and compare the 6‐month incidence of SAM among OTP‐cured and community control children and identify factors associated with SAM relapse. We conducted a prospective matched cohort study that tracked 553 OTP‐cured and 526 control children in Sokoto State, Northern Nigeria. Outcomes and covariates were measured fortnightly in up to 12 home visits. We used multivariate Cox and accelerated failure time models to identify significant risk correlates, where the covariates to be tested for correlation with relapse were selected using domain knowledge and automatic feature selection methods. SAM incidence rates were 52 times higher in the OTP‐cured cohort (0.204/100 child‐days) than in the community control cohort (0.004/100 child‐days). Children with lower mid‐upper arm circumference at OTP admission, with lower height/length‐for‐age z ‐scores, whose household head did not work over the full year, who lived in an area previously affected by environmental shocks, who were female and who had diarrhoea before the visit had a significantly higher relapse risk. Our study shows that OTP‐cured children remain at a significantly excess risk of SAM. To improve long‐term health outcomes of these children, programmes adopting a CMAM approach should strengthen follow‐up care and be integrated with other preventive services.

Time to Relapse of Severe Acute Malnutrition and Associated Factors Among Under Five Children in Hadiya Zone, Southern Ethiopia.

“…We found out that the mean(±SD) time for relapse of severe acute malnutrition among under ve children was 22(±9.9) weeks, which is a long relapse time compared to in the report from Nigeria (26). This may be due to differences in study design as study conducted in Nigeria was prospective cohort conducted for only six months, while this study is captured data over ve years in addition to being a retrospective cohort which may result in a different result.…”

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

“…The relative importance of these factors differs across settings, and studies have linked risk of relapse to factors such as age and gender (Abitew, Yalew, Bezabih, & Bazzano, 2020;Adegoke et al, 2020;Chang et al, 2012;Stobaugh et al, 2018), HIV status (Bahwere et al, 2008;Chang et al, 2012), vaccination status (Somassè, Dramaix, Bahwere, & Donnen, 2016), diet and feeding practices (Abitew, Yalew, Bezabih, & Bazzano, 2020;Somassè, Dramaix, Bahwere, & Donnen, 2016), household handwashing practices and distance to water sources (Abitew, Yalew, Bezabih, & T A B L E 1 Terminology and definitions pertaining to severe wasting following treatment for severe wasting as per recommendations by the CORTASAM Bazzano, 2020), seasonality and food security (Abitew, Yalew, Bezabih, & Bazzano, 2020;Burza et al, 2016;Chang et al, 2012;Grellety et al, 2017;Stobaugh et al, 2018), and environmental shocks (Adegoke et al, 2020). These contextual factors have broad influence on access to treatment, type of exit from treatment for these factors hypothesised to be associated with relapse and regression is limited, and our framework aims to illustrate these large gaps in the evidence on severe wasting following exit from treatment.…”

“…These factors may be present before, during and/or after treatment for severe wasting and may be the same factors causing severe wasting in the first place while also contributing to relapse, regression or reoccurrence after treatment. The relative importance of these factors differs across settings, and studies have linked risk of relapse to factors such as age and gender (Abitew, Yalew, Bezabih, & Bazzano, 2020; Adegoke et al, 2020; Chang et al, 2012; Stobaugh et al, 2018), HIV status (Bahwere et al, 2008; Chang et al, 2012), vaccination status (Somassè, Dramaix, Bahwere, & Donnen, 2016), diet and feeding practices (Abitew, Yalew, Bezabih, & Bazzano, 2020; Somassè, Dramaix, Bahwere, & Donnen, 2016), household handwashing practices and distance to water sources (Abitew, Yalew, Bezabih, & Bazzano, 2020), seasonality and food security (Abitew, Yalew, Bezabih, & Bazzano, 2020; Burza et al, 2016; Chang et al, 2012; Grellety et al, 2017; Stobaugh et al, 2018), and environmental shocks (Adegoke et al, 2020). These contextual factors have broad influence on access to treatment, type of exit from treatment (e.g., by affecting risks of defaulting), characteristics before and at entry into and exit from treatment, and risk of developing severe wasting after exiting treatment.…”

“…Risks of relapse and regression to severe wasting are likely related to the extent to which a child treated for severe wasting reaches full recovery, which in turn is influenced by the characteristics of the child before entry into treatment. A cohort study in Ethiopia (Tadesse, Worku, Berhane, & Ekström, 2018) and in Nigeria (Adegoke et al, 2020) found relatively more severe wasting at admission to treatment (lower anthropometric measures and presence of oedema) to be associated with increased relapse risks after discharge. The associations of severity of wasting at admission with relapse in these studies were likely due to associations with status at exit from treatment, although this was not evaluated.…”

“…The current evidence base is too limited to conclude confidently that factors hypothesised to affect risks of relapse and regression are relevant beyond contextual factors that have broad influence on the incidence of severe wasting as well as access to treatment and treatment outcomes. Studies are needed that evaluate whether associations between contextual factors and wasting differ between children who exited treatment for severe wasting and a community comparison group of children not previously wasted (Abitew, Worku, Mulugeta, & Bazzano, 2020; Action Against Hunger USA, 2020; Adegoke et al, 2020). Even where treatment‐related factors are found relevant for severe wasting after treatment beyond contextual factors, research needs to pay attention to how these associations differ by case characteristics and how they relate to risk of severe wasting through children's nutritional and immunological status at exit from treatment.…”