Relevance of more stringent discharge standards for acute malnutrition treatment: A pooled analysis of post-treatment relapse in 21 studies.

BACKGROUND: The World Health Organization recently recommended that both Weight-for-Height Z-score (WHZ) and Mid-Upper-Arm-Circumference (MUAC) exceed Moderate Acute Malnutrition (MAM) thresholds before a child with Severe Acute Malnutrition (SAM) is safely discharged from treatment. However, this recommendation is based on very low certainty evidence.

OBJECTIVE: We aimed at estimating the risk of relapse to SAM in children with anthropometric profiles below MAM case definition thresholds upon discharge, compared to those with full recovery.

METHODS: We performed a pooled analysis of studies that followed acutely malnourished children discharged as cured from treatment, until six months after discharge. Data from 21 studies conducted in 13 countries, including 15,394 children admitted to treatment with SAM or MAM, discharged as cured free of SAM, and with non-missing information for both MUAC and WHZ upon discharge, contributed to the analysis. Inverse-variance random effects Cox models were used.

RESULTS: Overall, 32.1% of the pooled cohort had MAM defined by WHZ -2 and/or MUAC 12.5cm at discharge from treatment. During follow-up, 1243 children (8.1%) relapsed to SAM. Relapse was 2-3 fold higher in children with MAM at discharge: 14.2% (13.2, 15.2) compared with 5.2% (4.8, 5.6) in those without MAM. Children with MAM by WHZ at discharge had twice higher cumulative incidence of relapse to SAM compared with children with MAM by MUAC at discharge: 19.2% (17.4, 21.0) compared with 9.4% (8.2, 10.6). Of note, a MUAC-only definition of SAM would have missed >60% of relapse cases.

CONCLUSIONS: Both MUAC and WHZ should reach levels above MAM cut-offs before children with SAM or MAM safely exit from nutritional treatment. Further studies with adequately defined outcomes should investigate optimal discharge criteria for maximizing effectiveness as well as sustainability and acceptability of medico-nutritional services.

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