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.

The authors have declared no competing interest.

NCT06642012

https://clinicaltrials.gov/study/NCT06642012

The CashPlus for Nutrition research study was funded by Elrha (grant number 200011671). The CashPlus for Nutrition Project was implemented by Save the Children Somalia and funded by the United States Agency for International Development (USAID)/Bureau for Humanitarian Assistance (BHA).

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The IRB of the Johns Hopkins Bloomberg School of Public Health gave ethical approval for this work (protocol code 24476, date of approval: May 17, 2023). The IRB of the Ministry of Health and Human Services in Somalia gave ethical approval for this work (XAG/203/23, date of approval: April 26th, 2023). The Save the Children International Ethics Review Committee gave ethical approval for this work.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

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I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

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This data was collected on a vulnerable population linked to a large scale cash assistance program in Somalia. The data may be made available upon request with permission from local study investigators.