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Background
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Acute malnutrition is an important concern for children aged under 5 years, both globally and in Nigeria. Since the 2000s and the advent of Ready-to-Use Therapeutic Foods (RUTF), Severe Acute Malnutrition (SAM) has been commonly addressed through the WHO-recommended approach of Community-based Management of Acute Malnutrition (CMAM). CMAM programs provide treatment for children aged 6-59 months through an outpatient therapeutic program (OTP) service for uncomplicated cases and an inpatient service for complicated cases.
In Nigeria, children are admitted and discharged from the CMAM program using mid-upper arm circumference (MUAC) as the main criterion. Children with a MUAC <115 mm and no apparent health complications are admitted into the OTP.
CMAM is evidently effective in resolving SAM. However, evidence exists that children who have gone through an episode of SAM remain at higher risk of morbidity and mortality than children who have not. The evidence on SAM relapse is sparse with a high variation in estimates in the literature due to both contextual and methodological differences. This makes it difficult to understand the persistent risk of a SAM episode after initial recovery from the CMAM program, as well as the associated risk factors. Another important gap in the literature is the absence of comparison groups, making it difficult to determine the excess risk for SAM associated with a recent SAM episode.
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Research objectives
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The primary objective of this study was to assess the persistent and excess risk of SAM among children treated by the CMAM program.
· The persistent risk was assessed by measuring the 6-month incidence rate of relapse into SAM among children discharged as cured from the OTP services of the CMAM program.
· Excess risk was assessed by comparing this rate of relapse to the 6-month incidence rate of SAM in a cohort of community controls.
Our secondary objective was to identify factors that are associated with the risk of relapse.
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Methods
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We conducted a prospective matched cohort study that tracked 553 children who were discharged as cured from OTP and 526 community control children in Sokoto State, Northern Nigeria. Data were collected from September 2018 to May 2019. OTP-cured children were recruited from the health facilities at discharge from OTP. Control children were recruited in the same communities the OTP-cured children lived in. Outcomes and potential risk factors were measured in up to 12 fortnightly home visits, i.e. in a period of up to six months for each child.
This cohort study was implemented in several phases that took place sequentially, and that included recruitment of OTP-cured children, recruitment of community control children, first home visit (to collect baseline characteristics), and subsequent follow-up home visits. At each phase, different questionnaires were administered.