Why do some malnourished kids relapse? Study finds urban-rural divide

A significant portion of children who are treated for severe acute malnutrition, or SAM, are vulnerable to relapse, a new study from Action Against Hunger found. Relapse rates are nearly 50% higher in rural areas, a finding that could help aid organizations determine where to invest in malnutrition work. The study, released today, was the first of its kind and tracked children treated for severe acute malnutrition, a life-threatening form of hunger, across Mali, Somalia, and South Sudan. Their progress was compared to that of their otherwise healthy peers. After six months of follow-up, 31%, 47%, and 5% of post-treatment children in Mali, South Sudan, and Somalia, respectively, relapsed to acute malnutrition or died. Overall, the study found that post-severe acute malnutrition children are 3.8 times as likely to again become acutely malnourished or die, and 7.8 times as likely to redevelop SAM compared to their peers without a recent history of acute malnutrition. Those delivering malnutrition assistance have noticed this trend for years. Sarah King, now a nutritional epidemiologist for the Centers for Disease Control and Prevention and a co-author of the study, previously worked as a nutrition program manager in countries with high rates of SAM. “I had seen firsthand that we kept getting severe acute malnutrition patients who had been treated, but then came back again and again,” she told Devex. “We didn’t have tangible evidence to say this is what’s happening and what you’re seeing is true. But what we’re seeing now is that those observations are true. We’re seeing anywhere from up to 50% of children needing to be re-treated within six months.” The study was co-authored by experts from Action Against Hunger, CDC, the London School of Tropical Medicine, Washington University in St. Louis, and the University of Washington. It was ​​funded by USAID’s Bureau for Humanitarian Assistance. The urban vs rural divide The findings provided insight into why and how children relapse. In Mali and South Sudan, relapse rates were high. But in Somalia, they were only 5%. Study authors found that access to services such as health care, cash, remittances, and food distribution plays a significant role in determining children’s longer-term well-being. “It seems that context really drives a lot of this repetitive acute malnutrition in the same child,” said Heather Stobaugh, senior research and learning specialist at Action Against Hunger. “In Somalia, the population was in an [internally displaced persons] camp, where they had access to health care services, food distributions, and cash transfers.” In contrast, the populations in South Sudan and Mali live in remote settings without access to the kinds of services available in IDP camps. “The food security situation doesn’t change, access to healthcare remains poor, distances to markets remain far,” Stobaugh said. “So what brought children to being malnourished in the first place remains unchanged. We’re sending them back into the context that led them there in the first place.” In Somalia, about 90% of children in the study lived 0 to 3 kilometers from a health care facility, King said. In South Sudan, almost 40% lived more than 5 kilometers away from such services. A global issue The prevalence of acute malnutrition in young children is high. In 2022, approximately 45 million children under the age of five suffered from acute malnutrition, with 137 million affected by severe acute malnutrition. Only 34% of countries are on track to meet the wasting targets set out in the United Nations’ Sustainable Development Goals. “These children are really vulnerable. When we’re talking about treatment, and we define these children having gone through the treatment protocol, they’re discharged as recovered and labeled as healthy children at that point. But what we’re seeing is they’re just nutritionally different,” King said. The study looked at microbiome health, pathogens children were infected with at the time of discharge, how well their immune systems were functioning, and how much weight they put on. Stobaugh said a driving factor in relapse was how well-nourished a child was. Those who responded better to treatment and put on more weight were able to sustain recovery a bit better. While the results of this study are specific to three countries, they help shed light on malnutrition overall. “We know more generally now that children experiencing acute malnutrition are at high risk of relapse. We also know that there are specific drivers for acute malnutrition, this urban and rural divide, and those drivers we’re seeing in these contexts are often similar in other contexts,” King said. What comes next? The next step is shifting from defining the problem to targeting the most effective solutions. “We’re always trying to target aid to the most vulnerable populations, but I don’t think this population has been considered in the past,” Stobaugh said. “We will be advocating that we should look to households that have a child that was previously treated for severe acute malnutrition as being a household we should prioritize to receive aid.” She said organizations can look into what can be done in a cost-effective way in addition to treatments. Things like cash distributions, additional antibiotics, a food basket, or a number of other wrap-around services. “Any of those models will be a much more cost-efficient way of keeping relapse from happening,” she said. Currently, the treatment for severe acute malnutrition, most often a product called Plumpy’Nut, is expensive. Globally, Stobaugh said only about 30% of children who need treatment can access it. As of 2017, the cost to treat one child with Plumpy’Nut over eight weeks was $50, though that can be higher during times of increased need or when ingredient costs go up. “What we see here is that we need to really prioritize how we use that specialized nutritious food. Once we use it to treat a child, we don’t want to use it again for them to come back again through relapse. We should find other aid delivery mechanisms so we can use more product to treat more kids,” Stobaugh said. The World Health Organization released new guidelines in November for the standard of treatment for children who are acutely malnourished. Recommendations include caring for mothers and infants as an interdependent pair, increasing breastfeeding and access to nutrient-dense home diets, and using community health workers to provide evidence-based care for children with acute malnutrition. “It’s very exciting, because WHO is bringing attention to it, and Action Against Hunger is giving really good evidence for us to now move forward and take action on it. Hopefully, the next steps after test interventions can start really making grounds,” Stobaugh said. Update, Dec. 19, 2023: This story has been updated to reflect the rates at which post-severe acute malnutrition children are likely to relapse.