Relapse Study

Identifying the Prevalence of and Risk Factors for Relapse After Recovery from Severe Acute Malnutrition


Severe acute malnutrition (SAM) is a life-threatening condition – children with SAM are 10 times more likely to die than a non-malnourished child. Most cases of SAM can be treated with specially formulated food and medication in an outpatient-based treatment approached called community-based management of acute malnutrition (CMAM). While CMAM does provide SAM children access to the life-saving treatment they require, an emerging body of evidence demonstrates a portion of children who recover from the condition, go on to experience poor health and nutrition after their discharge from these programs. They may even relapse – a condition that occurs when a child recovers from SAM and is successfully discharged from treatment program, but soon thereafter develops SAM once again. Repeated episodes of SAM not only heighten the child’s risk of death and longer-term developmental problems, it also contributes to persistently high rates of malnutrition across the world. This can undermine CMAM treatment programs’ effectiveness and cost-effectiveness, by deploying limited resources to treat the same child multiple times.


This study aims to identify how many children relapse back to SAM after successful treatment and recovery from SAM in a CMAM program in four operational settings – Chad, Mali, Somalia, and South Sudan. Across these contexts, we will follow a total of 2,446 children (aged 6-59 months) for one-year post-discharge, observing how their growth and health evolve in comparison to those that have not experienced an episode of SAM. We will collect ongoing data for 12 months, in order to identify the rate of relapse and better understand when relapse is most likely to occur. Data will be collected on potential risk factors for relapse, such as child care and feeding practices, sanitary living conditions, as well as access to water, food, and health care. This will facilitate a stronger understanding of what factors might put certain children at higher risk for relapsing and, therefore, learn how we might reduce such risks in the future.

A costing analysis will be conducted which aims to estimate the proportion of CMAM resources that are allocated towards treating relapses (as opposed to treating new children with SAM). Given there is a shortage of overall resources allocated to treat SAM, it is critical that we aim to maximize our treatment and obtain sustained recovery without relapse, so that we can use those resources to reach as many new children with SAM as possible.

Lastly, we will complete a process evaluation that includes an in-depth examination of each of the CMAM treatment program’s quality of implementation and contextual factors. This will help to identify specific programmatic characteristics and conditions that may help to explain differing rates of relapse within and across contexts.

Results from all four study countries will be pooled in the final analysis, in order to draw generalized, global-level conclusions and recommendations for policy and practice.


This study aims to increase our collective understanding of the global burden of relapse following initial SAM recovery through an innovative, multi-context, multi-faceted research design. Results are expected to contribute towards the creation of a standardized relapse definition and methods for measuring and reporting relapse—critical precursors for developing program standards for high-quality treatment programs. The study will also produce recommendations for adjustments that could be made to existing CMAM programming that might to reduce relapse. Taken together, these changes are expected to lead to sustainable reductions in the global burden of SAM – by helping to prevent relapse among those children treated using the CMAM approach, as well as freeing up critical resources to boost coverage of CMAM programs to even more children who require the life-saving treatment.

Project Information

Thematic Area: Nutrition and Health Water Sanitation and Hygiene
Intervention Area: Chad Mali Somalia South Sudan
Implementation Period: October 2019 – September 2021
Results Expected: November 2021
Partners: Action Against Hunger USA (Prime), London School of Hygiene and Tropical Medicine, Action Against Hunger France, Action Against Hunger Spain, Action Against Hunger UK
Donors: Office of Foreign Disaster Assistance (OFDA) / United States Agency for International Development (USAID)


Heather Stobaugh - Principal Investigator
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