Reducing relapses after acute malnutrition treatment: evidence from a simplified approach in emergency settings of Mali

Abstract

Background: Acute malnutrition remains a critical public health issue, particularly in emergency settings. While simplified treatment protocols show promise in improving access and cost-effectiveness, evidence on their impact on relapse rates remains limited. This study aimed to compare relapse incidence among children treated for severe acute malnutrition (SAM) using a simplified protocol versus the standard Community Management of Acute Malnutrition (CMAM) protocol in the emergency context of Gao, Mali. Methods: This is a non-randomized controlled trial conducted between December 2022 and December 2023, involving 506 children aged 6–59 months discharged as cured from SAM. The intervention group (n = 270) received treatment via a simplified protocol using Mid-upper arm circumference, (MUAC)-only criteria and fixed ready-to-use therapeutic (RUTF) dose, while the standard protocol group (n = 236) followed the standard CMAM protocol. Children were followed for up to eight months post-discharge. Relapse was defined as meeting anthropometric criteria for acute malnutrition during follow-up. Cox regression models were used to identify risk factors. Results: Relapse incidence was significantly lower in the simplified protocol group (5.6%) compared to the standard one (39.8%). The simplified protocol also had longer length of stay, used lower quantity of RUTF, and fewer comorbidities at discharge. We found similar results when analyzing the sub-sample with those children admitted with MUAC-only in the control group. Multivariate analysis identified treatment with the simplified protocol, older age at discharge, and greater MUAC gain as protective factors. Comorbidities during follow-up were the strongest predictor of relapse. Conclusion: Simplified protocols may reduce relapse rates after SAM treatment, even with reduced RUTF doses. Strengthening discharge procedures and post-discharge monitoring, particularly in emergency settings, is essential to sustain recovery and prevent relapse.