Acute malnutrition relapse and associated factors among 6–59 months old children treated in the community-based management of acute malnutrition in Dessie, Kombolcha, and Haik towns, Northeast Ethiopia

Introduction Undernutrition is a major health concern in many developing countries, and is one of the main health problems affecting children in Ethiopia. Although many children experience multiple relapses following the management of severe acute malnutrition, it is scarcely studied in Ethiopia. Methods A community-based cross-sectional study was conducted in Dessie, Kombolcha, and Haik towns among 6-59-month-old children enrolled and discharged from community-based acute malnutrition management (CMAM). The total sample size was 318 children, and data were collected from April 15, 2021, to May 14, 2021. The data were entered into EPI data version 4.4.1 before being exported and analyzed with SPSS version 25 software. A multivariate logistic regression analysis was performed, and a 95% confidence interval and p-value <0.05 were used to identify significantly associated variables. Additionally, the weight-for-height z-score (WHZ) was generated using the WHO Anthro 3.2.2 software. Result The overall acute malnutrition relapse after discharge from CMAM was 35.2% (6.6% relapsed to severe acute malnutrition and 28.6% relapsed to moderate acute malnutrition). The following variables were significantly associated with the relapse of acute malnutrition: child age (AOR: 3.08, 95% CI; 1.76, 5.39), diarrhea after discharge (AOR: 2.93, 95%CI; 1.51, 5.69), have not immunized (AOR: 3.05, 95% CI; 1.14, 8.23), MUAC at discharge (AOR: 3.16, 95% CI; 1.56, 6.40), and poorest and poor wealth index (AOR: 3.65, 95% CI; 1.45, 9.18) and (AOR: 2.73, 95% CI; 1.13, 6.59), respectively. Conclusion Over one-third of children treated with the CMAM program reverted to SAM or MAM. The age of the child, diarrhea after discharge, lack of immunization, MUAC at discharge (<13 cm), and poor and poorest wealth index were significantly associated with acute malnutrition relapse. Therefore, adequate health education and counseling services are essential for mothers to improve child immunization coverage and maintain adequate hygiene to prevent diarrhea. In addition, further experimental research is needed to investigate the effect of MUAC at discharge on the risk of acute malnutrition relapse.


Introduction
Malnutrition in children refers to deficiencies, excesses, or imbalances in the nutrient intake.It addresses three groups of conditions: undernutrition, micronutrient-related malnutrition, and overweight or obesity (1).Malnutrition in children can be either acute (wasting) or chronic (stunting).Based on severity, acute malnutrition can be either moderate acute malnutrition (MAM) or severe acute malnutrition (SAM) (2,3).Children with SAM are treated either in an outpatient therapeutic program or inpatient setting based on the age of the child, severity of malnutrition and the presence or absence of complications.Subsequently, they will be discharged from the therapeutic program when their weight-for-height/length (WHZ) is > − 2 Z-score, mid-upper-arm circumference (MUAC) is ≥12.5 cm, and there is no edema for at least 2 weeks (4).
Severe acute malnutrition is one of the most common causes of morbidity and mortality among children under 5 years of age worldwide.Children with SAM are 10 times more likely to die than non-malnourished children (5).According to the 2019 estimate, globally, 144 million under-5-year-old children were stunted, 47 million were wasted, and 38 million were overweight.Approximately 45% of deaths among children under 5 years of age are linked to undernutrition (1,6,7).Undernutrition is a major health concern in many developing countries, and is one of the main health problems affecting children in Ethiopia.Ethiopia has the second-highest malnutrition rate in sub-Saharan Africa (8).According to the 2016 Ethiopian Demographic and Health Survey, 37% of children under age 5 were stunted, 10% were wasted, 24% were underweight, and 1% were overweight (9).
Relapse after treatment for acute malnutrition is a serious health problem faced by humanitarian and developmental communities (10).Many children experience multiple relapses, and relapsed cases take longer to recover (11).Studies indicate that nearly half of all children who are successfully treated for malnutrition do not maintain their recovery for up to 12 months (12,13).This situation undermines the cost-effectiveness of community-based management of acute malnutrition (CMAM) treatment programs by deploying limited resources to treat the same child multiple times.Furthermore, repeated episodes of severe acute malnutrition (SAM) increase the risk of death and long-term developmental problems and contributing to a persistently high rate of malnutrition (14).
Globally, the magnitude of malnutrition relapse ranges from 0 to 37%, and in Ethiopia, the re-admission (relapse) rate ranges from 2.6 to 37.5% (15)(16)(17)(18)(19)(20).The risk of relapse or death was highest in the 3 months following release from the CMAM, with nearly half of all relapses to either moderate acute malnutrition or SAM occurring during the first 3 months of recovery (11).Child feeding practices, sex, food insecurity, lack of vitamin A supplements, prelacteal feeding, MUAC at discharge, complete vaccination, lower anthropometric measurements, and poor linear growth are the main factors contributing to the relapse of acute malnutrition (13,(21)(22)(23).
Recovered children are at a higher risk of acute malnutrition than children who have never been treated for acute malnutrition (20).Hence, identifying factors associated with relapses of acute malnutrition significantly contributes to achieving the national goal of ending all forms of malnutrition in Ethiopia by 2030 (24).However, relapse following treatment of severe acute malnutrition has rarely been measured across programs and research (23).Therefore, this study aimed to assess the prevalence of acute malnutrition relapse and its associated factors among 6-59 month-old children treated in the community-based acute malnutrition management program in Dessie, Kombolcha, and Haik towns.

Operational definition/definition of terms
Acute malnutrition: MUAC <12.5 cm and/or WHZ <−2.Severe acute malnutrition: MUAC <11.5 cm and/or presence of bilateral edema and/or WFL/H < −3, no medical complication and pass appetite test.
Relapse: MUAC <12.5 cm (both SAM and MAM) and/or bilateral edema and/or WHZ < −2 following discharge from the CMAM program.
Protected water source: water source from the pipe or modern well.
Food preparation training: mothers/caretakers who have received training in food preparation for children from health professionals, health extension workers, etc.
Wealth index: it was categorized into four quintiles (five groups), namely: poorest, poor, medium, rich, and richest, based on principal component analysis (PCA).

Data collection tools and techniques
Data were collected using a semi-structured questionnaire designed after reviewing related articles (21-23, 25-37).Information related to the treatment and address of the participants was collected from the malnutrition registration logbook and medical records.After obtaining the address information, health extension workers accessed the participants and recorded the child's current nutritional status and other related data.The weight of the children was measured using a well-calibrated, portable digital weight scale.A portable stadiometer was used to measure the height of the child, and an infantometer was used to measure the length of children under the age of two.MUAC of the child was measured using non-stretchable tape snugly at the midpoint of the arm.The wealth index was computed using fifteen items from the standard equity tool (38).The data were collected by nine trained health extension workers for four weeks and supervised by three MSc pediatric nursing professionals.

Data quality assurance
Data quality was ensured through the training of data collectors, regular supervision, immediate feedback, and spot-checking.Moreover, supervisors and principal investigators checked the completeness of the collected data daily.Pretesting of the questionnaire was undertaken on 5% ( 16) of the final sample size in Kutaber town.

Data processing and analysis
All filled questionnaires were checked for completeness, consistency, and accuracy.The data were then entered into EPI data (version 4.4.1.0)and exported to SPSS version 25 software for analysis.Descriptive statistics (frequency table, pie chart, and bar graph) were performed to summarize the data.WHZ were generated using WHO Anthro software 3.2.2.Bivariate logistic regression was used to check variables associated with acute malnutrition relapse.Variables found to have a p-value ≤0.2 were further analyzed using multivariate logistic regression.Crude and adjusted odds ratio with 95% CI were computed, and variables that had a p-value <0.05 in the multivariate logistic regression were considered as significantly associated with the dependent variable.Furthermore, the model fitness was checked using the Hosmer and Lemeshow goodness-of-fit test, which gave a p-value of 0.28.

Socio-demographic characteristics of the respondents
In the study areas, there were a total of 356 children treated for acute malnutrition and discharged within 4-54 weeks before the survey.Among those treated children, 318 were accessed and included in the analysis (Figure 1).The majority (59.1%) of mothers/caretakers were aged 25-34 years, with a mean ± SD of 30 ± 5.5 years.Over half (54.4%) of children were male and 49.7% were aged ≥24 months, with a mean ± SD of 27.9 ± 14 months.Nearly three-fourths (72.6%) of mothers/caretakers were housewives, 89.3% were married, 7.2% had a college or university education, and 88.7% were urban dwellers.Nearly one-third (31.4%) of fathers were daily laborers, 34% had primary education, and 22.3% of families had the lowest wealth index (Table 1).

Child and mother/caretaker-related factors
The vast majority (91.2%) of mothers attended ANC, 94% delivered in health facilities, and 72.6% utilized family planning at the time of data collection.One-fourth (23.9%) of children had diarrhea, 24.2% had fever, and 27.4% had cough after malnutrition treatment.Almost all children (98.1%) had no chronic disease, 31.1% took anthelmintic drugs, 87.7% took

Nutritional factors
One-fourth (26.7%) of mothers ate extra meals while pregnant, 88.1% of children received colostrum, 91.2% exclusively breastfed for 6 months, and 84% of mothers/caregivers prepared food separately for the child.Almost one-tenth of the children (10.7%) received malnutrition treatment for 4 weeks, 26.1% had MUAC measurements

Factors associated with acute malnutrition relapse
In the bivariate logistic regression, the age of the child, educational level of the mother, diarrhea after management, immunization status, birth space, MUAC at discharge, WHZ at discharge, duration after discharge, and wealth index had a p-value of ≤0.2.Further analysis of these variables in the multivariable logistic regression revealed that age of the child, immunization status, diarrhea after management, MUAC at discharge, and wealth index had a significant association with acute malnutrition relapse.

Discussion
According to the findings of this study, the prevalence of overall acute malnutrition relapse among children treated in the CMAM program was 35.2% (95% CI, 30.2, 41.5%).6.6% of the relapsed cases were SAM and 28.6% were MAM, indicating that more than  one-fourth of the treated children had returned to MAM.Other studies conducted in Gambella region and Hadiya zone indicated a 10.1 and 9.6% relapse to SAM, respectively which is higher than the relapse reported in this study (6.6%) (39, 40).The discrepancy might be attributed to variations in the study design, setting and cultural and sociodemographic diferences.On the other side, comparable findings of overall acute malnutrition relapse were reported from studies conducted in Malawi (41%), Eastern Ethiopia (36.2%) and South Gondar, Ethiopia (34.3%) (11,20,41).However, studies in Burkina Faso (15.4%), a systematic review of low and middle-income countries (27.5%), and the United States (27%), all found a lower prevalence of relapse (22, 28, 42).To the contrary, a higher magnitude of relapse was reported from the study in the Democratic Republic of the Congo (44.2%) (43).These discrepancies might be attributed to the variations in the study design, duration of follow-up, study setting, and cultural and economic factors.
One of the significantly associated variables with the relapse of acute malnutrition was the child's age.Children aged <24 months had higher odds of acute malnutrition relapse compared to children older than ≥24 months.Children under the age of two require more nutrition and energy for growth and development than at any other stage in their lives, making them more vulnerable to malnutrition (44).Similar studies from Nepal and Nigeria also reported that the age of children had an association with malnutrition (45,46).
In this study, having diarrhea after discharge from malnutrition management was significantly associated with acute malnutrition relapse.Children who had diarrhea after discharge had higher odds of acute malnutrition relapse compared to children without diarrhea.Diarrhea contributes to malnutrition by reducing food intake, decreasing nutrient absorption, and increasing nutrient catabolism (47).This finding is consistent with other studies undertaken in Ethiopia (48) and Nigeria (49).The immunization status of children had a significant association with acute malnutrition relapse.Children who were not immunized experienced a higher occurrence of acute malnutrition relapse compared to fully vaccinated children.Immunization protects children from a wide range of illnesses, including pneumonia and diarrhea, which can put them at risk of malnutrition.A significantly   Furthermore, the MUAC measurement of children at discharge showed significant associations with acute malnutrition relapse.Children with a MUAC measurement of <13 cm were more likely to have an acute malnutrition relapse compared to children with a MUAC measurement of ≥13 cm.Adequate nutritional achievement before discharge might enable the child to sustain their nutritional status.A similar study from Ethiopia and Nigeria also reported that the discharge MUAC of children was a significant predictor of relapse (40,46).
Finally, the wealth index was reported to have a significant association with acute malnutrition relapse.Children from the poorest families had higher odds of developing an acute malnutrition relapse compared to children from the richest families.Poverty and malnutrition are deeply interrelated, and low socioeconomic status remains one of the most important predictors of child malnutrition (52).Related studies from India (53), Ethiopia (27,54), and Bangladesh (55) reported similar results.

Limitations of the study
This study addresses the gross acute malnutrition relapses from 1 to 12 months following CMAM treatment.It did not figure out the relapse rate in relation to various periods.Therefore, further largescale prospective cohort studies are needed to describe the relapse rate in various periods.Moreover, given that the study used a crosssectional design, the associations observed in the study do not infer a causal relationship, and there might be recall biases for certain items.

Conclusion
Over one-third of children treated under the CMAM program reverted to SAM or MAM.The age of the child, diarrhea after

FIGURE 1 Flow
FIGURE 1Flow diagram for inclusion of subjects in the analysis (N = 318).

TABLE 3
Nutritional characteristics of the study participants in Dessie, Kombolcha, and Haik towns, Northeast Ethiopia (N = 318).

TABLE 4
Factors associated with acute malnutrition relapse in Dessie, Kombolcha, and Haik towns, Northeast Ethiopia (N = 318)., immunization, MUAC at discharge, and wealth index were all significantly associated variables with acute malnutrition relapse.Therefore, adequate health education and counseling services are required for mothers to improve child immunization coverage and maintain adequate hygiene to prevent diarrhea.In addition, further experimental research is needed to investigate the effect of MUAC at discharge on the risk of acute malnutrition relapse. discharge