Relapse of Severe Acute Malnutrition Post-Discharge from Outpatient Programs Among Children Recovered from Complicated SAM in a Conflict-Affected Setting: A Matched Cohort Study, Sana’a, Yemen

Background Little evidence exists on post-discharge outcomes and the sustainability of recovery among children recovering from complicated severe acute malnutrition (SAM). This study assessed the incidence and predictors of SAM relapse and changes in nutritional status over time, including transitions between normal, moderate acute malnutrition (MAM), and SAM, among children discharged from outpatient therapeutic programs (OTPs) in Sana’a, Yemen. Methods A prospective cohort study followed 148 children (74 post-SAM and 74 community controls) at 3, 6, and 9 months post-discharge from OTP. Incidence rates of SAM and MAM were calculated. Poisson regression with generalized estimating equations estimated incidence rate ratios (IRRs) for SAM and MAM, and competing-risk regression accounting for MAM estimated sub-hazard ratios (SHRs) for SAM relapse. Results At 6 months, 36% of post-SAM children had SAM compared with 9% of controls, rising to 45% versus 14% at 9 months. MAM occurred in 58% of post-SAM children versus 20% of controls, with 36% of post-SAM children with MAM progressing to SAM, compared with 8% of controls. Poisson regression showed higher SAM incidence in post-SAM children (IRR = 2.57), peaking at six months (IRR = 2.20), with lower baseline WHZ (IRR per 1-unit increase = 0.70) and fever (IRR = 2.60) predicting SAM. MAM incidence did not differ significantly but was predicted by fever (IRR = 2.20) and diarrhea (IRR = 1.70). Competing-risk regression confirmed higher SAM relapse among post-SAM children (SHR = 2.38), with lower baseline WHZ (SHR = 0.72) and fever (SHR = 2.24) as predictors; SAM risk declined by nine months (SHR = 0.39). Conclusion Children recovering from complicated SAM and discharged from OTPs remain at high risk of relapse, particularly to SAM, during the first nine months. Persistent MAM and transitions between MAM and SAM highlight ongoing nutritional fragility. Lower baseline WHZ and acute illnesses such as fever increase relapse risk, whereas household and sociodemographic factors appear less influential. Sustained post-discharge monitoring, management of acute illnesses, and integrated MAM care are essential. Further research is needed before recommending specific discharge thresholds for WHZ or MUAC to prevent relapse in fragile and conflict-affected settings.