Research: Relapse After Recovery from Severe Acute Malnutrition

Action Against Hunger launched a new research project in 2019 to identify the prevalence of and risk factors for relapse after recovery from severe acute malnutrition – the deadliest form of hunger.


Severe acute malnutrition (SAM) is a life-threatening condition – children with SAM are 11 times more likely to die than a non-malnourished child. Most acutely malnourished children can be treated as outpatients in their communities using specially formulated food and medication through an approach called community-based management of acute malnutrition (CMAM).

Now used in more than 60 countries worldwide, CMAM programs provide many children access to the lifesaving treatment they need. However, an emerging body of evidence shows that some children who recover from SAM go on to experience poor health and nutrition after they are discharged from the CMAM program, including relapse. Relapse occurs when a child’s health and nutritional state deteriorates back to SAM after a period of recovery.

Such repeated episodes of SAM not only heighten children’s risk of death and longer-term developmental problems, but also contribute to persistently high rates of malnutrition across the world. Relapse can also undermine the effectiveness of CMAM treatment programs and can also be a drain on limited resources when programs treat the same child multiple times.

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

A mother takes her daughter, who had recently recovered from severe acute malnutrition, home.

A mother takes her daughter, who had recently recovered from severe acute malnutrition, home.

Photo: Lys Arango
for Action Against Hunger,
South Sudan

Action Against Hunger aims to identify how frequently relapse occurs after recovery from SAM in CMAM programs across Chad, Mali, Somalia, and South Sudan. We will follow a total of 2,446 children (aged 6-59 months) for one year after discharge from SAM treatment, observing their health and nutritional status in comparison to those who have not experienced an episode of SAM.

We aim to answer the following questions:

  1. What are relapse rates among children who have recovered from SAM in CMAM programs across various settings?
  2. What are the financial costs of treating the same child multiple times?
  3. What risk factors at the individual, household, and program level are associated with relapse after initial recovery?
  4. What specific water, sanitation, and hygiene factors may be associated with an increased risk for relapse?

During the one-year follow-up period, we will collect data on each child in the study on eight separate occasions to identify relapse rates and to collect information on potential risk factors for relapse, including:

  • Child care and feeding practices
  • Sanitary living conditions
  • Access to water, food, and healthcare

This will facilitate a stronger understanding of why certain children are at higher risk for relapsing and inform how we might adapt treatment programs to achieve more sustainable recovery, thus reducing relapse.

Action Against Hunger’s teams will follow children who have recovered from severe acute malnutrition over a 12-month period.

Photo: Christophe Da Silva
for Action Against Hunger, Chad

As part of the study, we will conduct a cost analysis to estimate the proportion of CMAM resources allocated to treating the same child repeatedly as opposed to allocating those resources to newly identified children with SAM. Given the limited resources allocated for CMAM programs, it is critical to maximize the sustainability of recovery without relapse, so that we can use 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 programs involved in the study to assess the quality of implementation and contextual factors. This will help to identify specific program characteristics and conditions that may explain differing rates of relapse within and across contexts.

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


Through an innovative, multi-context, multi-faceted research design, this study is unique and among the first of its kind. This is the first study to measure relapse following SAM treatment in CMAM programs in a systematic way across multiple countries. Additionally, few studies have followed children for as long as one year following SAM treatment to examine their health and nutrition outcomes. With frequent data collection points over a one-year follow-up period, we will have the ability to examine how seasonality may relate to relapse.

Furthermore, we are collecting a myriad of information from the children and their living conditions in order to triangulate results and capture various dynamics of children’s levels of infections, immune function, and exposure to environmental contamination. Adding this child and household-level information with the programmatic quality and costing analyses, we aim to build a holistic understanding of how well children fair after SAM recovery and why. 

We expect our results will contribute towards the creation of an evidence-based, standardized definition of relapse after SAM as well as 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 programs to reduce relapse. Together, these changes could lead to sustainable reductions in the global burden of SAM.

By helping to prevent SAM relapse and freeing up critical resources to boost treatment coverage through community-based programs, we can reach even more children who need lifesaving treatment.

A mother and child bond in one of Action Against Hunger's health centers in Somalia.

Photo: Fardosa Hussein
for Action Against Hunger,


THEMATIC AREA:  Nutrition and Health, Water and Sanitation
INTERVENTION AREAS: Chad, Mali, Somalia, South Sudan
IMPLEMENTATION PERIOD: October 2019 – September 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)


Name: Heather Stobaugh, Ph.D.
Role: Principal Investigator, Action Against Hunger USA
Email address:

General inquiries:

Action Against Hunger is leading a global movement to end hunger in our lifetimes. It innovates solutions, advocates for change, and reaches 25 million people every year with proven hunger prevention and treatment programs. As a nonprofit that works across 50 countries, its 8,300 dedicated staff members partner with communities to address the root causes of hunger, including climate change, conflict, inequity, and emergencies. It strives to create a world free from hunger, for everyone, for good.