Definition of Recovery from Severe Acute Malnutrition
Recovery from severe acute malnutrition is defined as achieving a weight-for-height Z-score greater than -2, mid-upper arm circumference (MUAC) greater than 12.5 cm, and being oedema-free since the last study visit. 1
Core Anthropometric Criteria
Recovery requires meeting all three of the following criteria simultaneously:
- Weight-for-height Z-score (WHZ) > -2: This indicates the child has achieved adequate weight relative to their height, moving out of the wasting category 1
- MUAC > 12.5 cm: Mid-upper arm circumference must exceed 125 mm, demonstrating adequate muscle and fat mass restoration 1, 2
- Absence of nutritional oedema: The child must be oedema-free since the last assessment visit, confirming resolution of kwashiorkor-type malnutrition 1
Important Clinical Context
Timing and Assessment
- These criteria must be sustained at the time of discharge assessment, not just transiently achieved 1
- In community-based management programs, children are typically assessed monthly during follow-up to confirm sustained recovery 2
- The median time to achieve recovery is approximately 16 weeks in targeted supplementary feeding programs, though this varies by context 3
Recovery Rates and Outcomes
- Recovery rates vary significantly by setting: 73% in Ethiopia 3, 70-78% in Mali and Somalia, but only 37% in South Sudan 2
- Children who achieve these recovery criteria still face substantial relapse risk: 22-63% develop acute malnutrition again within 6 months post-discharge, depending on context 2
- The addition of antibiotics to therapeutic regimens improves recovery rates from 85% to 89-91% in uncomplicated severe acute malnutrition 4
Critical Pitfalls to Avoid
Do not rely on weight alone as a marker of recovery, as fluid status can significantly confound weight measurements, particularly in children with oedema or those who are overhydrated 5. Weight must be interpreted alongside height to calculate WHZ 1.
Do not discharge based on MUAC alone without confirming the other criteria are also met. Some programs historically used MUAC as the sole discharge criterion, but current evidence supports the composite definition requiring all three parameters 1, 2.
Do not assume recovery is permanent once these criteria are met. Children recovering from severe acute malnutrition remain at 1.2-6.2 times higher risk of developing acute malnutrition compared to never-malnourished peers 2. Higher anthropometric measurements at discharge are protective against relapse, but few other factors at discharge predict subsequent outcomes 2.
Additional Considerations for Complicated Cases
For children with complicated severe acute malnutrition requiring hospitalization, the same anthropometric criteria apply, but additional factors influence recovery assessment:
- Cerebral palsy is associated with nearly 3-fold increased risk of readmission (aSHR: 2.96) and poor nutritional recovery 6
- Non-oedematous SAM (marasmus) has 1.6-fold increased risk of readmission compared to oedematous forms 6
- Low height-for-age Z-score (HAZ) at discharge independently predicts both readmission and poor sustained recovery 6
- Children with these high-risk features require prioritization for additional convalescent care beyond standard discharge criteria 6