Long-term Follow-up of Children Discharged from Child Malnutrition Treatment Centres in Gujarat

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To combat this, Child Malnutrition Treatment Centres (CMTCs) have been set up to treat children suffering from Severe Acute Malnutrition (SAM) with medical complications. However, a significant number of children relapse after discharge, necessitating exploration of the factors contributing to relapse. Methods Between October and December 2024, a cross-sectional study was conducted in Devbhoomi Dwarka, Gujarat, involving 56 children discharged from two CMTCs. The research collected data through structured interviews with caregivers, anthropometric measurements, and evaluations of hygiene practices and feeding behaviors. Results Of the 56 children, discharged between June 2023 – September 2024, 10 children that is 18 per cent of the children relapsed into SAM after being discharged. The mean relapse time for females was 238.8 days, whereas for males, it was 162.8 days, indicating that male children relapse more quickly than females. The survival curves for the 11–36 months age groups showed a more rapid decline between 100 and 140 days, highlighting this period as critical. In addition, younger children aged 11–36 months were more prone to relapse than older children aged 37–62 months. Poor hygiene practices were strongly linked to higher relapse rates, with 33.3 per cent of children practicing open defecation relapsing compared to 14.9 per cent of those using toilets. Conclusion These findings highlight the importance of addressing environmental and behavioral factors, such as hygiene practices, in the post-discharge care of children with SAM. A long-term community-based follow-up of all CMTC/Nutritional Rehabilitation Centre (NRC) discharged children at risk should be incorporated. A holistic approach that includes health, nutrition, and hygiene education for caregivers is crucial to reduce relapse rates and ensure long-term recovery in these vulnerable children. The findings underscore the importance of effective monitoring of post-discharge children within 100-140 days, particularly for younger males. The findings also underscore the importance ofpractising hygiene and feeding practices to reduce relapse rates and ensure long-term recovery for these vulnerable children. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Health sciences/Risk factors Child Malnutrition Treatment Centres (CMTC) Severe Acute Malnutrition (SAM) Hygiene Feeding Behaviour Relapse Figures Figure 1 Figure 2 Figure 3 Introduction Child malnutrition under of five yearsyears of remains a critical public health concern. The repercussions of malnutrition extend beyond immediate health issues, affecting children's physical growth, cognitive development, and future socioeconomic opportunities [ 1 , 9 ]. Severe acute malnutrition (SAM), which results from a combination of insufficient food intake and illness, is characterized by rapid deterioration of nutritional status [ 1 ]. It is primarily evidenced by wasting, where a child’s weight-for-height ratio falls below the standard, indicating severe nutritional deficits. Wasting is closely associated with higher mortality rates and a compromised immune system, leading to muscle loss, fat depletion, and reduced ability to recover from illnesses [ 1 ]. In Gujarat, malnutrition rates remain disturbingly high, as highlighted by the National Family Health Survey (NFHS)-5. Approximately 39 per cent of children under five years of age are stunted during critical early development. Moreover, 35.7 per cent (25.1 per cent wasted and 10. Six percent of severely wasted individuals suffer from acute malnutrition or wasting, and 39.7 percent are underweight. These figures highlight the urgent need to address both macronutrient and micronutrient deficiencies [ 10 ]. India has taken numerous initiatives and measures to combat malnutrition, including both facility-based and community-based programs. As part of these initiatives, all children suffering from SAM with medical complications are treated at Child Malnutrition Treatment Centres (CMTCs) and Nutritional Rehabilitation Centers (NRCs). Similarly, Gujarat is working through several people-focused schemes to improve the health of young children in the state. The Mukhyamantri Paushtik Alpahar Yojana provides schoolchildren with simple, protein-rich snacks to keep them energetic and nourished. In tribal regions, the Doodh Sanjeevani Yojana offers a daily glass of fortified milk to help children grow stronger. For those who are severely malnourished, Bal Sewa Kendras provide special care and support under the CMAM program. Across villages, Anganwadi centers play a vital role in the ICDS scheme, offering daily meals and take-home rations [ 35 ]. Despite these measures, relapse remains a significant issue, with approximately 37 per cent of children discharged from CMTCs and NRCs relapsing back to SAM [ 14 ]. Therefore, it is essential to have an in-depth understanding of the factors influencing the efficacy of these centers and to assess them thoroughly [ 2 , 4 ]. CMTCs have been essential for the management of SAM, as their functioning holistically focuses on stabilizing the child’s condition, providing them with therapeutic feeds, and educating their caregivers. Studies conducted regarding the treatment effectiveness of CMTCs in the states of Bihar and Jharkhand have shown that the factors responsible for better efficacy of these centers include operational efficiency, compliance, and understanding of the child’s caregiver in accordance with the treatment being offered and their availability and readiness for the follow-up care of the child after being discharged from the center. In addition, poverty, poor dietary habits, and recurrent infections are other important factors that obstruct long-term recovery in children [ 2 , 3 ]. Another important factor associated with the relapse of malnutrition in children is water, sanitation, and hygiene (WASH) practices. Poor WASH conditions, particularly in rural and underserved areas, significantly contribute to infections in children, which in turn causes relapse [ 5 – 8 ]. Infections such as diarrhea impair nutrient absorption, thereby increasing the risk and relapse of malnutrition in children [ 6 , 7 ]. Improving household-level WASH practices can prevent malnutrition and aid in long-term recovery [ 5 , 6 ]. In regions lacking these basic services, the impact on children's health can be severe [ 5 , 6 ]. The link between WASH and malnutrition is particularly evident in rural areas, where disparities in access to essential services worsen health outcomes [ 7 , 8 ]. Project Tushti, a joint effort by the Government of Gujarat, Nayara Energy Limited, Indian Institute of Public Health Gandhinagar (IIPHG), and JSI R&T India Foundation, aims to reduce child malnutrition in Devbhumi Dwarka, Gujarat. The project focuses on profiling children, monitoring underweight children, and improving the healthcare system to ensure quality and timely service delivery. One key intervention includes establishing two CMTCs through a partnership with the Health Department of Gujarat, aimed at providing clinical management and reducing mortality among children with SAM who have medical complications. These centers are situated at the Sub-District Hospital Dwarka and Community Health Center Bhanvad. IIPHG under Project Tushti supported building renovation, human resources including Nutrition Assistants, Field Coordinators, cook cum caretaker, provided therapeutic foods, counselling services, and transport services for children and caregivers while the respective healthcare facilities provided the space, infrastructure, and treatment services for medical complications. This study aimed to report the long-term follow-up of children discharged from the two CMTCs and the factors contributing to post-discharge relapse of children with SAM. Additionally, the study aims to examine the influence of hygiene conditions on malnutrition, cooking and feeding practices at home following discharge, and the outcomes of these practices based on the guidance provided during counselling sessions. By addressing these areas, this study seeks to inform policies and programs that take a more comprehensive approach to addressing malnutrition in India. Methods Study Design This study adopted a cross-sectional design to assess relapse and associated factors among children discharged after treatment for SAM at CMTCs in Devbhoomi Dwarka, Gujarat, India. Study Setting and Duration The study was conducted in the Devbhoomi Dwarka district of Gujarat, focusing on children discharged after 14 days of complete treatment and three rounds of follow-up at two CMTCs located at the Sub-District Hospital, Dwarka, and Community Health Centre, Bhanvad. Data collection will be conducted between October 2024 and December 2024. Eligible children will be discharged between June 2023 and September 2024. Study Population and Eligibility The target population comprised children under five years of age who had been admitted to CMTCs for SAM management. The inclusion criteria were as follows: Completion of the 14-day CMTC treatment protocol for SAM, All three scheduled follow-ups completed post-discharge, Discharged after full recovery, and Age below five years as of December 2024 Children were excluded if they had any of the following: Migrated, resulting in loss to follow-up Did not complete the entire treatment at the CMTCs Could not be followed-up for all three schedules post their discharge from the CMTCs Sample Size and Participant Selection A total of 96 children were discharged after completing their treatment for SAM at the CMTCs during the study period. Of these, 56 children met the eligibility criteria and were successfully enrolled. Children who had migrated or died were excluded. Thus, the final sample size was determined by the number of eligible and traceable participants (56 of 96), rather than a statistical sample size calculation. Data Collection Data were collected using KoboToolbox through structured interviews with caregivers, focusing on various aspects of the child’s health, anthropometric measurements, household conditions, and feeding practices. Anthropometric measurements were performed: height was measured in centimeters (cm) using an infantometer or stadiometer; weight was measured in kilograms (kg); and mid-upper arm circumference (MUAC) was measured in centimeters (cm) using an MUAC tape. The World Health Organization (WHO) Growth Standards were used to assess malnutrition and categorize children based on their weight-for-height z-scores (WHZ). The categorization was based on the WHO malnutrition classification, with the following categories: Severe Acute Malnutrition (SAM): Children with a weight-for-height Z-score (WHZ) of less than − 3 SD; Moderate Acute Malnutrition (MAM): Children with a WHZ between − 2 and − 3 SD; and Normal Nutrition: Children with a WHZ greater than − 2 SD [ 11 ]. Data regarding patient discharge and scheduled interview dates were recorded. Using this information, the precise duration (in days and months) following discharge was calculated, and the mean duration until relapse was determined. A comprehensive 24-hour dietary assessment was conducted using a semi-structured survey tool administered to primary caregivers to document dietary intake. The food items consumed were classified into various groups, including milk and dairy products, cereals and millets, pulses and legumes, meat and fish products, eggs, green leafy vegetables, fruits, nuts, and non-vegetarian items (including eggs). Nutrient deficiencies in terms of energy, protein, carbohydrates, fats, and micronutrients were assessed using the portion sizes defined in the Nutrient Exchange List outlined in the Dietary Guidelines for Indians (ICMR-NIN, 2024) as a reference. Explanatory Variables: The key explanatory variables considered in this study included age, gender, health condition, hygienic practice, and feeding practices of children. Age was categorised into two categories (11–36 and 37–62 months) following the guidelines of Ministry of Women and Child Development (MoWCD) The health status of children was assessed based on the response to the question, "Has the child ever been sick since discharge?" As there was a lack of other health-related data, this information was used as a proxy indicator for evaluating the health status of the children. Furthermore, hygienic practices were assessed based on the type of defecation. Analytical approach: Data were analyzed using MS Excel for initial data cleaning and Stata (version 17.0) for more advanced statistical analysis. Descriptive statistics, such as the mean, standard error, confidence interval, and prevalence, were measured. Further, a bivariate association was employed to examine the significant difference in terms of relapse and number of days. Kaplan-Meier survival analysis was used to investigate the time to relapse among children discharged after treatment for SAM. This analysis generated two distinct survival curves: one for children who did not relapse (relapse = 0) and another for those who relapsed (relapse = 1). Bias Management To minimize selection bias, only children who met the predefined eligibility criteria were included. Migration was recorded as a reason for exclusion, and recall bias in dietary intake was acknowledged due to reliance on caregiver recall. All anthropometric measurements were conducted using standardized tools to reduce measurement bias. Ethical Approval: The study was approved by the Institutional Ethics Committee of the Indian Institute of Public Health Gandhinagar (IEC/IRB approval number: 14/2019-20). All methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from the parent and/or legal guardian of all participating children prior to data collection. Results A total of 96 children were discharged after completions of their treatment for SAM from the CMTCs during the study period. Of these, 56 children met the eligibility criteria and were successfully contacted and enrolled. Figure 1 presents the proportion of children who experienced relapse into SAM after being discharged from CMTCs. Among the discharged cohort, 82.0 per cent remained free from SAM, while 18.0 per cent relapsed and were reclassified as SAM cases during follow-up. [Insert Figure 1 here] [Insert Table 1 here] Table 1 summarizes the average duration of relapse into SAM following discharge from CMTCs. Sex-based analysis revealed that female children relapsed after a mean of 238.8 days (SE: 95.1), whereas male children relapsed sooner, with a mean of 162.8 days (SE: 53.8), suggesting a higher vulnerability among males. Age-related patterns were also observed: children aged 11–36 months relapsed more rapidly (mean: 146.8 days, SE: 18.7) than those aged 37–62 months (mean: 224.2 days, SE: 79.7). Across all groups, the overall mean time to relapse was 193.2 days (SE: 48.2). [Insert Figure 2 here] Figure 2 displays the Kaplan-Meier survival curves depicting the time to relapse into SAM among children discharged from CMTCs. The survival curve for children who did not relapse remained consistently high, indicating sustained nutritional recovery and a prolonged relapse-free period dischargecharge. In contrast, the curve for children who relapsed declined more rapidly, suggesting that most relapses occurred relatively early, particularly within the first 200 days of treatment. A pronounced drop was observed between 100 and 140 days, highlighting a critical post-discharge vulnerability window. The relapse-free group maintained a survival probability close to 1.0 throughout the follow-up period, whereas the relapse group exhibited a steep decline in survival probability. Statistical comparison using the log-rank test yielded a chi-square value of 44.93 (p < 0.001), confirming a highly significant difference in time-to-relapse distributions between the two groups. [Insert Figure 3 here] Figure 3 illustrates the Kaplan-Meier survival curves for time to relapse into SAM among children discharged from CMTCs, stratified by age group. Children aged 11–36 months exhibited a markedly steeper decline in survival probability than those aged 37–62 months, indicating an earlier and higher rate of relapse among the younger cohort. The most significant drop in survival probability occurred between 100 and 140 days post-discharge, suggesting a critical vulnerability window during this period. In contrast, the older age group demonstrated a more gradual decline, reflecting greater resilience and a delayed onset of relapse. The difference in relapse timing between the age groups was statistically significant, as confirmed by the log-rank test (χ² = 55.61, p < 0.001). [Insert Table 2 here] Table 2 presents the percentage distribution of children who relapsed into SAM following discharge from CMTCs, stratified by age and sex. Among children aged 37–62 months, 26.1 per cent experienced a relapse, compared to 12.1 per cent of those aged 11–36 months, indicating a higher relapse rate among the older age group. Gender-wise analysis showed that 23.1 per cent of male children relapsed, whereas only 13.3 per cent of female children experienced a relapse. These findings suggest that both age and sex may influence post-discharge vulnerability to SAM, warranting targeted follow-up strategies. [Insert Table 3 here] Table 3 presents the percentage distribution of children who relapsed into SAM following discharge from CMTCs, stratified by post-discharge health status and hygiene practices. Children who remained free from illness post-discharge exhibited a relapse rate of 11.1 per cent compared to those who experienced illness, among whom the relapse rate was 27.3 per cent. Hygiene practices also showed a notable association with relapse outcomes: children using public or private toilets had a relapse rate of 14.9 per cent, whereas those practicing open defecation exhibited a markedly higher relapse rate of 33.3 per cent. [Insert Table 4 here] Table 4 summarizes the nutritional deficiencies identified among the 10 children who relapsed into SAM following discharge from CMTCs, based on 24-hour dietary recall data. The analysis highlighted substantial shortfalls in both macronutrient and micronutrient intake when compared to age-specific dietary recommendations. Notably, 44.0 per cent of children had fat intake below the recommended threshold, suggesting inadequate consumption of energy-dense foods critical for growth and metabolic function. Protein deficiency was observed in 18.7 per cent of cases, while 64.9 per cent of children had insufficient overall energy intake. Micronutrient deficiencies were also observed. Zinc deficiency was the most prevalent, affecting 69.1 per cent of children, followed by calcium deficiency (64.2 per cent) and iron deficiency (62.3 per cent). These findings underscore the need for targeted nutritional interventions post-discharge, with an emphasis on improving dietary diversity and adequacy to support sustained recovery and prevent relapse. Discussion The present study aimed to report the long-term follow-up of children discharged from the two CMTCs and the factors contributing to the post-discharge relapse of children with SAM. Four out of five children discharged from the CMTCs remained healthy after discharge. However, one-fifth of the children experienced a relapse into SAM after discharge, underscoring the need for long-term community-based follow-up of all children discharged from CMTCs who are at risk of maintaining adequate nutrition, medical interventions, and support in their home environment. A study by Stobaug et al., (2018) in their study to identify factors associated with sustained recovery found to have a relapse of SAM children to be about 37 per cent, which was found to be higher compared to 18 per cent relapse as per our study. Their study also stated that continued nutritional support, such as supplementary feeding programs, aided in relapse rates of these children and emphasized the quality of follow-up visits at home after the discharge of children from these centers [12]. In our study, we found that gender, age, health condition of the child, and hygiene practices followed had a significant impact on the child’s health and contributed to being factors of importance leading to relapse. We observed that male children relapsed earlier in terms of duration and had a higher incidence of relapse than their female counterparts. A study by Lambebo also observed sex disparities in relapse, with the mean relapse time being 21(±8.6) weeks for male children and 24(±11.1) weeks for female children, which aligns with the findings of this study. These findings indicate a significant sex disparity, with males being more vulnerable, possibly due to differences in biological immunity. The study findings indicated that the average duration until relapse was shorter in younger children (11–36 months) than in older children (37–62 months) in our study. This observation aligns with the established notion that younger children are more vulnerable to malnutrition because of their rapid growth and increased developmental demands [12]. However, it was also noted that the overall relapse rate was higher among the older age group. This suggests that while younger children are more likely to relapse earlier, a considerable proportion of older children who initially maintain nutritional stability are at risk of experiencing relapse over time following discharge. These findings emphasize the necessity of providing age-appropriate dietary interventions to meet the physiological requirements of children at different developmental stages. Furthermore, a higher relapse rate was observed among children from households practicing open defecation than among those with access to toilets, highlighting the crucial role of domestic hygiene in preventing relapses [8,13,15]. Previous research has similarly demonstrated that the absence of latrines increases the risk of SAM relapse among children [15]. One potential explanation for this is that open defecation is a recognized risk factor for the transmission of infectious diseases, particularly gastrointestinal infections, which can significantly impair nutrient absorption and contribute to malnutrition [15,16]. Children residing in households that engage in open defecation are at a heightened risk of exposure to contaminated water, food, and soil, making them more susceptible to infections such as diarrhea, which can lead to a rapid decline in their nutritional status [16]. The present study also sought to examine the time to relapse. Notably, the findings revealed that the majority of children experienced relapse between 100 and 140 days after discharge, identifying this period as a critical window requiring close monitoring and intervention. Additionally, a 24-hour dietary recall conducted for 10 children who had relapsed into the SAM category revealed a substantial gap between their energy requirements and actual intake, with energy deficits ranging from 50% to 85 per cent. Although the consumption of wheat- and millet-based bread was relatively high, the overall dietary energy intake remained insufficient, with an average shortfall of 64.94 per cent across all cases of SAM relapse. This finding underscores the inadequacy of dietary intake relative to nutritional needs, reinforcing the importance of sustained nutritional support after discharge. Fat consumption was also found to be 44.01 per cent deficient compared to age-appropriate recommendations. Additionally, the intake of nutrient-rich foods, such as fruits, milk, and green leafy vegetables, was minimal, contributing to micronutrient deficiencies. Noting micronutrient deficiencies for calcium, it was noted that various cross-sectional studies documented the prevalence of hypocalcaemia among children with severe malnutrition [20,21]. Hypocalcemia, characterized by a serum calcium concentration below 8.8 mg/dL (2.2 mmol/L) or an ionized calcium concentration below 4.6 mg/dL (1.15 mmol/L), is a potential consequence of inadequate dietary calcium intake [20,21]. Although its clinical presentation is often subtle, manifesting primarily as neuromuscular irritability, hypocalcemia plays a crucial role in the pathophysiology of conditions such as rickets and osteomalacia, which are frequently observed in children with SAM. Two independent studies, encompassing cohorts of 150 and 333 children, respectively, reported that 26 per cent of children hospitalized with complicated SAM exhibited hypocalcemia [20,21]. A separate study conducted in Nepal, involving a smaller sample size (n=120), indicated an even higher prevalence of 47 per cent among malnourished children, compared to only 7 per cent in the control group [22]. Iron is an essential micronutrient required for haemoglobin synthesis, enzymatic reactions, and the overall functionality of red blood cells. Iron deficiency, particularly in the form of iron deficiency anaemia (IDA), can lead to fatigue, generalised weakness, cognitive impairment, and growth retardation, with severe cases necessitating medical intervention. Globally, IDA affects nearly 300 million children, with the highest burden observed in low- and middle-income countries (LMICs), where the prevalence of SAM is also substantial [23,24]. Studies consistently demonstrated a high incidence of IDA among children with SAM. For instance, a study conducted in Burkina Faso reported a 40 per cent prevalence of IDA among 801 children admitted with SAM [25]. Smaller studies in Malawi and India documented even higher prevalence rates, ranging from 48 – 94 per cent [26–28]. Furthermore, severe anaemia, requiring blood transfusion, was identified in 25 – 46 per cent of affected children [27,28]. Zinc deficiency is associated with multiple adverse clinical outcomes, including impaired growth, reduced appetite, dermatological manifestations, compromised immune function, and heightened susceptibility to diarrheal diseases. In LMICs, an estimated 30 – 70 per cent of children experience zinc deficiency, largely due to insufficient dietary intake, malabsorption, and increased losses related to recurrent infections such as diarrhoea [29–32]. Studies consistently report significantly lower serum zinc concentrations in children with SAM compared to their well-nourished counterparts [32–34]. A concerning dietary trend was also noted, with a high consumption of processed snack foods, including biscuits and wafers. Caregivers frequently cited convenience and the child's preference as primary factors influencing these choices. However, responsive feeding practices—characterized by active engagement between the caregiver and child during meals—were notably deficient. Instead, passive feeding methods, such as allowing children to eat while distracted or engaged in play, were commonly observed. Limitation The following limitations need to be kept in mind while interpreting the results and findings. Firstly, the present study was just based on bivariate association. We did not examine the age-adjusted prevalence of relapse, and further, due to the sample size limitation. Secondly, the relapse to SAM in children does not follow a fixed timeline of 6-10 months. The timing of relapse varies depending on several factors and cannot be broadly generalised to a specific period. Also, we included hygiene practices as a representative for WASH indicator, although it does not entirely represent the same. The 24 hours dietary recall has limitations due to recall bias. 24-hour dietary recall was performed only for 10 children who had relapsed to SAM so an accurate correlation cannot be established. Conclusion The management of SAM requires a comprehensive approach that goes beyond addressing the immediate nutritional needs of children to tackling the broader socio-environmental factors that contribute to relapse. The study highlights the crucial role of hygiene practices in ensuring long-term recovery, emphasising the need for integrated policies that cover health, nutrition, and hygiene. Additionally, educational programs for caregivers about optimal feeding practices and the significance of frequent, balanced meals can improve the outcomes of CMTC interventions. Coupled with ongoing community support and monitoring, these strategies could promote a more sustainable recovery for children treated for SAM. According to the WHO recommended schedules, healthcare workers should follow the follow-up for 1, 3, and 6 months and twice annually until the child is at least three years old. Hence, a proper follow-up can halt children from falling into relapse. Declarations Human Ethics Consent was obtained by all participants in this study. Institutional Ethics Committee of the Indian Institute of Public Health Gandhinagar issued approval IEC/IRB: 14/2019-20 Animal Ethics Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Ethics Approval and Consent to Participate Ethical approval was obtained. Consent was obtained by all participants in this study. Institutional Ethics Committee of the Indian Institute of Public Health Gandhinagar issued approval IEC/IRB: 14/2019-20 All methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from the parent and/or legal guardian of all participating children prior to data collection. Consent for Publication Not applicable. Data Availability Data will be available upon request to the investigators. Competing Interests The authors declare that there are no conflicts of interest related to the content, authorship, or publication of this manuscript. No financial, personal, or professional affiliations have influenced the research outcomes or interpretations presented in this study. All data were analysed and reported with objectivity and academic integrity. The study was conducted independently, and the authors received no specific funding or benefits from any commercial or non-commercial entity that could be perceived to influence the work. Financial Support The authors declare that this study received funding from Nayara Energy. Centre of Excellence in Nutrition (CoEN) is an initiative of Project Tushti at Indian Institute of Public Health Gandhinagar to support Gujarat's Nutrition initiatives. CoEN is supported through Nayara Energy Ltd.'s CSR support. Author Contributions S.S. conceptualized the study and designed the methodology. P.B. conducted the data analysis and interpreted the results. K.J. led the manuscript drafting. S.S. and M.M. reviewed the manuscript and provided technical inputs throughout the development of the study. S.S. also contributed technical support during the modelling and validation phases. All authors reviewed and approved the final manuscript. Conflict of Interest Statement The authors declare no conflicts of interest related to the design, execution, or publication of this study. The research was conducted independently, and no financial, personal, or professional affiliations have influenced the outcomes or interpretations presented. All analyses and reporting were carried out with academic integrity and transparency. Acknowledgement The authors extend their sincere gratitude to Nayara Energy Limited for supporting Project Tushti , a multi-sectoral initiative aimed at addressing childhood malnutrition in Devbhumi Dwarka. We also acknowledge the Department of Women and Child Development, Government of Gujarat, for their collaboration through the Integrated Child Development Services (ICDS) program, alongside the Health and Family Welfare Department. We also acknowledge continuous ongoing efforts of our field staff and intern Dr. Daksh Parmar for their role in collecting the data for the study. References Das, J. K., Salam, R. A., Saeed, M., Kazmi, F. A. & Bhutta, Z. A. Effectiveness of interventions for managing acute malnutrition in children under five years of age in low-income and middle-income countries: a systematic review and meta-analysis. Nutrients 12 (1), 116 (2020). Kumar, P., Zode, M. & Basu, S. 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Health Nutr. 23 , 3181–3186. 10.1017/S1368980020001895 (2020). Mishra, S. K., Bastola, S. P. & Jha, B. Biochemical nutritional indicators in children with protein energy malnutrition attending Kanti Children Hospital, Kathmandu, Nepal. Kathmandu Univ. Med. J. 7 , 129–134. 10.3126/kumj.v7i2.2705 (2009). World Health Organization. Guideline: daily iron supplementation in infants and children. (2016). Available at: https://www.who.int/publications/i/item/ 9789241549523. Accessed January 18, 2024. United Nations Children’s Fund (UNICEF). Levels and Trends in Child Malnutrition: Key Findings of the 2019 Edition of the Joint Child Malnutrition Estimates (World Health Organization, International Bank for Reconstruction and Development/ The World Bank, 2019). Kangas, S. T. et al. Vitamin A and iron status of children before and after treatment of uncomplicated severe acute malnutrition. Clin. Nutr. 39 , 3512–3519. 10.1016/j.clnu.2020.03.016 (2020). Akomo, P. et al. Soya, maize and sorghum ready-to-use therapeutic foods are more effective in correcting anaemia and iron deficiency than the standard ready-to-use therapeutic food: randomized controlled trial. BMC Public. Health . 19 , 806. 10.1186/s12889-019-7170-x (2019). Thakur, N. et al. Anemia in severe acute malnutrition. Nutrition 30 , 440–442. 10.1016/j.nut.2013.09.011 (2014). Yaikhomba, T., Poswal, L. & Goyal, S. Assessment of iron, folate and vitamin B12 status in severe acute malnutrition. Indian J. Pediatr. 82 , 511–514. 10.1007/s12098-014-1600-7 (2015). Bhaskaram, P. Immunobiology of mild micronutrient deficiencies. Br. J. Nutr. 85 (suppl 2), S75–S80. 10.1079/BJN2000297 (2001). Bhaskaram, P. & Hemalatha, P. Zinc status of Indian children. Indian J. Med. Res. 102 , 210–215 (1995). Caulfield, L. & Black, R. Zinc deficiency. In: (eds Ezzati, M., Lopez, A., Rodgers, A. & Murray, C.) Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to Selected Major Risk Factors. World Health Organization; :257–259 (2004). Thakur, S., Gupta, N. & Kakkar, P. Serum copper and zinc concentrations and their relation to superoxide dismutase in severe malnutrition. Eur. J. Pediatr. 163 , 742–744. 10.1007/s00431-004-1517-7 (2004). Chowdhury, B. et al. Serum zinc, copper, magnesium & phosphorus level in children with severe acute malnutrition (SAM). Mymensingh Med. J. 25 , 635–640 (2016). Ghone, R. A. et al. A study of oxidative stress biomarkers and effect of oral antioxidant supplementation in severe acute malnutrition. J. Clin. Diagn. Res. 7 , 2146–2148. 10.7860/JCDR/2013/ 6019.3454 (2013). published online. Chaudhari, M. & Shukkoor, T. Impact of Public Health Programs on Maternal and Child Health in Gujarat 144 (Growth Trajectory of Gujarat—Public Policy Intervention, 2025). Tables Table 1 Mean number of days to relapse after discharge (n = 56) Mean days SE 95% CI Gender Female 238.8 95.1 48.1 429.4 Male 162.8 53.8 55.0 270.7 Age 11–36 months 146.8 18.7 109.3 184.2 37–62 months 224.2 79.7 64.4 384.0 Total 193.2 48.2 96.6 289.8 Note: SE: Standard Error; CI: Confidence Interval Table 2 Distribution of relapse and non-relapse rates by children's background characteristics Non-relapse Relapse n Gender of children Female 13.3 86.7 30 Male 23.1 76.9 26 Age of children 11–36 months 12.1 87.9 33 37–62 months 26.1 73.9 23 Total 82.1 17.9 56 Table 3 Key factors influencing relapse and non-relapse rates among children Key factors No relapse Relapse n Health condition Has the child ever been sick since discharge? No 88.9 11.1 41 Yes 63.7 27.3 15 Hygienic Practices Latrine/Toilet type Public and Private 85.1 14.9 47 Open defecation 66.7 33.3 9 Total 82.1 17.9 56 Table 4 Nutritional deficiencies in 10 SAM children based on 24-hour dietary recall (N = 10) Nutritional Deficiency Indicators Percentage Energy deficit 64.9 Protein deficit 18.7 Fat deficit 44.0 Iron deficit 62.3 Calcium deficit 64.2 Zinc deficit 69.1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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16:18:25","extension":"html","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":115186,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7788572/v1/4b4078f6f997473c09233632.html"},{"id":98245819,"identity":"390ca685-02d2-44c5-9d82-19b32996844d","added_by":"auto","created_at":"2025-12-15 16:18:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20119,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage distribution of relapse and non-relapse cases in discharged children (n=56)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7788572/v1/7ca238e7b272a348c5695543.png"},{"id":98246017,"identity":"8e046c57-9081-4862-916d-99d060610043","added_by":"auto","created_at":"2025-12-15 16:18:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34092,"visible":true,"origin":"","legend":"\u003cp\u003eTime to relapse among the children after treatment at CMTC\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: Chi-square statistic: 44.93, P\u0026lt;0.000\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7788572/v1/11efb3eb9cf6049472ea07cd.png"},{"id":98245972,"identity":"617b9135-de91-43bf-9143-d8364ae7929b","added_by":"auto","created_at":"2025-12-15 16:18:43","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":47316,"visible":true,"origin":"","legend":"\u003cp\u003eTime to relapse among the children after treatment for SAM by age at CMTC\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: Chi-square statistic: 55.61, P\u0026lt;0.000\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7788572/v1/1e94a6922ef0cf55184e7da7.png"},{"id":108390795,"identity":"09a44c88-c018-495d-b48f-d9084cd6f767","added_by":"auto","created_at":"2026-05-04 06:57:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":411708,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7788572/v1/b1fa90a6-66b2-4154-aced-7c723eae22ae.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Long-term Follow-up of Children Discharged from Child Malnutrition Treatment Centres in Gujarat","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChild malnutrition under of five yearsyears of remains a critical public health concern. The repercussions of malnutrition extend beyond immediate health issues, affecting children's physical growth, cognitive development, and future socioeconomic opportunities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Severe acute malnutrition (SAM), which results from a combination of insufficient food intake and illness, is characterized by rapid deterioration of nutritional status [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is primarily evidenced by wasting, where a child\u0026rsquo;s weight-for-height ratio falls below the standard, indicating severe nutritional deficits. Wasting is closely associated with higher mortality rates and a compromised immune system, leading to muscle loss, fat depletion, and reduced ability to recover from illnesses [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Gujarat, malnutrition rates remain disturbingly high, as highlighted by the National Family Health Survey (NFHS)-5. Approximately 39 per cent of children under five years of age are stunted during critical early development. Moreover, 35.7 per cent (25.1 per cent wasted and 10. Six percent of severely wasted individuals suffer from acute malnutrition or wasting, and 39.7 percent are underweight. These figures highlight the urgent need to address both macronutrient and micronutrient deficiencies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIndia has taken numerous initiatives and measures to combat malnutrition, including both facility-based and community-based programs. As part of these initiatives, all children suffering from SAM with medical complications are treated at Child Malnutrition Treatment Centres (CMTCs) and Nutritional Rehabilitation Centers (NRCs).\u003c/p\u003e\u003cp\u003eSimilarly, Gujarat is working through several people-focused schemes to improve the health of young children in the state. The Mukhyamantri Paushtik Alpahar Yojana provides schoolchildren with simple, protein-rich snacks to keep them energetic and nourished. In tribal regions, the Doodh Sanjeevani Yojana offers a daily glass of fortified milk to help children grow stronger. For those who are severely malnourished, Bal Sewa Kendras provide special care and support under the CMAM program. Across villages, Anganwadi centers play a vital role in the ICDS scheme, offering daily meals and take-home rations [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite these measures, relapse remains a significant issue, with approximately 37 per cent of children discharged from CMTCs and NRCs relapsing back to SAM [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Therefore, it is essential to have an in-depth understanding of the factors influencing the efficacy of these centers and to assess them thoroughly [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCMTCs have been essential for the management of SAM, as their functioning holistically focuses on stabilizing the child\u0026rsquo;s condition, providing them with therapeutic feeds, and educating their caregivers.\u003c/p\u003e\u003cp\u003eStudies conducted regarding the treatment effectiveness of CMTCs in the states of Bihar and Jharkhand have shown that the factors responsible for better efficacy of these centers include operational efficiency, compliance, and understanding of the child\u0026rsquo;s caregiver in accordance with the treatment being offered and their availability and readiness for the follow-up care of the child after being discharged from the center. In addition, poverty, poor dietary habits, and recurrent infections are other important factors that obstruct long-term recovery in children [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAnother important factor associated with the relapse of malnutrition in children is water, sanitation, and hygiene (WASH) practices. Poor WASH conditions, particularly in rural and underserved areas, significantly contribute to infections in children, which in turn causes relapse [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Infections such as diarrhea impair nutrient absorption, thereby increasing the risk and relapse of malnutrition in children [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Improving household-level WASH practices can prevent malnutrition and aid in long-term recovery [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn regions lacking these basic services, the impact on children's health can be severe [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The link between WASH and malnutrition is particularly evident in rural areas, where disparities in access to essential services worsen health outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eProject Tushti, a joint effort by the Government of Gujarat, Nayara Energy Limited, Indian Institute of Public Health Gandhinagar (IIPHG), and JSI R\u0026amp;T India Foundation, aims to reduce child malnutrition in Devbhumi Dwarka, Gujarat. The project focuses on profiling children, monitoring underweight children, and improving the healthcare system to ensure quality and timely service delivery. One key intervention includes establishing two CMTCs through a partnership with the Health Department of Gujarat, aimed at providing clinical management and reducing mortality among children with SAM who have medical complications. These centers are situated at the Sub-District Hospital Dwarka and Community Health Center Bhanvad. IIPHG under Project Tushti supported building renovation, human resources including Nutrition Assistants, Field Coordinators, cook cum caretaker, provided therapeutic foods, counselling services, and transport services for children and caregivers while the respective healthcare facilities provided the space, infrastructure, and treatment services for medical complications.\u003c/p\u003e\u003cp\u003eThis study aimed to report the long-term follow-up of children discharged from the two CMTCs and the factors contributing to post-discharge relapse of children with SAM. Additionally, the study aims to examine the influence of hygiene conditions on malnutrition, cooking and feeding practices at home following discharge, and the outcomes of these practices based on the guidance provided during counselling sessions. By addressing these areas, this study seeks to inform policies and programs that take a more comprehensive approach to addressing malnutrition in India.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis study adopted a cross-sectional design to assess relapse and associated factors among children discharged after treatment for SAM at CMTCs in Devbhoomi Dwarka, Gujarat, India.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Setting and Duration\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in the Devbhoomi Dwarka district of Gujarat, focusing on children discharged after 14 days of complete treatment and three rounds of follow-up at two CMTCs located at the Sub-District Hospital, Dwarka, and Community Health Centre, Bhanvad.\u003c/p\u003e\u003cp\u003eData collection will be conducted between October 2024 and December 2024. Eligible children will be discharged between June 2023 and September 2024.\u003c/p\u003e\n\u003ch3\u003eStudy Population and Eligibility\u003c/h3\u003e\n\u003cp\u003eThe target population comprised children under five years of age who had been admitted to CMTCs for SAM management. The inclusion criteria were as follows:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eCompletion of the 14-day CMTC treatment protocol for SAM,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAll three scheduled follow-ups completed post-discharge,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDischarged after full recovery, and\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAge below five years as of December 2024\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eChildren were excluded if they had any of the following:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eMigrated, resulting in loss to follow-up\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDid not complete the entire treatment at the CMTCs\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCould not be followed-up for all three schedules post their discharge from the CMTCs\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eSample Size and Participant Selection\u003c/h3\u003e\n\u003cp\u003eA total of 96 children were discharged after completing their treatment for SAM at the CMTCs during the study period. Of these, 56 children met the eligibility criteria and were successfully enrolled. Children who had migrated or died were excluded. Thus, the final sample size was determined by the number of eligible and traceable participants (56 of 96), rather than a statistical sample size calculation.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData were collected using KoboToolbox through structured interviews with caregivers, focusing on various aspects of the child\u0026rsquo;s health, anthropometric measurements, household conditions, and feeding practices.\u003c/p\u003e\u003cp\u003eAnthropometric measurements were performed: height was measured in centimeters (cm) using an infantometer or stadiometer; weight was measured in kilograms (kg); and mid-upper arm circumference (MUAC) was measured in centimeters (cm) using an MUAC tape. The World Health Organization (WHO) Growth Standards were used to assess malnutrition and categorize children based on their weight-for-height z-scores (WHZ). The categorization was based on the WHO malnutrition classification, with the following categories: Severe Acute Malnutrition (SAM): Children with a weight-for-height Z-score (WHZ) of less than \u0026minus;\u0026thinsp;3 SD; Moderate Acute Malnutrition (MAM): Children with a WHZ between \u0026minus;\u0026thinsp;2 and \u0026minus;\u0026thinsp;3 SD; and Normal Nutrition: Children with a WHZ greater than \u0026minus;\u0026thinsp;2 SD [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eData regarding patient discharge and scheduled interview dates were recorded. Using this information, the precise duration (in days and months) following discharge was calculated, and the mean duration until relapse was determined.\u003c/p\u003e\u003cp\u003eA comprehensive 24-hour dietary assessment was conducted using a semi-structured survey tool administered to primary caregivers to document dietary intake. The food items consumed were classified into various groups, including milk and dairy products, cereals and millets, pulses and legumes, meat and fish products, eggs, green leafy vegetables, fruits, nuts, and non-vegetarian items (including eggs).\u003c/p\u003e\u003cp\u003eNutrient deficiencies in terms of energy, protein, carbohydrates, fats, and micronutrients were assessed using the portion sizes defined in the \u003cem\u003eNutrient\u003c/em\u003e Exchange List outlined in the Dietary Guidelines for Indians (ICMR-NIN, 2024) as a reference.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eExplanatory Variables:\u003c/h2\u003e\u003cp\u003eThe key explanatory variables considered in this study included age, gender, health condition, hygienic practice, and feeding practices of children. Age was categorised into two categories (11\u0026ndash;36 and 37\u0026ndash;62 months) following the guidelines of Ministry of Women and Child Development (MoWCD) The health status of children was assessed based on the response to the question, \"Has the child ever been sick since discharge?\" As there was a lack of other health-related data, this information was used as a proxy indicator for evaluating the health status of the children. Furthermore, hygienic practices were assessed based on the type of defecation.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAnalytical approach:\u003c/h3\u003e\n\u003cp\u003eData were analyzed using MS Excel for initial data cleaning and Stata (version 17.0) for more advanced statistical analysis. Descriptive statistics, such as the mean, standard error, confidence interval, and prevalence, were measured. Further, a bivariate association was employed to examine the significant difference in terms of relapse and number of days. Kaplan-Meier survival analysis was used to investigate the time to relapse among children discharged after treatment for SAM. This analysis generated two distinct survival curves: one for children who did not relapse (relapse\u0026thinsp;=\u0026thinsp;0) and another for those who relapsed (relapse\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e\n\u003ch3\u003eBias Management\u003c/h3\u003e\n\u003cp\u003eTo minimize selection bias, only children who met the predefined eligibility criteria were included. Migration was recorded as a reason for exclusion, and recall bias in dietary intake was acknowledged due to reliance on caregiver recall. All anthropometric measurements were conducted using standardized tools to reduce measurement bias.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Ethics Committee of the Indian Institute of Public Health Gandhinagar (IEC/IRB approval number: 14/2019-20).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from the parent and/or legal guardian of all participating children prior to data collection.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 96 children were discharged after completions of their treatment for SAM from the CMTCs during the study period. Of these, 56 children met the eligibility criteria and were successfully contacted and enrolled.\u003c/p\u003e\n\u003cp\u003eFigure 1 presents the proportion of children who experienced relapse into SAM after being discharged from CMTCs. Among the discharged cohort, 82.0 per cent remained free from SAM, while 18.0 per cent relapsed and were reclassified as SAM cases during follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Insert Figure 1 here]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Insert Table 1 here]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 summarizes the average duration of relapse into SAM following discharge from CMTCs. Sex-based analysis revealed that female children relapsed after a mean of 238.8 days (SE: 95.1), whereas male children relapsed sooner, with a mean of 162.8 days (SE: 53.8), suggesting a higher vulnerability among males. Age-related patterns were also observed: children aged 11–36 months relapsed more rapidly (mean: 146.8 days, SE: 18.7) than those aged 37–62 months (mean: 224.2 days, SE: 79.7). Across all groups, the overall mean time to relapse was 193.2 days (SE: 48.2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Insert Figure 2 here]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 2 displays the Kaplan-Meier survival curves depicting the\u0026nbsp;time to relapse into SAM among children discharged from CMTCs. The survival curve for children who did not relapse remained consistently high, indicating sustained nutritional recovery and a prolonged relapse-free period dischargecharge. In contrast, the curve for children who relapsed declined more rapidly, suggesting that most relapses occurred relatively early, particularly within the first 200 days\u0026nbsp;of treatment. A pronounced drop was observed between 100 and 140 days, highlighting a critical post-discharge vulnerability window. The relapse-free group maintained a survival probability close to 1.0 throughout the follow-up period, whereas the relapse group exhibited a steep decline in survival probability. Statistical comparison using the log-rank test yielded a chi-square value of 44.93 (p \u0026lt; 0.001), confirming a highly significant difference in time-to-relapse distributions between the two groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Insert Figure 3 here]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 3 illustrates the Kaplan-Meier survival curves for time to relapse into SAM among children discharged from CMTCs, stratified by age group. Children aged 11–36 months exhibited a markedly steeper decline in survival probability than those aged 37–62 months, indicating an earlier and higher rate of relapse among the younger cohort. The most significant drop in survival probability occurred between 100 and 140 days post-discharge, suggesting a critical vulnerability window\u0026nbsp;during this period. In contrast, the older age group demonstrated a more gradual decline, reflecting greater resilience and a\u0026nbsp;delayed onset of relapse. The difference in relapse timing between the\u0026nbsp;age groups was statistically significant, as confirmed by the log-rank test (χ² = 55.61, p \u0026lt; 0.001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Insert Table 2 here]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 presents the percentage distribution of children who relapsed into SAM following discharge from CMTCs, stratified by age and sex. Among children aged 37–62 months, 26.1 per cent experienced a relapse, compared to 12.1 per cent of those aged 11–36 months, indicating a higher relapse rate among the older age group. Gender-wise analysis showed that 23.1 per cent of male children relapsed, whereas only 13.3 per cent of female children experienced a relapse. These findings suggest that both age and sex may influence post-discharge vulnerability to SAM, warranting targeted follow-up strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Insert Table 3 here]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 presents the percentage distribution of children who relapsed into SAM following discharge from CMTCs, stratified by post-discharge health status and hygiene practices. Children who remained free from illness post-discharge exhibited a relapse rate of 11.1 per cent compared to those who experienced illness, among whom the relapse rate was 27.3 per cent. Hygiene practices also showed a notable association with relapse outcomes: children using public or private toilets had a relapse rate of 14.9 per cent, whereas those practicing open defecation exhibited a markedly higher relapse rate of 33.3 per cent. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[Insert Table 4 here]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 summarizes the nutritional deficiencies identified among the\u0026nbsp;10 children who relapsed into SAM following discharge from CMTCs, based on 24-hour dietary recall data. The analysis highlighted substantial shortfalls in both macronutrient and micronutrient intake when compared to age-specific dietary recommendations. Notably, 44.0 per cent of children had fat intake below the recommended threshold, suggesting inadequate consumption of energy-dense foods critical for growth and metabolic function. Protein deficiency was observed in 18.7 per cent of cases, while 64.9 per cent of children had insufficient overall energy intake.\u003c/p\u003e\n\u003cp\u003eMicronutrient deficiencies were also observed. Zinc deficiency was the most prevalent, affecting 69.1 per cent of children, followed by calcium deficiency (64.2 per cent) and iron deficiency (62.3 per cent). These findings underscore the need for targeted nutritional interventions post-discharge, with an emphasis on improving dietary diversity and adequacy to support sustained recovery and prevent relapse.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study aimed to report the long-term follow-up of children discharged from the two CMTCs and the factors contributing to the post-discharge relapse of children with SAM. Four out of five children discharged from the CMTCs remained healthy after discharge. However, one-fifth of the\u0026nbsp;children experienced a relapse into SAM after discharge, underscoring the need for long-term community-based follow-up of all children discharged from CMTCs who are at risk of maintaining adequate nutrition, medical interventions, and support in their home environment. A study by Stobaug et al., (2018) in their study to identify factors associated with sustained recovery found to have a relapse of SAM children to be about 37 per cent, which was found to be higher compared to 18 per cent relapse as per our study. Their study also stated that continued nutritional support, such as supplementary feeding programs, aided in relapse rates of these children and emphasized the quality of follow-up visits at home after the discharge of children from these centers [12].\u003c/p\u003e\n\u003cp\u003eIn our study, we found that gender, age, health condition of the child, and hygiene practices followed had a significant impact on the child\u0026rsquo;s health and contributed to being factors of importance leading to relapse. We observed that male children relapsed earlier in terms of duration and had a higher incidence of relapse than their female counterparts. A study by Lambebo also observed sex disparities in relapse, with the mean relapse time being 21(\u0026plusmn;8.6) weeks for male children and 24(\u0026plusmn;11.1) weeks for female children, which aligns with the findings of this study. These findings indicate a significant sex disparity, with males being more vulnerable, possibly due to differences in biological immunity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study findings indicated that the average duration until relapse was shorter in younger children (11\u0026ndash;36 months) than in older children (37\u0026ndash;62 months) in our study. This observation aligns with the established notion that younger children are more vulnerable to malnutrition because of their rapid growth and increased developmental demands [12]. However, it was also noted that the overall relapse rate was higher among the older age group. This suggests that while younger children are more likely to relapse earlier, a considerable proportion of older children who initially maintain nutritional stability are at risk of experiencing relapse over time following discharge. These findings emphasize the necessity of providing age-appropriate dietary interventions to meet the physiological requirements of children at different developmental stages.\u003c/p\u003e\n\u003cp\u003eFurthermore, a higher relapse rate was observed among children from households practicing open defecation than among those with access to toilets, highlighting the crucial role of domestic hygiene in preventing relapses [8,13,15]. Previous research has\u0026nbsp;similarly demonstrated that the absence of latrines increases the risk of SAM relapse among children [15]. One potential explanation for this is that open defecation is a recognized risk factor for the transmission of infectious diseases, particularly gastrointestinal infections, which can significantly impair nutrient absorption and contribute to malnutrition [15,16]. Children residing in households that engage in open defecation are at a heightened risk of exposure to contaminated water, food, and soil, making them more susceptible to infections such as diarrhea, which can lead to a rapid decline in their\u0026nbsp;nutritional status [16].\u003c/p\u003e\n\u003cp\u003eThe present study also sought to examine the time to relapse. Notably, the\u0026nbsp;findings revealed that the majority of children experienced relapse between 100 and 140 days after discharge, identifying this period as a critical window requiring close monitoring and intervention.\u003c/p\u003e\n\u003cp\u003eAdditionally, a 24-hour dietary recall conducted for 10 children who had relapsed into the SAM category revealed a substantial gap between their energy requirements and actual intake, with energy deficits ranging from 50% to 85 per cent. Although the consumption of wheat- and millet-based bread was relatively high, the overall dietary energy intake remained insufficient, with an average shortfall of 64.94 per cent across all cases of SAM relapse. This finding underscores the inadequacy of dietary intake relative to nutritional needs, reinforcing the importance of sustained nutritional support after discharge.\u003c/p\u003e\n\u003cp\u003eFat consumption was also found to be 44.01 per cent deficient compared to age-appropriate recommendations. Additionally, the intake of nutrient-rich foods, such as fruits, milk, and green leafy vegetables, was minimal, contributing to micronutrient deficiencies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNoting micronutrient deficiencies for calcium, it was noted that various cross-sectional studies documented the prevalence of hypocalcaemia among children with severe malnutrition [20,21]. Hypocalcemia, characterized by a serum calcium concentration below 8.8 mg/dL (2.2 mmol/L) or an ionized calcium concentration below 4.6 mg/dL (1.15 mmol/L), is a potential consequence of inadequate dietary calcium intake [20,21]. Although its clinical presentation is often subtle, manifesting primarily as neuromuscular irritability, hypocalcemia plays a crucial role in the pathophysiology of conditions such as rickets and osteomalacia, which are frequently observed in children with SAM.\u003c/p\u003e\n\u003cp\u003eTwo independent studies, encompassing cohorts of 150 and 333 children, respectively, reported that 26 per cent of children hospitalized with complicated SAM exhibited hypocalcemia [20,21]. A separate study conducted in Nepal, involving a smaller sample size (n=120), indicated an even higher prevalence of 47 per cent among malnourished children, compared to only 7 per cent in the control group [22].\u003c/p\u003e\n\u003cp\u003eIron is an essential micronutrient required for haemoglobin synthesis, enzymatic reactions, and the overall functionality of red blood cells. Iron deficiency, particularly in the form of iron deficiency anaemia (IDA), can lead to fatigue, generalised weakness, cognitive impairment, and growth retardation, with severe cases necessitating medical intervention. Globally, IDA affects nearly 300 million children, with the highest burden observed in low- and middle-income countries (LMICs), where the prevalence of SAM is also substantial [23,24]. Studies consistently demonstrated a high incidence of IDA among children with SAM. For instance, a study conducted in Burkina Faso reported a 40 per cent prevalence of IDA among 801 children admitted with SAM [25]. Smaller studies in Malawi and India documented even higher prevalence rates, ranging from 48 \u0026ndash; 94 per cent [26\u0026ndash;28]. Furthermore, severe anaemia, requiring blood transfusion, was identified in 25 \u0026ndash; 46 per cent of affected children [27,28].\u003c/p\u003e\n\u003cp\u003eZinc deficiency is associated with multiple adverse clinical outcomes, including impaired growth, reduced appetite, dermatological manifestations, compromised immune function, and heightened susceptibility to diarrheal diseases. In LMICs, an estimated 30 \u0026ndash; 70 per cent of children experience zinc deficiency, largely due to insufficient dietary intake, malabsorption, and increased losses related to recurrent infections such as diarrhoea [29\u0026ndash;32]. Studies consistently report significantly lower serum zinc concentrations in children with SAM compared to their well-nourished counterparts [32\u0026ndash;34].\u003c/p\u003e\n\u003cp\u003eA concerning dietary trend was also noted, with a high consumption of processed snack foods, including biscuits and wafers. Caregivers frequently cited convenience and the child\u0026apos;s preference as primary factors influencing these choices. However, responsive feeding practices\u0026mdash;characterized by active engagement between the caregiver and child during meals\u0026mdash;were notably deficient. Instead, passive feeding methods, such as allowing children to eat while distracted or engaged in play, were commonly observed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following limitations need to be kept in mind while interpreting the results and findings. Firstly, the present study was just based on bivariate association. We did not examine the age-adjusted prevalence of relapse, and further, due to the sample size limitation. Secondly, the relapse to SAM in children does not follow a fixed timeline of 6-10 months. The timing of relapse varies depending on several factors and cannot be broadly generalised to a specific period. Also, we included hygiene practices as a representative for WASH indicator, although it does not entirely represent the same. The 24 hours dietary recall has limitations due to recall bias. \u0026nbsp; 24-hour dietary recall was performed only for 10 children who had relapsed to SAM so an accurate correlation cannot be established.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe management of SAM requires a comprehensive approach that goes beyond addressing the immediate nutritional needs of children to tackling the broader socio-environmental factors that contribute to relapse. The study highlights the crucial role of hygiene practices in ensuring long-term recovery, emphasising the need for integrated policies that cover health, nutrition, and hygiene.\u003c/p\u003e\n\u003cp\u003eAdditionally, educational programs for caregivers about optimal feeding practices and the significance of frequent, balanced meals can improve the outcomes of CMTC interventions. Coupled with ongoing community support and monitoring, these strategies could promote a more sustainable recovery for children treated for SAM. According to the WHO recommended schedules, healthcare workers should follow the follow-up for 1, 3, and 6 months and twice annually until the child is at least three years old. Hence, a proper follow-up can halt children from falling into relapse.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eHuman Ethics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConsent was obtained by all participants in this study. Institutional Ethics Committee of the Indian Institute of Public Health Gandhinagar issued approval IEC/IRB: 14/2019-20\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnimal Ethics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnimal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics Approval and Consent to Participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained. Consent was obtained by all participants in this study. Institutional Ethics Committee of the Indian Institute of Public Health Gandhinagar issued approval IEC/IRB: 14/2019-20\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with relevant guidelines and regulations. Written informed consent was obtained from the parent and/or legal guardian of all participating children prior to data collection.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for Publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Availability\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData will be available upon request to the investigators.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting Interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest related to the content, authorship, or publication of this manuscript. No financial, personal, or professional affiliations have influenced the research outcomes or interpretations presented in this study. All data were analysed and reported with objectivity and academic integrity. The study was conducted independently, and the authors received no specific funding or benefits from any commercial or non-commercial entity that could be perceived to influence the work.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFinancial Support\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that this study received funding from Nayara Energy. Centre of Excellence in Nutrition (CoEN) is an initiative of Project Tushti at Indian Institute of Public Health Gandhinagar to support Gujarat\u0026apos;s Nutrition initiatives. CoEN is supported through Nayara Energy Ltd.\u0026apos;s CSR support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor Contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eS.S. conceptualized the study and designed the methodology. P.B. conducted the data analysis and interpreted the results. K.J. led the manuscript drafting. S.S. and M.M. reviewed the manuscript and provided technical inputs throughout the development of the study. S.S. also contributed technical support during the modelling and validation phases. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConflict of Interest Statement\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest related to the design, execution, or publication of this study. The research was conducted independently, and no financial, personal, or professional affiliations have influenced the outcomes or interpretations presented. All analyses and reporting were carried out with academic integrity and transparency.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;Acknowledgement\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors extend their sincere gratitude to Nayara Energy Limited for supporting \u003cem\u003eProject Tushti\u003c/em\u003e, a multi-sectoral initiative aimed at addressing childhood malnutrition in Devbhumi Dwarka. We also acknowledge the Department of Women and Child Development, Government of Gujarat, for their collaboration through the Integrated Child Development Services (ICDS) program, alongside the Health and Family Welfare Department.\u003c/p\u003e\n\u003cp\u003eWe also acknowledge continuous ongoing efforts of our field staff and intern Dr. Daksh Parmar for their role in collecting the data for the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDas, J. K., Salam, R. A., Saeed, M., Kazmi, F. A. \u0026amp; Bhutta, Z. A. Effectiveness of interventions for managing acute malnutrition in children under five years of age in low-income and middle-income countries: a systematic review and meta-analysis. \u003cem\u003eNutrients\u003c/em\u003e \u003cb\u003e12\u003c/b\u003e (1), 116 (2020).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKumar, P., Zode, M. \u0026amp; Basu, S. The effectiveness of facility-based management of children with Severe acute malnutrition and their determinants in Jharkhand, India: A retrospective study. \u003cem\u003eDialogues Health\u003c/em\u003e. \u003cb\u003e2\u003c/b\u003e, 100096 (2023).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBurza, S. et al. Community-based management of severe acute malnutrition in India: new evidence from Bihar. \u003cem\u003eAm. J. Clin. Nutr.\u003c/em\u003e \u003cb\u003e101\u003c/b\u003e (4), 847\u0026ndash;859 (2015).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eParikh, V. \u0026amp; Amreliwala, M. J. OVERVIEW OF CHILD MALNUTRITION TREATMENT CENTRES (CMTC) SERVICES THROUGH QUALITY DIMENSIONS OF SERVQUAL MODEL. \u003cem\u003eIndian J. Home Sci.\u003c/em\u003e \u003cb\u003e33\u003c/b\u003e (1), 1 (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatl\u0026aacute;n-Hern\u0026aacute;ndez, A. R. et al. Water, sanitation and hygiene interventions and the prevention and treatment of childhood acute malnutrition: A systematic review. \u003cem\u003eMatern. Child Nutr.\u003c/em\u003e \u003cb\u003e18\u003c/b\u003e (1), e13257 (2022).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Cooten, M. H., Bilal, S. M., Gebremedhin, S. \u0026amp; Spigt, M. The association between acute malnutrition and water, sanitation, and hygiene among children aged 6\u0026ndash;59 months in rural E thiopia. \u003cem\u003eMatern. Child Nutr.\u003c/em\u003e, \u003cb\u003e15\u003c/b\u003e(1), e12631. (2019).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMomberg, D. J. et al. Water, sanitation and hygiene (WASH) in sub-Saharan Africa and associations with undernutrition, and governance in children under five years of age: a systematic review. \u003cem\u003eJ. Dev. 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(n.d.). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.rchiips.org/nfhs\u003c/span\u003e\u003cspan address=\"http://www.rchiips.org/nfhs\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003eHow to Calculate Weight-for-Height Z-Score (WHZ) in Children 0\u0026thinsp;\u0026ndash;\u0026thinsp;59 Months of Age\u003c/em\u003e. (n.d.). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.fantaproject.org/sites/default/files/download/Calculate-WHZ-2.6-NACS-Users-Guide-Apr2016.pdf\u003c/span\u003e\u003cspan address=\"https://www.fantaproject.org/sites/default/files/download/Calculate-WHZ-2.6-NACS-Users-Guide-Apr2016.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReddy\u0026sup1;, S. et al. 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T., Ketema, I., Habte, S., Goshu, A. T., Mehadi, A., \u0026hellip; Ayele, B.H. (2023). Relapse of acute malnutrition and associated factors after discharge from nutrition stabilization centres among children in Eastern Ethiopia. Frontiers in Nutrition, 10, 1095523..\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e.Brown, J., Cairncross, S. \u0026amp; Ensink, J. H. Water, sanitation, hygiene and enteric infections in children. \u003cem\u003eArch. Dis. Child.\u003c/em\u003e \u003cb\u003e98\u003c/b\u003e (8), 629\u0026ndash;634 (2013).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorldHealthOrganization[WHO].Guideline. \u003cem\u003eUpdates on the Management of Severe Acute Malnutrition in Infants and Children\u003c/em\u003e (World Health Organization, 2013). 9789241506328_eng.pdf.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLambebo, A., Tamiru, D. \u0026amp; Belachew, T. Time to relapse of severe acute malnutrition and risk factors among under-five children treated in the health posts of Hadiya Zone, Southern Ethiopia. \u003cem\u003eJ. Nutritional Sci.\u003c/em\u003e \u003cb\u003e10\u003c/b\u003e, e105 (2021).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eICMR-NIN Expert Committee. Dietary Guidelines for Indian-2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChisti, M. J. et al. Prevalence, clinical predictors, and outcome of hypocalcaemia in severely-malnourished under-five children admitted to an urban hospital in Bangladesh: a case-control study. \u003cem\u003eJ. Health Popul. Nutr.\u003c/em\u003e \u003cb\u003e32\u003c/b\u003e, 270\u0026ndash;275 (2014).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSmilie, C. et al. Prevalence and predictors of hypocalcaemia in severe acute malnutrition. \u003cem\u003ePublic. 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Pediatr.\u003c/em\u003e \u003cb\u003e163\u003c/b\u003e, 742\u0026ndash;744. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00431-004-1517-7\u003c/span\u003e\u003cspan address=\"10.1007/s00431-004-1517-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2004).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChowdhury, B. et al. Serum zinc, copper, magnesium \u0026amp; phosphorus level in children with severe acute malnutrition (SAM). \u003cem\u003eMymensingh Med. J.\u003c/em\u003e \u003cb\u003e25\u003c/b\u003e, 635\u0026ndash;640 (2016).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGhone, R. A. et al. A study of oxidative stress biomarkers and effect of oral antioxidant supplementation in severe acute malnutrition. \u003cem\u003eJ. Clin. Diagn. Res.\u003c/em\u003e \u003cb\u003e7\u003c/b\u003e, 2146\u0026ndash;2148. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7860/JCDR/2013/ 6019.3454\u003c/span\u003e\u003cspan address=\"10.7860/JCDR/2013/ 6019.3454\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2013). published online.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChaudhari, M. \u0026amp; Shukkoor, T. \u003cem\u003eImpact of Public Health Programs on Maternal and Child Health in Gujarat\u003c/em\u003e 144 (Growth Trajectory of Gujarat\u0026mdash;Public Policy Intervention, 2025).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cdiv class=\"SimplePara\"\u003eMean number of days to relapse after discharge (n\u0026thinsp;=\u0026thinsp;56)\u003c/div\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003eMean days\u003c/div\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003eSE\u003c/div\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e95% CI\u003c/div\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eGender\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eFemale\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e238.8\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e95.1\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e48.1\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cdiv class=\"SimplePara\"\u003e429.4\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eMale\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e162.8\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e53.8\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e55.0\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cdiv class=\"SimplePara\"\u003e270.7\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eAge\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003e11\u0026ndash;36 months\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e146.8\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e18.7\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e109.3\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cdiv class=\"SimplePara\"\u003e184.2\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003e37\u0026ndash;62 months\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e224.2\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e79.7\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e64.4\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cdiv class=\"SimplePara\"\u003e384.0\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eTotal\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e193.2\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e48.2\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e96.6\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cdiv class=\"SimplePara\"\u003e289.8\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eNote: SE: Standard Error; CI: Confidence Interval\u003c/span\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003cbr/\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cdiv class=\"SimplePara\"\u003eDistribution of relapse and non-relapse rates by children's background characteristics\u003c/div\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003eNon-relapse\u003c/div\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003eRelapse\u003c/div\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cdiv class=\"SimplePara\"\u003en\u003c/div\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eGender of children\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eFemale\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e13.3\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e86.7\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cdiv class=\"SimplePara\"\u003e30\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eMale\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e23.1\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e76.9\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cdiv class=\"SimplePara\"\u003e26\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eAge of children\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003e11\u0026ndash;36 months\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e12.1\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e87.9\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cdiv class=\"SimplePara\"\u003e33\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003e37\u0026ndash;62 months\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e26.1\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e73.9\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cdiv class=\"SimplePara\"\u003e23\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eTotal\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e82.1\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e17.9\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e56\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003cbr/\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cdiv class=\"SimplePara\"\u003eKey factors influencing relapse and non-relapse rates among children\u003c/div\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eKey factors\u003c/div\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003eNo relapse\u003c/div\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003eRelapse\u003c/div\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003en\u003c/div\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eHealth condition\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eHas the child ever been sick since discharge?\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e88.9\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e11.1\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e41\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e63.7\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e27.3\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e15\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eHygienic Practices\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eLatrine/Toilet type\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003ePublic and Private\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e85.1\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e14.9\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e47\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eOpen defecation\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e66.7\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e33.3\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e9\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eTotal\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e82.1\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e17.9\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e56\u003c/span\u003e\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003cbr/\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cdiv class=\"SimplePara\"\u003eNutritional deficiencies in 10 SAM children based on 24-hour dietary recall \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e(N\u0026thinsp;=\u0026thinsp;10)\u003c/span\u003e\u003c/div\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eNutritional Deficiency Indicators\u003c/div\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003ePercentage\u003c/div\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eEnergy deficit\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e64.9\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eProtein deficit\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e18.7\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eFat deficit\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e44.0\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eIron deficit\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e62.3\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eCalcium deficit\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e64.2\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cdiv class=\"SimplePara\"\u003eZinc deficit\u003c/div\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cdiv class=\"SimplePara\"\u003e69.1\u003c/div\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003cbr/\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Child Malnutrition Treatment Centres (CMTC), Severe Acute Malnutrition (SAM), Hygiene, Feeding Behaviour, Relapse","lastPublishedDoi":"10.21203/rs.3.rs-7788572/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7788572/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMalnutrition among children under five years of age is a pressing health concern in India, especially in the state of Gujarat. To combat this, Child Malnutrition Treatment Centres (CMTCs) have been set up to treat children suffering from Severe Acute Malnutrition (SAM) with medical complications. However, a significant number of children relapse after discharge, necessitating exploration of the factors contributing to relapse.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBetween October and December 2024, a cross-sectional study was conducted in Devbhoomi Dwarka, Gujarat, involving 56 children discharged from two CMTCs. The research collected data through structured interviews with caregivers, anthropometric measurements, and evaluations of hygiene practices and feeding behaviors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 56 children, discharged between June 2023 – September 2024, 10 children that is 18 per cent of the children relapsed into SAM after being discharged. The mean relapse time for females was 238.8 days, whereas for males, it was 162.8 days, indicating that male children relapse more quickly than females. The survival curves for the 11–36 months age groups showed a more rapid decline between 100 and 140 days, highlighting this period as critical. In addition, younger children aged 11–36 months were more prone to relapse than older children aged 37–62 months. Poor hygiene practices were strongly linked to higher relapse rates, with 33.3 per cent of children practicing open defecation relapsing compared to 14.9 per cent of those using toilets.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese findings highlight the importance of addressing environmental and behavioral factors, such as hygiene practices, in the post-discharge care of children with SAM. A long-term community-based follow-up of all CMTC/Nutritional Rehabilitation Centre (NRC) discharged children at risk should be incorporated. A holistic approach that includes health, nutrition, and hygiene education for caregivers is crucial to reduce relapse rates and ensure long-term recovery in these vulnerable children.\u003c/p\u003e\n\u003cp\u003eThe findings underscore the importance of effective monitoring of post-discharge children within 100-140 days, particularly for younger males. The findings also underscore the importance ofpractising hygiene and feeding practices to reduce relapse rates and ensure long-term recovery for these vulnerable children.\u003c/p\u003e","manuscriptTitle":"Long-term Follow-up of Children Discharged from Child Malnutrition Treatment Centres in Gujarat","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-15 16:12:58","doi":"10.21203/rs.3.rs-7788572/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5aa2a2ce-753b-496b-becb-4f4ff85fcbd0","owner":[],"postedDate":"December 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":59619248,"name":"Health sciences/Diseases"},{"id":59619249,"name":"Health sciences/Health care"},{"id":59619250,"name":"Health sciences/Medical research"},{"id":59619251,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2026-05-04T06:57:26+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-15 16:12:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7788572","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7788572","identity":"rs-7788572","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}