Addressing dual deficiencies of SAM indicators; gaps and insights from inpatient admission to outpatient discharge, in conflict-affected Yemen; a retrospective study

Abstract

Background

Severe acute malnutrition (SAM) remains a critical public health challenge in conflict-affected settings, where children face heightened vulnerability. Dual deficiencies in weight-for-height z-score (WHZ < -3) and mid-upper arm circumference (MUAC < 11.5 cm) indicate a more severe form of SAM, yet current admission protocols prioritize WHZ-based criteria for inpatient therapeutic feeding centers (TFCs). This approach may exclude children with MUAC deficiencies from optimal inpatient care, potentially impacting recovery outcomes in outpatient therapeutic programs (OTPs). In Yemen, prolonged conflict has exacerbated SAM burdens, leading to an expansion of TFC and OTP services since 2015. The aim is to determine whether existing WHO recovery criteria adequately support comprehensive recovery and prevent premature discharge.

Method

A retrospective analysis was conducted using data from a prospective longitudinal study of children admitted with complicated SAM to TFCs in Sana’a City from September 2023 to November 2024. Children were categorized based on SAM diagnostic criteria (WHZ < -3, MUAC < 11.5 cm, or both) and analyzed under four discharge scenarios: (1) WHZ recovery, (2) MUAC recovery, (3) recovery by either WHZ or MUAC, and (4) recovery of both indicators. Chi-square and Kruskal-Wallis tests were used to assess differences between groups, and P < 0.05 was used to determine statistical significance.

Results

Among 188 children admitted with complicated SAM, 56% (105) were female, 53% (100) were aged 6–<12 months, and 59% (111/188) presented with dual deficiencies. Admission based on WHZ criteria accounted for 82% (154/188) of admissions, of whom 72% also had MUAC < 11.5 cm. At OTP discharge, 96% met WHO recovery criteria, yet only 38% achieved full recovery (WHZ ≥ -2 and MUAC ≥ 12.5 cm). Full recovery was significantly lower among children with dual deficiencies at TFC admission than those with single deficiencies in MUAC or WHZ (31% vs. 47% and 51%, respectively, p = 0.032).

Conclusions

These findings underscore the need to integrate WHZ and MUAC into discharge criteria to prevent premature discharge and ensure comprehensive recovery. Revising WHO protocols and enhancing SAM management in conflict-affected settings are critical to improving treatment outcomes.