**Background:** Wasting affects at least 45 million children worldwide and is associated with increased morbidity and mortality. Children successfully discharged from nutritional treatment remain at elevated risk of relapse (up to 37%), postdischarge mortality (up to 9%), and increased burden of morbidities such as fever, cough, and diarrhea. Current WHO guidelines provide no or limited recommendations for postdischarge interventions. This systematic review was commissioned by the WHO in 2021 to evaluate evidence on postdischarge interventions for children treated for moderate or severe wasting, growth failure or faltering, or edema.
**Methods:** The review followed PRISMA and Cochrane Handbook guidelines, with a protocol registered in Prospero (CRD42022308380). Eight databases were searched from inception through December 2021 without language or geographical restrictions. Eligible studies included individually randomized clinical trials (RCTs), cluster RCTs, quasi-randomized studies, controlled before-after studies, or interrupted time series assessing children aged 0–59 months treated for MAM, SAM, growth faltering/failure, or edema. Interventions had to be delivered partially or completely after discharge from nutritional treatment. Outcomes included relapse, deterioration to severe wasting, readmission, anthropometric measures, all-cause mortality, or morbidity up to 6 months after discharge. Two reviewers independently screened, extracted data, and assessed risk of bias using Cochrane Risk of Bias 2 and ROBINS-I tools. Certainty of evidence was assessed using GRADE.
**Key Results:** From 7124 records, 8 studies (5 RCTs, 2 cluster-RCTs, 1 quasi-experimental study) from 7 countries (Ethiopia, Kenya, India, Democratic Republic of the Congo, Lesotho, Bangladesh, Malawi) with 5965 participants were included, published between 2003 and 2019. Six studies enrolled children admitted to hospital, 1 in an outpatient therapeutic program, and 1 in a community-based supplementary feeding program. Six studies included children treated for SAM, 1 for MAM, and 1 for protein-energy malnutrition. No studies addressed growth faltering, growth failure, or edema.
BIOMEDICAL INTERVENTIONS
Zinc supplementation (10 mg/day from admission to 90 days postdischarge) was associated with higher MUAC and WAZ at 90 days, and lower prevalence of diarrhea, skin infections, vomiting, fever, acute respiratory infection, and pallor at 30, 60, and 90 days (moderate certainty). Co-trimoxazole prophylaxis (6 months) showed no association with reduced mortality or adverse events (low risk of bias).
FOOD SUPPLEMENTATION
Nonmilk-based local therapeutic food (833 kcal/day for 6 weeks) was associated with improved weight gain and anthropometric outcomes at 6 weeks (low certainty). Lower-dose supplementation (150 kcal/day for 3 months) showed no benefit.
PSYCHOSOCIAL STIMULATION
One quasi-experimental study found improved WAZ at 6 months (−3.1 vs −3.6; P=0.03), but RCTs showed no significant anthropometric improvements (very low certainty).
CASH TRANSFERS
Unconditional cash transfers (US $40/month for 6 months) were associated with reduced MAM relapse (HR 0.21; 95% CI 0.11–0.41) and SAM relapse (HR 0.30; 95% CI 0.16–0.58), and positive anthropometric changes (moderate certainty).
INTEGRATED PACKAGE
Biomedical support, food supplementation (200 kcal/day for 8 weeks), and malaria prevention showed improved sustained recovery at 1 month (78% vs 74%; P=0.04), 3 months (69% vs 63%; P=0.02), and 6 months (64% vs 59%; P=0.04), but no effect on relapse, deterioration to severe wasting, or all-cause mortality (low certainty).
Risk of bias was low for 4 studies, moderate for 2, and high for 2. No intervention reduced all-cause mortality.
**Clinical Implications:** This review confirms a paucity of evidence on postdischarge interventions for children treated for acute malnutrition. Biomedical interventions (zinc), cash transfers, and integrated packages show promise but require replication in contemporary settings. The findings support the need for rigorous evidence on efficacy, effectiveness, and programmatic feasibility to inform global policy. Future research should standardize outcome definitions, report outcomes by treatment phase, include longer follow-up, and assess subgroup effects to identify children most likely to benefit.