Review of observational data on post-diarrheal nutritional recovery trajectories in malnourished children aged 6 to 35 months

Although the cooccurrence of diarrhea and malnutrition is well documented, research has largely focused on the acute management of diarrheal illness. Despite its importance, longitudinal evidence characterizing post diarrheal recovery trajectories is sparse. We sought to characterize post diarrheal nutritional recovery trajectories among children aged between 6 and 35 months who were malnourished at enrollment using data from the Enterics for Global Health (EFGH) Shigella Surveillance study (2022 to 2024). EFGH enrolled children aged between 6 and 35 months presenting with medically attended diarrhea and followed them at 4 weeks and 3 months post enrollment. This analysis included children with baseline wasting, stunting, or underweight (z score < 2) and complete anthropometric follow up. Latent class mixed effects models were used to identify distinct post diarrheal growth trajectories based on changes in anthropometric z scores over time. Multinomial modified Poisson regression models examined associations between baseline factors and trajectory membership. Among 9,480 enrolled children, 16.5% (n=1,561) were wasted, 22.7% (n=2,155) stunted, and 21.0% (n=1,994) underweight at baseline. Wasting showed greater recovery potential (80.8%) compared with stunting (38.5%) and underweight (40.3%). Recovery was shaped by factors across multiple levels. Clinical severity markers (prolonged diarrhea, dehydration, and hypoxemia) increased the risk of nutritional failure. Age also influenced outcomes: infants were more likely to worsen, whereas older toddlers more often experienced stagnation. Interventions including exclusive breastfeeding, oral rehydration therapy, appropriate antibiotics, and zinc supplementation, improved outcomes, while unimproved sanitation undermined recovery. These findings highlight the need for integrated strategies combining infection control, nutritional rehabilitation, and water, sanitation, and hygiene interventions tailored to the developmental stage of the child.