Dear Anonymous,
Firstly let me underline that there is no MAXIMUM stay in OTP as suggested in a previous reply. The child should be treated with RUTF until they have reached discharge criteria. If guidelines recommend discharging a child from OTP after a maximum of 8 weeks of treatment they should be revised as a matter of urgency and the latest WHO recommendations used.
WHO recommends that children admitted by WFH should be discharged by WFH criteria, whilst those admitted by MUAC should be discharged by MUAC criteria.
The old discharge criteria introduced many years ago by Valid International for MUAC programming suggested:
MUAC > 11.5cm +
a MINIMUM stay of 8 weeks +
No edema and clinically well for at least 2 weeks
These criteria have largely been replaced by WHO recommendations which, for MUAC admissions recommend:
- a MUAC of > 12.5cm and edema absent for 2 consecutive weeks
- Clinically well
In a study in Malawi using MUAC 12.5cm as the discharge threshold for children ADMITTED USING MUAC, there was a very small relapse rate (1.9%). It was found that there was little difference between children discharged to SFP and those discharged without SFP. There was a slight positive effect noted for those receiving SFP although the study was not powered to indicate any significant differences.
The length of stay in OTP depends on how malnourished the child was to begin with. The more malnourished they are the longer they need to stay in treatment for recovery. In the Malawi study children admitted with a MUAC above 11cm took about 6 weeks to recover. Children admitted with a MUAC below 10cm took up to 15 weeks to recover (to a discharge criterion of MUAC > 12.5cm). It should be noted that this study was done in a stable context in MoH clinics (although there was seasonal food insecurity in some area). Care should be taken when extrapolating the results to emergency contexts.
The cause of relapse of children discharged from OTP will be context dependent. During recovery, RUTF should be given before other family foods. This does not mean that RUTF should be fed exclusively until discharge. Counselling regarding IYCF and the use of family foods should be given, especially during the latter stages of recovery. While I have heard many reports of children relapsing because they refuse to eat other foods apart from RUTF, I have never seen a verifiable case that couldn't be explained by some other mechanism. I would suggest that those cases that appear to be doing so, should have a follow up in the community to identify other potential health issues and feeding practices in the home and receive the necessary counselling.
For the children discharged with a WFH > -1.5 z scores, you can carry on using that discharge criterion for WFH admissions.
Regarding the use of a 'maintenance dose of RUTF' until follow up, this practice largely depends on the amount of funding and supplies you have. There is very little difference between RUTF and RUSF and the giving of 1 packet per day of RUTF is effectively maintaining the child in a 'SFP programme'. You may wish to consider sourcing RUSF instead of RUTF as a cheaper alternative if this is a possibility. If resources are tight then it should be ok to discharge the child without 'maintenance RUTF' and follow them up as you would normally do.
I hope this helps.