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How long to continue RUTF for SAM children enrolled in OTP?

This question was posted the Management of wasting/acute malnutrition forum area and has 5 replies.

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Normal user

12 Oct 2016, 11:03

Dear all,
I would like to know for how long RUTF should be continued in SAM children in the absence of SFP?
Protocol says that the discharge criteria for SAM is W/H - W/L =-1.5 score (WHO growth standards 2006) on more than one occasion 2 (Two days for inpatients, two
weeks for outpatients) and MUAC above admission criteria and No oedema for 14 days and then enroll them into SFP for follow up.
We do not have functional SFP in our project area. Also we have observed that children who were eating 2 to 3 packets of RUTF per day refused to take another food hence causing loss of weight after their doscharge from OTP.
So we are rethinking if we should directly stop RUTF once children are discharged from OTP or they should be given maintenance dose of RUTF till the time of follow up?

Health and Nutrition Developments Society


Normal user

12 Oct 2016, 19:20

According my experience Children can be discharged MUA over >12.5cm for 2 consecutive visit
Weight/Height zcore over >-2 % sustained weight gain and clinically well
No Odema for 2 consecutive visits,
Medical complications controlled resolved without complications totally
Given 2 weeks ration follow up to prevent relapse.

Desta zeweldi

Emergency Nutrition program manager /concern

Normal user

13 Oct 2016, 08:01

dear All
as we know the maximum length of stay in any OTP program is two months. But the recovery may be less than that. If an individual is admitted to our OTP program by MUAC the discharge criteria is target weight for two consecutive visits and if by WFH median the discharge will be WFH>=85 then it has to be linked to a SFP. But in areas with no SFP two weeks ration +feeding counselling has to be given to the care taker.


Technical expert

14 Oct 2016, 10:05

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.

Marie McGrath

Technical Director, ENN

Frequent user

14 Oct 2016, 16:06

Dear Anon,
You may be interested in an article that will feature in Field Exchange 53 (end Oct) that details the findings of the first phase of the ComPAS study, that is investigating a combined simplified protocol for SAM and MAM treatment. The article is available online early.

Best regards

Nitsuh Fikir

Public Health

Normal user

28 Oct 2016, 12:46

Anonymous 2862,

According to Ethiopian SAM guideline, if the child didnt reach the discharge criteria after '8 WEEKS', then we will discharge him as NON RESPONDENT and refer him/her for medical follow-up (for treatment of other underlying problems). In south Sudan, SAM child who did not meet discharge criteria after 4 MONTHS in OTP is discharged as NON RESPONDENT.

Similarly, you need to refer to your national guideline where you are operating. Depend on the context, a SAM child who fails to meet the discharge criteria between 8 - 12 WEEKS should be discharged as 'non respondent’

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