Dear El, This is a good question. Let me share what we do in our project in West Bengal India. We have no Community based management for SAM with RUTF so all cases of SAM are treated in the facility.We have many cases of defaulting from the facility like you mention- no complications, MUAC >11.5 <12.5. Mothers in most cases are unable to stay in the facility till such time that the child reaches a green MUAC. We admit a child in such cases to the MAM programme because that is the best we can do - in addition to the MAM ration we think the major advantage is that with fortnightly contacts there is better monitoring of the child's nutritional status and opportunities to educate the mother on better care practices. I am not sure where your project is situated and what is the mortality related to SAM but typically in our project area mortality with a RED MUAC is lower than reported from African contexts. In this situation, the approach employed above works for us. Look forward to other responses

I totally agree with doctor Charulatha.

I would treat this case as an interrupted treatment episode for SAM. This is a recovering SAM case and should be treated as such (i.e. re-admitted into the SAM program to complete the treatment episode). This is not a "MAM never SAM" case or a "SAM case spontaneously recovered to MAM" so entry into a MAM program is not indicated. This is looking at the issue from the perspective of individual cases. We can look at this from a program coverage perspective. A returning defaulter is a good thing. We want to have no defaulters. Failing that, we want defaulters to come back to the program. I think that "punishing" the defaulter by putting them on a second tier program (i.e. less appetising food with lower energy density than RUTF, less clinical supervision, no systemic antimicrobials, &c.) may not be the best message to be giving out if you want defaulters to return. I have to take issue with: I am not sure where your project is situated and what is the mortality related to SAM but typically in our project area mortality with a RED MUAC is lower than reported from African contexts. In this situation, the approach employed above works for us. This is unlikely to be true as one of the main reasons for using MUAC in CMAM programs is that mortality risk at different MUAC thresholds is similar regardless of location (so much so that it is reasonable to assume that all studies measured the same underlying rate). See [url=http://www.brixtonhealth.com/FNB.27.3.Myatt.pdf]this Food and Nutrition Bulletin article[/url] for a review of evidence. It may be that you are mistaking case-fatality under treatment for case-fatality without treatment. Case-fatality under treatment will depend on factors such as early treatment seeking, timely case-finding and recruitment, and compliance of program and beneficiary which are known to vary from program to program.