Hi, It would be good to know your countries recommendations for exit and entry criteria but 12 in the absence of SFP would be safer. once a child recorver's it's important that you follow them up for two consecutive visits to avoid relapse and after which you give 7 satchets as a weaning off ration. if the changes in weight are negligible it is important that you work as a team with the other members to review in case there are underlying medical conditions or with community volunteers to assess home situation and after ruling out is when you can make a proper judgement. Insufficient dosing of RUTF I would not recommended because the food is given as medication and therefore you may not achieve desirable results after the given period which is usually one month. MUAC usually measures adipose tissue which means that as MUAC increases the body weight also increases so this is a rare occurrence. This is dificult but I think 6mm would be sufficient in a day. Since we know that MUAC is a good screening tool I would recommend that for good results use height/length, weight because there are reference charts for it and they give more reliable information than MUAC

Just picking up on the MUAC comments. (1) MUAC measures bone, skin, neuro-vascular bundle, muscle, and fat in the upper arm. The relative proportion of fat to muscle in the upper arm changes with age (i.e. more fat in younger children). Recently collected data shows that recovery from SAM exhibits deposition of both muscle and fat in the upper arm. The response of MUAC to treatment means that it can be used for screening, admission, monitoring of response, and discussion to discharge. The relationship between MUAC gain and weight gain is consistent and linear so we can use MUAC in place of weight for monitoring. More work is needed to work out how best to do this. (2) There is no evidence that MUAC is less reliable than W/H. The available evidence is to the contrary. That is, MUAC is measured more accurately and more reliably than W/H. I am interested to know why you think otherwise. Have I missed some key research? (3) There are MUAC/A and MUAC/H references just as there are W/A, H/A, and W/H references. They are not used much as raw MUAC works well enough at selecting children at high of death if untreated (sometimes better that using MUAC/A or MUAC/H and very much better than using W/H).

Hi Mark, It's quite interesting to learn from you that there are MUAC/A and MUAC/H cut offs I would be interested if you shared with me these otherwise from what I know MUAC would only tell you more of increase in adipose tissue and not linear growth. I believe any nutrition programme would be interested in managing the child wholly which involves knowing their height as well as weight (MUAC)

See [url=http://www.who.int/childgrowth/standards/ac_for_age/en/] for the WHO MUAC/A reference[/url]. See [url=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2486965/pdf/bullwho00395-0041.pdf] for a MUAC/H reference[/url]. MUAC/H and MUAC/A are not often used as they tend not to preform as well as raw MUAC at the task of predicting survival and are more complicated to use. You are right in that MUAC is not measuring linear growth that requires repeated measurements of hight and length. MUAC measures more than adiposity. There is skin, bone, neuromuscular bundle, and fat (non-connective adipose tissue) but there is also muscle. It is also affected by hydration but less so that W/A and W/H. We are on a SAM forum ... In SAM we are seldom (almost never) interested in height. Some programs still use W/H but this is used as a composite indicator and is measuring weight with a height adjustment. OTP is a child survival program and the best indicator is one that best predicts survival. MUAC does this job pretty well (better than other practicable indicators).

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There has been some work on safe discharge criteria for OTP in the absence of SFP. This has concentrated on the MUAC >= 125 mm threshold. All the work I have seen. Some programs are already using this threshold.

in my experience; The exit criteria of OTP MUAC cut off is >11.5 for two consecutive visit weight gain and clinical well. Also there was some indication for discharge criteria of SAM case MUAC >12.5 for two consecutive visit where their is no SFP program.