Hi Anonymous,

Guidelines vary so the first reference should be your national CMAM guidelines. The rationale for a discharge ration of RUTF also varies depending on who you speak to and is anecdotal rather than evidence based. These were largely born out of cautious approaches to discharge in early CTC / CMAM programmes but has become a 'fact' or a 'protocol' through repetition and inclusion in training modules. Whether the guidance appears in a guideline tends to depend on the previous practices and experience and preferences of the team developing them.

Rationales I have heard include:

1. The child becomes addicted to RUTF and will not eat family food so needs a 'weaning ration' to transition to a normal diet

2. The child will relapse if RUTF is discontinued suddenly

3. It is additional supplementary support for 1-2 weeks after OTP

In my opinion (also anecdotal based on experience) none of these is correct.

If you feel that food insecurity may be an issue then the programme should consider referring the child to an SFP following discharge from OTP for continuing nutritional support and monitoring rather than offering a limited 'discharge ration'.

In an integrated programme (e.g. integrated with primary health services) then ongoing monitoring and support could be done through maternal and child nutrition clinics / under-5 clinics / IYCF or growth monitoring programming.

In my personal opinion 'discharge rations' are costly on a programme level (almost one box RUTF / 20 cases) and unnecessary if you are using WHO recommended discharge criteria and monitor the child post discharge as is recommended by WHO (see 2013 updates). Any rationale I have heard of can be dealt with in other ways than giving additional RUTF following cure. Family foods should not be withheld from the child until recovery so that 'weaning' or 'transition' to family foods should not be an issue.

If you feel that you must give a discharge ration then a reference for this is the first CTC guideline by Valid International (which states 7 packets):

http://www.validinternational.org/docs/CTC%20Field%20Manual.pdf

also FANTA training module on CMAM (give a discharge ration):

https://www.fantaproject.org/sites/default/files/resources/CMAM_Training_Mod4_ENGLISH_Nov2008.pdf

Bear in mind that these recommendations were given when the children were discharged with specific discharge criteria (MUAC > 11cm + 2 months minimum stay + sustained weight gain) which are lower than the MUAC > 12.5 cm recommended by WHO.

This issue has also been mentioned / discussed on en-net in other posts in the past with varying responses:

https://www.en-net.org/question/2678.aspx
https://www.en-net.org/question/490.aspx
https://www.en-net.org/question/1085.aspx

I hope this helps,

Paul