Actually thats the safest and effective way as out patient treatment ensures that those children are not exposed to other infections as it would have been the case with in patient treatment. From experience in the Malawi CMAM programme, most children postively respond to treatment and the oedema quickly subsides within a short number of days.

Treating children with edema grade 1 and grade 2 is very safe and effective as long as CTC guide line protocols are followed properly and there is enough evidence to back up this information currently in Malawi children without complications with edema grade1 and 2 are being treated in all districts and the results have shown that over 90% of children are cured within few weeks of treatment.

Can somebody educate me about this edema grading system that is being referred to? I have heard people mention this, but none of the major standard international references (see below) that i checked on how to manage acute malnutrition describe what this grading system means or how to differentiate one grade of edema from another. And what is the significance of a higher grade of edema? Perhaps i am thinking too simplistically, but doesn't it essentially mean that the edema has been accruing for a longer period of time? Does it actually signify a different pathophysiological process or etiology of the edema? And if we believe that a given disease comes in gradations, with some patients having more severe or longstanding disease than others, than does that mean that the therapy should changed from something that has consistently been proven better (in this case, RUTF outpatient therapy) than to something that has consistently been proven inferior (inpatient milk-based therapy)? My point :: The essential criteria about starting a child on outpatient management with RUTF vs. admitting them to hospital is not some antiquated subjective grading system but rather whether the child has an appetite. It is not particularly relevant how edematous a child is -- if they demonstrate a good appetite, treat them as outpatients with RUTF. The diagnostic criteria of appetite-or-no-appetite can be applied more consistently and reliably than grade-1-2-3 by minimally trained health workers in the rural communities where these children live. Especially when there is no standard reference manual to educate these health workers to know what grade-1-2-3 is. Let's stop talking about grades of edema -- it is meaningless. (references checked :: 1999 WHO "Management of severe malnutrition: a manual for physicians and other senior health workers"; 2000 WHO "Management of the child with a serious infection or serious malnutrition"; 2005 WHO "Pocket book of hospital care for children"; 2006 Valid International "Community-based therapeutic care (CTC): a field manual"; 2007 WHO "Community-based management of severe acute malnutrition"; 2009 "WHO child growth standards and the identification of severe acute malnutrition in infants and children")

I have noted some concerns from your post regarding the understanding of how oedema is graded. I will refer you to the simplest and easiest to understand book by virtually anyone written by Ann Ashworth and Ann Burgess (2003)"Caring for severely malnourished children" as one of the references which can help you understand this grading system. The science explaining how oedema develops is there, but i will say it is complex and inconclusive but the evidence is enough to appreciate its use and appreciate it. This is comprehensively written in the famous book written by Waterlow (2006) "Protein energy malnutrition".

A couple of references that may be helpful: The SCN Nutrition Policy Paper No. 21 WHO, UNICEF, and SCN Informal Consultation on Community-Based Management of Severe Malnutrition in Children. See p63 for a breakdown on recovery rates for children with nutritional oedema disaggregated between those that were directly addmitted to OTP and those that had an inpatient phase of treatment. And: Ciliberto, M. A., Manary, M. J., Ndekha, M. J., Briend, A. and Ashorn, P. (2006), Home-based therapy for oedematous malnutrition with ready-to-use therapeutic food. Acta Paediatrica, 95: 1012–1015.

Here is another reference - the Training Guide for CMAM, developed by FANTA. I has a clear description. You may think the gradation is not subjective after looking this over. In our programs, I encourage our staff to stick to established protocols, including the appetite and medical exam at each OTP session. I am not a fan of relying on only the appetite test to determine whether children can be in OTP or not. I have seen programs where this was done and children got sent to OTP or even SFP with very dangerous conditions, even while having eaten the Plumpy'Nut. Oddly, we have also had our own donor push to skip the appetite test since they felt it was a waste of Plumpy'nut and then rely only on the medical exam and/or questioning the mother to determine whether the child should be in OTP or SC. I am also not in favor of this and we refused. http://www.fantaproject.org/downloads/pdfs/CMAM_Training_Mod2_ENGLISH_Nov2008.pdf