guidelines for the integrated management of severe acute malnutrition

ACF-In Guidelines for the integrated management of SAM Out-patient 54
Discharge Procedure
1. Criteria of discharge
The children are discharged when they reach the discharge criteria shown in the following table.
Less than 6 months See separate section for these infants.
6 months to 59 months • W/H - W/L ≥-1.5 score (WHO growth standards 2006) 1 on
more than one occasion 2 (Two days for inpatients, two
weeks for outpatients) and
Standard OTP discharge is used for children who have had their height measured, whether they have
been admitted on MUAC or weight-for-height criteria.
All the patients should be discharged to supplementary feeding programme (SFP) for follow up where
this is available. Where this is not available the criteria for discharge should be more conservative or
caretakers could be requested to come back for anthropometric follow up only, i.e. every two weeks
during one month.
2. Recording the outcome of treatment
The following are the possibilities:
• MUAC above admission criteria and
• No oedema for 14 days
5 to 10 years • W/H ≥ 85% NCHS on more than one occasion (Two days
for inpatients, two weeks for outpatients) and
• No oedema for 14 days
Adults • Refer to adults guidelines
Other age groups • Refer to ACF nutrition advisor for specific cases
- Cured: the patient has reached the criteria for discharge
- Dead: if the patients died during treatment in the OTP
- Defaulter: the patient has not returned for 2 consecutive visits and a home visit confirms that
the patient is not dead
1 Children often gain height quite rapidly on RUTF. The situation can arise where they do not reach the
discharge criteria because they are gaining height so rapidly that the “target” weight continues to increase as fast
as or faster than their actual weight. Height gain is a much better indicator of nutritional health than weight gain
and such a rapid gain in height indicates nutritional wellbeing. This reversal of stunting on the other hand is very
beneficial for the child; if logistics, space and resources permit it is desirable to keep these children in the
programme until their “height spurt” slows. If there is pressure on space, RUTF supply, staff and other resources
then the admission height can be used to determine the target weight to be gained before discharge.
2 Frequently, when mothers are told that their child has reached the discharge weight and will be discharged
after the next visit the child loses weight in the subsequent week because the mothers want to remain in the
programme to obtain RUTF or other benefits for the family. If this is commonly found then either the mothers
should not be made aware that their child will be discharged at the next visit, or the child can be discharged after
reaching the target weight on one occasion. In the latter case the weight should be double-checked before
discharge.