The weeks after the sachets finish

The weeks a child spends on treatment are the weeks the household has the most help. There is a food that only that child eats, a weight taken every week, and somebody asking questions. The child gains, everybody can see it, and then the course ends.

What ends on that day is the support. What has not changed is the household. The same number of pots, the same money, the same hungry months coming. If nothing else has been put in place, the child goes back to exactly the conditions that made her ill.

This is why relapse is common and why it is not a failure of the treatment. The treatment did what it does. The months after it are a separate piece of work, and they belong to the household with the field team alongside.

Two things change, and both matter more than they sound. The child loses a food that nobody else could touch, and she loses her place at the front of the queue.

During treatment, that child ate first and ate separately, because the sachets were hers. Afterwards she is back at the shared pot with older siblings who eat faster and reach further. A three-year-old competing with a nine-year-old for the same dish loses every time.

The mother's attention also goes back to where it was needed all along, to the garden, the market, the other children. The child who was watched closely for eight weeks is now with whoever is around. Neither of these is anybody's fault. They are just what happens, and they can be planned for.

The single change that does the most is the number of eating times. A recently recovered child needs to eat five or six times across the day, because her stomach is small and she cannot take what she needs from two adult meals. Three meals and two or three snacks between them is the shape of it.

Every one of those should carry more than plain starch. What to stir into a pot that is already on the fire is set out in the guide on spotting a child who has stopped gaining, and the same short list applies here.

The harder part is the two or three feeds between the meals, because most households have no habit of them and nothing set aside for them. Decide the night before what those feeds will be, and keep something ready that does not need a fire lit again. A covered bowl of the morning porridge held back for the middle of the afternoon. A sweet potato boiled with the morning food and left aside. Groundnuts already shelled and pounded, because a small child cannot chew them whole. A feed that has to be cooked from cold does not happen on a busy day.

Give her her own bowl and serve her before the others, so what she was given is a fact rather than a guess. Then sit with her while she eats it. A small child left alone with a bowl eats a fraction of it and wanders off, and nobody in a busy compound notices.

More often at the beginning, then monthly for as long as you can keep it up. The first two months after discharge are when most relapse starts, so those are the ones to guard.

Write down the discharge weight and keep it where you will find it, on the card and somewhere else as well. That number is the floor. A child who drops back below her discharge weight is not having a slow week, she is sliding, and that is the point to go back to the facility rather than to wait for the next outreach.

Ask the health worker, on the day of discharge, when she wants the child seen and where. Ask what to do if that outreach is cancelled, which happens. Getting the answer while somebody is standing in front of you is much easier than working it out in six weeks.

A recovered child who gets malaria, or a week of diarrhoea, or a chest illness, stops eating for the length of it and loses part of what she gained. Two of those in a season and the gain is gone.

So the ordinary things matter more for this child than for others. A net over the bed she actually sleeps in, and used every night, including in the hot months when it is uncomfortable. Clean drinking water. Hands washed with soap before food is handled.

Take the illnesses to the facility early rather than watching them. And take the child health card each time, so the person seeing her can look at the growth chart and knows she is recently discharged. Ask on that visit whether she is due for deworming or for any routine immunisation she has missed.

If one child under five in a household has been treated for malnutrition, check the others. The conditions that produced it are shared by everybody eating from the same pot, and a second child is often already faltering when the first is discharged.

Ask the village health team member to take a MUAC reading for every child under five in the compound at the same visit. It takes a minute each and it changes what the household is planning for. Red in any of them means the health facility that day. Yellow means telling the village health team member about that child too, and starting the same extra eating times and the same enriched pot the discharged child is getting, this week rather than after the next screening.

Look at the mother too, particularly if she is pregnant or breastfeeding. In most households the mother eats last and eats least, and a mother who is short of food is not going to feed a recovering child well for long.

Every district has months when the last harvest is finished, the next is not in, and food in the market costs more than it did. If discharge falls a couple of months before that stretch, the plan has to reach across it or it will not hold.

Do the preparation while food is cheap and available rather than when it is not. Dry greens in the shade and store them covered. Keep pumpkins. Buy the staple in a sack after harvest instead of in cupfuls every week through the lean months. Make and store groundnut paste.

This is also where a savings group earns its place. A share-out or a small loan timed to land in the hungry months is the difference between a household that keeps feeding a recovered child properly and one that cuts back to one pot a day and hopes.

Go back, and go back early. Do not wait to see whether the next weighing is better. A child who has already been treated once has less in reserve than a child who has not.

Take the child health card and the discharge information with you, and say plainly that this child was discharged from treatment and has lost weight since. That sentence changes how quickly she is seen.