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READY-TO-USE THERAPEUTIC FOOD FOR CHILDREN WITH SEVERE ACUTE MALNUTRITION

UNICEF supports community-based management of acute malnutrition with ready-to-use therapeutic foods (RUTF). The organization is the primary global procur-er of RUTF, therapeutic milk and other essential food products for treating severe acute malnutrition, and also provides technical support to governments and non-gov-ernmental organizations on their application and use. Other notable procurers include Mèdicins sans Fron-tières and the Clinton Foundation.

Properly used, RUTF is safe, cost effective, and has saved hundreds of thousands of children’s lives in re-cent years. Severe acute malnutrition is a major killer of children under five, accounting for approximately 1 million deaths annually. Around 20 million children worldwide are estimated to be suffering from this con-dition, of which only approximately 10 -15 per cent cur-rently receive treatment using RUTF. Although most RUTFs are currently manufactured in and imported from advanced economies, the technology to produce

them can be introduced in developing countries with minimal industrial infrastructure and is already in use in several countries.

UNICEF fully adheres to established international norms and guidelines for infant and young child feed-ing, including exclusive breastfeeding for the first six months of life, followed by continued breastfeeding and the use of appropriate complementary foods for children 6-24 months; micronutrient supplementation for vulnerable groups; and advocating best practices for child nutrition, health and hygiene. The organization categorically does not view RUTF as a substitute for best nutritional practices or normal household food, but sees it as one part of a medical protocol that should only be used as part of the community-based manage-ment of acute malnutrition in children, in accordance with international standards for such care and in con-junction with essential primary health care. ■

POSITION STATEMENT

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No.1•April2013

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UNICEF Position Paper No.1•April2013

RUTFs have revolutionized the treatment of uncomplicated forms of severe acute malnutri-tion among children

Ready-to-use therapeutic food (RUTF) are energy-dense, micronutrient enhanced pastes used in therapeutic feeding.Thesesoftfoodsareahomogenousmixoflipidrichfoods,withanutritionalprofilesimilartotheWorldHealthOrganization-recommended therapeuticmilk for-mulausedforinpatienttherapeuticfeedingprogrammes.TypicalprimaryingredientsforRUTFincludepeanuts,oil,sugar,milkpowderandvitaminandmineralsupplements.

Forseveralreasons,RUTFisessentialforthecommu-nity-basedmanagementofchildrenwhoaresufferingfromuncomplicatedsevereacutemalnutritionandwhoretainanappetite.First,itprovidesallthenutrientsrequiredforrecov-ery.Second,ithasanexcellentshelflife,anddoesnotspoilevenafteropening.Third,sinceRUTFisnotwaterbased,bacteriacannotgrow,andconsequentlyitissafetousewith-out refrigeration and in areas with poor hygiene conditions. Fourth,itislikedbychildren,safeandeasytousewithoutclosemedicalsupervision.Finally,itcanbeusedincombi-nation with breastfeeding and other best practices for infant andyoungchildfeeding.

TheadventofRUTFhasrevolutionizedthetreat-mentofchildrensufferingfromsevereacutemalnutri-tion.Thisconditionisamajorkillerofchildrenunderfive:thelatestavailable(2007)estimatesfromtheWorldHealth Organization (WHO) suggest that it accountsforaround1millionchilddeathsannually.Theneedis substantial: In2007WHO indicated that there arearound 20million childrenunder five suffering fromsevereacutemalnutrition.In2008,anarticlepublishedin The Lancet Series on Maternal and Child Undernutrition estimatedthatchildrensufferingfromsevereacutemal-nutritionhaveariskofdeathmorethan9timesgreaterthantheirwell-nourishedpeers.

Children suffering from severe acutemalnutritionhaveverylowweight-for-height(below-3zscoresoftheWHOmediangrowthstandard),visiblewasting,nutri-tionaloedemaormid-upperarmcircumferenceoflessthan 115millimetres (in children 6–59months). Theconditiongenerallyoccursinchildrenoffamilieswithlimitedaccesstonutritiousfoods,notutilizingbestprac-

ticesforinfantandyoungchildfeeding,withfrequentexposure to infectious disease, and in emergency set-tings. Itcan,however,alsooccur incommunities thatare food secure.

Formanydecades,allformsofsevereacutemalnutri-tionweretreatedinfacilities.Onceachildhadbeeniden-tifiedasaffectedbythecondition,theywouldbeseenbyaskilledhealthworkertrainedinahealthfacilitytoassesswhethertheyrequirereferraltoinpatientcare.However,the standard treatment of specialized therapeutic milkgivenaccordingtoastrictregimenwasoftenunabletopreventmanyofthedeathsofseverelymalnourishedchil-dren–primarilybecausechildrenwerebroughttoolateto the feeding centres.

Inmanysettings,particularlyamongthepoorestandmostmarginalizedcommunities,themajorityofchildrenwith this conditionarenotbrought to ahealth facilityatall.Manyfactorsimpedecare-seekinginhealthfacili-ties, includingthedistancefromandtimeexpendedingoing to the centre; cost of treatment, transport and sub-sistence; and thedurationof the treatment (up to fiveweeks),whichpreventparentsandcaregiversfromlook-ingafterotherchildrenorgoingtowork.Insuchcases,theonlypossiblewaytoprovidesevereacutelymalnour-ishedchildrenwithappropriatecareistoemployanap-proach with a strong community component.

Use of RUTF is undertaken through commu-nity-based management of acute malnutrition

RUTF was first introduced in situations of humanitar-ianemergenciesduringtheearly2000swhenaccesswasaconsiderablebarriertoexpandingcoverageofinpatienttreatment.Itsapplicationwithincommunitymanagementofacutemalnutrition(CMAM)–aninter-agencystrategysupported byWHO, theWorld FoodProgramme, theUNStandingCommitteeonNutritionandUNICEF–hasresultedinasharpriseinprogrammecoverageandchildrentreatedsuccessfully.InEthiopiaalone,therehasbeen a twelve-fold increase in the number of childrentreated in the past nine years. Currently, 61 countrieshavesomeformoftreatmentforsevereacutemalnutri-tionwithacommunitycomponentavailable,comparedtojust9in2005.

Context and Considerations

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The standard dose of RUTF is adjusted according to theweightofthechildundertreatment.Itcanbecon-sumedinthehomeatanytimeunderminimalsupervi-sionuntilthechildhasgainedadequateweight.BecauseRUTFdonotcontainwater,childrenshouldalsobeof-feredsafedrinkingwater toconsumeatwill.Theyalsorequirea shortcourseofbasicoralmedication to treatanyinfectionsandfordeworming,vitaminAsupplemen-tationandfolicacid.HealthworkersshouldalsoprovidefollowupcareintheformofthenextsupplyofRUTFonaweeklyorbiweeklybasis,andshouldmonitor thechild’scondition.Anaveragefullcourseoftreatmentforachildamountstoaround10-15kilogrammesofRUTFovera6-8weekperiod,whichisapproximatelyonecartonofRUTF(150sachets).Incommunity-basedmanagementofacutemalnutri-

tion (CMAM),RUTF should always be dispensed as apartofatreatmentprotocolthatprovidesafullmedicalconsultation,inconjunctionwithinfantfeedingcounsel-lingandprovisionofroutinemedicaltreatment,includ-ing essentialdrugs, and referral to inpatient carewhennecessary. InUNICEF-supportedCMAMprogrammes,cleanwaterisprovidedateverysiteandchildrendrinkwaterwhiletreated.Additionally,appetitetestsarecon-ductedandafull intakequestionnaireundertakenthatincludesmedicalhistory,dietaryhistoryandhouseholdfood security assessment. Detectionearlyintheprogressionofsevereacutemalnu-

trition,beforeitdevelopscomplications(oftenlife-threat-ening), is critical to the success of treatment regimensincluding those involvingRUTF.The finding of activecases involves community healthworkers or volunteersidentifying affected children using simple plastic stripsthat are designed to measure mid-upper arm circumfer-ence,orthosesufferingfromnutritionaloedema.Withstrongactive case finding, andmobilizingcommunitiesto accessdecentralized services themselves, 80per centofchildrenwithsevereacutemalnutritioncanbesuccess-fullytreatedathome.Appropriatecaremanagementcanlowercase-fatalityratestoaslowas5percentbothinthecommunityandinhealthcarefacilities.UNICEFistheworld’slargestpurchaseranddistribu-

torofRUTF.OthernotableprocurersincludeMédecins

sans Frontières and the Clinton Foundation. Around1.96millionchildrensufferingfromsevereacutemalnu-tritionweretreatedwithRUTFin2011,accountingforaround10percentoftheestimated20millionsufferingfromsevereacutemalnutritionglobally.

RUTF is a medical treatment for severe acute malnutrition, not a panacea for all forms of childhood malnutrition RUTFisnotapanaceaforallformsofsevereacutemal-nutritioninchildren.Thosesufferingfrommedicalcom-plications,includinglossofappetite,severeoedema,an-orexia,highfeverorseveredehydrationrequireinpatienttreatmentwithspecializedtherapeuticmilksandround-the-clockmedical care. All infants less than 6monthsold suffering from the condition shouldbe referred toastabilizationcentre,whichisoftenhospitalbased,andshouldreceivebreastfeedingsupport.Undermedicalsu-pervision,dilutedtherapeuticmilkorspecialready-to-useinfantformula(RUIF)maybeconsideredappropriateinextremecases, suchas formaternalorphan infantsun-dersixmonthssufferingfromsevereacutemalnutrition,infants whose mothers cannot breastfeed, or with HIV-positivemotherswhodecidenottobreastfeed.AlthoughRUTFisgenerallyanappropriatetreatment

for uncomplicated forms of severe acute malnutritioninHIV-positive children, their recovery rates are lowerand case fatality rateshigher than thosewho areHIVnegative.GiventheoverlapinthepresentationofsevereacutemalnutritionandHIVinfectioninchildren,par-ticularlyinpoorareas,itisessentialtomaintainstronglinksbetweenthecasemanagementof theformerandthelatter.Whilebroadlyacceptedasanefficacioustreatmentin-

terventionforsevereacutemalnutrition,useofRUTFis not without criticism. One concern centres on itscost–afullcourseoftreatmentcostsaround$100perchild and, therefore, currently can only be supportedbyexternaldevelopmentfinancingformanypoordevel-opingnations.Anotheristhepotentialforcommercialexploitationbeyondthetreatmentofsevereacutemal-nutrition,andtheassociatedriskofunderminingbestpractices for infant and child feeding, notably breast-

Context and Considerations

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UNICEF Position Paper No.1•April2013

feeding.Finally,thereisconcernabouttherelianceofdeveloping nations on imported, processed and sugarfoodssincethemajorityofRUTFiscurrentlyshippedfromadvancedeconomies.Wherelocalpossibilitiesex-ist to create sustained improvednutrition for children,UNICEFisfullysupportiveoftheseefforts.Theorgani-zationsupportsthelocalproductionofRUTFs,andhasdiversifieditsownsupplierbasetoincludemanufacturersinDominicanRepublic,Ethiopia, India,Kenya,Mada-gascar,NigerandSouthAfrica.Otherorganizationsalsouselocalsuppliersfromothercountries.UNICEF considers that, given its proven results in

savingchildren’s lives, thebenefitsofusingRUTFs forthetreatmentofsevereacutemalnutritionsubstantiallyoutweightheconcerns.Ouroverridingpriorityistosavechildren’sliveswithproven,efficaciousandcosteffectivesolutions–particularlyinbothacuteemergencies,suchas the on-going food crisis in the Sahel,where around 1millionchildrenareatriskofsevereacutemalnutrition;andinchronicsettingsofsevereacutemalnutrition,suchas in theDemographicRepublic of theCongo, wherearound700,000childrenareaffected.Insum,theorganizationviewsRUTFasamedicaltreat-

mentthatshouldbeemployedaspartofthecommunity-basedmanagementofacutemalnutritioninchildren,inaccordancewithinternationalguidelinesandinconjunc-tionwithappropriatemedicaltreatment,essentialprimaryhealthcareandbestinfantandyoungchildfeedingprac-tices.Treatmentofsevereacutemalnutritioninchildrenfallsundertheorganization’scommitmentto,andstrate-giesfor,thepreventionandtreatmentofundernutrition.In general,UNICEFdoesnot use ready-to-use foods

orsupplementsforthepreventionofchildmalnutrition,nor does it engage in the distribution of food or food securityprogrammesapartfromafewexceptionalcircum-stances.Preventionofallformsofmalnutritionisideallybestundertaken throughwell-established interventions:exclusivebreastfeeding for infantsunder6months, fol-lowed by breastfeeding with complimentary foods forchildren aged 6–24months; expanding access to highqualityfoods,qualityhealthcare,improvedwatersourcesandsanitationfacilities;micronutrientsupplementationfor vulnerable children; andbetterknowledgeofnutri-tion,healthandhygienepracticesincommunities.■

Sources• Black,RobertE.,etal.,‘Maternalandchildundernutrition:globalandre-

gionalexposuresandhealthconsequences’,TheLancetSeriesonMaternalandChildUndernutrition,TheLancet,vol371,January19,2008,247.

• Ciliberto,M.A.;Sandige,H.;Ndekha,M.J.;Ashorn,P.;Briend,A.;Ciliberto,H.M.;Manary,M.J.(2005)Comparisonofhome-basedtherapywithready-to-usetherapeuticfoodwithstandardtherapyinthetreatmentofmalnour-ishedMalawianchildren:acontrolled,clinicaleffectivenesstrial.AmJClinNutr;81:864-70.

• Hendricks,Kirsty,M.,‘Readytousetherapeuticfoodforpreventionofchild-hoodundernutrition’,NutritionReviews,Vol68(7):429–435.

• Isanaka,S.;Nombela,N.;Djibo,A.;Poupard,M.;VanBeckhoven,D;Gaboulaud,V.;Guerin,P.J.;Grais,R.F.(2009)Effectofpreventivesupple-mentationwithready-to-use-therapeuticfoodonthenutritionalstatus,mor-talityandmorbidityofchildren6to60monthsinNiger:aclusterrandomizedtrial.JAMA.January21;301(3):277–285.

• Latham,Michael,etal.,‘RUTFstuff.Canchildrenbesavedwithfortifiedpeanutpaste?’,Commentary,WorldNutrition,Vol.2,No.2,February2010.

• Manary,MJ(2006)‘Localproductionandprovisionofready-to-usetherapeu-ticfood(RUTF)spreadforthetreatmentofseverechildhoodmalnutrition.FoodandNutritionBulletin.27(3):83-89(7).

• TheMotherandChildHealthandEducationTrust(2011).ManagementofSevereAcuteMalnutritioninChildrenUnderFiveYears:Ready-to-UseTherapeuticFood(RUTF).

• UNICEF/ValidCMAMmappingreport,internalcommunication,May2012.• ValidInternational,Community-basedTherapeuticCare:AFieldManual,

FirstEdition,2006.• WorldHealthOrganization,‘ManagementofSevereMalnutrition:AManual

forPhysiciansandOtherSeniorHealthWorkers,1999.• WorldHealthOrganizationandUnitedNationsChildren’sFund,‘WHO

childgrowthstandardsandtheidentificationofsevereacutemalnutritionininfantsandchildren:AjointstatementbytheWorldHealthOrganizationandtheUnitedNationsChildren’sFund,2008.

• WorldHealthOrganization,WorldFoodProgramme,theUNSystemStand-ingCommitteeonNutritionandtheUnitedNationsChildren’sFund,‘Com-munityBasedManagementofSevereAcuteMalnutrition:AjointstatementbytheWorldHealthOrganization,theWorldFoodProgramme,theUnitedNationsSystemStandingCommitteeonNutritionandtheUnitedNationsChildren’sFund,2007.

Consultations

UNICEFexpertsconsultedinthepreparationofthispositionpaperincludeWernerSchultink,AssociateDirector,NutritionSection,ProgrammeDivision;RobertJenkins,ActingDirector,DivisionofPolicyandStrategy;IlkaEsquivel,ErinBoyd,NuneMangasaryan,NitaDalmiyaandDavidClark,NutritionSection,ProgrammeDivision.

ThispositionpaperwaspreparedbythePolicyAdvisoryUnitinUNICEF’sDivisionofPolicyandStrategy.

SourcesandConsultations

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