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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 procurer of RUTF, therapeutic milk and other essential products for treating severe acute malnutrition, and also provides technical support to governments and non-governmen-tal organizations on their application and use. Another notable procurer is Médecins Sans Frontières.
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 currently receive treatment using RUTF. Although most RUTFs are currently manufactured in and im-ported from advanced economies, the technology to produce them has been introduced in developing
countries with minimal industrial infrastructure. By 2012, African-produced RUTF represented 45% of the total purchased by UNICEF.
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•June2013
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UNICEF Position Paper No.1•June2013
RUTFs have revolutionized the treatment of uncomplicated forms of severe acute malnutri-tion among children
Ready-to-use therapeutic food (RUTF) are energy-dense,micronutrientenhancedpastesusedintherapeuticfeeding.Thesesoftfoodsareahomogenousmixoflipidrichfoods,withanutritionalprofilesimilartotheWorldHealthOrganization-recommended therapeuticmilk for-mulausedforinpatienttherapeuticfeedingprogrammes.TypicalprimaryingredientsforRUTFincludepeanuts,oil,sugar,milkpowderandvitaminandmineralsupplements.
Forseveralreasons,RUTFisessentialforthecommu-nity-basedmanagementofchildrenwhoaresufferingfromuncomplicated severe acutemalnutritionandwho retainanappetite.First,itprovidesallthenutrientsrequiredforrecovery.Second,ithasagoodshelflife,anddoesnotspoileasilyevenafteropening.Third,sinceRUTFisnotwaterbased,theriskofbacterialgrowthisverylimited,andcon-sequentlyitissafetousewithoutrefrigerationathouseholdlevel.Fourth, it is likedbychildren, safeandeasy tousewithoutclosemedicalsupervision.Finally,itcanbeusedincombinationwithbreastfeedingandotherbestpracticesforinfantandyoungchildfeeding.
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 thatarefoodsecure.
Formanydecades,allformsofsevereacutemalnutri-tionweretreatedinfacilities.Onceachildhadbeeniden-tifiedasaffectedbythecondition,theywouldbeseenbyaskilledhealthworkertrainedinahealthfacilitytoassesswhethertheyrequirereferraltoinpatientcare.However,the standard treatment of specialized therapeutic milkgivenaccordingtoastrictregimenwasoftenunabletopreventmanyofthedeathsofseverelymalnourishedchil-dren–primarilybecausechildrenwerebroughttoolatetothefeedingcentres.
Inmanysettings,particularlyamongthepoorestandmostmarginalizedcommunities,themajorityofchildrenwith this conditionarenotbrought to ahealth facilityatall.Manyfactorsimpedecare-seekinginhealthfacili-ties, includingthedistancefromandtimeexpendedingoingtothecentre;costoftreatment,transportandsub-sistence; and thedurationof the treatment (up to fiveweeks),whichpreventparentsandcaregiversfromlook-ingafterotherchildrenorgoingtowork.Insuchcases,theonlypossiblewaytoprovidesevereacutelymalnour-ishedchildrenwithappropriatecareistoemployanap-proachwithastrongcommunitycomponent.
Use of RUTF is undertaken through commu-nity-based management of acute malnutritionRUTFwasfirstintroducedinsituationsofhumanitar-
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.
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ThestandarddoseofRUTFisadjustedaccording totheweightofthechildundertreatment.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,dietaryhistoryandhouseholdfoodsecurityassessment.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 stripsthataredesigned tomeasuremid-upperarmcircumfer-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,infantswhosemotherscannotbreastfeed,orwithHIV-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,useofRUTFisnotwithoutcriticism.Oneconcerncentresonitscost–afullcourseoftreatmentcostsaround$100perchildand,therefore,currentlycanonlybesupportedbyexter-naldevelopmentfinancingformanypoordevelopingna-tions.Anotheristhepotentialforcommercialexploita-tionbeyondthetreatmentofsevereacutemalnutrition,andtheassociatedriskofunderminingbestpracticesforinfantandchildfeeding,notablybreastfeeding.Finally,
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there is concern about the reliance of developing na-tionsonimportedprocessedfoods;localmanufacturingcapacityisgrowingandmet27%ofneedsin2012,butthemajorityofRUTFiscurrentlymanufacturedinandimported fromadvanced economies.Where localpos-sibilitiesexisttocreatesustainedimprovednutritionforchildren,UNICEFisfullysupportiveoftheseefforts.TheorganizationsupportsthelocalproductionofRUTFs,andhasdiversifieditsownsupplierbasetoincludemanufac-turers inBurkinaFaso,DominicanRepublic,Ethiopia,France,Haiti,India,Kenya,Madagascar,Malawi,Niger,SierraLeone,SouthAfrica,Sudan,TanzaniaandUSA.Someofthesecountriesaremeetingallorpartoftheirownnationalneeds.Anumberoforganizationsarealsoworkingwithlocalsuppliersbasedinothercountries.UNICEF considers that, given its proven results in
saving children’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 foodsecurityprogrammesapartfromafewexceptionalcircum-stances.Preventionofallformsofmalnutritionisideallybestundertaken throughwell-established interventions:exclusivebreastfeeding for infantsunder6months, fol-lowed by breastfeeding with complementary foods forchildren aged 6–24 months; expanding access to high
qualityfoods,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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© UNICEF/BANA2010-01070/Ahsan Khan© UNICEF/NYHQ2005-2240-Pirozzi
