Home-Based Therapy With RUTF In Malawi

By Dr. Mark Manary and Heidi Sandige

Dr. Mark Manary is an Associate Professor of Paediatrics at Washington University School of Medicine and Lecturer at Malawi School of Medicine in Blantyre, Malawi. He has been involved in nutrition and metabolism research in Malawi for the past 9 years, and served as principal investigator for the RUTF studies there.

Heidi Sandige is a medical student at Washington University in St. Louis who spent the 2002-2003 year in Malawi on a Doris Duke Clinical Research Fellowship. She worked as field manager of the RUTF project, managing local production, and initiating the rural RUTF clinics.

Thanks to Andre Briend, Per Ashorn, and MacDonald Ndeka who co-authored the research papers¹ on RUTF, Peter Fellows and Valid International for RUTF testing, and the RUTF Chiponde staff in Blantyre.

This article describes the positive experiences of the St Louis Nutrition Project using Ready to Use Therapeutic Food (RUTF) in Malawi, and how this approach was integrated into the existing national network for managing severe and moderate malnutrition².

Programme enrolment and first tastes of RUTF, at Namitambo Rural Health Clinic

In Malawi, like many poor countries, childhood malnutrition is a chronic problem, such that thousands seek aid each year and 13% of all children under the age of five die of malnutrition³. This has necessitated a national network of permanent Nutritional Rehabilitation Units (NRUs) for therapeutic and supplementary feeding programmes (TFPs/SFPs), which follow the guidelines for inpatient treatment advised by the World Health Organization⁴. In addition, each year, humanitarian agencies institute food distributions and supplementary feeding programmes.

The inpatient problem

Standard therapy for the severely malnourished consists of inpatient feeding of therapeutic milk administered in two phases. This approach has numerous limitations in a stable country where malnutrition is chronic and geographically widespread. The therapeutic milk (F-100, F-75, or a locally designed alternative) must be prepared and given by trained staff many times daily, as it requires hygienic mixing. The milk cannot be prepared in advance, as it spoils easily. It cannot be sent home with mothers, as the regimen is demanding of time and resources. The strategy promotes overcrowding of immuno-compromised children in hospitals, and the inevitable spread of nosocomial infections. During the 2003 hungry season in Malawi, as many as 100 children were together in the Queen Elizabeth Central Hospital NRU at a time, with up to 12 deaths in a single week, and an overall mortality rate of 28%.

Graduate of RUTF programme with a happy mother, at Namitambo District Health Clinic

Other serious constraints with standard therapy include the expense of importing therapeutic milk, the need for accurate estimation of the amount of milk to be used in advance to assure availability, the training of a large staff to administer the programme, and the careful coordination required between the many NGOs involved in NRU and SFP programmes so that children are appropriately referred at discharge. The typical outcomes of this strategy attest to its shortcomings - only 25% of those wasted children treated in NRUs in Malawi reach 80% of weight for height standard, while 10% of those who have reached this goal go on to die, and 20% to relapse to an NRU⁵.

RUTF as an alternative

The peanut butter-based RUTF is an energy dense lipid paste with a complete complement of micronutrients. It has been successfully used as the primary foodstuff for an outpatient therapeutic phase 2 feeding. It has also been used in place of grain and oil in SFP distributions for moderate to severely malnourished children, to effect a more lasting recovery. It can be purchased as the commercial product, Plumpy'nut (Nutriset, France), or it can be made locally with importation of only the Complex Multi-Vitamin (CMV) component, and used in a wide variety of locations. Success with RUTF home-based therapy in Malawi suggests that it may play an important role in treating malnutrition worldwide. It resists bacterial contamination because of its low water content, and it does not need to be cooked before it is consumed⁶. Therefore, RUTF does not need to be administered in the supervised environment of an NRU by trained staff.

Home therapy as a solution

Happy child eating RUTF, Domasi Rural Health Clinic, Malawi.

In Malawi, The St Louis Nutrition Project⁷ instituted a programme whereby the mothers of malnourished children were given a two-week supply of RUTF appropriate to the child's weight (175 kcal/kg/d and 5.3 g protein /kg/d), and asked to attend follow up fortnightly until recovery. On follow-up, the child's growth was measured and a new supply of RUTF was given if the child had not completely recovered. Children achieved remarkable recoveries in their home environments, surrounded by their communities rather than a ward of similarly ill children. Avery small cadre of local staff was able to adequately instruct the mothers in the administration of the RUTF and manage the follow-up assessments.

In the 2000-2001 hungry season, home therapy was instituted by the St Louis Project at the large NRU of the Queen Elizabeth Central Hospital in Blantyre, Malawi. RUTF replaced the phase 2 inpatient treatment after the initial phase one stabilisation. Used in this way, 85% of the children receiving a full diet of RUTF reached their 100% weight for height goal, within 2 to 12 weeks⁸. Crowding in the unit was decreased significantly, so that the most severely ill children received more attention in their inpatient treatment phase.

Marasmic child receiving first RUTF sample Chikwawa District Health Clinic, Malawi

During the 2001-2002 hungry season, similar results were achieved in the same hospital using a locally produced version of the RUTF. Eighty per cent of all children treated with the locally produced RUTF reached their 100% weight for height growth goal, including 59% of HIV positive children and 95% of all HIV negative children. Six months later, recovered children returned for a weight check. In the interval, they received only their local diet, yet only 9% of children had relapsed⁹. This indicates that the indigenous cereal/ legume diet can sustain normal growth in well-nourished children.

In the 2002-2003 hungry season, encouraging results were again achieved, on a much larger scale in a wide variety of field sites. Seven sites, including mission, rural, and district NRUs, participated in the home therapy programme, acting as stabilisation centres to manage a very small phase 1 group. Inpatients were directly transferred to the home therapy programme for phase 2 treatment. In addition, both severely and moderately malnourished children were directly admitted from the community without an inpatient therapy, provided that their condition was stable and they were not anorexic. This eliminated the need for supplementary feeding for the targeted age group (10 months to 5 years) at these seven sites. Again, 80% of these children reached a weight-for-height over 85%, with a mean time in the programme of 6 weeks¹⁰. In the 2002-2003 season, Concern Worldwide also undertook therapeutic feeding with RUTF in another district in Malawi.
Because of these consistently positive results, the Malawi Ministry of Health currently advocates the use of RUTF phase 2 home therapy for the treatment of moderate to severe malnutrition in the Southern Region of Malawi. The World Food Programme is able to donate oil, sugar, and milk powder towards the local production of RUTF and requests to them for SFP foodstuffs are greatly decreased due to the success of this approach.

Logistics of RTUF production and distribution

Child eating RUTF with fingers, Pirimiti Rural Health Clinic.

In-country production of RUTF can simply consist of a local team of workers producing RUTF on a relatively small-scale. One to two people can produce 15 kg of RUTF per half hour with a mixer, a laboratory scale, and an assortment of locally available plastic implements (see recipe box). In Malawi, an independent food technologist determined that the RUTF produced in this manner, even after contamination with a child's dirty hands, harboured no microbial contamination and had aflatoxin levels below the most stringent safety standards¹¹. A local company may also be identified and staff trained to undertake the production of RUTF according to specifications. In-country production means that only the CMV component (1.6% of the total product by weight) needs to be imported. Whether peanut paste or completed RUTF are purchased from local industries, the enterprise supports the local economy and decreases shipping costs tremendously

Management of care

Because home therapy with RUTF is essentially an outpatient nutrition clinic, it can be easily managed by a small team of local staff. A very simple flowchart can be followed, through which any screened child can be allocated into one of three groups:

Group 1 RUTF home therapy

Group 2 Healthy, and not in need of SFP or NRU/TFP treatment

Group 3 Too sick for home therapy (by clini cal criteria - active infection process or >2+ oedema). These children should be admitted to an NRU for stabilisation, then to home therapy when stable.

The criteria for admission can be tailored to the local situation. Standard, portable nutrition survey equipment can be used for measurements, and the clinic need only operate a single day per week. In Malawi, the St Louis Nutrition Project staffed seven weekly clinics with three full time nurses, a part-time nurse, a driver and a single expatriate field worker. Because the protocol is so easy to follow, the Project has been largely handed over to local NRU staff. In a country like Malawi with a shortage of trained nurses, the reduction in rigorous inpatient work in the NRU also means better care for the sickest children.

The average child remains in the programme for 6 weeks (involving 3-4 follow up visits), depending on the severity of malnutrition, and consumes about 11 kg of RUTF in total. Depending on local peanut prices, staple donation, and manufacturing costs, a complete recovery can be achieved for about US$10 per child. Older children easily feed themselves, with their hands or fingers. RUTF is sweet and children like it. Peanuts are a staple ingredient in Africa, and a culturally accepted treatment.

The RUTF home therapy model is easily accepted in the local community. Mothers no longer have to navigate through multiple agencies to determine the proper nutrition programme for their child, and they are more likely to bring a child in for treatment if they believe the inpatient stay will be either short or nonexistent. The treatment requires no additional gathering of firewood, cooking, or preparing specialised meals for the child. Instead, she can give the ideal treatment - multiple small feedings per day with adequate additional hydration - without compromising her ability to care for her home or family. Home therapy with RUTF is emerging as an important, successful, and easy to administer method for the treatment of childhood malnutrition.

For further information on this article, contact Mark Manary email: manary@kids.wustl.edu, or Heidi Sandige, email: heidi@sandige.com

Recipe box

Mixer for local production of RUTF (with student volunteer, Jennifer Gill) Blantyre, Malawi

Ingredients

• 30% milk powder
• 28% sugar (powdered if hand-mixing)
• 25% peanut paste (salt-free)
• 15% oil
• 1.6% vitamin mineral mix (CMV, Nutriset)

Supplies

• electronic laboratory scale (battery powered, to 0.01g accuracy)
• 40L planetary bakery mixer (MacAdams S 401)
• large plastic drums for both mixing and storage
• smaller plastic buckets and scoops for measuring
• spoons, spatulas, andcleaning supplies

Ingredients for RUTF, Blantyre, Malawi

Method

1. Combine oil and peanut paste in the mixing bowl at 105 rpm until homogenous. A z-shaped kneader blade minimises the amount of air impregnated into the mixer.
2. Stir together sugar, milk powder, and CMV in a dedicated plastic drum, and then empty it into the electric mixing bowl.
3. Mix at gear 1 (105rpm) for 6 minutes, gear 2 (210rpm) for 6 minutes, and gear 3 (323rpm) for 6 minutes. The mixing time ensures homogeneity and prevents separation during storage.
4. Empty the RUTF into a large plastic drum.
5. Later, pack RUTF as desired.

Notes

• All implements should be washed thoroughly after each production day, but not during the production, to prevent accidental addition of water to the product.
• In Malawi, we utilize a recycling system, in which mothers return the 275g plastic bottles with screw tops for cleaning and reuse. This reduces costs, but is also more environmen tally friendly. The peanuts, peanut paste, or finished RUTF (depending on method) must be tested to confirm absent or minimal aflatoxin levels. In Malawi, this was already a part of the peanut paste production process.
• Volumetric containers can be designed or found for each ingredient (a plastic bucket that holds exactly 4.5kg of powdered sugar when filled and levelled, etc.) so that no scale is required. In this case, pro duction staff need not be literate, simply careful and consistent.
• If a local company does the production, the recipe can be modified to use crystalline rather than powdered sugar. Roasted peanuts can be mixed directly to the oil and dry ingredients, and the RUTF extruded as completed paste.

Further information and suggestions about production can be found on the Nutriset web page (http://www.nutriset.fr), or directed to Mark Manary, email manary@kids.wustl.ed

¹At time of writing, two articles accepted/submitted for publication with detailed academic research findings on the first RUTF home therapy study and the RUTF local production project.

²This publication was made possible through the support provided to the Food and Nutrition Technical Assistance (FANTA) Project by the Office of Foreign Disaster Assistance of the Bureau for Democracy, Conflict and Humanitarian Assistance and the Office of Health, Infectious Diseases and Nutrition of the Bureau for Global Health at the U.S. Agency for International Development, under terms of Cooperative Agreement No. HRN-A-00-98-00046-00 awarded to the Academy for Educational Development (AED). The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development.

³Pelletier DL, Low JW, Johnson FC, et al (1994). Child anthropometry and mortality in Malawi: testing for the effect modification by age and length of followup and confounding socio-economic factors. J Nutr 1994;12 (10Suppl):2082S- 105S

⁴WHO, 1999. Management of severe malnutrition: a manual for physicians and other senior health workers. WHO, Geneva.

⁵Brewster DR, Manary MJ, Graham SM. Case management of kwashiorkor: an intervention project at seven nutrition rehabilitation centres in Malawi. Eur J Clin Nutr 1997;51:139-47

⁶Briend A. Highly nutrient-dense spreads: a new approach to delivering multiple micronutrients to high-risk groups. Br J Nutr 2001;85 (Suppl2):S175-9.

⁷The authors of this article, known collectively as the St. Louis Nutrition Project, started and maintained this project through the College of Medicine, University of Malawi.

⁸ Manary MJ, Ndekha MJ, Ashorn P, et al. Home-based therapy for severe malnutrition with ready-to-use food. Arch of Dis Child accepted for publication.

⁹Sandige H, Ndekha MJ, Briend A, Ashorn P, Manary MJ. Locally produced and imported ready-to-use-food in the home-based treatment of malnourished Malawian chidren. Submitted for publication.

¹⁰Ciliberto M, Sandige H, Manary MJ et al, as yet unpublished data from 2002-2003 study in Southern Malawi.

¹¹Peter Fellows, Valid International, and Oxford Brooks University: Results of Analysis of RUTF produced at Tambala Food Products, Malawi, March 2003.