Is there available literature/evidence now on the safety of using peanut based RUTF for children with G6PD deficiency. Our country is now doing a roll out of SAM management and often, health workers ask about this issue. I have read the previous reply that peanuts do not seem to have the pro-oxidant activity that renders those G6PD deficient susceptible to developing symptoms associated with the condition. However, this article (http://cdn.intechopen.com/pdfs/29974.pdf) does mention that though peanuts (polyphenols) actually have abundant anti-oxidant properties, it may also have pro-oxidant properties depending on the dose and the presence of metals. IN the short form, is there a formal advisory regarding this matter? Thank you.

There is no formal advisory and, as André mentions, that there is no published medical literature at all on peanuts and G6PD. The US patient group websites for G6PD advise to avoid all legumes, including peanuts, but nowhere are they specifically highlighted as a problem. Peanuts appear most likely to cause low level haemolysis, which could have some longer term heath effects, rather than the full-blown haemolytic crisis induced by some drugs.

see: http://g6pddeficiency.org/wp/g6pd-deficiency-home/why-avoid-legumes/#.V_XmaNx2gq4

My view is that this is a question of assessing likely risks and benefits, which may depend on the context and setting as well as the individual child. Where an alternative exists, such as a milk-based product then it may be sensible to use that. This might potentially be formulated with a cereal (without soy protein) by a nutritionist if capacity exists for that. Where no alternative exists and you are concerned that significant harm may result from not treating, then careful use of RUTF may be appropriate. If this is done, it should be with additional follow up and monitoring and documented. There is an ethical imperative on you to report on your experiences to benefit other children. I expect that ENN would be interested in publishing such as report.

Thanks for replying, Jay, and the clarification.

We advise the same points but wondered for an official pronouncement to further add credence when our health front liners in the communities bring it up...and they have done that, consistently.

No actual field encounter of a child with G6PD deficiency but assuredly, should such cases come up, the experience would be documented and shared.

Dear all concerned,
Just to say, as Jay suggests, at ENN we'd be happy to document any experience or case management regarding this scenario should it arise. For example, as an article in Field Exchange. Contact me anytime on marie@ennonline.net

I think an 'official' announcement might need to come from our colleagues at UNICEF. It could take some time for them to assemble the evidence and a statement. But it would be worth getting the ball rolling.

It would be interesting as well to have information re. children with G6PD deficiency treated with peanut based RUTF without any problems. Journals hate reporting negative results, but this may be an important information in some contexts. It would be great if Field Exchange could publish data on this topic.

All this boils down to a balance of risk / cost as mentioned by Jay. In absence of reported effects of peanuts in these children, the risk is mainly theoretical. On the other hand, the cost of avoiding this problem is real and high. It is technically possible to make RUTF not containing any peanut nor any legume, but the price would be considerably higher.

I agree a statement on this by WHO /UNICEF would be welcome.

Donna and 'Anonymous 2408', a few more questions:

What kinds of numbers of children with G6PD are you expecting?

Are all children screened for G6PD? If not, then it is likely that many would be treated without knowing it.

Not screening for children. But there is mandatory screening for newborns since 2004, when the testing was institutionalized as law in my country.
G6PD deficiency is part of the screen. This is why our health front liners are so aware. Here, the condition is reported to have a prevalence of 1:52 among newborns screened.

But still, not all newborns get screened for various reasons particularly those who reside in the geographically removed and the disadvantaged areas. In 2013, if I recall correctly, of the 2M newborns, roughly half got screened.

So, Jay, you are correct. There will likely be many who have the condition unknowingly and get treated with RUTF and end up all the better, healthy from being severely undernourished.