A global protocol must be done before giving plummy nut. What s about diarrhea or fever ? In case of diarrhea this child must be hydrated by perfusion. After 2 days depending of her amelioration or none, ppn must be given .

In our experience, the health volunteer give F-100 under close supervision since the child of the same case with yours cannot really tolerate the consistency of the plumpy nut. However, it should always be kept in mind that in these cases with congenital anomalies and conditions, treatment might be longer than the average or they may not respond at all.

Dear Marie, RUTF should not be given to patients with swallowing difficulties. In this case, it is better to give F -100. RUTF mixes poorly with water in contrast to F-100 which is designed for that. You could advise the family to mix F-100 with water and give it rapidly (within an hour) of mixing. There is no risk associated with imprecise dilution of F100 in patients who can drink water and can ask for it when thirsty (as for RUTF). I hope this helps

Dear Marie, We have had a discussion before about feeding children with SAM and cerebral palsy, also initiated by you: [url]http://www.en-net.org.uk/question/1276.aspx[/url] The last post in that discussion suggests others have fed similar cases diluted RUTF with some success, but under close supervision. However, I hope others might also respond to your question and share experience. Best wishes, Tamsin

The reason for the swallowing difficulties need to be better understood first. If the problem is thrush related - feeding both Plumpynut and F100 could be a problem because of the high sugar content (30%). Thrush feeds off sugar and the sugar will make the thrush problem worse. The other issue is lactose intolerance and once again - feeding malnourished children who are lactose intolerant with products that contain high levels of lactose could be a problem using both these products.

The main concern here is why can she not tolerate the mashed food and plumpy nut? Does she choke when trying to swallow it? Is she chronically aspirating liquids and is that why she had a pneumonia? Plumpy nut can be mixed with liquid (eg water or milk) which some children prefer – we certainly found this in South Sudan – however I would be concerned that she might aspirate or choke on this. Alternatives are BP100, although she will likely not tolerate this if she isn’t tolerating plumpy nut. Then the other question is about long-term management. Presuming that she stays in hospital until she is into the rehab phase, what do the family plan on feeding her in the long term? There are different recipes available that can be used to make an F100 equivalent in the community, if the ready made mix packets aren’t available (see page 13) http://www.who.int/nutrition/publications/severemalnutrition/9241545119/en/ Also consider multivitamins and anti-reflux medications, depending on what you have available.