Dear Anonymous 3835
I was working in an organization in Yemen targeting hard to reach areas"mountainous districts and scattered households where most of children live very far from the health facilities". The project was emergency-type intervention, and we were distributing RUTF/RUSF on biweekly basis, then we see absentees rate increases and care givers still complaining from the very long distance. Then we switched to monthly distribution ration. As many SAM/MAM children have also normal under 2 relatives so we give them plumpy doz under BSFP in monthly basis altogether with their relatives SAM/MAM and not to burden the family twice trip.

I think managing severe and moderate malnutrition using RUTF/RUSF is the revolution that the world needed however all good things come with challenges ;
Distance- Its difficult to have mothers walk long distance especially if they have 2 children strapped on their back
Sharing - The men may never understand the rationale behind giving the children and may use the feeds all together any way where mothers will seek for a more for a longer period without disclosing issues
Possibly the health and nutrition team should visit the villages and issue the much needed therapeutic feeds or engage volunteers.Remember RUTF can easily kill

Hello --

Epicentre/Médecins Sans Frontières also have some experience using a monthly distribution of RUTF for the outpatient treatment of uncomplicated SAM in Maradi, Niger. We conducted a non-randomized pilot intervention study in which 115 children eligible for the outpatient treatment of SAM were provided a monthly ration of RUTF. Anthropometric measurements were taken on a weekly basis for 4 weeks to monitor treatment response defined as weight and mid-upper arm circumference (MUAC) gain, failure defined by weight loss > 5%, and the development of edema. Unannounced household spot checks were conducted over 4 weeks to assess household utilization of RUTF and storage practices. We found adequate weight and MUAC throughout the 4-week follow-up period. Observed mean (standard deviation, SD) weight gain from admission was 9.8 (6.8) g/kg/day at week 1 and 4.2 (2.1) g/kg/day by week 4. Unplanned household spot checks found an average surplus of RUTF sachets compared to the number expected based on the date of distribution and recommended dosing throughout the 4 weeks of follow-up. Full results are in press. A larger, cluster randomized study to compare monthly vs. weekly follow-up in terms of nutritional recovery is planned to begin within the coming months in Northwestern Nigeria (Sokoto State).

Distance is often a problem in CMAM programmes and poor attendance reduces the likelihood of cure. Sheila presents very interesting findings and, with some caution, you can probably advocate for monthly distributions in individual cases, however you should consider some practical issues. There is also a danger that staff may start doing monthly distributions as standard since it is potentially less work intensive and as far as possible this should be avoided since, unlike in Sheila's example, your cases would probably not be monitored as closely.

How could you monitor the child's condition in individual cases? Since you have been conducting screening activities in these hard to reach places, with a little extra effort you could teach the mother (or volunteer or elder) to use a MUAC tape. See the links below below;

http://www.ennonline.net/fex/50/mothersmuac
http://www.en-net.org/question/1632.aspx
https://archpublichealth.biomedcentral.com/articles/10.1186/s13690-015-0074-z

Is there someone (e.g. village elder) who possesses a mobile phone? Staff could call weekly and discuss progress with the mother. The change in MUAC could possibly be monitored using a marker pen on the MUAC tape, noting the change each week. The mother can be advised to return to the clinic if the MUAC does not increase each week. If no phone is available is the village accessible by volunteers from other locations (with or without incentives)?

Can you devise a simple questionnaire (e.g. using pictures) which allow the mother (or volunteer or village elder) to monitor the child for illnesses such as diarrhoea, vomiting etc? This at least would provide some record for review at the next visit. The mother should be advised under what circumstances she should return to the clinic, bringing the marked MUAC tape and questionnaire.

In any case the mother should return after 4 weeks and the child followed up if they do not return. You will need to decide how you will adapt your reporting criteria (e.g. for defaulters).

I would reiterate that I am not advocating this as a safe method of managing children with SAM and it is fraught with dangers.In addition to monthly unmonitored distribution becoming widespread, another concern is that it is possible that monthly distributions will be used for ever decreasing distances. It will become common knowledge in the communities that complaining about distance will mean you can get monthly distributions instead of weekly or 2-weekly. Before you start using monthly distributions for hard to reach areas you will need to decide on your own criteria and who will have the responsibility (and be accountable) for making the decision. You will need to ensure that you do some excellent community sensitisation and Information should include messaging that encourages weekly or 2-weekly attendance as the better alternative.

The responsible programme manager should take steps to ensure that monthly distributions are used in approved cases only and they should not be a substitute for advocating for the proper provision of services. Treating a child that is unmonitored is not the standard we should be aiming for.

Contrary to a previous comment I would not agree that "RUTF can easily kill" - this is not the kind of message we should be telling communities. Provided that the RUTF is manufactured and stored correctly the risk of illness or death from RUTF is minimal. I am not aware of any deaths directly attributed to RUTF, however the risk of death from untreated SAM is well known.

There have been concerns raised about various toxicities (e.g. iron and vitamin A), however i would direct you to a previous post by Judy Canahuati; which discusses the issue:: (http://www.en-net.org/question/2252.aspx) (posted below)

=======================================================================

"... If you look at the latest version of Nut Val you can see the calculations for vitamins and some of the minerals in several versions of RUTF. Possible toxicity is pretty specific to a particular micronutrient and generally over time. In the US for example, iron toxicity has occurred in children from consumption of mother's iron (ferrous sulfate) tablets which have about 20% elemental iron. Toxicity has occurred with ingestion of about 60mg/kg of iron. A child would need to consume a tremendous amount of RUTF to get to that level of iron. Two sachets of RUTF, for example, have about 24mg of iron. There also seems to be a difference in the way the body absorbs micronutrients when they are in concentrated tablet form and when they are embedded in a food matrix but we probably need to learn a great deal more about that.

The amount of time a child would consume RUTF is relatively short. Also, we don't really have a great deal of information about what "needs" are when a child is severely acutely malnourished as this has a great deal to do with absorption and absorption is probably severely compromised in the SAM child and that is probably why some of the quantities of the micronutrients (eg Vitamin A) are so much higher than "normal". If you look at the WHO technical note on feeding of moderately acutely malnourished, the guidance (http://apps.who.int/iris/bitstream/10665/75836/1/9789241504423_eng.pdf) sets up a range per 1000 calories for macro and micronutrients. One of the micronutrients that people "worry" about is Vitamin A and the range is 2000-3000 mcg per 1000 calories. 1000 calories corresponds to 2 sachets and in general young children might consume between 2-3 sachets in a day in addition to breastmilk. If you triangulate the two documents, an infant/young child would need to get to 3 sachets per day before getting to the 3000mcg upper end of the range for Vitamin A.

Thinking about the realities of feeding a 14-month old 3 sachets of RUTF a day, it seems highly unlikely that s/he would consume enough Vitamin A to be worrisome. There is some good guidance for use of micronutrients in the Codex Guideline for formulated complementary foods for older infants and young children

"6.6.1.3 If the dietary intake data for the target population is not available, the vitamins and minerals listed in the Table in the Annex to these Guidelines can be used as a reference for the selection of particular vitamins and minerals and their amounts for addition to a Formulated Complementary Food.
6.6.2 National authorities should ensure that the total micronutrient intake from the Formulated Complementary Foods, local diet (including breastmilk and/or breastmilk substitutes) and other sources do not regularly exceed recommended upper levels of micronutrient intake for older infants and young children."

I think that the key would be "regularly exceed" in this guidance. RUTF is provided for a specific purpose for a fairly defined period that is relatively short-term. We still don't understand enough about what the actual micronutrient status is of infants and young children at the end of treatment -- which means that we don't know that much about how recovering SAM kids are actually aborbing these micronutrients.

My hypothesis would be that appetite would probably be key to consumption of the micronutrients and that it would be difficult to "make" an older infant consume enough so that toxicity might be an issue. If you've ever eaten a packet of RUSF or RUTF, you know they are pretty filling, even for an adult-- much less an infant with much smaller stomach capacity at any one "meal" --who might also be breastfeeding.

Don't know if this helps -- but the sum of this is that, while not an "easy" question, the chances of over consumption to the point of toxicity, provided that food safety and quality standards are followed in the process of the food -- is probably minimal."

Thank you, Paul, for these additional reflections. I just want to echo that we agree that monthly follow-up and RUTF distributions should still be considered with caution.

Our work with this new model will be closely monitored through a formal research study, and we have spent quite a bit of time developing educational tools to support caregivers' home surveillance of children in between monthly visits. Just as you mention, there are two tools developed in the local language and with pictures to help show caregivers how to 1) monitor their child’s MUAC for any deterioration (we use a black tape placed at the admission measurement to help indicate when there has been a subsequent decrease) and 2) detect 9 clinical danger signs (e.g. diarrhea, vomiting, fever, etc.) that warrant returning to the health facility.

A monthly schedule of follow-up may be useful in very specific settings, but we agree that additional supports and monitoring are required to do this safely.

Sheila