Hi Spencer,
Your question refers to a child that was undergoing treatment with RUTF as an outpatient / ambulatory patient and has been transferred to inpatient care having developed an infection.

The answers to your questions are not straightforward. The most important question is whether it is forbidden to give RUTF as the initial nutritional support on admission to inpatient care. There are no absolute rules on this and examination of the previous history, accurate diagnosis and an appetite test are required before prescribing RUTF as an initial treatment.

Standard SAM management protocols are:
- For outpatients with no complications and good appetite use RUTF
- For inpatients use F75 therapeutic milk on admission then transition to F100 / RUTF

For safety, F75 should be the treatment of choice on admission unless the clinician decides that the previous history, clinical status and appetite test indicate otherwise.

In the generic treatment guidelines for acute malnutrition for West Africa https://www.researchgate.net/publication/292131715_Golden_MH_Grellety_Y_Integrated_Management_of_Acute_Malnutrition_IMAM_Generic_Protocol_ENGLISH_version_662 , Professor Golden states:

1. Reasonably accurate assessment of the appetite is often the only way to differentiate a complicated from an uncomplicated case of SAM. Other signs (IMCI) of severe illness are less reliable in the severely malnourished child.

2. By far the best sign of severe metabolic-malnutrition is a reduction in appetite, and the appetite test is the most important criterion to decide if a patient should be sent for in- or out- patient management.

3. A poor appetite means that the child has a significant infection or a major metabolic abnormality such as liver dysfunction, electrolyte imbalance, and cell membrane damage or damaged biochemical pathways. These are the patients at immediate risk of death. Furthermore, a child with a poor appetite will not take sufficient amounts of the therapeutic diet at home to prevent deterioration.

In some cases a child may be transferred from outpatient care to inpatient care because they are not responding to outpatient treatment (not gaining weight) and require direct observation of treatment and further diagnosis. They may have appetite and be able to eat the RUTF. In this case the RUTF would be continued on admission unless there were other indications that it should be stopped.

Alternatively, for example, a child may have developed an infection (e.g. pneumonia) requiring intravenous medications, and is transferred to inpatient care for closer monitoring and to give treatment not available in the outpatient setting. Despite the infection the child may still have appetite, be able to eat RUTF and be gaining weight during ambulatory care. If so, the child may continue eating RUTF on admission as an inpatient unless otherwise indicated.

F75 would be required on admission if there is a lack of appetite, any uncertainty in the diagnosis, or the infection is so severe that the child has developed sepsis (note that a child with sepsis is also likely to have poor appetite). If the child was unconscious, no feeding at all would be given until resuscitated. The exact protocol to implement in each situation should be identified in your national inpatient treatment guidelines.

There are also nuances to be considered. If the child is alert, conscious and has appetite but is short of breath and cannot eat sufficient RUTF, then nasogastric feeding with frequent, small volumes of therapeutic milk may be preferred initially.

The concern over iron is related to potential liver dysfunction and increased mortality risk. The appetite test for RUTF is a good guide as to whether this should be a concern for the individual child. in the examples above, if appetite is present, the child is able to eat the RUTF and there are no other contraindications, it is OK for the child to take the RUTF (containing iron) on admission.

To reiterate, if there is no clinician available to look at the clinical condition and history of the individual child and make a decision on nutritional therapy, then it is best to be cautious and start treatment with F75 on admission until a clinician decides otherwise.

I hope this helps,

Paul

Good afternoon
I agree with Paul that not in all cases children start with F75. From personal observations in the malnutrition ward, children with good appetite started on F75 will crave for other solid foods available which should not be given when in "stabilization phase". When the appetite is good then stabilization (meaning you are slowly allowing the body organs, such as the heart,liver, digestive and absorptive ability of the GIT to return to normal function) is not required for these children.
Some children can have infections with good or poor appetite. The rule is continuous daily follow up of these children, since with good nutrient supply and recovery of the immunity, some children tend to worsen and need restabilization even when they had passed this phase. Or some get new infections while admitted.
But for oedematous children (++,+++) F75 is the feed to start with since the fluid intake is calculated and reduces risk of CCF.
Thank you

Hi Anonymous,
Just to note that the protocol for oedema cases may be context specific. In many contexts +2 oedema cases with appetite and without complications are treated outpatients. Practitioners should refer to national guidelines for specific protocols.

Regards,
Paul