Dear Nawid,  

Could you provide details on what country you are in? What are the reasons behind the anticipated RUTF stock out?

Many thanks

Marie

Nawid,

Let us know where you are. I work for a RUTF producer and will try to get you sorted out. 

Hello Anonymous,

Sounds like a tricky situation and I wish you and all of the others good luck in facing it.

First, I would recommend developing an advocacy strategy. You still have several months before the stock out which could give you and others some time to loudly proclaim how unacceptable this situation is and perhaps rectify it…

I can think of several other resources that could help you think through possible responses if that is unsuccessful.

1. This does sound to me like an ‘exceptional’ circumstance, thus this decision tree from WFP on treating MAM and SAM in such situations :

https://reliefweb.int/report/world/moderate-acute-malnutrition-decision-tool-emergencies

It is a relatively dense document, but I find Annexe D helpful.

2. Here are several articles on groups that have used dose reductions in programs.

Maust et al report from Sierra Leone comparing MUAC only <125 mm with 2 sachets RUTF per child admitted <115 and 1 sachet RUTF for those >115 mm either at admission or during treatment :

https://academic.oup.com/jn/article/145/11/2604/4585811

James et al report from this ACF program in Myanmar that faced just such a stock out : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4672709/

Please note that admissions in James et al used a length restriction for checking MUAC – thus children <65 cm did not have their MUAC checked. This is common practice in some Francophone African countries. What it does is excludes kids who are simultaneously stunted and low MUAC, so we are advocating an end to the practice. I can share more info if you like on this score, but ALIMA has published some work on this, one of which is here :

https://academic.oup.com/ajcn/article/103/2/415/4668534

3. Several research projects have been completed looking at dose reduction, either on its own with current SAM definitions (Mango) or as a component to simplifying protocols and trying to capture SAM and MAM by MUAC in one protocol (usually by expanding admlissions criteria edema or MUAC <125 mm (ComPAS and OptiMA-Burkina Faso.) All of these studies are finished but the results are not yet available (I bvelieve all have been submitted so publication bis pending). Descriptions of each study can be found here :

Mango : https://www.nowastedlives.org/research-mango

ComPAS : https://www.ennonline.net/fex/53/thecompasstudy

OptiMA-Burkina Faso : https://www.ennonline.net/fex/60/optimastudyburkinafaso

(Mother MUAC is also an important element that should not be overloked :  https://www.ncbi.nlm.nih.gov/pubmed/27602207

ALIMA even put together some guidelines that may prove useful : https://www.alima-ngo.org/uploads/b5cb311474e9a36f414a69bd64d39596.pdf

4. MSF’s MAM/SAM program in Niger in 2007 is also instructive, even if It may seem counterintuitive. By treating kids earlier in the wasting process (at the MAM stage) with the current full dosing regimen can lead to shorter lenghts of stay which can then lead to less RUTF per child treated, thus more kids treated overall for a similar amount of RUTF :

https://www.ennonline.net//fex/31/rutfinniger

5. MSF also conducted a program using only MUAC <120 mm for admissions (and edema) in Burkina Faso with an exit criteria of just 1 visit of >=125 mm in the late 00s. Here is the recent Isanaka et al report of this program :

https://onlinelibrary.wiley.com/doi/pdf/10.1111/mcn.12688

In any event, I will stop here and again wish you, your colleagues, and the families where you are good luck in dealing with this situation.

Kevin PQ Phelan, ALIMA

Hello, If there is no other solution to remedy the breakdown, some solutions are possible: Adopt your proposal for the reduction of the number of sachets, but in this case, this requires a prioritisation according to the SAM cases and the degree of anorexia. The ration for children most malnourished (W/H - 4) with a positive appetite test is maintained. For malnourished children (W/H <-3) whose test is negative you refer them for the F75 and F100 and save the RUTF. If there are children in the outpatient programme who do not finish their weekly ration, you adjust the amount at the appointment instead of giving the normal amount.

This is only a suggestion for a solution. Thank you.

Dear Nawid

I have alerted UNICEF supplies division and UNICEF HQ to your situation.  As outlined above, could you provide some more details on your location when you can?

Many thanks

Marie

Dear Alima and All,

Thank you for your kind responses. Very helpful!

Kind Regards,

Nawid

Still you have time to seek supply, if there is no solution for the problem of stockout , it is better to reduce you admission, also reduce length of stay by discharging each child once he/she reached discharge cirteria not to give extra weeks for checking/follow up.But it is not good to reduce number of sachets per SAM child perday, because this number of sachets comes from the child's energy requirement to recover so if you reduce it, it will impact the recovery speed of the child and child will stay longer , and this will lead a lot of SAM cases to accumalate (become incharge).