RWK40;

This is obviously an unusual situation. Keep in mind if a child truly has SAM, his/ her body willl find it very difficult to have any type of allergic reaction.  The malnourished body does not spend the nutrient resources to have an allergy, survivial is much more important.  So over the many decades of my work I have about 1/10,000 SAM children, usually mild ones with kwashirokor, with an eczcematous rash.

The short answer is you need to use f-100 milk.  But even the rare cases I have seen continued to get peanut RUTF, ketp having a rash and recovered.  One mother in Malawi begged me not to stop the RUTF, she recognzed how valuable it was.

Where are you located and why do you say there is allergy?  Many people believe that stomach aches, vomiting and not feeling good are signs of allergy.  This is not true.  The signs of allergy are really hives, itchy red welts on the body or eczema.

Thanks Mark.

I also hear of very few cases of an allergic reaction to groundnut-based RUTF in CMAM programs and I've been hanging about those programs for years

I remember groundnut allergy was an issue often raised when we started working on CTC (the precursor to CMAM) by strong proponents of the inpatient care (TFC) model and nutritionists try to look wise but little data was ever presented. Opposition shifted to claims that RUTF interfered with breastfeeding and should be banned and it then moved to claims of RUTF leading to overweight / obesity in treated cases and likely to lead to non-communicable disease in later life but we didn't see this when we looked for it in Malawi.

I have wondered if what we attribute to RUTF might be a reaction to the penicillin antibiotics that are often used in CMAM programs but true penicillin allergy is also quite rare. I guess that reaction to penicillin might be mistaken for a reaction to RUTF (and maybe vice-versa).

F100 could be used but is, I think, better suited to inpatient care. BP100 is another readily available product and in the UNICEF Supply Catalog. Shelf life is also good (4 years compared to 2 years for RUTF). Alternatives to groundnut-based RUTF have been developed (availability might be a barrier to their use). These use (e.g.) sesame, barley, maize, soybean, and lentils for the proteinaceous component. I have heard of chocolate-based RUTF but have never tried it. Chocolate has been a common ingredient in military rations for many years. Plumpy'Nut was inspired by Nutellla (a chocolate-hazelnut spread) that my be useful as a special case RUTF ... a recent BMJ article makes the claim that Nutella and Plumpy'Nut are "virtually identical" but the vitamin and mineral density differ.

Just my tuppence ... that's probably all it is worth!

Thank you Mark manary and Mark Myatt for the responses.