Hi Rachel, As you are aware, there isnt a simple answer, and no evidence based protocol for use in this type of situation as far as I am aware, just context specific actions that have been used. If there is no other option for SAM children they should be given the supplementary ration rather than nothing. The difficulty is that the first response should be treatment of SAM at the inpatient facility if there is no outpatient treatment available. If you start to treat SAM along with MAM then it is even more unlikely that children will go to the inpatient facility to start their treatment, especially if the treatment there is not considered effective. In some places where RUTF has not been available and inpatient treatment not possible, SAM children have been given double SFP rations as a temporary solution until RUTF becomes available. They are then monitored as if in OTP so that if they deteriorate further they can again be encouraged to go for inpatient treatment. This is done on the basis that it gives them a better chance of recovery than nothing, but is not intended as an ongoing strategy. If you can do this then make sure you get the understanding and agreement with the relevant authorities, health facilities and affected communities that it is a temporary solution either until inpatient treatment and referral can be improved or expanded, or until an acceptable RUTF is available.

From Charulatha Banerjee Dear Rachel, Thank you for this question- it is a very similar situation in the area we work in India. Was wondering where you work? IF in India/ Asia which is this collaboration for local RUTF that you refer to? Can you please provide details? In India currently we have no access to RUTF and in our area we run a Special Nutrition unit where SAM children are being admitted. Most of them come with appetite and no medical complications hence could have been treated with RUTF easily if it was allowed. We face the well known challenges of motivating mothers to bring their children and staying in a unit for nearly 2 weeks - many of the mothers do not recognise the children as sick until they develop an infection. We have no access to Specific rations from the Government or WFP - so for MAM children we organise cooking demonstrations and spot feeding exercises at hamlet levels and incorporate hygiene education into this. Often a SAM child who for various reasons cannot attend the SNU is also included in this group- another category which is included is the SAM Child who returns from SNU but is anthropometrically still SAM for 2 reasons - 1. even after gaining 15% he does not cross the <-3SD W/H and 2. some do not achieve 15% weight gain even after 2 weeks in the SNU. We just ensure for SAM children in the community the following 1. Regular home visits to educate the mother on feeding the child and also hygiene measures. 2. Educate her on danger signs specifically so that she can take the child early to a health centre in case of infection. 3.Continued motivation to access SNU services. Am looking forward to all the responses to your question - there is a very similar situation even in 2 areas in Bangladesh where we work and this discussion can have some important leads for us. Warm Regards Charulatha Terre des hommes Foundation

We are encountering a similar problem (also in India) working on developing CMAM guidelines for Save the Children India in the absence of RUTFs. We have been using a product called Hyderabad mix which is not ideal (as it has to be mixed with water)but currently the best option available (this is for an IDP population based very far away from inpatient facilities and not recognized by the authorities as residence of the state). Our question is how to manage the micro-nutrient side of the equation. RUTFs contain all the essential nutrients in the right quantities, how do we ensure that micro nutrient needs are met? Is there any micro-nutrient syrup that has been developed that is similar to blend of micro-nutrients found in RUTFs. How are other programmes attempting to deal with this problem? Thanks for the help!

From Charulatha Banerjee: Dear friend from India, Can you please outline the full composition of Hyderabad mix? As we are all aware, the crucial thing about RUTF is 1. lack of water and 2. correct balance of micro nutrients. Terre des hommes also works in Andhra Pradesh but not in Nutrition projects yet- it will be very useful to meet and exchange if you provide more contact details. Will the SAVE office in West Bengal be able to help? In the SNU also the most convenient method is to use the Combined Mineral Vitamin Mix directly into F75 and F100. We are unable to procure this and hence use all syrups separately- Multi Vitamin syrup, Potklor, Zinc, Iron and Folic acid - which is very cumbersome and causes a lot of vomiting in children. Other micro nutrients cannot be given which are proven to be beneficial as they are not available in these formulations. There is need for a more concerted advocacy on evidence building within the country- for or against a product can be decided only after this effort. Joining hands to do this can help I am sure. Regards Charulatha

Not my area. I thought "Hyderabad Mix" was designed as a preventive not a curative. One recipe that I have to hand is: Whole wheat 300 g Green gram ('dal' ) 300 g Ragi (Nachani) 200 g (this is Millet) Groundnuts 80 g Pure Ghee 80 g (this is clarified butter) Jaggery 400 g (this is whole cane sugar) The recipe is (I think) designed to be adapted to use locally available produce.

The recipe we use is: Food item Daily in grams Whole wheat 125 g Bengal grams 50 g Oil 30gr Ground nuts 25 gr Sugar 38 gr Total 268gr While its not ideal to use it for treatment, we had to do it this way because of strict government restrictions regarding the use of RUTF and an organizational policy committed to following government regulations. However, it has very low levels of micronutrients and must be supplemented, but we are a bit unsure of how to do this, especially as we are trying (as much as possible) to use vitamins and minerals available through the government supply. Any ideas would be appreciated.

This is a wonderful discussion because World Vision is facing the same challenges in India. Hi Mark, Thank you for sharing a recipe you have at hand. I was just wondering, is your recipe for consumption throughout the day or for one meal? I'm just asking because the total quantity looks high for a single meal. Also, Kat and Mark, are the quantities of both your recipes for raw values or cooked values? Thank you all for this on-going discussion! Warmest Regards, Diane

Hi Diane, This is the raw values, the flour mix is than cooked with water/ milk to created a porridge for the child. We have been using this mix for about six months and have found children recover but at about half the speed you would find using other RUTFs. I am working with Save the Children India and would be interested to connect with you about where and what you have been doing in terms of programming. We are in the process of scaling up our nutrition programmes and we have been talking to some other NGOs about what type of programmes that have been doing in India. If you would be interested in sharing experiences please contact me at k.pittore at savethechildren dot org.uk. Thanks

I must emphasise that this is not my area. The values are raw values. It's a "boil up to make a porridge" recipe. The quantities are indicative. You would really want to do this in much smaller quantities rather than make and keep for a day or two for reasons of microbiological safety. These "wet-feeding" products can be quite dangerous. BTW. Someone might like to look at the micronutrient profile of these recipes and see what might need adding. A 'Sprinkles" type product could then be used.