We use plumpy nuts to SAM children under 5 and often the child is also anemic. We do not give any iron at the beginning. After the 2nd week we provide folic acid 5 mg once. If we suspect that the child has severe anaemia, we give iron syrup at time of discharge. Regarding the co-existence of type 1 daibetes, I won't be able to help you here. Perhaps, it could be done by starting in small quantities and measuring blood glucose and see the effects. This studyr this could be valuable.

Dear Dr Huda, I received the same question when i was visiting Yemen. I think when a child has type I diabetes, the causes of malnutrition need to be really looked at within the context of the disease. When the insulin treatment is not well regulated, glucose is lost through urine and weight loss can be one of the consequences. I did not see any children with the combination during my visit, so could not test this with a case study. RUTF could be considered a food as any other when looking at the effect on the blood glucose levels. And thus, it is a matter of regular diet and adapting the insulin doses based on the food intake. I did not have previous experience but advised the doctor to admit the child even if it has appetite, so the blood glucose can be monitored till an adapted treatment schedule is developed. One of the biggest imitations i noticed was the absence of a dietician as part of the care provided. The nutrition advise was limited, and occasionally incorrect so it could be beneficial to include this. Let me know how it went, and if anybody else had experience with the matter as i would like to know the outcome as well. my advice was based on my technical background and common sense as i could not find any research on the matter.

.I think If the patient is insulin depended we can gave RUTF because insulin is already there to control the sugar level. Second severe malnourished cases are already hypoglycemic than not giving any food will make it danger for his/her health

Certainly the case of insulin dependent diabetes in SAM makes the treatment of SAM challenging. I would put aside all standard management protocols, keep the child under physician's care in Hospital and feed a regimen that provides adequate/ ample amounts of micronutrients, and modest amounts of macronutrients. The energy requirement is about 100 kcal/kg/d. I would provide this as 15% from protein, 50% from fat and 35% from carbohydrate. The age of the child is quite important to me in his/ her management. My suspicion is that the child is either older, with some type of severe deprivation or malabsorption from another GI cause. Or the child could be quite young with an inborn error of metabolism related to insulin regulation. Whatever you do, it is best to stop thinking about the child as 'having SAM' and thus reaching for SAM management guidelines, and considering this person as a very ill, unique child with a metabolic disease. Be careful about the diagnosis of diabetes, in that high blood sugars may be an associated sign of something other than standard diabetes as well. Sickle cell anemia can be managed as would SAM be except I would not add large amounts of iron to the feeding