One week missing doses of Plumpy Nut? What to do?

I think you need to deliver as much or the CTC protocol as is possible. That is, give antihelminthics, antimicrobials, refer complicated cases for inpatient care, &c.

You have to replace the commercial RUTF. There are a number of things you could do. If you can get a fortified cereal legume blend (e.g. CSB), oil, and sugar then you could give a "premix". It will be better than nothing. Many older guides (e.g. Young(1992)) provide a number of recipes that might be used with local ingredients (e.g. bean flours) if CSB is unavailable.

You may be able to get peanut butter in the market. If so then you can make RUTF. It is just peanut butter, milk powder (you could use F100 milk if available), sugar, vegetable oil, and a mineral/vitamin mix. A number of recipes are available. There are number of experts on this forum who can advise on this.

Recipes are available. Here is an example with some information on sourcing of ingredients and production techniques.

EN-NET's partner publication (Field Exchange) has published related articles. See here and here and here and here and here.

I hope this helps.

Thank you for your kind comments.

You may want to ask EN-NET to put you in touch with Mark Manary. He has considerable experience with establishing and running local production at different scales. Even a brief chat with him will probably help you avoid common pratfalls.

It may be "questionable" if (i) the delay is really just one week and (ii) we expect there to be no prolonged stock-outs in future.

If (i) is untrue then I think we have to be able to give something other than advice (see below).

If (ii) is untrue then we should have a plan to carry to carry us over stockouts. This is usually done by holding a buffer stock but a mixed buffer stock / local production system may have a place. In settings with weak logistics it can be difficult to build a buffer stock.

I don't think giving advice is a sufficient strategy as it is unlikely to be efective with very severe cases and, at the start of a program, we expect there to be many very severe cases. I think we really ought to try to give something with some proven clinical effectiveness - hence my suggestion to give the CTC protocol (antimicrobials, antihelminthics, antimalarials, ORS, &c.) with an RUTF substitute or a locally prepared RUTF.

I also worry that coverage can be difficult to build unless something approaching a complete protocol with much better than marginal clinical effectiveness is given. "Go to this program and get nothing but patronising lectures" or "Go to this program and watch you child die slowly" are not the best impressions to have in circulation. Such impressions can be very hard to correct once they gain circulation. It may even be better from a utilitarian perspective to delay program start until supplies are sorted.

I agree that you can beg and borrow. This can be hard to do as RUTF supplies are often centralised (e.g. one agency may be responsible for a key link in the RUTF supply chain) and everyone may be feeling the pinch. In situations like this I usually turn to organisations with good logistics such as MSF and ask nicely.

It is good to have a plan. I think it likely that the original poster had a plan but they were let down by a partner organistion who promised to supply RUTF but failed to deliver.