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

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 16 replies. You can also reply via email – be sure to leave the subject unchanged.

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Dina

Assistant PHO

Normal user

25 Aug 2015, 08:23

We have OTP program with SAM kids enrolled. the shipment of Plumpy Nut will take sometime to reach the county? what to do in the meantime?

Tammam Ahmed

H&N Project Manager/Relief International

Normal user

25 Aug 2015, 09:45

we faced the same problem. But we requested from Health office, they provided us with half the requested amount. Then we give the children half the required quantity.
I don't know if you are INGO or working for healht office.

Dina

Assistant PHO

Normal user

25 Aug 2015, 09:51

I work for UNHCR, and we are waiting the shipment to reach Jordan, so requesting half quantities is not an option

Damien Pereyra

Independant Nutrition Evaluation Expert

Normal user

25 Aug 2015, 10:08

Hello,

Many years ago ACF face similar situation in Myanmar and the mission innovate with an alternative treatment (1 RUTF/Children/Day, etc.), It seem to be working...
Have a look on this article : http://www.ennonline.net/fex/42/qualitative
Good luck
Regards
Damien

Dina

Assistant PHO

Normal user

25 Aug 2015, 10:13

Thanks a lot, Unfortunately we don't have any quantities left so we cannot use this option of one RTUF for each child. I am looking for an alternative solution for one week other than using plumpy nut. it may include specific nutritional counselling advices, what do you think that would be?

Bertha Munthali

Nutritionist

Normal user

25 Aug 2015, 10:20

is there no substitute food items that can work effectively just like RUTF which could yield same nutrient base?

Mark Myatt

Consultant Epideomiologist

Frequent user

25 Aug 2015, 11:43

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.

Henry Allieu

International Medical Corps/SNAP

Normal user

25 Aug 2015, 18:00

Yes Mark, I somehow agree but what about the quantities of these ingredients to prepare the RUTF?

Mark Myatt

Consultant Epideomiologist

Frequent user

26 Aug 2015, 08:36

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.

Namesius

Nutritionist

Normal user

26 Aug 2015, 20:09

Thanks Mark this information will help.

Dina

Assistant PHO

Normal user

27 Aug 2015, 05:12

Thanks a lot Mark. that is really helpful.

Mark Myatt

Consultant Epideomiologist

Frequent user

27 Aug 2015, 08:50

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.

Naciimo

Nurse

Normal user

27 Aug 2015, 11:00

Really this is a questionable , preparation of alternative product using locally available source will take time, needs budget allocation, and there is no any quantity at this time, even shipment may come during preparation, and there will be gap so it is better to give appropriate advice to the caretaker asking kinds of foods he/she can get, thus selecting the most relevant foods those can provide needed nutrients and telling them to give children.

Also you can request from other agency operating in your area to lend some product and will give later when you get your 's

Addition to that to avoid such problems it is better to have advanced plan, since products is not locally available item.

Mark Myatt

Consultant Epideomiologist

Frequent user

27 Aug 2015, 14:00

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.

Sameh Al-Awlaqi

Public Health and Nutrition Consultant

Normal user

27 Aug 2015, 14:30

I can't agree more,thanks Mark and Naciimo.

Kevin PHELAN

Nutrition advisor, ALIMA

Normal user

4 Sep 2015, 14:07

I may be late to this, but you could also think of RUSF (esp LNS Large Quantity) to fill the gap if WFP has any stocks or other groups have MAM programming...

Judy Canahuati

Retired

Normal user

5 Sep 2015, 03:36

I think that Mark's first link to publications in Field Exchange might be particularly helpful. Valid has done some trials using corn soy sorghum blend as a base for a lipid spread with milk powder as well as for one without milk powder along with the recipes they shared in the Field Exchange article. Looking at the situation in Jordan, the challenge to alternative recipes may be the premix if you don't have something local that you can use. Mark suggested corn-soy blend. What WFP calls SC and Super Cereal Plus, with milk powder and 3% additional oil could be a good alternative, but more oil would need to be added for the lipid spread when you open up the SC or the SC+. The current specification that we have in Food for Peace for an RUTF or RUSF can be between 26g and 36g of oil/100 gms of protein. If you consider that SC+ already has 3% oil you can experiment with the quantity of oil. Since you would be mixing it and using it fresh you want to have a peanut butter like consistency. If there is not SC or SC+ available you can certainly even make an F100 paste. The important point is to limit the water activity because that is what will allow caregivers to take home the rations. It is possible to put the rations for several days, even a week (700 grams or so) into plastic jars. Your main limitation is probably the pre-mix and if the hospitals have premix for making F100 milk, you could probably use that. Otherwise SC or SC+ or the equivalent if WFP has them could be the basis for your RUTF.

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