4. Ready-to-use therapeutic foods (RUTF)

Other types of specialized nutritious foods

-High-energy bar for integrated mgmt of SAM (rice/soy/mung bean-based RUTF) -fortified blended foods -ready to use foods -high-energy biscuits -micronutrient powder- "Sprinkles" -compressed food bars

Advantages of RUTFs

-consumed directly by the child, providing sufficient nutrients for recovery -children can be treated at home (children treated at home with RUTF have better recovery vs those hospitalized) -mothers not required to stay at hospital, away from home (compared to F75 and F100 which is given at clinic) -can be given to be used at home, so children can be with family more, moms can return to work, can carry on with life which = survival -no added water required (avoids risk of bacterial proliferation, contamination -no cooking required (firewood, electricity) -can be stored unopened for 3-4 mos w/o refrigeration -feasible component for community interventions -high acceptability in many countries; but some countries have low acceptability

Ready-to-use therapeutic food

-high energy fortified foods suitable for children with SAM -consumed directly without prior dilution or cooking (less risk of contamination) -5x greater energy density (vs F-100) and similar nutrient to energy-ratio

Cons of RUTF

-long-term consumption effects are not elucidated: -potential for epigenetic changes -potential to influence children's taste preferences toward sweet, fatty food and rejection of different foods/family foods -potential to impact gut microbiome/not fully understood the impact on microbiome -being used in non-emergency/SAM scenarios -replacing family foods and breastmilk in children >6mos -replacing nutrition counseling towards a healthy diet with a magic-bullet foil-wrapped food -costs are declining b/c high production but still costly for the poorest countries that need it -cases of families sharing the RUTF with non-SAM children and selling the RUTF for income -commercial industry building from people not involved in public health using unethical marketing practices -would be better to increase agriculture and real food than supplement with processed food (more efficient, cost-effective, healthy)

Barriers to widespread adoption

-only ~15% of children with SAM will receive RUTF (though this is probably an underestimation since the industry has grown exponentially, more exposure now) -often stigmatized- imported food made with exogenous ingredients (not culturally appropriate) -more recently, local production: issues of QC -we do not know impact of using RUTFs long-term, or with adults -sometimes used inappropriately, as regular food or for adults

RUTF labeling

-product name: RUTF (written out) -statement "RUTF for children with severe acute malnutrition", raw materials listed in order of descending quantities -clear *pictorial* instructions -manufacture date, best before date, storage conditions, leaflet in carton with detailed nutritional composition

WHO/UNICEF strategy for severe acute malnutrition (SAM)

-reduce deaths by improving treatment -Integrated Management of Childhood Illness (IMCI)- special guidelines required for the recovery of severely malnourished children -lack of appropriate care leads to diarrhea, poor appetite, slow recovery, high mortality -stabilization phase (1-7 days) and then longer rehabilitation phase (2-6 weeks)

F-100

-requires water- not recommended for use at home -risk of bacterial contamination is high -use at the clinic, same with F-75

Severe malnutrition definition

-severe malnutrition- presence of severe wasting (<70% of weight-for-height or <-3 SD) and/or edema

Step 7: Cautious feeding

-small, infrequent meals; just enough energy and protein to maintain basic functions -oral or nasogastric feeds -100kcal/kg/d -F-75= milk-based starter formula (75kcal/100mL and 0.9g protein/100mL) -encourage continuation of breastfeeding and prescribed amounts of starter formula

RUTF characteristics

-smooth, homogenous texture -oil should not separate -pleasant sweet flavor -low moisture content; produces a low water activity, preventing the growth of microorganisms -can be given safely for home consumption

Step 8: Catch-up growth

-vigorous approach to feeding, readiness is indicated by return of appetite (~1wk after admission) -goal: achieve very high intakes, rapid weight gain -milk-based F-100 (100kcal/100ml and 2.9g protein/100mL); or sometimes Plumpy'nut is used instead of F-100 -modified porridges or modified family foods can be used if similar in energy and protein -breastmilk does not have enough energy and protein to support rapid catch-up growth)

10 Essential Steps for routine care for SAM in children

1. Treat/prevent hypoglycemia 2. Treat/prevent hypothermia 3. Treat/prevent dehydration (but, oral rehydration not recommended bc low K/Na ratio (not enough K, too much Na) 4. Correct electrolyte imbalance 5. Treat/prevent infection 6. Correct micronutrient deficiencies 7. Start cautious feeding 8. Achieve catch-up growth 9. Provide sensory stimulation and emotional support 10. Prepare for follow-up after recovery *think about prevention, not just treatment, prevent these things in the first place

RUTF nutritional composition

Energy: 520-550kcal Proteins: 10-12% (at least half from dairy) Lipids: 45-60% N-6 fatty acids: 3-10% N-3 fatty acids: 0.3-2.5% -miconutrient powder: A, D, E, K, C, B1, B3, B6, B12, iron, Folic acid, zinc, copper -specify if peanuts are roasted -no honey (botulism risk) -palm oil, rapeseed oil, soy bean, and sunflower oils -lecithin, mono and diglycerides as emulsifiers

Define stunting

Low height-for-age -chronic insufficient nutrient intake and frequent infections -1/3 of children are <5 -delays in motor development, cognitive function, poor school performance -largely irreversible -increases risk of Type 2 diabetes

Define wasting

Low weight-for-height -childhood mortality -acute significant food shortage and/or disease -24 countries have rates of 10% or more

Which step does use of RUTFs fall under?

Step 8- achieve catch-up growth