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ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 4  |  Page : 223-228

Home Based Food Supplemented With RUTF (Ready To Use Therapeutic Food) Versus Only Home Based Food for Post Discharge Rehabilitation Phase Weight Gain in Children with Severe Acute Malnutrition


GMERS Sola, Ahmedabad, Gujarat, India

Date of Submission14-Jun-2020
Date of Decision21-Jul-2020
Date of Acceptance30-Jul-2020
Date of Web Publication01-Oct-2020

Correspondence Address:
Nehal H Patel
Professor and Head, Pediatrics Department, GMERS Medical College and Sola Civil Hospital, Near Sola High Court, Ahmedabad, 380060, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnpnd.ijnpnd_53_20

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   Abstract 


Background: Weight gain in patients of Severe Acute Malnutrition(SAM) after discharge from child malnutrition treatment centre (CMTC) is generally not satisfactory(<5gm/kg/day) on Home-based food alone. Aim: To compare post discharge weight gain in SAM patients gradually shifted from Ready To Use Therapeutic Food to home based food with those started directly on home based food. Materials and Methods: Sixty four children with SAM were included in study. The case group was given RUTF to be consumed at home along with other home based food while for control group only home based food was advised. In both the groups patients were followed up regularly every fortnight for three visits. Their weight, Height, Mid upper arm circumference(MUAC) and Z score were monitored in each visit. The difference in weight gain in both the groups was analysed using unpaired t test. Results: Thirty two children each in both case and control group were included. Rate of weight gain in case group was 2.08gms/kg/day while in the control group was 1.6gms/kg/day. The difference was statistically not significant. But age wise subgroup analysis showed that in toddler group weight gain in case group was 2.37gms/kg/day while in control was 1.13gm/kg/day, which is statistically significant (P<0.05). Conclusion: Introduction of RUTF as supplement to home based food significantly improves post discharge weight gain in toddler age group.

Keywords: RUTF, SAM, weight gain


How to cite this article:
Pandav GN, Nagadia QM, Solanki PR, Thanvi RS, Dhamecha NP, Patel NH. Home Based Food Supplemented With RUTF (Ready To Use Therapeutic Food) Versus Only Home Based Food for Post Discharge Rehabilitation Phase Weight Gain in Children with Severe Acute Malnutrition. Int J Nutr Pharmacol Neurol Dis 2020;10:223-8

How to cite this URL:
Pandav GN, Nagadia QM, Solanki PR, Thanvi RS, Dhamecha NP, Patel NH. Home Based Food Supplemented With RUTF (Ready To Use Therapeutic Food) Versus Only Home Based Food for Post Discharge Rehabilitation Phase Weight Gain in Children with Severe Acute Malnutrition. Int J Nutr Pharmacol Neurol Dis [serial online] 2020 [cited 2020 Dec 3];10:223-8. Available from: https://www.ijnpnd.com/text.asp?2020/10/4/223/297508




   Introduction Top


Severe acute malnutrition (SAM) in children is defined as weight-for-height Z-score<-3 SD(as per median WHO child growth standards), and/or Mid Upper Arm Circumference < 11.5cm and/or Bilateral pitting pedal oedema, in children between 6months to 59 months.[1] Globally around 20 million children under 5 years of age suffer from SAM.[2] In India, prevalence of SAM is 6.4%, as per National Family Health Survey 3 (NFHS-3). India is home to 8 million children with SAM. One third of world’s severely wasted children live in India.[3] Children who are severely wasted are nine times more likely to die than well-nourished children.[1]

Children with SAM should be assessed for medical complications and appetite. Children who pass appetite test, clinically well and alert should be treated as outpatients with Ready To Use Therapeutic Food(RUTF). Children with medical complications, severe oedema, or those who fail the appetite test should be treated as inpatients. Admitted children are managed in two phases: (1) Stabilization Phase:-Treatment of complications like hypoglycaemia, hypothermia, electrolyte imbalances and infections, start feeding with starter formula like F-75. (2) Rehabilitation Phase: Aim is weight gain and to prepare child for discharge. F-100 and RUTF are given in this phase.[4]

RUTFs are homogeneous mixture of lipid-rich and water-soluble foods. The lipids used in formulating RUTFs are in a viscous liquid form. The other ingredients are protein, carbohydrate, vitamins and minerals. The mixture needs to be homogeneous for it to be effectively consumed. To do this, a specific mixing process is needed.[5] RUTF gives malnourished children the vital nutrients they need to recover. The original and most well-known RUTF, Plumpy’nut, was invented in 1996 by French pediatrician André Briend. As the name suggests, Plumpy’nut is a peanut-based paste served in a foil pouch. It was portable, non-perishable, and can be eaten by babies who weren’t yet ready for solid foods. During the famine emergencies of the 1980s and 1990s in Ethiopia, a peanut based RUTF was used for SAM children. In famine, child mortality rate is often 20 to 30%. With the combined use of CMAM(Community Management of Acute Malnutrition) and RUTF, mortality rates were 4.5%. For a crisis like a famine, that meant an incredible number of lives saved.[6]

Since 2007, WHO recommends RUTF for home-based management of uncomplicated SAM[7]. However, acceptance of this recommendation has been limited in countries like India. In our study we compared RUTF as a supplement to home based food with only home base food for post discharge rehabilitation phase management of children with SAM. Our aim was to compare the weight gain and recovery rate in both the group.


   Materials and Methods Top


Settings and Design: Study has been conducted at Child malnutrition treatment centre(CMTC) in Paediatrics department, GMERS Medical college and hospital Sola, Ahmedabad.

Study design

Retrospective case control study

Inclusion criteria

All the patients fulfilling criteria for SAM as defined by Guidelines provided by Government of India.

Exclusion criteria

Those patients not completed all the 3 post discharge follow up visit at every fortnight.

According to government of Gujarat guidelines for management of SAM, in stabilization phase patients were managed for complications and in rehabilitation phase patients were given RUTF − Bal Amrutam. (Composition shown in [Table 1]) At the time of discharge parents were advised to give home based nutritious food.
Table 1 Bal Amrutam made up of milk powder, peanutpest, soya or palm oil, maltodextrin, vitamins and minerals, emulsifiers (Nutrition value per 92 grams)

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Study period: From May 2017 to April 2018.

Cases: Patients were given home based food supplemented with RUTF .They were gradually shifted from RUTF to home based food in 42 days. 1 packet per day of RUTF was given. Total 49 patients admitted from November 2017 to April 2018 were enrolled in case group. Out of which thirty two patients completed all three visits.

Controls

Patients advised only home based food. They were directly shifted from RUTF given in hospital to home base food alone when discharged from hospital. From May 2017 to October 2017 total 84 patients were admitted. Out of them 63 patients completed all three visits. From these 63, every alternate patient was selected and total 32 patients were included in control group.

We gave list of home based nutritious food to parents in each group. In both the groups weight, height, MUAC and Z score were measured on discharge and at each follow up.

Statistical analysis used: Collected data was analysed using unpaired t test. P value <0.05 was considered as significant.


   Results Top


Thirty two patients were included in each group. Characteristics of each group like male-female, average age in months, weight and height on discharge from hospital are shown in [Table 2]. Rate of weight gain in case group was 2.08 ± 1.86 gms/kg/day while in the control group was 1.6±1.48 gms/kg/day. When unpaired t test was applied, we got the p value of o.o7 which was not of statistical significance (p>0.05). We divided the total children in subgroups like infant, toddler and preschool and measured the weight gain pattern in each subgroup [Table 3]. We found the statistically significant difference (P value=0.0158) in weight gain in only toddler group. Gain of height during six weeks was 2 cm in both the intervention and control group. As height is a criterion for chronic malnutrition, it is not relevant to our study.
Table 2 Characteristics of patients in both the groups at discharge

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Table 3 Distribution of patients in sub groups

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The findings of MUAC are depicted in [Table 4]. Two patients in intervention group had MUAC of <11.5 cm compared to three patients in control group. 43.75% of patients in case group compared to 28.1% in control group had MUAC<11.5 cm to begin with. 71.8% in case group compared to 46.8% in control group had crossed 12.5 cm after 6 weeks. This was a statistically significant difference with P value of 0.04.
Table 4 MUAC wise distribution of patients in cases and controls

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[Table 5] shows distribution of both groups as per weight for height criteria. After three follow-ups (six weeks) 68.75% had > −2SD weight for height in case group as compared to 50% in control group. Recovery rates were higher (22 out of 32 (68.75%)) in RUTF group compared to non-RUTF group (16 out of 32 (50%)) though difference is statistically not significant. 6.25% in intervention group and 18.75% in control group remained severely wasted at the end of six weeks.
Table 5 Distribution of patients in each group according to Z score

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In toddler sub group 70% recovered in case group compared to 38% in control group [Table 6]. The difference is statistically significant with P value of 0.04. Also if MUAC is considered in toddler age group difference is statistically significant with p value of 0.019 [Table 7].
Table 6 Z score wise distribution of patients in toddler

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Table 7 MUAC wise distribution of patients in toddler sub group

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   Discussion Top


Severe acute malnutrition is a preventable and treatable cause of childhood morbidity and mortality. According to guidelines for management of SAM only RUTF is given for inpatient management in rehabilitation phase. On discharge parents are advised to give home cooked nutritious food to their children.[8] Many studies have proved that SAM patients have poor weight gain after discharge if they are offered only home-based food.[5],[9],[10] Transition from only RUTF to only home based food becomes difficult. To understand this issue we have done this study to shift children gradually from only RUTF to Home based cooked food. We gave one packet of RUTF per day to each child in case group. One packet of RUTF provides 500 kilocalories. In infants, toddlers and preschool groups, average of 76.81, 72.3l and 41.6 kcal/kg/day was provided respectively by RUTF. The additional caloric requirement needed to be fulfilled by home cooked food.

Not many studies comparing outcome of shifting patients gradually from only RUTF to only Home cooked food has been available in India. In one study similar to ours Chauhan et al.[11] compared weight gain between SAM children on discharge from NRC(Nutritional Rahabilitation Center) taking non-milk based LTF (Local Therapeutic Food) with home-based diet with those taking only home-based diet. Rate of weight gain in intervention group was 5.48 g/kg/day while in the control group was 2.47 g/kg/day. The difference was statistically highly significant (p<0.001). They gave approximately 180-220kcal/kg/day from RUTF. That was as per recommended dose of RUTF in SAM. In study done by Kangas et al.[12], they assessed impact of reduced dose of RUTF in children with uncomplicated severe acute malnutrition. In their study reducing the RUTF dose in children with SAM after two weeks of treatment did not reduce overall weight gain, MUAC gain velocity nor affect recovery. In study done by Philip T. James et al low dose RUTF protocol consisted of two treatment stages. During stage 1, RUTF was dosed according to the child’s body weight from admission until the child reached an MUAC ≥ 110 mm and a WHZ ≥ −3. At this point, the child’s treatment changed to stage 2, whereby the RUTF was dosed at one sachet per day (92 g or 500 kcal ), regardless of weight, until completion of treatment. In stage 1 children were given only RUTF. In stage 2, patients were also advised to take home based food with RUTF. Their study results indicated that a low-dose RUTF protocol, combined with specific measures to ensure good service quality and beneficiary support, was successful in treating uncomplicated SAM.[13] In our study also RUTF was given in standard dose for initial 2 weeks. After that RUTF was given in reduced dose along with home cooked food.

We documented that rate of weight gain in toddler age (12 months to 36 months), is significantly higher in patients given RUTF as a supplement to home base food. For recovery rate, MUAC was significantly higher in case group. When Z score was compared recovery rate is higher in case group but it was not statistically significant. In sub group analysis, the toddler age having significantly higher recovery rate according to both MUAC and Z score criteria. In study by Chauhan et al.[11], they also found significantly higher recovery rate in RUTF group. But they gave therapeutic dose of RUTF and in our study we gave RUTF to provide approximately 40-45% caloric requirement. Still we found significantly higher weight gain and recovery rate in toddler age group. It indicates that RUTF in therapeutic dose for first 2 weeks followed by low dose for next 6 weeks is cost effective and beneficial approach. Toddler age group is very crucial as far as development is concerned. After 12 months of age children become more independent, able to walk and run, trying to explore surroundings, vocabulary develops, has particular likes and dislikes. They become interested in the colour, texture, consistency and taste of food.[14] According to their development, their food habits change. They become more fussy and choosy. In pre school sub group we have very less number of patients and difference in weight gain is statistically not significant. In study by James et al.[13], children older than 48 months of age were more likely to become non responders due to higher total energy and nutrient requirements. Therefore a bigger gap between energy and nutrient requirements and the amount of RUTF provided as compared to younger children. We should consider giving higher amount of RUTF in pre school sub group to observe for their response. Infants between 6-12 months of age are predominantly on breast feeding with complementary feeds. So, their extra calories and protein requirements are getting full filled by breast feed also. That may be the reason for not finding significant difference in weight gain in infants. Toddlers are generally gradually weaned from breast milk. Scientific evidence has shown that beyond the age of 2-3 years, many effects of chronic undernutrition are irreversible.[1] So, for this crucial phase of growth and development supplementing home cooked food with RUTF will definitely improve rate of weight gain. RUTF is nutritious, palatable and do not require any special preparation. Most of toddlers like it’s taste and it is easy to consume. Findings of our study open a new door for further large scale studies for using RUTF post discharge particularly in toddler age group. It also suggests that we should consider individualised approach in management of SAM. We have to convey the importance of nutritious food in the wholesome nutrition and growth of children to the parents. As unavailability of food is not the only issue but also unawareness about giving nutritious food to children forms an important aspect for SAM in our country.

Limitation

The limitations of the study were relatively small sample size and this study has data from single centre. Another limitation that since the RUTF was handed over to the parents it could not be monitored at home. We had to depend on the collection of the empty RUTF packets brought by parents on follow up.


   Conclusion Top


In conclusion, the findings of the study showed that giving RUTF to SAM patients on discharge from CMTC significantly improved their rate of weight gain at home in toddler age group though in other age groups the difference is not significant. It gives an important message that we should consider age and feeding habits of child while treating SAM patients.

Key message:-RUTF supplemented to home based food increases rate of weight gain particularly in toddler age group. Toddler are fussy eaters and our study suggest that we should also consider eating habits and create awareness in parents about giving nutritious food to their children.

Acknowledgement

I would like to acknowledge support from Ms. Anagha Anant Parab. She is working as nutritionist in child malnutrition treatment center in our institute. She gave her valuable support for data collection and also in patient management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Operational guidelines on facility based management of children with severe acute malnutrition by ministry of health and family welfare, Government of India 2011  Back to cited text no. 1
    
2.
Uauy R, Desjeux JF, Ahmed T et al. Global efforts to address severe acute malnutrition. J Pediatr Gastroenterol Nutr 2012;55:476-81.  Back to cited text no. 2
    
3.
International Institute for Population Sciences (IIPS) and Macro International. 2007 National Family Health Survey 3 (NFHS-3), 2005-06, Volume 2. Mumbai: IIPS, India, 1-168.  Back to cited text no. 3
    
4.
WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children. Geneva, World Health Organization; 2013 (http://www.who.int/nutrition/publications/guidelines/updates_management_SAM_infantandchildren/en/.  Back to cited text no. 4
    
5.
Manary MJ. Local production and provision of ready-to-use therapeutic food (RUTF) spread for the treatment of severe childhood malnutrition. Food and Nutrition Bulletin 2006;27:S83-9. doi:10.1177/15648265060273 S305. PMID 17076214  Back to cited text no. 5
    
6.
RUTF and CMAM: how a simple peanut paste became a humanitarian revolutionAugust 26, 2019. Available from https://www.concernusa.org/story/rutf-cmam-humanitarian-revolution/  Back to cited text no. 6
    
7.
World Health Organization. World Food Programme. Unit ed Nations System Standing Committee on Nutrition. UNICEF. Community-Based Management of Severe Acute Malnutrition. A Joint Statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children’s Fund. World Health Organization Geneva, Switzerland: 2007. [Google Scholar]  Back to cited text no. 7
    
8.
Guidelines on Management of Bal Shaktim Kendra (Village Child Nutrition Center) at the level of Anganwadi. Health and family welfare department, Government of Gujarat; 2012.  Back to cited text no. 8
    
9.
Singh AS, Kang G, Ramachandran A, Sarkar R, Peter P, Bose A. et al... Locally made RUTF for the treatment of severe acute malnutrition. A randomized controlled trial. Indian Paediatr 2010;47:679-86.  Back to cited text no. 9
    
10.
Ciliberto MA, Sandige H, Ndekha MJ, Ashorn P, Briend A, Ciliberto HM et al. Comparison of home-based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children: a controlled, clinical effectiveness trial. Am J Clin Nutr 2005:864-70.  Back to cited text no. 10
    
11.
Chauhan HH et al. Comparison of Non-milk based LTF Plus Home-based diet with home-based diet alone. JCDR 2019;13:SC05-SC08  Back to cited text no. 11
    
12.
Kangas ST, Salpéteur C, Nikièma V, Talley L, Ritz C, Friis H, Briend A, Kaestel P. Impact of reduced dose of ready-to-use therapeutic foods in children with uncomplicated severe acute malnutrition: a randomised non-inferiority trial in Burkina Faso. Available from https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002887  Back to cited text no. 12
    
13.
James PT, Van den Briel N, Rozet A, Israël AD, Fenn B, Navarro-Colorado C. Low-dose RUTF protocol and improved service delivery lead to good programme outcomes in the treatment of uncomplicated SAM: a programme report from Myanmar © 2015 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd Maternal and Child Nutrition (2015) 11, pp. 859-869  Back to cited text no. 13
    
14.
Agarwal R, Sankhyan N. Development in: Vinod K Paul, Arvind Bugga, editor. Ghai essential Pediatrics, ninth edition CPS Publishers; 2019. p. 43-48.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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