Prevalence of malnutrition in children under 5 is very high in India. It is estimated that 3% of world’s children suffer from severe acute malnutrition & the figure for South Central Asia is 5.1%1 . The NFHS (National Family Health Survey,India) 4 survey conduced in 2015-16 has shown an increase in SAM from 6.4% to 7.5% in a decade2.
Treatment of children of SAM is a national priority. As per WHO & UNICEF, the management of children with SAM is broadly divided in two categories for ease of medical care. Children who have medical complications like diarrhoea, dehydration, pneumonia, hypoglycemia, electrolyte imbalance, hypothermia or others, oedema or loss of appetite would generally need hospitalization. Stabilization & nutrition rehabilitations is done for children admitted to NRCs (Nutrition rehabilitation centers). These comprise of around 10-15% patients of SAM. However, majority i.e. the remaining 85-90% of the patients can be managed at home in the communities and such patients can be given therapeutic feeding along with antibiotics deworming and other ambulatory care. For these children various therapeutic regimes are tried by various workers.
In our study, we compared 3 therapeutic feeding options in terms of their efficacy, tolerability,palatabibility and logistic issues.
These three therapeutic feeds were C-RUTF, L-RUTF & ARF which were randomly given to SAM children from 6 tribal blocks of Nandurbar from Maharashtra State, India during 2014-15.
1) C-RUTF - Commercially available ready to use therapeutic food was available in sachets which had a shelf life of 18 months was easy to store, moisture free, sterile. It did not require any preparation. It is in the form of paste of ground nuts, milk powder, sugar and oil in proportions as given in Table 1. Micronutrients are added to the paste. The particle size is less than 200µ. Taste is sweet and is highly palatable. The cost was around Rs.4,140/- approx. per child’s treatment for 2 months.
2) L-RUTF - Locally prepared ready to use therapeutic food. This was prepared locally in the village anganwadi center using the same ingredients as C-RUTF. The paste was made in a mixer. It had more bulk, was voluminous and had to be prepared afresh. Storage, safety and contamination (sespecially bacterial) are major issues in anganwadis that are ill equipped. Even moisture is likely to spoil ground nuts and milk powder. The particle size of the powder is much larger than 200µ and grinding of paste depended on availability of electricity at the village anganwadi center. The number of calories provided by L-RUTF are nearly similar to those provided by C-RUTF. Cost of treatment was Rs.3,848/- per child for 8 weeks.
3) ARF - Amylase rich food was prepared in anganwadi by sprouting wheat, green gram, then drying it and grinding into powder. Sugar, oil & milk powders are added separately while preparing porridge like ‘sheera’ or ‘upma’. It is not as calorie dense as C-RUTF or L-RUTF. Large amount is required to give calories like RUTF. It requires cooking, boiling every day like a hot cooked meal. Constituents may vary from day to day and from person to person while cooking. Multivitamin syrup is given to the child separately to provide micronutrients. Cost per child was Rs.2400/- for 8 weeks. From this, it was observed that C-RUTF has extreme ease of administration, ease of transport, storage and is least contaminated, hence safe. It is finely ground; hence, easily absorbed compared to L-RUTF & ARF which are difficult to prepare, though is economically a bit cheaper.
As is seen from table 3, the number of untoward events were maximum for L-RUTF 32.35% as compared to 15.7% for ARF and were seen to be the least i.e. 7.89% in C-RUTF. Thus the safety of C- RUTF has been obvious in this study. No. of episodes of diarrhoea were highest in L-RUTF group. The main reason could be bacterial contamination.
As seen from Table 4, 52.8% of children on C- RUTF recovered at the end of 8 weeks, the same figures were 44.8% with ARF & 43.5% with L- RUTF. This difference was found to be statistically significant.
There are few published reports on the use of therapeutic food in treatment of uncomplicated SAM. N. Bhandari found L- RUTF to show 57% recovery while C- RUTF showed 47% recovery3. In African setting C- RUTF has been seen to show 60.8% recovery.
Our study has also analysed untoward effects that are the least with C- RUTF. Indian studies on this qualitative aspect are not published so far.
Considering all these facts, it appears that C- RUTF will definitely form the pillar of community management of SAM in Indian children and should be tried in SAM children by scaling up CMAM program in all States of India where malnutrition is prevalent.
The C-RUTF used was from Amul,Gujarat. There are 22 manufacturers of RUTF approved by UNICEF. Three important ones from India are Bal-Amul by Kaira District co-operative milk producers union ltd.(AMUL),Compact India pvt Ltd. and Proactiva by Hexagon Ltd .Other common brands are Plumpy nut paste manufactured by Nutriset,Mana nutritive aid products,,Diva nutritional products,Nuflower foods,Nutrivita foods,Meds and foods,Power food industries,Edesia USA and Vitaset.