Comparison of the Efficacy of a Solid Ready-to-Use Food and a Liquid, Milk- Based Diet in Treating Severe Malnutrition

Kwashiorkor case, before and after management using RUTF (oedema resolved). Nutritional Rehabilitation Centre (Dispensaire Saint Martin), Senegal 2001

Summary of published research¹

The World Health Organisation (WHO) recommends a liquid, milk-based diet (F100) during the rehabilitation phase of the treatment of severe malnutrition. However, a dry, solid, ready-to-use food (RTUF) that can be eaten without adding water, thus eliminating the risk of water-sourced bacterial contamination, has recently been developed. This food is obtained by replacing part of the dried skim milk used in the F100 formula with peanut butter. RTUF is at least as well accepted by children as is F100, and its availability has raised the possibility of treating severely malnourished cases in the community. However, since the efficacy of RTUF has never been tested in a controlled trial, its recommendation for extensive use in the community might be premature. The objective of a recent study in Senegal was to compare the efficacy of RTUF and F100 in promoting weight gain in malnourished children.

The open-labelled, randomised trial took place in a therapeutic feeding centre attached to a clinic² in Dakar, Senegal, that is attended by poor families. Recruitment and follow-up were conducted between March and September 2001, the peak season for malnutrition. Eligible children were identified by the study physician, based on anthropometric criteria.

A total of 70 severely malnourished Senegalese children, aged between 6 and 36 months, were selected. Each was randomly allocated to receive three meals containing either F100 (n = 35) or RTUF (n = 35), in addition to the local diet. Most of the children (27 in F100 group, 29 in the RTUF group) were fed by their mothers, while the remainder (n=14) were fed by another member of the family. All efforts were made to have children fed ad libitum. Breastfed children were offered their meals after being breastfed.

Data from 30 children in each group were available for analysis. The main findings were:

• The mean daily energy intake in the RTUF group was 808 ± 280 kJ³/kg/day (95% CI: 703.8, 912.9) and in the F100 group was 573 ± 201 kJ /kg /day (95% CI: 497.9, 648.7, p<0.001).
• The average weight gains in the RTUF and F100 groups were 15.6 g/kg/d (95% CI: 13.4, 17.8) and 10.1g/kg/d (95% CI: 8.7, 11.4), respectively (p<0.001).
• The difference in weight gain was greater in the most wasted children (p< 0.05).
• The average duration of rehabilitation was 13.4 days (95% CI: 12.1, 14.7) in the RTUF group and 17.3 days (95% CI: 15.6, 19.0) in the F100 group (p<0.001).

These results suggest that RTUF, given in a supervised setting, is superior to F100 in promoting weight gain during the rehabilitation phase of the management of severe malnutrition. The authors of the study recommend that further work be undertaken to measure the effectiveness (in terms of weight gain) of RTUFs consumed at home. Weight gain at home is likely to be lower than that in a controlled setting since the RTUF might be shared with siblings and will be consumed with less supervision. Yet, achieving a rapid weight gain is not as important at home as it is in a residential treatment unit, for economic, social, and familial reasons. Also, the lower risk of cross infection from other children in a family setting makes a rapid recovery less important. A lower weight gain seems acceptable during homebased treatment; even so, the weight gain observed in the current study was over ten times the weight gain of well-nourished children of the same age.

The authors reflect that if effectiveness studies of RTUF and of its locally produced equivalents in a community setting yield positive results, the widespread use of these foods could change the way we treat severe malnutrition.

¹El Hadji Issakha Diop, Nicole Idohou Dossou, Marie Madeleine Ndour, André Briend, and Salimata Wade (2003). Comparison of the efficacy of a solid ready-to-use food and a liquid, milk-based diet for the rehabilitation of severely malnourished children: a randomised trial. Am J Clin Nutr 2003;78:302-7.

²Dispensaire Saint Martin, Rebeuss, Dakar, Sénégal

³Conversion of kJ to kcal: kJ x 0.2388 = kcal