This is a common situation. it is common in all programs where food is distributed including "medical" foods such as RUTF - it is very rarely assessed and I know of only one confidential document where this has been properly assessed (and sharing is very extensive,selling less so). It is partly caused because of the amounts of RUTF that are given by some agencies/protocols. We can easily calculate the amount of energy that a recovering child actually takes from the rate of weight gain. There have been many studies that show that the energy cost of tissue deposition averages 5kcal/g of new tissue - and the energy cost of maintaining weight is about 100kcal/kg/d. Thus, if a child is gaining weight at say 8 g/kg/d then her/his total intake averages 100+5x8 = 140kcal/kg/d. (some of this may come from other foods, family pot etc. so that this is the MAXIMUM amount of the RUTF that the child is actually taking) In actual fact the mean rate of weight gain in many OTP programs is much less than 8g/kg/d. Some as low as 4g/kg/d (indicating an intake of 120kcal/kg/d) or even less! What happens to all the rest of the RUTF (in this example at 80kcal/kg/d and more if some of the child's intake is from other foods). Now most malnourished children when newly admitted have moderate appetites and will not take more than about 100-130kcal/kg/d until their physiological adaptations reverse and they are ready to consume very large amounts of the diet. So what happens when we give 200kcal/kg/d to mother to take home when the child is newly diagnosed? Ideally she does not give other foods to the child so if we take the situation where no other foods are given, and the child is fed and encouraged to take only the RUTF, s/he will become satitated at about 100 to 130 kcal/kg/d during the first week - leading 70-100kcal/kg/d uneaten and unwanted by the malnourished child. What is she to do with this valuable resource? Well usually there is quite extensive sharing within the family (and sometime to neighbouring families) and then some is sold and we find it in the market and get angry and call the police! This is:
1) wasteful and expensive for the program 2) potentially dangerous. If the child, when newly admitted to the program, actually does take that amount it can lead to the "refeeding syndrome" (which can cause death - I can send references to anyone that wants to know more about refeeding syndrome) and refeeding diarrhoea (a different problem not to be confused with refeeding syndrome) 3) in the context of this discussion having fairly large amounts of "left-overs" encourages mothers to share and sell. And indeed the family can become habituated to sharing - then later when the child does regain his/her appetite, the habit of sharing and/or selling is alrady firmly established within the family. 200kcal/kg/d was the MAXIMUM amount that children took in TFCs during the rapid growth phase (after an acute phase AND a transition phase during which the physiological adaptations reversed - those who took all the diet achieved rates of weight gain around 20g/kg/d - a figure that is never achieved in OTP programs). This amount was simply transferred to OTP protocols without testing any other amount or consideration of the implications. Now, it may be that sharing and to a lesser extent selling is inevitable, in which case we should give excess to ensure that the child does indeed get sufficient to recover - but there are really no data on this. In my protocol we have tables that deliver 170kcal/kg/d and the rates of weight gain are the same as when 200kcal/kg/d are given - but there is no documentation about sharing or selling with either of these protocols. The rates of weight gain in OTP in the early, experimental days by ACF when they brought children into residential care for a few days before transfer to OTP averaged around 10g/kg/d (intake 150kcal/kg/d - amount given to patients 170kcal/kg/d), which far exceeds most other program's rates of weight gain. This sort of weight gain can also be achieved with more detailed counselling of the mothers before they go home with the week's ration - but this is uncommon in my experience - but does occasionally happen with well trained teams. The analogy with malaria tablets is not apposite - we do not give a much higher dose of malaria tablets out to patients than are required or can be taken by the patient - and if we do drug monitoring we normally find that the patient has taken the dose prescribed - whereasa with RUTF we give excess and routinely find (from the rate of weight gain) that a large proportion of the "medicine" has not been taken! In theory, we should start with a much smaller amount for the first week of treatment and then increase a bit for the second week and then go to the full amount from then onwards (depending upon the appetite and response of the child) -but this would complicate treatment protocols and I am unsure whether it should be introduced - but it needs to be properly investigated. I have written a draft protocol and constructed tables for giving 135kcal/kg/d for the first week (or so depending upon appetite test) and then 150 for the next week progressing to 170kcal/kg/d thereafter - but this needs to be properly tested before it is written into a generic protocol. If any NGO would like to conduct such a study, I would be happy to work with them. It is also common to find that children are given large amounts of RUTF at the start of a program, and then the supply starts to run out so that after a while the children get a reduced amount (ad hoc and not based upon calculation or tables of what sort of reduction is "acceptable") to "conserve" stocks until the next logistic supply - so some get to much and some to little in practice! This is particularly the case where logistics are problematic (not with well resourced focused INGOs. but often with scaled up services implemented by overstretched MoHs). There is a lot of work to be done on these issues to refine the protocols and advice we give to cartakers - simply getting angry, blaming mothers, designing penalties and inviting the police to intervene does not seem to be the right way to go about things! First we must understand why, do the operational reseach and then refine protocols to address the problem (if it can or should be solved at all). Mike Golden |