Frustrated by years of developing recipes that did not work, including fortified doughnuts and pancakes, paediatric nutritionist André Briend was inspired by a jar of the chocolate spread, Nutella. Borrowing a mixer from a local restaurant, he made his first cocktail of milk powder, sugar, peanut paste, oil and a dash of vitamins and minerals ten years ago in Malawi.
Briend became convinced he had hit on a formula that could help children under five recover from severe malnutrition, often at home, without having to be admitted to a feeding centre.
His kitchen recipe has since been refined into a product commonly marketed as Plumpy'Nut.
Plumpy'Nut and the concept of Ready to Use Therapeutic Food (RUTF) has already led to a radical change in the way severe malnutrition is treated in several hunger-prone countries, and has been endorsed by major UN agencies and non-governmental organisations (NGOs).
Briend, who now works for the World Health Organisation, at first found few takers for his recipe. "Only two [doctors] responded positively and were ready to test it: Mark Manary [a professor of paediatrics at the Washington University School of Medicine, in St Louis, USA] who worked in Malawi, the other was Steve Collins [now a director of Valid International, a research NGO] who worked mainly in emergency settings," Briend told IRIN in Geneva.
Manary did extensive groundwork and was the first to provide evidence that RUTF was effective in the field, according to Briend. "This helped a lot to have RUTF introduced and accepted in Malawi. Steve [Collins] did the same in an emergency crisis in Ethiopia, and progressively convinced emergency NGOs to change their approach to treating severe malnutrition."
Production development took another year, but collecting evidence, convincing colleagues and allowing them to collect their own evidence took even longer. "I had the idea of using a spread at the end of 1996, so it took about 10 years to have the idea fully developed and accepted," Briend said.
What made RUTF revolutionary was that it provided the nutrients required to treat a severely malnourished child at home, without refrigeration, and even where hygiene conditions were not perfect. It is dispensed as foil-covered bars or in locally available plastic containers and can be stored in tropical conditions for three to four months.
The palatable, soft and crushable nutrient- and energy-rich food can be eaten by children over the age of six months without adding water, reducing the risk of infection. "An additional advantage of RUTF is that most children prefer it because of its pleasant taste," Briend commented.
Before RUTF, the traditional response to severe acute malnutrition had been to refer children to a hospital or specialised in-patient treatment unit, where they were fed special milk-based diets. Though this was effective, families in some of the world's poorest countries did not always have easy access to health facilities that could provide such care, according to UNICEF.
In-patient treatment is also often difficult for parents who cannot afford to leave their homes for several weeks, while the weakened immune systems of severely malnourished children can make them more vulnerable to infections, a significant risk in crowded hospital wards or feeding centres.
The technology required to produce RUTF is relatively simple: it takes only a peanut paste processor. Most of the ingredients are available locally in many countries, but the milk powder, a main constituent of the paste, can be expensive.
However, costs can be kept in check, and a Malawian plant producing the mixture has kept them to a minimum: the ingredients are donated and the factory is operated by only eight employees. Besides Malawi and Niger, there are plants in Kenya, the Democratic Republic of Congo and some processing capacity in Zambia as well as by the company Nutriset, based in France.
On June 7 this year, the policy-making UN Standing Committee on Nutrition formally endorsed the RUTF approach, saying it could be used to treat three-quarters of children with severe acute malnutrition.
The UN Children's Fund (UNICEF), one of the two biggest buyers of RUTF globally - the other is Médecins Sans Frontières (MSF), the medical non-governmental organisation (NGO) - is now set to roll out the food in many more countries early next year.
Steve Jarrett, principal advisor in UNICEF's supply division, told IRIN that RUTF had greatly improved survival rates of severely malnourished children during emergencies in Ethiopia, Malawi, Niger and Sudan.
Severe acute malnutrition kills an estimated one million children each year, according to UNICEF.
RUTF is not a miracle cure, however. The causes of malnutrition are numerous, and some children with complications will always require in-patient treatment, according to a statement from the standing committee.
Results and opportunities
"The results in Niger, where MSF was dispensing RUTF [in 2004/05], was the tipping point in favour of the rollout; the mortality rate among severely malnourished children dropped from 30 to 35 percent, to five percent." In Niger, MSF posted a phenomenal 90 percent success rate after treating more than 60,000 severely malnourished children with RUTF.
Through the RUFT approach, UNICEF expects to be able to to reach larger numbers of children in communities untouched by classical emergencies but suffering severe acute malnutrition. "Over half the countries in Africa have large numbers of severely malnourished children," Jarrett said.