|Peanut based diet for severely malnourished children|
|Diet for severely malnourished child||Britta Schumacher||16.11.2000|
|Peanut based diet for severely malnourished children||André Briend||17.11.2000|
Date: Thu, 16 Nov 2000 15:24:00 +0100
Subject: Diet for severely malnourished child
A query from a colleague working for WFP in Guinea.
A colleague of mine who works in health centres in east Guinea, West Africa, is frequently confronted with severely malnourished children who are not able to eat even mash. They are aware of the WHO recommendations but face the problem that milk products are not affordable nor available in the area concerned.
Due to this situation they started giving children between eight months and five years in the initial phase a what they call "peanut milk" made from 90 g peanut paste and 70 g sugar per one litre of water. The children receive six meals per day.
So far the clinical effects have been satisfying (including stop of diarrhea) and no side effects have occurred.
Still, they are uncertain about the appropriateness of this diet since they have not found any indication in the available literature and would thus like to have some professional back-stopping. Their queries in detail are the following:
1. Are there known experiences with "peanut milk" in the initial phase of treatment of severely malnourished children and is there written evidence on this (documents, reports, any kind of literature)?
2. Is there evidence on side effects of a peanut-based diet in this context or are these to be expected? (If yes: which?)
3. Should the peanut milk be cooked for a long time or only heated (regarding exploitation of nutrients, digestibility)?
We would be grateful if you could share your experience with us and give us your advice.
Date: Fri, 17 Nov 2000 11:52:23 +0100
From: "André Briend" briendaatcnam.fr
Subject: peanut based diet for severely malnourished children
Some comments to Britta's queries.
Peanuts are better than no food, or than a plain cereal based porridge with 90% water, but not ideal to be used in isolation for feeding severely malnourished children. Several reasons for that.
1- Peanuts do not have a good amino acid profile, and in particular have a low lysin content. As a result, they do not provide a good complement to cereal based diets in contrast to other legumes.
2- Peanuts have a very high phytate content, about 1% weight / weight. As a result, their phytate zinc ratio is very high, above 30, whereas a phytate zinc ratio above 15 means poor mineral absorption.
3- Peanuts have a high concentration of anti nutrient factors (this problem can be partially solved by using a spread prepared by cooked peanuts)
4- They may contain aflatoxin
5- They may induce allergy (although this is not usually reported in Africa, and may represent a minor problem compared to life threatening malnutrition).
In conclusion, if you feed a severely malnourished child with peanut only (or peanut + sugar) he will put on fat, and little else, because he will not get some key nutrients (Class 2 nutrient in Mike's classification) needed for lean tissues synthesis : balanced proteins + zinc in particular.
This is worrying because some lean tissues are very important for survival, in particular immune cells and muscle. Weight gain will be poor in relation to energy intake because synthesis of fat tissue requires much more energy than lean tissues.
Having said that, peanut used in combination with other foods may be very useful. You may have heard from previous NGOnut contributions about the Ready to Use Therapeutic Food (plumpy'nut) which contains peanuts and apparently gives very good results in terms of weight gain, comparable to WHO F100 (of which it is a copy in terms of nutritonal formulation). The difference, however, is that RUTF contains a lot of milk proteins, which balance the amino acid profile. Moreover, it is highly fortified with zinc and other minerals and peanut makes only a small part of the product (about 25%) and as a result, it has a very low phytate/zinc ratio. Incidentally, this food is very well accepted by children and is eaten without addition of water. Bacteria cannot grow in it which makes this food safe for community based treatment of severe malnutrition.
Now what can we do for children in Guinea ? Ideally they should receive the WHO recommended diets (F100 and F75) especially if they have a poor appetite at the beginning of treatement. I understand this is not possible.
Another alternative would be to improve the peanut based diet propsoed by Britta. This can be done by mixing dried skimmed milk with groundnut + sugar to improve the amino acid profile and add minereals and vitamins. Is it really not possible that WFP gets some powdered skimmed milk in Guinea to try this approach ? This would be surprising. If DSM is really not available, the amino acid balance could also be imprioved by mixing groundunt with soy flour. This is not ideal because soy has a high phytate content, but this should be an improvement. Minerals and vitamins should be added too (not the same mix). I suggest the resulting diet should be given directly, without addition of water, to take advantage of the absence of water in the resulting spread and keep it resistant to bacterial contamination.
For your information, Nutriset, the company which developed RUTF and produces it commercially (and for which I am a consultant) would be ready to help any NGO interested in developing a locally produced spread-like food derived from the RUTF recipe. This local appraoch is not yet field tested, and interested NGO's should be ready to accept a road with trial and errors. Some ingredients and processes used during the industrial preparation of RUTF are not easy or impossible to transfer at the local level and the resulting product will not have the same taste, will have a shorter shelf life... but it might help.
I believe that this innovative approach should help us to move away from the traditonal TFC / SFP programmes, which seem little effective outside the emergency setting (and even then are far from ideal; see previous mails from Steve). Looking forward to getting feedback from interested innovative NGO's.
With best regards,
PS: I will be out of the net for the next 10 days.
André Briend, MD, PhD
CNAM - ISTNA, 5 rue du Vertbois, 75003 Paris, France
tel : 33-1-53 01 80 36 fax : 33-1-53 01 80 05