What is rutf
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RUTF ready-to-use therapeutic food severe acute malnutrition
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"ready-to-use therapeutic food" AND "severe acute malnutrition"
Here is a full overview of RUTF:
RUTF - Ready-to-Use Therapeutic Food
What is it?
RUTF is a specially formulated, nutrient-dense food used to treat severe acute malnutrition (SAM) in children, primarily those aged 6 months to 5 years. The most common form is a soft, oil-based peanut paste (brand name: Plumpy'Nut), though biscuit and other formats exist.
Composition
RUTF is designed to closely mimic the nutrient profile of F-100 therapeutic milk, the original in-patient malnutrition treatment formula. A standard sachet (92g) typically contains:
- Energy: ~500 kcal
- Protein: ~13g (largely from milk powder and peanut paste)
- Fat: ~26-31g (mainly peanut oil and palm oil)
- Vitamins & minerals: Full spectrum including zinc, iron, vitamin A, vitamin C, vitamin D, B-complex
- Water activity is very low - this means it does not require refrigeration and has a long shelf life (~2 years), which is critical for use in resource-limited settings
Why RUTF Changed Treatment
Before RUTF, treating SAM required hospital admission - children had to stay in therapeutic feeding centers for weeks at a time. RUTF enabled a shift to Community-based Management of Acute Malnutrition (CMAM), where children are treated at home. This had a massive impact because:
- Only children with medical complications (infection, edema, poor appetite) now need hospitalization
- Caregivers can administer treatment at home
- Far more children can be reached at lower cost
Effectiveness
- ~90% recovery rate in children with uncomplicated SAM
- Full nutritional recovery typically in 4-8 weeks
- Endorsed by the WHO, UNICEF, WFP, and UNHCR as the standard of care for outpatient SAM treatment
- UNICEF procures and distributes RUTF globally; in 2023 alone, Action Against Hunger treated 355,000 children with SAM using RUTF
How It Is Used
- Child is screened for SAM using mid-upper arm circumference (MUAC) or weight-for-height Z-score
- If no medical complications, child is enrolled in outpatient therapeutic program (OTP)
- Caregiver receives weekly or bi-weekly supply of RUTF sachets
- Child eats directly from the sachet - no water or cooking required
- Child is monitored weekly for weight gain and appetite
Ongoing Research
A recent meta-analysis (2026) examined low-dairy RUTF formulations with amino acid fortification as a potentially lower-cost alternative to standard high-dairy RUTF, which is relevant for scaling up production in high-burden countries.
Key Facts at a Glance
| Feature | Detail |
|---|---|
| Target population | Children 6 months - 5 years with SAM |
| Basis | Peanut paste + milk powder + oil + vitamins/minerals |
| WHO standard | Yes - endorsed for outpatient SAM treatment |
| Shelf life | ~2 years, no refrigeration needed |
| Recovery rate | ~90% within 4-8 weeks |
| Main brand | Plumpy'Nut (Nutriset, France) |
RUTF is considered one of the most impactful interventions in global nutrition, saving hundreds of thousands of children from malnutrition-related death every year. UNICEF's supply division is the largest procurer globally.
What is resomal
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ReSoMal rehydration solution malnutrition composition WHO
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https://medicalguidelines.msf.org/en/viewport/EssDr/english/…
Here is a complete breakdown of ReSoMal:
ReSoMal - Rehydration Solution for Malnutrition
What is it?
ReSoMal (REhydration SOlution for MALnutrition) is a specially modified oral rehydration solution (ORS) developed by the WHO for rehydrating children with severe acute malnutrition (SAM) who have diarrhoea and dehydration.
Standard WHO-ORS cannot be safely used in SAM children because these children have profoundly altered physiology - they have too much body sodium and too little potassium. Giving standard high-sodium ORS risks sodium overload, fluid overload, and heart failure.
Why Standard ORS is Dangerous in SAM
Children with SAM have:
- Depleted intracellular potassium - cells have lost potassium and filled with sodium
- Impaired kidney function - cannot handle sodium loads normally
- Compromised cardiac function - at risk of heart failure with fluid overload
- Hyponatraemia on admission is actually a risk factor for poor outcome in SAM with diarrhoea (paradoxically, despite body sodium excess)
This makes standard ORS (sodium 75-90 mmol/L) dangerous in this group.
Composition (per litre)
| Electrolyte | ReSoMal | Standard WHO-ORS |
|---|---|---|
| Sodium | 45 mmol/L | 75 mmol/L |
| Potassium | 40 mmol/L | 20 mmol/L |
| Chloride | 76 mmol/L | 65 mmol/L |
| Glucose | 125 mmol/L | 75 mmol/L |
| Osmolarity | ~300 mOsm/L | 245 mOsm/L |
| + Magnesium, Zinc, Copper | Yes | No |
Key differences: ReSoMal has half the sodium and double the potassium of standard ORS. It also contains added micronutrients (magnesium, zinc) to address common deficiencies in SAM.
Dosing Protocol (WHO)
Prevention of dehydration (loose stools, no clinical dehydration):
- 5 ml/kg after each loose stool
Treatment of some dehydration:
- 5 ml/kg every 30 minutes for 2 hours
- Then 5-10 ml/kg/hour, alternating ReSoMal with F-75 therapeutic milk for 4-10 hours
Treatment of severe dehydration (no circulatory shock):
- Oral or nasogastric route at 5 ml/kg every 30 minutes for 2 hours, then alternate with F-75
If in shock: IV fluids are used first (Ringer's lactate + 5% dextrose), then switch to ReSoMal/F-75 once stable.
Important Precautions
- Never use in circulatory shock - requires IV fluids first
- Monitor closely for signs of fluid overload: rising respiratory rate, increasing oedema, puffy eyelids
- Hyponatraemia can paradoxically occur with ReSoMal use - reported in studies, with some children developing severe hyponatraemia and convulsions
- Do not use standard ORS as a substitute in SAM
- Prepared solution must be used within 24 hours
Clinical Context
ReSoMal is used as part of the WHO 10-step protocol for managing SAM in inpatient settings, typically alongside:
- F-75 (starter therapeutic milk, low protein/energy) in the stabilization phase
- F-100 or RUTF in the rehabilitation phase
Key Facts
| Feature | Detail |
|---|---|
| Full name | REhydration SOlution for MALnutrition |
| Target | Children with SAM + diarrhoea + dehydration |
| WHO endorsed | Yes |
| Sodium content | 45 mmol/L (low) |
| Potassium content | 40 mmol/L (high) |
| Given with | Alternated with F-75 therapeutic milk |
| Risk to watch | Fluid overload, hyponatraemia |
As described in the MSF Medical Guidelines and supported by a systematic review (PMC), ReSoMal remains the WHO-recommended rehydration choice for SAM, though careful monitoring is essential due to the risk of hyponatraemia.
What nutrition recovery syndrome
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Here is a thorough explanation of Refeeding/Nutrition Recovery Syndrome:
Nutrition Recovery Syndrome (Refeeding Syndrome)
Refeeding syndrome is the term used in clinical medicine. "Nutrition recovery syndrome" is another way of referring to the same condition - the dangerous metabolic complications that arise when a malnourished or starved person is re-fed too quickly, causing life-threatening shifts in electrolytes and fluids.
It was first reported after World War II, when severely malnourished Japanese prisoners of war were refed and then experienced electrolyte crises and sudden death.
Pathophysiology
The diagram below (from Yamada's Textbook of Gastroenterology) illustrates the mechanism clearly:
Step 1 - During prolonged malnutrition/starvation:
- The body switches to fat and amino acids as fuel (gluconeogenesis)
- Intracellular phosphate, potassium, magnesium, and vitamins are depleted
- But serum levels can appear normal - the body borrows from bone and other stores to maintain blood levels
- Insulin secretion is low
Step 2 - On refeeding (carbohydrate reintroduction):
- Carbohydrates become the main fuel again
- This triggers a surge in insulin secretion
- Insulin activates Na-K ATPase pumps, driving potassium, phosphate, and magnesium from the blood into cells
- Phosphate is also consumed in glycolysis (needed for ATP production)
- Thiamine demand increases sharply (it is a cofactor for pyruvate dehydrogenase - without it, pyruvate cannot enter the Krebs cycle)
Step 3 - Result:
- Sudden, severe hypophosphatemia, hypokalemia, hypomagnesemia
- Sodium and water retention
- Thiamine deficiency
Clinical Features / Complications
| System | Manifestation |
|---|---|
| Cardiac | Arrhythmias, heart failure, edema |
| Respiratory | Respiratory failure (diaphragm weakness) |
| Neurological | Confusion, Wernicke's encephalopathy (thiamine deficiency), seizures |
| Muscular | Rhabdomyolysis, weakness |
| Haematological | Haemolytic anaemia |
| Metabolic | Hyperglycaemia (blunted insulin in severe cases) |
Who is at Risk?
- Prolonged starvation or fasting
- Severe acute malnutrition (SAM) in children
- Anorexia nervosa
- Chronic alcoholism
- Delayed or absent nutritional support in ICU patients
- Massive weight loss
- Patients with chronic diarrhoea or fistulas (electrolyte losses)
- Patients on diuretics or insulin
The NICE criteria define high risk as: low BMI, unintentional weight loss >10%, starvation for >5 days, or low initial electrolyte levels.
ASPEN Diagnostic Criteria
Refeeding syndrome is diagnosed when there is a decrease in serum phosphate, potassium, and/or magnesium after starting feeding:
- Mild: decrease of 10-20%
- Moderate: decrease of 20-30%
- Severe: decrease of >30% and/or organ dysfunction, or thiamine deficiency
Prevention and Management
- Correct electrolyte deficits before starting feeding - replete potassium, phosphate, and magnesium first
- Give thiamine before feeding begins - to prevent Wernicke's encephalopathy
- Start feeding slowly - begin at 50% of caloric target (or <10 kcal/kg/day in very high-risk patients)
- Gradually increase over 5-7 days up to full target
- Monitor closely - daily electrolytes (phosphate, potassium, magnesium), fluid balance, vital signs, blood glucose
- Correct deficits aggressively as they appear
In SAM children, this is why F-75 (low-energy starter formula) is used in the stabilisation phase rather than jumping straight to high-calorie F-100 or RUTF. The gradual progression from F-75 to F-100/RUTF specifically protects against refeeding syndrome.
Key Takeaway
| Feature | Detail |
|---|---|
| Trigger | Rapid refeeding after starvation/malnutrition |
| Hallmark | Hypophosphatemia (+ hypokalemia, hypomagnesemia) |
| Mechanism | Insulin surge → electrolytes shift into cells |
| Key danger | Cardiac arrhythmia, respiratory failure, death |
| Prevention | Slow refeeding + thiamine + electrolyte correction first |
| First described | Post-WWII Japanese POW camps |
- Yamada's Textbook of Gastroenterology, p. 548
- Schwartz's Principles of Surgery, 11th ed., p. 126
What is appetite test
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appetite test severe acute malnutrition RUTF procedure pass fail criteria WHO CMAM
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appetite test SAM children RUTF grams per kg body weight pass criteria table
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https://www.researchgate.net/publication/337910105_Critical_…
Here is a complete explanation of the appetite test:
The Appetite Test
What is it?
The appetite test is a simple, standardised clinical assessment used in the management of severe acute malnutrition (SAM) to determine whether a child has enough appetite to eat therapeutic food. It is a key triage tool that decides whether a child with SAM should be:
- Treated as an outpatient (OTP - Outpatient Therapeutic Programme) - if they pass
- Admitted for inpatient care - if they fail
Poor appetite in SAM is a sign of serious illness or metabolic derangement, making it a reliable proxy for severity.
Why Appetite Matters in SAM
A malnourished child who can eat is far safer to treat at home. One who cannot eat is at high risk of deterioration and likely has a medical complication (infection, severe oedema, metabolic crisis). Loss of appetite also reflects impaired gut function, systemic illness, and inability to receive adequate RUTF to recover.
How to Conduct the Appetite Test
The test is done using RUTF (Ready-to-Use Therapeutic Food), typically Plumpy'Nut paste:
- Find a quiet, comfortable area - the mother/caregiver should be present and seated comfortably with the child on their lap
- Explain the procedure to the caregiver
- Wash hands - both health worker and caregiver
- Offer a known amount of RUTF to the child (see table below)
- Allow up to 30 minutes for the child to eat
- Encourage gently - do NOT force-feed
- Offer clean drinking water alongside the RUTF
- Observe and measure how much the child eats
Pass/Fail Criteria
The child must eat at least ~1/3 to 1/4 of the daily RUTF ration (approximately 5 g RUTF/kg body weight) within the test period to pass.
| Body weight (kg) | Minimum to PASS (approx.) |
|---|---|
| 3-3.9 kg | 15-20 g |
| 4-4.9 kg | 20-25 g |
| 5-6.9 kg | 25-35 g |
| 7-8.9 kg | 35-45 g |
| 9-10.9 kg | 45-55 g |
| ≥ 11 kg | ≥ 55 g |
(Values vary slightly by national protocol; the general threshold is ~5 g RUTF/kg body weight.)
Outcome of the Test
| Result | Meaning | Action |
|---|---|---|
| PASS - eats required amount willingly | Good appetite, no severe complications | Enroll in outpatient OTP with RUTF at home |
| FAIL - refuses or cannot eat enough | Poor appetite, likely complicated SAM | Admit for inpatient care (stabilisation with F-75) |
Who Should NOT be Sent Outpatient Even if They Pass?
Even a child who passes the appetite test must be admitted if they have any of the following:
- Severe bilateral oedema (grade +++)
- Any general danger sign (unconscious, unable to drink, convulsions, vomiting everything)
- Medical complication: severe anaemia, respiratory distress, severe dehydration, high fever, hypoglycaemia
- Age < 6 months
Clinical Significance
The appetite test is a cornerstone of the CMAM (Community-based Management of Acute Malnutrition) model endorsed by WHO, UNICEF, and WFP. Before CMAM, all SAM children were hospitalised. The appetite test allows the majority of SAM children (those who are medically stable with good appetite) to be treated safely at home, dramatically increasing coverage and reducing cost.
As stated in the WHO Pocket Book of Hospital Care for Children:
"Children who have an appetite (pass the appetite test) and are clinically well and alert should be treated as outpatients for uncomplicated severe acute malnutrition."
Summary
| Feature | Detail |
|---|---|
| Purpose | Triage SAM children for inpatient vs. outpatient care |
| Tool used | RUTF (peanut paste sachet) |
| Duration | Up to 30 minutes |
| Pass threshold | ~5 g RUTF/kg body weight eaten willingly |
| Pass = | Outpatient OTP |
| Fail = | Inpatient stabilisation (F-75) |
| Done by | Health worker or trained community worker |
What is f75 and f100diet
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F-75 F-100 therapeutic milk diet severe acute malnutrition composition WHO stabilisation rehabilitation phase
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Here is a thorough explanation of both therapeutic milk diets:
F-75 and F-100 Therapeutic Milk Diets
Both are WHO-formulated liquid therapeutic feeds used in the inpatient treatment of severe acute malnutrition (SAM). The names reflect their caloric density - F-75 gives 75 kcal per 100 mL, and F-100 gives 100 kcal per 100 mL.
Nutritional Composition (per 100 mL)
From Goldman-Cecil Medicine, the comparison is as follows:
| Nutrient | F-75 | F-100 | RUTF (per 100g) |
|---|---|---|---|
| Energy (kcal) | 75 | 100 | 543 |
| Protein (g) | 0.9 | 2.9 | 13.6 |
| Lactose (g) | 1.3 | 4.2 | - |
| Potassium (mg) | 156 | 246 | 1111 |
| Sodium (mg) | 14 | 44 | 189 |
| Magnesium (mg) | 10.5 | 17.7 | 92 |
| Zinc (mg) | 2.0 | 2.3 | 14 |
| Copper (mg) | 0.25 | 0.25 | 1.78 |
| Osmolarity | 413 mOsm/L | 419 mOsm/L | - |
| % energy from protein | 5% | 12% | 10-12% |
| % energy from fat | 36% | 53% | 45-60% |
- Goldman-Cecil Medicine, International Edition, Table 197-1
F-75 - The Stabilisation Diet
Purpose
F-75 is the "starter" or stabilisation formula. It is intentionally low in energy and protein to allow the child's damaged metabolic systems to recover safely, without triggering refeeding syndrome.
When Used
- Phase 1: Stabilisation - typically the first 1-7 days of inpatient care
- Used in children who:
- Failed the appetite test
- Have medical complications (infection, severe oedema, hypoglycaemia)
- Are too ill or weak to tolerate full nutrition
Why Low Protein?
In SAM, the liver, kidneys, and gut are all impaired. High protein loads at this stage cannot be processed and may worsen the condition. The gut needs time to recover its absorptive capacity.
Key Features
- 75 kcal / 100 mL - deliberately restricted energy
- Very low sodium (14 mg/100 mL) - prevents fluid overload in a child with abnormal sodium metabolism
- Low lactose - reduces risk of lactose intolerance (common in SAM)
- Given in small frequent feeds (every 2-3 hours, day and night) at 100 mL/kg/day
- Can be given by nasogastric (NG) tube if child cannot drink
Goal
Stabilisation, NOT weight gain. F-75 should stop the child deteriorating - weight gain is NOT expected at this stage.
F-100 - The Rehabilitation Diet
Purpose
F-100 is the "catch-up" or rehabilitation formula. It is high in energy and protein to drive rapid weight gain once the child is metabolically stable.
When Used
- Phase 2: Rehabilitation - after the child passes the transition criteria
- Transition from F-75 to F-100 is made when:
- Oedema is resolving
- Appetite has returned
- Medical complications are resolving
- Child is alert and active
Key Features
- 100 kcal / 100 mL - higher energy density
- 2.9 g protein / 100 mL - much higher protein to rebuild muscle mass
- Higher fat content (53% of energy from fat)
- Given at approximately 150-220 kcal/kg/day to achieve catch-up growth
- Target weight gain: >5 g/kg/day (ideally 10-15 g/kg/day)
Goal
Rapid weight gain and nutritional recovery.
The Treatment Phases in SAM
ADMISSION
↓
Phase 1: STABILISATION (F-75)
- Duration: ~1-7 days
- Goal: Correct hypoglycaemia, hypothermia, dehydration, electrolytes
- Diet: F-75 every 2-3 hours
↓
TRANSITION (F-75 → F-100 or RUTF)
- Child passes appetite test
- Oedema improving
↓
Phase 2: REHABILITATION (F-100 or RUTF)
- Duration: ~2-6 weeks (inpatient or outpatient)
- Goal: Rapid catch-up weight gain
- Diet: F-100 or RUTF
↓
DISCHARGE when weight-for-height ≥ -2 SD (or MUAC ≥ 125mm)
F-75 vs F-100 - Key Differences at a Glance
| Feature | F-75 | F-100 |
|---|---|---|
| Phase | Stabilisation (Phase 1) | Rehabilitation (Phase 2) |
| Calories | 75 kcal/100 mL | 100 kcal/100 mL |
| Protein | 0.9 g/100 mL (low) | 2.9 g/100 mL (high) |
| Goal | Metabolic stability, NOT weight gain | Rapid weight gain |
| Volume/day | ~100 mL/kg/day | ~150-220 kcal/kg/day |
| Risk prevented | Refeeding syndrome, fluid overload | Used once risk has passed |
| Frequency | Every 2-3 hours (8-12 feeds/day) | Every 3-4 hours |
Important Notes
-
Never start with F-100 in a newly admitted SAM child - this risks fatal refeeding syndrome
-
Iron is withheld during the stabilisation phase and only introduced in rehabilitation (iron promotes bacterial growth and is dangerous in acute illness)
-
If RUTF is available and the child has appetite, F-100 can be replaced with RUTF in the rehabilitation phase for outpatient treatment
-
Both F-75 and F-100 can be prepared locally from basic ingredients (dried skim milk, sugar, vegetable oil, mineral/vitamin mix) or purchased as commercial powder (e.g. Nutriset's products)
-
Goldman-Cecil Medicine, International Edition, Table 197-1
-
Sleisenger and Fordtran's Gastrointestinal and Liver Disease, p. 2158
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