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Editor's comment. This month we publish a commentary on ready-to-use therapeutic food (RUTF). The authors, who share vast experience of infant and young child malnutrition, are perturbed by current and potential future policy and practice concerning RUTFs. Their concern is shared here by a paediatric physician working in Darfur, Sudan, who has direct daily experience of the impact of RUTF on the communities he serves.

Sir: Severe acute malnutition is the leading cause of ill-health of children here in Nyala, Darfur, in Sudan, where I work as a paediatric physician. Our 18- bed hospital has become a sort of a feeding centre. Children are admitted in very poor condition. Many die in the first 24 hours. We use the WHO ten steps of treatment.

Not all mothers of our children are poor or abandoned. Most of them own and use a cell phone, husbands are around, and most have an income. Yes, there is an ongoing conflict in Darfur, but there is also rain, cultivation of crops, plenty of food in the markets, non-governmental organisations, and international agencies.

Children here have no growth chart. In their vaccination card there is no graphic showing birthweight and how to plot increase in weight. In fact children are never weighed. Their nutritional status is measured through ad hoc surveys with measurements of mid and upper arm circumference. The month to month progression of birthweight is not plotted. The result is that failure of growth is never perceived, neither by the health officer nor by the mother. Indeed mothers are not aware that the reason of admission is malnutrition. They simply 'see' that the child is sick and has poor appetite.

The local Department of Nutrition of the Ministry of Heath gives us the fortified dried milk products F75 and F100, Vitamin A, and also the RUTF Plumpy'nut to use. F75 and F100 are easy to use and are effective. Plumpy'nut is a different story. We are becoming wary of it. Here are some of the reasons:

• A traditional food in Sudan is a paste of groundnuts, called dakua. This is much used in recipes but seldom given to children. Then why do we distribute Plumpy'nut, when dakua is available and has the same taste?
• Mothers have started to nickname Plumpy'nut as 'biscuit'. They will buy ordinary biscuits to give to their children when the import of Plumpy'nut ends
• One day Plumpy'nut will stop coming. By then we will have introduced an imported food, instead of encouraging the traditional and locally available foods
• Some children become 'affectionate' of Plumpy'nut, and then refuse ordinary food when Plumpy'nut is stopped.
• We are seeing Plumpy'nut being sold in the markets, and we see empty packets around the hospitals. Our impression is that it is distributed (too) liberally.

In my opinion Plumpy'nut should be reserved for emergency situations, such as natural catastrophes, war, or famine, and then just for a short period of time until normal life is re-established.

Plumpy'nut does not prevent severe acute malnutrition. Children will become malnourished for many years to come. Shall we send Plumpy'nut to Africa for the next 50 years? What about India, where 8 million children suffer from severe acute malnutrition? How many containers of Plumpy'nut every day should be sent?

And again: what will happen to vulnerable children when the supplies of Plumpy'Nut stop? They will still be in the same social and other conditions that caused the severa acute malnutrition in the first place.

Enriched flours have been available in the shops of Africa for years now. These are locally made from local ingredients. Why not encourage them? Why did somebody decide to manufacture a paste in France, where Plumpy'nut is manufactured, and not, let's say, in Kenya? Groundnuts are plentiful in Africa.

Scientific studies on Plumpy'nut cannot predict what will happen in the future. I feel that we are introducing something wrong.

If I conducted an evaluation study to find out if mothers here understand why Plumpy'nut is being given, I think that most of them would answer that it is a drug or a 'special food', given by white men to cure their child's illness.

Imported foods are dangerous, and they create dependency. Plumpy'nut has been said to be a 'drug'. But severe acute malnutrition is not exactly a disease; it is a nutritional error that can be prevented by the parents if they are adequately informed well before the child becomes malnourished. The renowned paediatric physician David Morley said this clearly. When the mother 'sees' the growth of her child on a chart, she then improves her child's diet. Indeed David Morley invented a new way of plotting growth charts that involves the mother fully. Growth monitoring must be done on a monthly basis for the initial two years of life, accompanied by words of warning, and of praise if the child is well nourished. Only in this way will mothers perceive that the health of their children is strictly linked to their growth. They will then seek food and not drugs.

African mothers do know how to feed their children. Indeed, most of them breastfeed for two years. However, because of poverty any nutritional error can become fatal. That's why we should alert them at the initial signs of danger. Growth monitoring is the way. Unfortunately it has been abandoned.

Massimo Serventi
Nyala, Darfur
Email: ser20@hotmail.it

Please cite as: Serventi M. RUTF is not the answer in Darfur.[Letter] World Nutrition, February 2011, 2, 2: 98-100. . Obtainable at www.wphna.org