How it began
In the hungry season of 2000 to 2001, the St. Louis Nutrition Project, led by pediatrician Mark Manary of Washington University and the Malawi School of Medicine, began home therapy at the nutritional rehabilitation unit of Queen Elizabeth Central Hospital in Blantyre. After a short stabilization in hospital, children were sent home with ready-to-use therapeutic food in place of the second phase of inpatient feeding. The peanut-based paste itself existed as a French commercial product, Plumpy'nut; the work in Malawi was to use it as a home treatment and to make it locally, where it was known as chiponde.
Before it existed
Standard care for severe malnutrition was inpatient feeding with therapeutic milk in two phases. The milk had to be mixed hygienically and given by trained staff many times a day, spoiled easily and could not be sent home. Wards became crowded with children whose immunity was weak, and infections spread. During the 2003 hungry season as many as 100 children were in the Blantyre unit at once, with up to 12 deaths in a single week.
How it works
The food is an energy-dense lipid paste based on peanut butter with a full set of micronutrients. Its low water content resists bacterial growth and it needs no cooking, so trained staff and a ward are not required. Mothers received a two-week supply matched to the child's weight and returned every fortnight, when the child was measured and a new supply given until recovery. The paste could be made in the country with a mixer and a scale, importing only the vitamin and mineral mix, 1.6 percent of the product by weight.
How it spread
A controlled comparison in Malawi published in the American Journal of Clinical Nutrition found higher recovery and less relapse with home-based therapy than with standard therapy. Malawi's Ministry of Health came to advocate home therapy with the paste for moderate to severe malnutrition in the Southern Region, and Concern Worldwide used it in another district in 2002 to 2003. The project staff wrote that the success in Malawi suggested a role for the method in treating malnutrition worldwide.
What changed first
In the first season, 85 percent of children receiving a full diet of the paste reached their weight-for-height goal within 2 to 12 weeks, and crowding in the unit fell. In 2001 to 2002 a locally made version gave similar results, with 80 percent reaching the goal, and six months later only 9 percent had relapsed. In 2002 to 2003 the program ran at seven sites, including rural and district units, and admitted stable children directly from the community.
