Background: Severe acute malnutrition (SAM) is currently defined by the WHO as either a low mid-upper arm circumference (i.e. MUAC <115 mm), a low weight-for-height z-score (i.e. WHZ <− 3), or bilateral pitting oedema. MUAC and WHZ do not always identify the same children as having SAM. This has generated broad debate, as illustrated by the recent article by Grellety & Golden (BMC Nutr. 2016;2:10). Discussion: Regional variations in the proportion of children selected by each index seem mostly related to differences in body shape, including stuntedness. However, the practical implications of these variations in relation to nutritional status and also to outcome are not clear. All studies that have examined the relationship between anthropometry and mortality in representative population samples in Africa and in Asia have consistently showed that MUAC is more sensitive at high specificity levels than WHZ for identifying children at high risk of death. Children identified as SAM cases by low MUAC gain both weight and MUAC in response to treatment. The widespread use of MUAC has brought enormous benefits in terms of the coverage and efficiency of programs. As a large high-risk group responding to treatment, children with low MUAC should be regarded as a public health priority independently of their WHZ. Conclusion: While a better understanding of the mechanism behind the discrepancy between MUAC and WHZ is desirable, research in this area should not delay the implementation of programs aiming at effectively reducing malnutrition-related deaths by prioritising the detection and treatment of children with low MUAC.
ObjectiveThe World Health Organization recommends discharging children admitted to nutrition programs treating severe acute malnutrition, with a low mid-upper arm circumference (MUAC <115 mm) when weight gain is >15%. When this recommendation is followed, the most severely malnourished children receive a shorter treatment compared to children that are less severely malnourished. This study assesses whether using MUAC >125 mm as discharge criteria eliminates this effect.Methods and FindingsData from 753 children cured from a Médecins Sans Frontières outpatient nutrition program in Gedaref, North Sudan were analyzed. MUAC >125 mm was used as discharge criteria. Length of stay and percent weight gain of children were compared in relation to nutritional status on admission. Children with low MUAC on admission had a longer duration of treatment (p = 0.000) and also a higher percent weight gain (p = 0.000) than children with higher MUAC. Similar results with weight-for-height z-scores categories were shown with both duration of treatment (p = 0.000) and percent weight gain (p = 0.000).ConclusionThis study shows that using MUAC as the discharge criteria eliminates the effect of shorter treatment in most severely malnourished children compared to least severely malnourished, as is observed with percent weight gain. The findings directly address the main concern that has been identified with the current WHO recommendation of using percent weight gain. MUAC could be used as discharge criteria, instead of percent weight gain, as having a longer duration of treatment and a higher percent weight gain for the most malnourished is highly desirable.
BackgroundThe use of proportional weight gain as a discharge criterion for MUAC admissions to programs treating severe acute malnutrition (SAM) is no longer recommended by WHO. The critical limitation with the proportional weight gain criterion was that children who are most severely malnourished tended to receive shorter treatment compared to less severely malnourished children. Studies have shown that using a discharge criterion of MUAC ≥ 125 mm eliminates this problem but concerns remain over the duration of treatment required to reach this criterion and whether this discharge criterion is safe. This study assessed the safety and practicability of using MUAC ≥ 125 mm as a discharge criterion for community based management of SAM in children aged 6 to 59 months.MethodsA standards-based trial was undertaken in health facilities for the outpatient treatment of SAM in Lilongwe District, Malawi. 258 children aged 6 to 51 months were enrolled with uncomplicated SAM as defined by a MUAC equal or less than 115 mm without serious medical complications. Children were discharged from treatment as ‘cured’ when they achieved a MUAC of 125 mm or greater for two consecutive visits. After discharge, children were followed-up at home every two weeks for three months.ResultsThis study confirms that a MUAC discharge criterion of 125 mm or greater is a safe discharge criterion and is associated with low levels of relapse to SAM (1.9 %) and mortality (1.3 %) with long durations of treatment seen only in the most severe SAM cases. The proportion of children experiencing a negative outcome was 3.2 % and significantly below the 10 % standard (p = 0.0013) established for the study. All children with negative outcomes had achieved weight-for-height z-score (WHZ) above −1 z-scores at discharge. Children admitted with lower MUAC had higher proportional weight gains (p < 0.001) and longer lengths of stay (p < 0.0001). MUAC at admission and attendance were both independently associated with cure (p < 0.0001). There was no association with negative outcomes at three months post discharge for children with heights at admission below 65 cm than for taller children (p = 0.5798).ConclusionsThese results are consistent with MUAC ≥ 125 mm for two consecutive visits being a safe and practicable discharge criterion. Use of a MUAC threshold of 125 mm for discharge achieves reasonable lengths of stay and was also found to be appropriate for children aged six months or older who are less than 65 cm in height at admission. Early detection and recruitment of SAM cases using MUAC in the community and compliance with the CMAM treatment protocols should reduce lengths of stay and associated treatment costs.
BackgroundThe objectives of this study were to (i) describe the relationship between weight changes and MUAC changes in children aged between 6 and 59 months during treatment for SAM in CMAM programmes in three country contexts (Malawi, Ethiopia and Bangladesh) admitted using MUAC and (ii) describe the sensitivity of both MUAC and weight to episodes of disease experienced during the SAM treatment episodes in CMAM programmes in three country contexts (Malawi, Ethiopia and Bangladesh) admitted using MUAC.MethodsData collected under research conditions in Malawi were analysed for the correlation between MUAC and weight changes using the Pearson product–moment correlation coefficient (Pearson’s r). Further data from other CMAM programmes implemented under field conditions in Ethiopia and Bangladesh were similarly analysed. The association of growth failure following recent episodes of illness were assessed for MUAC and weight change using a two-by-two table, box-plots and Kruskal Wallis non-parametric rank sum test.ResultsMUAC and weight gain acheived over the entire treatment episode were strongly correlated in all three country contexts, Ethiopia (median Pearson's r = 0.816, 95 % CI = 0.782 - 0.845), Malawi (median Pearson's r = 0.843, 95 % CI = 0.802 - 0.876) and Bangladesh (median Pearson's r = 0.725, 95 % CI = 0.663 - 0.777). MUAC and weight changes at each outpatient visit were closely correlated (median Pearson’s r = 0.954, 95 % CI = 0.602 – 0.997) under research conditions. The field data from Ethiopia and Bangladesh showed similar correlation (median Pearson’s r = 0.945, 95 % CI = 0.685 – 0.998) and (median Pearson’s r = 0.939, 95 % CI = 0.705 – 0.994) respectively. MUAC and weight appear to respond rapidly and similarly to episodes of illness reported during outpatient treatment for SAM for MUAC, diarrhoea RR = 1.88 (95 % CI = 1.64 - 2.15), vomiting RR = 1.89 (95 % CI = 1.58 - 2.26), fever RR = 1.57 (95 % CI = 1.36 - 1.82) and cough1.42 (95 % CI = 1.22 - 1.65). Similar relative risks are seen for weight; diarrhoea RR = 2.03 (95 % CI = 1.77 - 2.31), vomiting RR = 2.09 (95 % CI = 1.77 - 2.47), fever RR = 1.76 (95 % CI = 1.53 - 2.03) and cough RR = 1.25 (95 % CI = 1.06 - 1.48).ConclusionsThis study demonstrates a close relationship between MUAC and weight change during recovery from SAM under both research and operational field conditions. Furthermore, changes in both MUAC and weight are observed to occur similarly and rapidly during episodes of illness occurring during treatment with no lag effect on the part of MUAC. This presents the possibility for children undergoing outpatient treatment for SAM to be monitored using MUAC as an alternative to weight. Further research would be required to develop a tool which can be deployed safely and enable MUAC to be used as the sole anthropometric measure for admission, monitoring of recovery and discharge. This development would potentially allow the further decentralisation of the treatment of SAM thus improving programme coverage and child survival.
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