Objective: To compare the performance of mid-upper arm circumference (MUAC) against weight-for-height Z-score (WHZ) for predicting inpatient deaths in children under 5 years of age. Design: Diagnostic test accuracy study. Setting: Paediatric emergency department of a tertiary care hospital catering to semi-urban and rural population in Delhi, India. Subjects: Hospitalized children (n 1663) aged 6 months to 5 years, for whom discharge outcome was available, were consecutively recruited over 14 months. MUAC (cm), weight (kg) height (cm), clinical details and the outcome were recorded. MUAC (index test) was compared with WHZ based on the WHO growth standards (reference test) for predicting the outcome. Results: One hundred and twenty-four (7 %) children died during hospital stay. Both MUAC < 11·5 cm (adjusted OR (95 % CI): 3·7 (2·43, 5·60), P < 0·001) and WHZ < −3 (2·0 (1·37, 2·99), P < 0·001) served as independent predictors of inpatient mortality. However, MUAC was a significantly better predictor of mortality compared with WHZ in terms of area under the receiver-operating characteristic curve (MUAC = 0·698, WHZ = 0·541, P < 0·001). MUAC < 11·5 cm had the best trade-off of sensitivity and specificity for predicting inpatient mortality. A combination of WHZ < −3 and/or MUAC < 11·5 cm did not significantly improve the predictive value over that of MUAC/ WHZ, assessed individually. Conclusion: MUAC < 11·5 cm is a better predictor of mortality in hospitalized under-5 children, as compared with WHZ < −3. It should be measured in all emergency settings to identify the children at higher risk of death.
Keywords
Child mortality Mid-upper arm circumferenceSevere acute malnutrition Weight-for-height Z-score Directly or indirectly, malnutrition contributes to nearly two-thirds of global mortality caused by pneumonia, diarrhoea, measles and other infections among children under 5 years of age (under-5s) (1,2) . In hospitalized Indian children, malnutrition has been shown to increase the risk of mortality up to six times in diarrhoea (3)(4)(5) and up to six times in acute respiratory tract infections (6,7) . To achieve the UN Millennium Development Goal 4, which aims to further reduce under-5 mortality (8) , it is imperative to curtail child deaths occurring as a consequence of malnutrition. The first step in this direction will be to identify and manage the set of malnourished children at risk for imminent death. The WHO has defined severe acute malnutrition (SAM) in 6-59-month-old children as a weight-for-height < −3 SD (severe wasting) of the reference population (9) . The selection of weight-for-height Z-score (WHZ) over other anthropometric criteria, namely weight-for-age Z-score (WAZ) or height-for-age Z-score (HAZ), is based on the fact that it has been shown to be an indicator of not only present nutritional status but also involves measurement of height that can be utilized to assess past nutritional status. However, the use of WHZ for identification of SAM is associated with some inherent pitfalls, especiall...
