MUAC as the sole discharge criterion from community‐based management of severe acute malnutrition in Burkina Faso

Abstract

The use of mid upper arm circumference (MUAC) measurement to screen and determine eligibility for admission to therapeutic feeding programs has been established, but evidence and programmatic experience to inform guidance on the use of MUAC as a discharge criterion is limited. We present results from a large-scale nutritional program using MUAC for admission and discharge and compare program outcomes and response to treatment when determining eligibility for discharge by proportional weight gain versus discharge by MUAC. The study population included all children admitted to the Ministry of Health therapeutic feeding program supported by Médecins Sans Frontières in northern Burkina Faso from September 2007 to December 2011 (n = 50,841). Recovery was high overall using both discharge criteria, with low risks of death, nonresponse, and transfer to inpatient care and high daily gains in weight, MUAC, weight-for-height Z score, and height. When discharge was made by MUAC only, recovery increased, while all adverse program outcomes and length of stay decreased, with increasing MUAC on admission. MUAC-based programming, where MUAC is integrated into program screening, admission, and discharge, is one of several new approaches that can be used to target resources to the most at-risk malnourished children and improve program efficiency and coherency. This analysis provides additional programmatic experience on the use of MUAC-based discharge criterion, but more work may be needed to inform optimal discharge thresholds across settings.

New approach to simplifying and optimising acute malnutrition treatment in children aged 6–59 months: the OptiMA single-arm proof-of-concept trial in Burkina Faso

“…Non-responders and defaulters did achieve an average MUAC of 119•5 and 115•1 mm at exit, respectively, while the average MUAC at admission in the MUAC < 115 mm group was 109•5 mm. Mortality remained low at 1•5 % and is similar to the mortality rate of 1•6 % reported for children with MUAC < 115 mm at admission in the prior MUAC-based programme in this same district (6) . Elsewhere among MUAC-based programmes without RUTF reduction, recovery rates for this category have ranged from 57•4 % in India, 63•4 % in Malawi and 82 % in Sudan (20)(21)(22) .…”

“…Overall recovery and mortality rates reported here, 86•3 and 0•4 % respectively, compare favourably to the 83 % recovery and 4 % mortality reported by a similar MUAC-based study in Sierra Leone, which had a more rapid reduction in RUTF dosage than OptiMA (11) . A MUAC-based programme previously implemented in the same district of Burkina Faso and using MUAC < 120 mm for admissions reported 91•6 % recovery and 1•1 % mortality, but the present study did not use a reduced RUTF regimen and had a less stringent discharge criterion of a single measure of MUAC ≥ 124 mm (6) .…”

“…Confusion is further exacerbated by a complicated case definition using MUAC and WHZ to determine programme eligibility, even though WHZ does not offer a clear advantage over MUAC for identifying children at near-term risk of death (5) . MUAC-only programming is expanding as evidence accumulates that weight gain and MUAC gain track each other and that the trajectory of weight and MUAC gain is maximal during the first 2-3 weeks of treatment (6)(7)(8) . MUAC is therefore becoming a stand-alone practical tool for all phases of nutrition programming: screening, admission, monitoring recovery and determining discharge.…”

Acute malnutrition recovery energy requirements based on mid-upper arm circumference: Secondary analysis of feeding program data from 5 countries, Combined Protocol for Acute Malnutrition Study (ComPAS) Stage 1

“…These results are consistent with and bolster other global child malnutrition studies [23,56]. There is increasing evidence that MUAC-based admission and discharge criteria are effective at improving efficiency and care outcomes [20,57,58]. Several extant protocols that provide supplementary foods to families of children with MAM rather than provide all energy needs with therapeutic foods have been found to be successful [18,47].…”

Combined protocol for severe and moderate acute malnutrition in emergencies: Stakeholder perspectives in four countries

“…The results indicated greater coverage (number of children who received treatment/number of children eligible for treatment) in communities with integrated management (71 vs. 55%, P < .001), with comparable global acute malnutrition recovery rates [910 of 1,100 children (83%) with the integrated protocol, versus 682 of 857 (79%) with the standard]. In northern Burkina Faso, a CMAM program switched from proportional weight gain to MUAC ≥124 mm as the sole discharge criterion, and achieved a slightly higher recovery rate (Risk Ratio: 1.04, 95% CI [1.03, 1.05]) in a sample of 50,841 children (Isanaka et al, ). SAM children who were discharged in the second period using the MUAC‐based criterion also had shorter lengths of stay and fewer adverse program outcomes.…”