Safety and practicability of using mid-upper arm circumference as a discharge criterion in community based management of severe acute malnutrition in children aged 6 to 59 months programmes

Abstract

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.

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

“…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) . In the MUAC-based programme with RUTF dose reduction in Sierra Leone recovery for this sub-group was 75•3 % (23) ; however, nutritional oedema was more prevalent in Sierra Leone (2•9 v. 0•7 % in OptiMA).…”

Choosing Anthropometric Indicators to Monitor the Response to Treatment for Severe Acute Malnutrition in Rural Southern Ethiopia—Empirical Evidence

“…In children being treated for SAM in OTPs, the gains in MUAC and weight were shown to be closely correlated and follow a similar recovery trajectory [ 40 ]. As weight loss or the failure to gain weight in children may suggest that follow-up in the community or referral to hospital are necessary [ 7 , 40 ], the failure to gain MUAC in children may similarly be indicative of the need for such a procedure. Our findings are also in line with the results of the above studies.…”

Monitoring and discharging children being treated for severe acute malnutrition using mid-upper arm circumference: secondary data analysis from rural Gambia

“…They presented evidence that MUAC≥125 mm as a discharge criterion was associated with low levels of relapse and mortality during a 3-month follow-up. 22 The limited evidence base is a critical barrier to MUAC-only programming. Despite latest guidance suggesting using MUAC≥125 mm for discharge on the basis that mortality risk is very low above this threshold, more data are needed to know the implications of this recommendation.…”