Menu ENN Search

Is MUAC alone a sufficient criterion for admission of children at high risk of mortality in South Sudan?

Summary of research 1

Location: South Sudan

What we know: The operational implications of using MUAC as the sole anthropometric admission criterion to therapeutic feeding programmes are uncertain. 

What this article adds: A retrospective analysis of routine outpatient treatment programme data of children with uncomplicated SAM aged 6-59 months compared patient characteristics of children admitted under MUAC<115mm alone v. children admitted under weight for height z score < -3 (MUAC>115mm). The study shows that MUAC < 115mm identified more severely malnourished, more female and younger age children with a higher risk of mortality, but failed to identify a third of the children who died (98% were identified by WHZ < -3 alone and 100%  by MUAC < 130mm).  Adjusting for age and sex, the risk of death was over four times higher among children admitted with MUAC<115mm. The greater sensitivity of WHZ < -3 to identify nearly all deaths observed in this study could be specific to this population. Increasing the admission threshold to MUAC < 125mm would identify nearly all deaths but has programming implications.

Following endorsement of the community management of acute malnutrition (CMAM) model by United Nations (UN) agencies in 2007, programming has been widely scaled up across many countries. Current guidelines recommend three admission criteria to therapeutic feeding for children 6-59 months; i) weight-for-height Z-score (WHZ) < -3 (WHO growth standards 2006), ii) mid-upper arm circumference (MUAC) <115mm, or iii) presence of bilateral oedema. Recent years have seen the move towards using MUAC as the sole anthropometric admission criterion due to its simplicity of measurement and use. Transition to a single MUAC criterion for admission to therapeutic feeding is, however, complicated by MUAC and WHZ selecting different children at risk of acute malnutrition.  The objective of this study was to describe the operational implications of using MUAC as a single admission criterion for treatment of severe acute malnutrition (SAM) in South Sudan.

Design

The authors performed a retrospective analysis of routine programme data of children with uncomplicated SAM aged 6-59 months, admitted to an MSF outpatient therapeutic feeding programme (TFP) in Aweil, South Sudan in 2010. In order to understand the implications of using MUAC as a single admission criterion, the study compared patient characteristics and treatment outcomes for children admitted with MUAC <115 mm irrespective of WHZ (MUAC+ group) v. children admitted with WHZ < -3 and MUAC >115mm (MUAC −/WHZ+group). Treatment protocols were according to national guidelines and treatment outcomes were defined for all children as one of death, default, transfer or recovered.

Results

Of 2205 children included for analysis, median age was 14 months (interquartile range=10–24 months) and 53% were male. A total of 719 (32.6%) were admitted to the programme with MUAC < 115mm and 1486 (67.4%) with WHZ < -3 and MUAC > 115mm. Children in the MUAC+ group were more severely malnourished (average MUAC 107.3mm and average WHZ -4.3, compared to 122.5mm and -3.8 in the MUAC −/WHZ+group), and more likely to be female and younger. Children in the MUAC+ group were less likely to recover (54% v. 69%) and had higher risk of death (4% v. 1%) but responded to treatment with greater weight and MUAC gains. Adjusting for age and sex, the risk of death was over four times higher among children admitted with MUAC<115 mm compared with the MUAC −/WHZ+group (risk ratio=4·02; 95% CI 2·10, 8·08). MUAC < 115 mm would have failed to identify 33% (n=13) of deaths, while 98% (n=39) were identified by WHZ < -3 alone and 100% (n=40) by MUAC < 130mm.

Conclusions

The study shows that MUAC < 115mm identified more severely malnourished, more female and younger aged children with a higher risk of mortality, but failed to identify a third of the children who died. The greater sensitivity of WHZ < -3 to identify nearly all deaths observed in this study could be specific to the study context (the Nilotic population who have a tall slim body shape, associated with low WHZ) and therefore cannot be assumed to have high  external validity. The authors suggest that an upward adjustment of the MUAC admission threshold to MUAC < 125mm could be applied to identify nearly all deaths (e.g. 95%) in this setting. Any such upward adjustment would yield a more sensitive, but less specific criterion for admission and would have important programmatic implications including increased workload and costs. The authors conclude by stating that admission criteria for therapeutic feeding should be adapted to the programmatic context with consideration for both operational and public health implications.

Read more...

References

1 Grellety, E., Krause, L. K., Eldin, M. S., Porten, K., and Isnaka, S. (2015). Comparison of weight-for-height and mid-upper arm circumference (MUAC) in a therapeutic feeding programme in South Sudan: is MUAC alone a sufficient criterion for admission of children at high risk of mortality? Public Health Nutrition (2015) doi: 10.1017/S1368980015000737.

 

More like this

FEX: MUAC vs WHZ in predicting mortality in hospitalised children under five years of age

Summary of research1 This research contributes to the evidence base regarding which anthropometric indicators identify malnourished sick children most at risk of death. Low...

en-net: Only MUAC for admission and discharge?

There has been a discussion about the use of ONLY MUAC as an admission and discharge criteria (http://www.en-net.org/question/468.aspx). Although I understand the challenge in...

FEX: Weight-for-height and mid-upper-arm circumference should be used independently to diagnose acute malnutrition: policy implications

Summary of research1 Location: Global What we know: Overlap between mid-upper-arm circumference (MUAC) and weight-for-height Z-scores (WHZ) when assessing acute malnutrition...

en-net: WFH versus MUAC

I would like experts input in this regard. I wish Mark Myatt to be one of the respondent of my question. Much has been said about the discrepancy of MUAC and WFH in some...

en-net: Lenght of stay in OTP

According to CTC guidelines and SPHERE standards the internationally accepted length of stay in OTP is about 56 days. A program that was mainly admitting children to OTP using...

FEX: Simplifying the response to childhood malnutrition: MSF’s experience with MUAC-based (and oedema) programming

By Kevin P.Q. Phelan, Candelaria Lanusse, Saskia van der Kam, Pascale Delchevalerie, Nathalie Avril and Kerstin Hanson Kevin P.Q. Phelan was the Nutrition Working Group Leader...

FEX: Impact of WHO Growth Standards on SAM response to treatment

Summary of published research1 More younger admissions to therapeutic feeding programmes are one of the implications of moving to the new WHO Growth Standards. A recent study...

FEX: MUAC alone admission to SAM treatment in Bangladesh

Summary of research1 Location: Bangladesh What we know: MUAC and weight-for-height z score (WHZ) are common anthropometric criteria to diagnose severe acute malnutrition...

FEX: A consultation of operational agencies and academic specialists on MUAC and WHZ as indicators of SAM

Summary of meeting report1 The treatment of severe acute malnutrition (SAM) is a costeffective, evidence-based ‘direct’ nutrition intervention, according to the 2008 Lancet...

FEX: Short children with a low MUAC respond to food supplementation: an observational study from Burkina Faso

By Fabiansen, C., Phelan, Kevin, P.Q., Cichon, B., Ritz, C., Briend, A., Michaelsen, K.F., Friis, H. and Shepherd, S Summary of research: Short children with a low midupper...

FEX: Impact of WHO Growth Standards on programme admissions in Niger

Summary of research1 Severely malnourished children managed in the MSF-run Centre de Récupération Nutritionnelle Intensive (CRENI) in Maradi, Niger A recent study by...

FEX: MUAC Versus Weight-for-Height in Assessing Severe Malnutrition

Summary of published paper1 An infant having MUAC measured during the study in Kenya Current WHO guidelines for the management of severe malnutrition in children recommend...

en-net: MUAC and WHZ and mortality.

I can only see the abstract (not an open access journal) but

FEX: MUAC and weight-for-height in identifying high risk children

Summary of research1 The World Health Organisation (WHO) and UNICEF propose to use two independent criteria for diagnosing non-oedematous severe acute malnutrition (SAM) in...

FEX: Effect of nutrition survey ‘cleaning criteria’ on estimates of malnutrition prevalence and disease burden: secondary data analysis

Summary of research1 Location: Global What we know: Standardised methods for collection and reporting malnutrition prevalence data in nutrition surveys are used. What this...

en-net: Calcul des proportions de couverture

Is it possible to calculate the total proportion of children diagnosed with SAM ( both by MUAC and Z-score) in a sample population after undertaking a mass screening when...

FEX: Integration of CMAM into routine health services in Nepal

By Regine Kopplow Regine is a former CMAM Advisor with Concern Nepal. She is a nutritionist with a background in rural development. She has worked in the field of nutrition...

FEX: MUAC as discharge criterion and weight gain in malnourished children

Summary of published research1 A child on admission to the Gedaref nutrition programme In addition to guidance on admission criteria for nutrition programmes, the WHO...

en-net: Borderline MUAC and Z-score measurements

What is the most appropriete practical decision should one make when confronted with cases of borderline MUACs and Z-scores of 11.5cm and <2 SD respectively in nutrition...

FEX: Diagnostic criteria for severe acute malnutrition among infants under six months of age

Summary of research1 Location: Kenya What we know: Diagnosis of acute malnutrition in infants under six months old (U6M) is currently based on weight-for-length z score...

Close

Reference this page

Is MUAC alone a sufficient criterion for admission of children at high risk of mortality in South Sudan?. Field Exchange 52, June 2016. p31. www.ennonline.net/fex/52/muaccriterionmortalitysouthsudan