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Severely malnourished children with a low weight-for-height have a higher mortality than those with a low mid-upper-arm-circumference: III. Effect of case-load on malnutrition related mortality– policy implications

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Background Severe acute malnutrition (SAM) is diagnosed when the weight-for-height Z-score (WHZ) is <−3Z of the WHO2006 standards, or a mid-upper-arm circumference (MUAC) of < 115 mm or there is nutritional oedema. Although there has been a move to eliminate WHZ as a diagnostic criterion we have shown that children with a low WHZ have at least as high a mortality risk as those with a low MUAC. Here we take the estimated case fatality rates and published case-loads to estimate the proportion of total SAM related deaths occurring in children that would be excluded from treatment with a MUAC-only policy. Methods The effect of varying case-load and mortality rates on the proportion of all deaths that would occur in admitted children was examined. We used the same calculations to estimate the proportion of all SAM-related deaths that would be excluded with a MUAC-only policy in 48 countries with very different relative case loads for SAM by only MUAC, only WHZ and children with both deficits. The case fatality rates (CFR) are taken from simulations, empirical data and the literature. Results The relative number of cases of SAM by MUAC alone, WHZ alone and those with both criteria have a dominant effect on the proportion of all SAM-related deaths that would occur in children excluded from treatment by a MUAC-only program. Many countries, particularly in the Sahel, West Africa and South East Asia would fail to identify the majority of SAM-related deaths if a MUAC only program were to be implemented. Globally, the estimated minimum number of deaths that would occur among children excluded from treatment in our analyses is 300,000 annually. Conclusions The number, proportion or attributable fraction of children excluded from treatment with any change of current policy are the correct indicators to guide policy change. CRFs alone should not be used to guide policy in choosing whether or not to drop WHZ as a diagnostic for SAM. All the criteria for diagnosis of malnutrition need to be retained. It is critical that methods are found to identify those children with a low WHZ, but not a low MUAC, in the community so that they will not remain undetected.
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R E S E A R C H Open Access
Severely malnourished children with a low
weight-for-height have a higher mortality
than those with a low mid-upper-arm-
circumference: III. Effect of case-load on
malnutrition related mortalitypolicy
implications
Emmanuel Grellety
1*
and Michael H. Golden
2
Abstract
Background: Severe acute malnutrition (SAM) is diagnosed when the weight-for-height Z-score (WHZ) is <3Z of
the WHO
2006
standards, or a mid-upper-arm circumference (MUAC) of < 115 mm or there is nutritional oedema.
Although there has been a move to eliminate WHZ as a diagnostic criterion we have shown that children with a
low WHZ have at least as high a mortality risk as those with a low MUAC. Here we take the estimated case fatality
rates and published case-loads to estimate the proportion of total SAM related deaths occurring in children that
would be excluded from treatment with a MUAC-only policy.
Methods: The effect of varying case-load and mortality rates on the proportion of all deaths that would occur in
admitted children was examined. We used the same calculations to estimate the proportion of all SAM-related
deaths that would be excluded with a MUAC-only policy in 48 countries with very different relative case loads for
SAM by only MUAC, only WHZ and children with both deficits. The case fatality rates (CFR) are taken from
simulations, empirical data and the literature.
Results: The relative number of cases of SAM by MUAC alone, WHZ alone and those with both criteria have a
dominant effect on the proportion of all SAM-related deaths that would occur in children excluded from treatment
by a MUAC-only program. Many countries, particularly in the Sahel, West Africa and South East Asia would fail to
identify the majority of SAM-related deaths if a MUAC only program were to be implemented. Globally, the
estimated minimum number of deaths that would occur among children excluded from treatment in our analyses
is 300,000 annually.
Conclusions: The number, proportion or attributable fraction of children excluded from treatment with any change
of current policy are the correct indicators to guide policy change. CRFs alone should not be used to guide policy
in choosing whether or not to drop WHZ as a diagnostic for SAM. All the criteria for diagnosis of malnutrition need
to be retained. It is critical that methods are found to identify those children with a low WHZ, but not a low MUAC,
in the community so that they will not remain undetected.
(Continued on next page)
* Correspondence: Emmanuel.Grellety.Bosviel@ulb.ac.be
1
Research Center Health Policy and Systems - International Health, School of
Public Health, Université Libre de Bruxelles, Bruxelles, Belgium
Full list of author information is available at the end of the article
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International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Grellety and Golden Nutrition Journal (2018) 17:81
https://doi.org/10.1186/s12937-018-0382-6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
(Continued from previous page)
Keywords: Nutrition, Acute malnutrition, Severe acute malnutrition, SAM, Mid-upper-arm circumference, MUAC,
Weight-for-height, WHZ, Mortality, Case fatality rate, Wasting, Oedema, Kwashiorkor, Diagnosis, Case load, Prognosis,
Child, Human
Background
Severe acute malnutrition (SAM) is a lethal condition ac-
counting for about half to one million childhood deaths
[1] annually for children with a weight-for-height/length
(WHZ) below the recommended WHO cut-off. If children
with the other WHO definitions of SAM are added the
death toll is much larger. Identification and treatment of
all children with any of the current definitions of SAM
mandated by the World Health Organisation (WHO) is a
public health priority.
The WHO defines SAM using three independent cri-
teria, WHZ of <3Z of the WHO
2006
growth standards,
an absolute mid-upper-arm circumference (MUAC) of <
115 mm or the presence of nutritional oedema [2,3].
Some children satisfy several of these criteria.
MUAC can be easily and quickly measured using a
simple coloured tape around the upper arm and oedema
can also be easily assessed in the field. On the other
hand, assessment of WHZ requires the weight and
height to be taken and the resulting numbers looked up
in tables. There is no doubt that MUAC is much easier
to assess than WHZ. For reasons of speed, convenience,
cheapness and simplicity MUAC has been used for many
years to assess malnutrition [48]. The ease of use
makes community screening for SAM with MUAC prac-
tical and has been a great advance in identifying affected
individuals in the community.
However, there has now arisen a concerted movement
to stop the assessment of WHZ altogether, even in hospi-
tals and clinics where it is routinely measured at present.
The advocates for only using MUAC are adamant that any
research to develop innovative methods to assess WHZ in
the community is a waste of effortas MUAC is the only
criterion that is needed [911]. We examined community
based survey data from 48 countries and find that only
16.5% of children who fulfil the WHO definitions of SAM
meet both the MUAC and WHZ criteria. If WHZ is aban-
doned as a criterion about 45% of children with SAM by
WHZ alone will fail to be identified because their MUAC
is above 115 mm. Which criterion identifies the majority
of SAM children varies dramatically from country to
country and the two criteria identify different individuals.
For these reasons we advocated that both MUAC and
WHZ continue to be routinely used to assess children for
SAM and, critically, that convenient and simple ways to
assess WHZ in the community to identify children with
only a deficit in WHZ but not MUAC has to be a major
research priority [12].
These suggestions met with a forceful criticism from
a multi-authored paper [9] which appears to have wide-
spread support by both agencies and donors [13]. The
putative basis of the opinion that WHZ should not be
used at all was that anything that diverts resources
from the widespread use of MUAC to identify SAM
would hinder its implementation and therefore WHZ
assessment must be suppressed [9,14]. The reasons
given against the use of WHZ did not simply emphasise
its inconvenience, with which we agree. The following
were asserted: 1) children with a low WHZ are healthy;
2) their low WHZ is due entirely to their having longer
legs so they do not require treatment; 3) WHZ is a poor
predictor of mortality in children; 4) MUAC is a good
predictor of mortality in children; 5) the two diagnostic
parameters are not complementary; and 6) addition of
WHZ does not improve the sensitivity or specificity of
future all-cause mortality prediction with MUAC.
These contentions were robustly refuted [15].
We have shown in the two preceding papers [16,17],
1) that WHZ < 3Z carries as high, or higher, risk of
death as MUAC < 115 mm; they are clearly not healthy
and undeserving of treatment. 2) That the two parame-
ters not only identify different children, and therefore
different risks, but also children satisfying both criteria
have a higher mortality showing the defects to be addi-
tive. 3) That long legsis an inadequate explanation for
the regional difference in SAM by WHZ [12,18,19]. 4)
That all the data previously analysed by comparison of
ROC curves, and relied upon to make the assertions of
MUACs superiority are severely biased because of math-
ematical coupling [20,21] as well as stochastic and other
problems of interpretation [15]. 5) Despite the flaws the
data actually show that WHZ carries a higher mortality
risk than MUAC when appropriately analysed [16]. In-
deed, there are abundant data to confirm that WHZ <
3Z carries a substantial risk of death [2226], but these
papers did not measure MUAC for comparison. Thus,
all the criticisms asserted by Briend et al., and repeated
[9,14,27,28] are, in our opinion, incorrect. Neverthe-
less, their advocacy has led most humanitarian agencies
and some Governments to abandon WHZ altogether.
We do agree that WHZ is more inconvenient and dif-
ficult to measure than MUAC; but this is the only legit-
imate criticism of widespread use of WHZ. The question
arises as to the potential fate of the 45% of children
who would not be identified if WHZ measurement was
omitted completely.
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Having shown that the case fatality rates (CFRs) are not
lower in children with only a deficit in WHZ, this paper
examines the practical programmatic differences between
a MUAC-only program and a complete program.
The object of this study was to estimate the proportion
and where possible the numbers of all SAM related
deaths that would occur in children who would be ex-
cluded from treatment if a MUAC-only program re-
placed a complete program.
Methods
Effect of case-load
We used a simple excel spreadsheet to demonstrate the
effect of variations of the proportions of the total
case-load comprised of children with SAM by MUAC,
WHZ and by both MUAC and WHZ with their corre-
sponding CFRs on the proportion of SAM deaths that
would occur in excluded children if a MUAC-only pro-
gram was used.
The total SAM-related-deaths is given by:
(M
CL
xM
CFR
+W
CL
xW
CFR
+B
CL
xB
CFR
)
Where M = children with MUAC < 115 mm and
WHZ > 3Z (S-muac): W = children with WHZ < 3Z
and MUAC > 115 mm (S-whz): B = children with Both
MUAC < 115 mm and WHZ < 3Z (S-both): subscript
CL = the proportions of the total case load of SAM that
are in categories M, W and B: subscript CFR = Case fa-
tality rates for children with M, W and B. The case load
always sums to 100% of SAM children (i.e. SAM due to
oedema, kwashiorkor with or without wasting, is not
considered in this calculation).
Then the proportion of total SAM-related-deaths that
would occur in children that would not be eligible for
admission and treatment if WHZ were to be dropped as
an admission criterion is given by:
1(M
CL
xM
CFR
+B
CL
xB
CFR
)/(M
CL
xM
CFR
+
W
CL
xW
CFR
+B
CL
xB
CFR
).
For the simulation, the relative case-loads were varied
from zero children with S-muac to zero children with
S-whz. The remainder of the children either had the alter-
native criterion or had S-Both. The proportion of children
with S-both was varied from 10 to 30% (the limits we
found in representative nutritional surveys [12]). The
CFRs for S-muac, S-whz and S-both were examined by
changing the ratio of S-muac to S-whz mortality from half
to twice the mortality of the other to represent the likely
limits of the variation in mortality risk. S-boths CFR was
set at the sum of the CFRs of S-muac and S-whz in ac-
cordance with the empirical data and most of the litera-
ture reports [16,17]. Variation of the overall CFR will
affect the total number of deaths, but the proportions of
SAM-related deaths which would be eligible or ineligible
for treatment is not affected by the absolute CFRs, only by
their ratios and relative case-loads. Thus, if the sizes of the
three CFRs and the proportions of the three case loads do
not change the percent of children that will become ineli-
gible for treatment does not change when the total
SAM-related death rate rises or falls.
Proportion of all SAM-related-deaths that would occur in
children ineligible for treatment with a MUAC-only
program by country
The literature and patient data reported in the first and
second papers [16,17] were subject to ascertainment
bias which made the proportions of the case load com-
ing from the different categories unrepresentative of
SAM in the community. In particular, the proportion of
children in the S-both category was much higher than
that found in the community. That is, the case load ra-
tios of S-muac: S-whz: S-both differed significantly from
that found in representative community surveys of mal-
nourished children [9]. For that reason the case load ratios
of S-muac, S-whz and S-both reported in papers I and II
[16,17] were not used in any calculation. To fairly repre-
sent the situation of SAM children in the community we
used the data previously published from representative
community surveys [12]. These ratios are derived from ana-
lysis of 48,697 SAM children out of a total surveyed popu-
lation of 1,384,068 children, 659 months, (1832 surveys)
from 48 countries.
The community-derived, proportionate case-load esti-
mates were then used to estimate the proportion of the
total deaths that would occur in SAM children with a
MUAC-only program; the residue of S-whz would be ex-
cluded. As the mortality rates for S-muac, S-whz and
S-both that would occur in untreated SAM-children in
the communities are unknown we used mortality rates
from 3 sources. First, those used in our theoretical simula-
tion; second, those found in paper 1 [16]; third, the rela-
tive risks of death derived from the meta-analysis of the
literature values where WHO criteria were used and
oedematous cases excluded [17]. The forest plots from the
meta-analyses comparing S-muac with S-whz and S-both,
using adjustment for study quality, [17] are given in
Additional file 1. The relative risks of death from S-muac,
S-whz and S-both were 1.00: 1.14: 2.70 respectively.
The calculations were the same as for the theoretical
simulation.
How many are affected?
In order to estimate the number of children excluded by
a MUAC-only program we examined data from a global
estimate of SAM-related deaths [1] and from India [29].
These estimates are minimum estimates because they
were based upon prevalence data rather than incidence
data and only on WHZ data. We used case loads of
S-muac, 39.5%, S-whz 44.0% and S-both 16.5% for the
global SAM-deaths estimate and S-muac 15.5%, S-whz
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61.6% and S-both 22.9% for India [12]. The CFRs were
the same for the single deficits and double for S-both.
Ethical statement
This analysis used published data only thus no formal
ethical clearance was required.
Results
Theoretical considerations
Figure 1illustrates the effect of variation of the case-loads
of S-muac, S-whz and S-both and corresponding CFRs to
derive the percent of deaths occurring in children ex-
cluded by a MUAC-only program. The three lines in each
block show the effect of S-muac CFR being half, the same
or twice the CFR of S-whz. These CFRs represent the
likely relative risk and the outside limits. The three blocks
show the effect of an increasing S-both percentages.
If a WHZ-only program was used the results would be
the exact inverse of the percentage exclusion shown.
With a MUAC-only policy, if there are no children in
the community with S-whz (col 1) then all the SAM
children will be identified. If there are no children with
S-muac (last col) the only deaths of MUAC children will
be those who also have S-whz, i.e. those with S-both.
There will be slightly more deaths than the proportion
of overlap because of the higher mortality risk of S-both
children.
A likely scenario is given in block two, second row.
As the percentage of S-muac in the community de-
creases from 60 to 20% the deaths that occur in ex-
cluded children increases from 17 to 50%. To have
20% S-muac is frequently found in nutritional surveys
from some regions [12]. Figure 1also shows that the
exclusion rate is reduced with more S-both children.
For example, if 50% of the children have S-muac (col-
umn 5) as S-both increases from 10 to 20 to 30% the
relative proportion of deaths of excluded children de-
creases from 36, to 33 to 31% respectively. As the
proportion of S-muac decreases the effect of S-both
on excluded cases increases; thus, were there is 20%
of S-muac children (col 7) the percent of excluded
children falls from 64 to 50% to 38%.
Fig. 1 Percentage of SAM-related-deaths of children that would be excluded from treatment in a MUAC-only program. Simulation of the effect of
various case loads and case fatality rates for children with SAM by MUAC-only, WHZ-only and Both criteria. The data gives the percent of total
SAM-related-deaths that would occur in children excluded from treatment in a MUAC-only program. Case Loads and Case Fatality Rates for: S-
muac = MUAC < 115 mm with WHZ > = 3Z: S-whz = WHZ < 3Z with MUAC > 115 mm: S-both = MUAC < 115 mm and WHZ < 3Z. The colours
represent the percent of deaths occurring in cases that would be excluded from treatment in such a program: Red 75100%: Pink 5075%:
Orange 2550%: green 1025%: Blue 010%
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In contrast, a change of CFR ratios from half to
twice has a relatively minor effect on the proportion
of excluded children (compare the 3 rows vertically).
Thus, a change of case-load ratio is more important
than a change in CRFs ratio within the ranges re-
ported [16,17] in determining the extent of exclusion
of S-whz children.
It should be emphasised that these simulations com-
pares the deaths in excluded children (S-whz) with all
the children that would be identified using a MUAC
measurement (i.e. S-muac plus S-both). In papers [16,17],
CFRs from S-muac and S-whz were compared. Here, by
combining S-both with S-muac in the calculations we rep-
licate the actual effect of only measuring MUAC on the
proportion of deaths related to SAM that would be ex-
cluded from treatment or considered in a coverage survey.
Country data
Because the mortality ratios in nearly all communities is
unknown, in Fig. 2we have used the CFRs from the
simulation and estimated from papers I and II [16,17].
These CFRs are then combined with the actual country
case-loads found in community nutrition surveys pub-
lished previously [12].
In Fig. 2we present, by country, the estimates of the
percentage of deaths of SAM children that would occur in
children excluded from treatment if only MUAC measure-
ments are taken. There is reasonable agreement between
the estimates based upon the different CFRs. For example,
in Senegal the three main CFR estimates indicate that 82,
81 and 83% of deaths occur in excluded children; whereas,
in Mozambique only 13, 12 and 15% of deaths occur in
excluded children. Taking the average of the empirical and
literature exclusion rates, 12 countries would exclude
more than three quarters and 34 would exclude more than
half of the SAM children that die. Only 3 of the 48 coun-
tries would include more than 80% of children who die
with SAM.
The corresponding analysis using a WHZ-only pro-
gram is given in Additional file 2. It is clear that a
WHZ-only program would also fail to identify a large
proportion of the children at high risk of death.
The countries are grouped by region in Fig. 3.Ifthe
countries of South & South East Asia and the Sahel were
to adopt a MUAC-only policy then a substantial propor-
tion of SAM childrensdeathswouldoccurinexcluded
children. The same applies in many of the countries in
West Africa. Some of these countries are characterised by
a dry Sahalian type interior and a wet, heavily populated
coast. These ecologically different areas may have different
levels of exclusion of S-whz so that the effect of only
measuring MUAC may be more deleterious in some areas
than others, and may give a within-country bias to nutri-
tional surveys aimed at establishing the prevalence of
SAM and the level of exclusion. The same conditions
apply to some of the East African countries. On the other
hand several countries in West, East and Central Africa as
well as Asia and Latin America would exclude less than
25% of children that contribute to SAM mortality.
Numbers of excluded SAM children who die
Conversion of relative case loads and CFRs into the
number of deaths of SAM children who will be ineligible
for any treatment under a MUAC-only program is
shown in Table 1. Using Black et al.s[1] estimate of glo-
bal SAM deaths of 540,000 calculated from WHZ preva-
lence, the total deaths increases to over 800,000 when
we include S-muac deaths. Of these over 300,000 chil-
dren (38%) will die without the possibility of treatment if
WHZ is not measured. In India, although Black et al. es-
timated that there would be 145,000 deaths, Mohan &
Mohan [29] estimated the actual number of deaths due
to SAM to be 270.000; of these, more than half, 155,000,
would be excluded with a MUAC-only policy.
Discussion
If the primary objective of treating children with SAM is to
prevent death then it is logical to look at the percent of
deaths that occur in SAM children that would be excluded
from treatment with any change in policy. This should then
determine whether or not a policy change is unacceptable.
This information cannot be obtained from comparison of
CFRs by regression or areas under ROC curves.
The CFRs estimated from our empirical data [16] and
a meta-analysis of the literature [17] are consistent and
show that the CFRs for S-muac and S-whz are not suffi-
ciently different to affect the rate of exclusion when only
MUAC is used for SAM diagnosis. The dominant factor
is the case-load mix because even when the CFRs differ
substantially the numbers of children that are excluded
show relatively minor changes.
The present country data, by themselves, cannot be
used to determine the absolute numbers of children cal-
culated to die or that would be excluded because of a
change in policy. This requires our data to be combined
with the prevalence/incidence rates, population size and
community mortality rate for at least one of the diagnos-
tic groups. To then derive population attributable frac-
tions also needs the relative risks of death from SAM
children using the non-malnourished children in the
same community as the reference [30,31]. The results
comparing Black et al. [1] and Mohan & Mohan [29]
demonstrate the difficulties in arriving at accurate esti-
mates. Nevertheless, the numbers of children who die
with SAM who would be ignored, if only MUAC is used
is massive. We estimate this to be about 40% of all SAM
childrens deaths globally; but this is variable by country
and region as Fig. 3shows. Ignoring these children and
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their deaths is the real cost of promoting a MUAC-only
program, and begs the question of what is acceptable
from a humanitarian point of view. Reliable and appropri-
ate estimates are essential if correct priorities and policies
are to be set by Governments to address SAM. Death is
not the only adverse effect of severe malnutrition. There
are other major health and long term consequences of
failing to identify and treat the very much larger number
of children with SAM that do not die, estimated to be 10
million in India by WHZ [29].
Fig. 2 Percentage of SAM-related-deaths of children that would be excluded for treatment with a MUAC-only program by country. Sim simulation data
from Fig. 1, representing the probable ratio of case fatality rates (CFRs) and likely extremes; All, IPF, OPT, SFC are the empirical case fatality rates of patients
under different modes of treatment [16]; Literature mortality rates from Additional file 1derived from the data in reference [17]; Case Loads S-muac = MUAC
< 115 mm with WHZ > = 3Z: S-whz = WHZ < 3Z with MUAC > 115 mm: S-both = MUAC < 115 mm and WHZ < 3Z; DRC Democratic Republic of the
Congo; CAR Central African Republic. The case loads per country are from reference [12]. The colours represent the percent of total SAM-related-deaths
occurring in cases that would be excluded from treatment in a MUAC-only program: Red 75100%: Pink 5075%: Orange 2550%: green 1025%: Blue 0
10%. * These countries case load comes from a small sample size. ** The case load from Kenya comes from the North of Kenya (similar to Sahel)
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One answer to the problem of excluded children could
be to increase the MUAC cut-off point. This is a simplistic
suggestion that is impractical as it would then include a
very large proportion of the whole childhood population
at a much lower risk of death [9,13,28,32,33] and divert
and dilute the attention needed for the high risk children.
The paper from Uttar Pradesh, India, by Kapil et al.
[34] is germane to addressing this suggestion. SAM in
Uttar Pradesh by WHZ was 2.2%; when MUAC was
added the prevalence increased to 2.5%. If the MUAC
cut-off was increased to 135 mm then 17% of all the
children in the population would need to be identified;
however, 12% of the S-whz children would still be missed
and the extra case load would only identify a further 15%
of S-whz. Five in 6 of the extra children would be false
positivesfor SAM. Our unpublished analysis from Africa
is in agreement with these figures. The cost, logistics, staff
time with inevitable disruption to other essential medical
services, add-on costs for the parents, possible family guilt
or stigma concerning the need to be checked for SAM
and risk of bringing the program into disrepute all miti-
gate against this policy. Elsewhere evidence shows that
Table 1 Estimation of the possible number of deaths from SAM that would be missed using a MUAC only program
WHZ deaths Total deaths WHZ only
(S-whz)
MUAC only
(S-muac)
Both criteria
(S-both)
MUAC-only
%missed
WHZ-only
%missed
Global 540,000
a
817,000 309,000 277,000 231,000 37.8 33.9
India 270, 000
b
309,000 155,000 39,000 115,000 50.2 12.6
The estimates of total deaths and proportions were derived as in methods. WHZ deaths deaths estimated by WHZ < 3Z (i.e. S-whz + S-both); Total deaths WHZ
deaths plus MUAC-only deaths based on ratios found in reference [12] for Global and India (S-both = 16.5 and 22.9%). Equal mortality risk for S-whz < 3Z and S-
muac < 115 mm and twice the morta lity risk for S-bot h is assumed.
a
Data from reference [1];
b
Data from reference [29]
Fig. 3 Percentage of SAM-related-deaths of children that would be excluded for treatment with a MUAC-only program by Region. Simulation see
Fig. 1;Literature data from [17]; Empirical data from [16]; Case load data from [12]; CFRs Case fatality rates; SE Asia South East Asia; S Asia South
Asia; DRC Democratic Republic of the Congo; CAR Central African Republic. The colour code is the same as Figs. 1and 2. * Case load ratios from
these countries is based on a small sample size. ** For Kenya the case load data comes from the North of Kenya (could be counted with Sahel).
In bold are some of the countries whose governments have officially adopted a MUAC-only program (2017)
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there are several major difficulties when a false positive
rate exceeds the true positive rate [35,36]. Furthermore,
WHO now recommends not to provide formulated sup-
plementary foods on a routine basis to children who are
moderately wasted[37].
In view of the evidence, why has MUAC morphed
from a simple and effective community screening pro-
gram into a MUAC-only program? Is it really necessary
for total suppression of WHZ as a diagnostic for SAM
to legitimise the use of MUAC?
We suggest that there are several reasons. First, based
upon the data presented in the first two papers of this series
[16,17] as well as the present paper it is clear that an in-
appropriate statistical strategy has been exclusively used in
the past using ROC curve analysis of entire populations to
compare the relative CFRs [15]; when the risks are suffered
by different children entirely, the risks are also different,
making comparisons for diagnostic purposes largely mean-
ingless. Second, the exclusive focus on CFRs alone and the
notion that MUAC is a superiortest; it can only be super-
ior if it identifies the same risk. Third, the neglect of case
load in determining the numbers of excluded children or
the calculation and use of further derived statistics such as
population attributable fraction. Fourth, repeated assertions
that it is safe to ignore S-whz children because they are
healthy when there are no data to support this contention
and abundant data to show that these children are at high
risk of death combined with misquotation and criticism of
any data that does not support the proposition [38]. Fifth,
by forceful advocacy to donors, research funding agencies,
UN agencies and many in the humanitarian organisations
[13]. Sixth, because of an understandable desire to make
everything as simple as possible whilst denying there is any
cost of excluding SAM children [26]. Simplification beyond
what is possible renders programs unworkable or unethical
(try removing the cold chain from vaccination services). An
effort to simplify SAM treatment by suppressing use of F75,
the initial diet designed for the most critically ill of children
[39] was dropped when the reasons for F75 were properly
explained to the agencies. Only using MUAC is certainly
simple, but it has a real cost, and that is measured in lives
lost. Last, because of cognitive biases, particularly confirm-
ation bias [40] among those subscribing to a MUAC-only
policy and those providing confirmatorylow quality evi-
dence such as some of the papers reviewed in [17].
TheeaseofuseofMUACmakescommunityscreening
to identify children in need to SAM treatment practical and
has led to increasingly greater coveragerates for those
children with MUAC < 115 mm. Our data does not ques-
tion the utility of this, what is does demand is research to
find ways that are sufficiently simple to be applied in the
community so that children with WHZ < 3 can also be
included in treatment programs. Stereo-photography has
been used for many years [41]butwithmoderntechnology
this has become practical [4244]. There are reports of low
cost scanning attachments to smart-phones that give pre-
cise measures of height, head-circumference and MUAC
[45]. Therefore, on the horizon are techniques that will
make the assessment of WHZ simple to use in the commu-
nity. Such studies must be properly funded, supported and
then implemented and make it premature to cease consid-
eringWHZasaproperdiagnosticforSAM.
Conclusions
Some within the nutritional community has been misled
by replicated but flawed analyses and assertions. They are
also attracted by the ease and low cost of MUAC screen-
ing; these practical aspects are clearly advantages to be
considered. MUAC-only programs fail to identify enor-
mous numbers of the most vulnerable children in many
societies. It may be difficult to identify S-whz children, but
that is not a reason to pretend these children do not exist
or to justify ignoring them by making false claims such as
that they are healthy. It is essential that they are included
in any program that claims to address the scourge of
SAM. In our opinion many of these programs should be
considered as contravening the dictates of Hippocrates.
Both a WHZ < 3Z and MUAC < 115 mm must be
retained and used wherever possible as diagnostic cri-
teria for SAM. The research priority must be to develop
innovative ways of assessing WHZ so that it can be ex-
tended to S-whz identification in the community.
Additional files
Additional file 1: Figure S1. Forest plots of papers 17of[17]to
determine the CRFs of children with S-muac, S-whz and S-both. The
meta-analyses were performed as in [17] using the quality of the study as
weighting (QE); only reports that used the recommended WHO diagnos-
tic criteria, and excluded oedematous (oed) cases were selected for this
analysis. IND India; NER Niger; SDN South Sudan; UGA Uganda; MWI
Malawi; SEN Senegal; RR relative risk; CI confidence intervals. (TIF 1732 kb)
Additional file 2: Figure S2. Percentage of SAM-related-deaths of children
that would be excluded from treatment by a WHZ-only program. Sim simula-
tion data from Fig. 1, representing the likely extremes and probable ratio of
case fatality rates (CFRs); All, IPF, OPT, SFC are the empirical case fatality rates of
patients under different modes of treatment [16]; Literature mortality rates from
Additional file S1, from reference [17]; Case Loads S-muac = MUAC < 115 mm
with WHZ > = 3Z: S-whz = WHZ < 3Z with MUAC > 115 mm: S-both =
MUAC < 115 mm and WHZ < 3Z; DRC Democratic Republic of the Congo;
CAR Central African Republic. The case loads per country are from reference
[12]. The colours represent the percent of total SAM-related-deaths occurring
in cases that would be excluded from treatment in a MUAC-only program:
Red 75100%: Pink 5075%: Orange 2550%: green 1025%: Blue 010%. *
These countries case load comes from a small sample size. ** The case load
from Kenya comes from the North of Kenya (similar to Sahel). (TIF 4541 kb)
Abbreviations
CFR: Case fatality rate; IPFs: In-patient treatment facilities; MAM: Moderate
acute malnutrition; MUAC: Mid-upper-arm-circumference; NGOs: Non-
governmental organisations; OTPs: Out-patient treatment programs; ROC
curve: Receiver operating characteristic curve; SAM: Severe acute
malnutrition; SFCs: Supplementary feeding centres; WHO: the World Health
Organisation; WHZ: Weight-for-height Z-score
Grellety and Golden Nutrition Journal (2018) 17:81 Page 8 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Funding
Nutriset provided a PhD fellowship to Université Libre de Bruxelles in
support of EG. Nutriset had no role in any aspect of this research including
data collection, design, analysis, interpretation or writing the article. MHG
received no support.
Availability of data and materials
The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
Authorscontributions
EG & MHG were involved in all stages from the conception and design, data
acquisition, analysis and interpretation. Both authors approved the final
version of the article.
Ethics approval and consent to participate
This is a secondary analysis of anonymous published data. As no individual,
location or administrative district could be identified no formal ethical
clearance was required.
Consent for publication
Not applicable
Competing interests
The authors declare that they have no competing interests.
PublishersNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Research Center Health Policy and Systems - International Health, School of
Public Health, Université Libre de Bruxelles, Bruxelles, Belgium.
2
Department
of Medicine and Therapeutics, University of Aberdeen, Aberdeen, Scotland.
Received: 24 May 2017 Accepted: 25 July 2018
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... This adjustment enhances the likelihood of accurately diagnosing severe wasting and reduces the occurrence of false-negative results by 12%. [10] Among children categorized by the gold standard as yellow, MUAC criteria have surprisingly put >93% of these children in the green category, while only a few, that are approximately 5% were labeled correctly as yellow and MUAC tape has even misdiagnosed around 1% of these children as red category. Lastly, within the WHZ green categorized children (39.7%), approximately 95% of them were screened as green, while 4.9% of these were incorrectly labeled as yellow and none of these were categorized as red by MUAC tool. ...
... Keeping the above values regarding the power of MUAC tool in consideration, we can also conclude that WHZ needs to be retained as an independent criterion for the diagnosis of SAM in the community. [10] Moreover, using MUAC alone as a means to identify child undernutrition within a community is not recommended. While it is a convenient and straightforward tool, its effectiveness as a screening measure for undernutrition has been a subject of scrutiny by numerous researchers. ...
Article
Full-text available
Introduction Mid-upper arm circumference (MUAC) measures the arm muscle and fat area. The use of MUAC as a screening measure for assessing undernutrition has the following advantages; it makes use of a simple equipment, is easy to carry at the field sites, and requires minimal training. In India, “mid-upper arm circumference” is widely used and accepted in many nutritional programs. Objectives This study was conducted with the primary objective to compare different anthropometric parameters of children and to validate the usefulness and limitations of MUAC to screen out undernourished children. Subject and Methods Anthropometric measurements were recorded for all the anganwadi centers of the selected sub-center that comes under the field practice area of our department. The measurements like weight, height, MUAC were done according to the standard guidelines as per WHO, and further, calculations were done with the help of “Anthro software 3.2.2.” Comparisons were done between categorization of MUAC tape and Weight-for-Height Z-scores (WHZ) , and hence, the sensitivity and specificity of the MUAC tape to screen the malnourished child were found out. Results Sensitivity of MUAC to categorize a child in red/yellow was only 9.03%, negative predictive value (NPV) was 40.75%, specificity came 95.10%, and positive predictive value was 73.68% on taking WHZ as the gold standard. Conclusion MUAC has a limited role in screening out an undernourished child (red/yellow category), whereas it has a good role in screening healthy children (green category).
... Although the international normative guidance does not endorse the possibility that SAM treatment programs restrict admission to children with MUAC < 115 mm or nutritional edema [8], this proposal has been increasingly promoted and applied [9,10]. As opposed to its consequences on targeting and assessing eligibility to treatment, which have been described and discussed elsewhere [6,[11][12][13], the impacts on discharge have not been analyzed. However, in programs abandoning the assessment of WHZ, MUAC ≥ 125 mm is used as the only restrictive criterion to consider children as cured, irrespective of the WHZ deficits that may be present upon admission. ...
... Since WHZ<-3 is the dominant SAM diagnosis among these children, higher levels of WHZ at discharge may logically reflect a larger recovery during treatment and therefore more sustained protection against nutritional risk and relapse. We believe that a similar result would likely be obtained in all contexts where WHZ<-3 is the predominant anthropometric deficit among SAM cases, which is a prevailing situation in most countries across the world [6,11]. This is particularly true in the high burden countries of the south-east Asia region, in the Sahel, as well as under acute crisis contexts [27]. ...
Article
Full-text available
Abstract Background There is a dearth of evidence on what should be the optimal criteria for discharging children from severe acute malnutrition (SAM) treatment. Programs discharging children while they are still presenting varying levels of weight-for-height (WHZ) or mid-upper-arm circumference (MUAC) deficits, such as those implemented under the current national protocol in Nepal, are opportunities to fill this evidence gap. Methods We followed a cohort of children discharged as cured from SAM treatment in Parasi district, Nepal. Relapse as SAM, defined as the occurrence of WHZ
... MUACZ proves to be crucial, especially in the presence of kwashiorkor and chronic malnutrition, becoming a valuable tool for assessing severe acute malnutrition in our context. Keywords Severe acute malnutrition, MUAC, WHZ, MUACZ, Concordance, DR Congo and the risk of mortality in the community in the absence of management [31][32][33][34][35]. ...
Article
Full-text available
Background Little is known about the use of mid-upper arm circumference for age (MUACZ) for diagnosing of severe acute malnutrition (SAM) and its correlation with WHZ (weight-for-height Z-score) in an area endemic for severe acute malnutrition (SAM) and with a high prevalence of kwashiorkor. Our study aims to analyze the concordance between the diagnostic criteria of SAM in a region presenting these characteristics. Methods We analyzed a database of children admitted from 1987 to 2008 for the management of SAM in Eastern Democratic Republic of Congo. Anthropometric indicators (z-score) were calculated and classified into 3 categories according to WHO standards. Cohen’s kappa coefficient (κ) was calculated to assess the concordance between these indicators. Results Out of the 9969 selected children aged 6 to 59 months, 30.2% had nutritional edema, 70.1% had a height-for-age (HAZ) z-score <-2, 11.5% WHZ<-3 z-score, 14.9% had a MUAC < 115 mm and 21.8% had a MUACZ <-3 z-score. With the classic combination WHZ and MUAC, 36% of children with SAM had both criteria at the same time and MUAC alone being the indicator that recruited more children with SAM (77%) compared with 65% with WHZ only. By replacing MUAC with MUACZ, 34% of SAM children fulfilled both criteria, WHZ and MUACZ. MUACZ alone recruited more children with SAM (88%) compared with 46% with WHZ alone. Considering these three indicators together, MUACZ remained the indicator that recruited more children with SAM (85%). WHZ and MUAC showed a moderate agreement [ κ (95% CI) = 0.408(0.392–0.424)], WHZ and MUACZ a weak agreement [ κ (95% CI) = 0.363(0.347–0.379)] and MUAC and MUACZ a good agreement [ κ (95% CI) = 0.604 (0.590–0.618)]. Conclusion Adjusting MUAC according to age improves its effectiveness in identifying severe acute malnutrition. With low concordance, MUAC and WHZ remain complementary in our context. MUACZ proves to be crucial, especially in the presence of kwashiorkor and chronic malnutrition, becoming a valuable tool for assessing severe acute malnutrition in our context.
... Some studies support the exclusive use of MUAC on the basis that it was a better predictor of mortality than WHZ (17,(27)(28)(29). However, this was not observed in all studies and only a limited number of these studies assessed the relationship between these indicators and the risk of mortality in the community in the absence of management (30)(31)(32)(33)(34). ...
Preprint
Full-text available
Background Little is known about the use of mid-upper arm circumference for age (MUACZ) for diagnose of severe acute malnutrition (SAM) and its correlation with WHZ (weight-for-height Z-score) in an area endemic for severe acute malnutrition (SAM) and with a high prevalence of kwashiorkor. Our study aims to analyze the concordance between the diagnostic criteria of SAM in a region presenting these characteristics. Methods We analyzed a database of children admitted from 1987 to 2008 for the management of SAM in Eastern Democratic Republic of Congo. Anthropometric indicators (z-score) were calculated and classified into 3 categories according to WHO standards. Cohen's kappa coefficient (κ) was calculated to assess the concordance between these indicators. Results Out of the 9969 selected children aged 6 to 59 months, 30.2% had nutritional edema, 70.1% had a height-for-age (HAZ) z-score <-2, 11.5% WHZ<-3 z-score, 14.9% had a MUAC < 115 and 21.8% had a MUACZ <-3 z-score. With the classic combination WHZ and MUAC, 36% of children with SAM had both criteria at the same time and MUAC alone being the indicator that recruited more children with SAM (77%) compared with 65% with WHZ only. By replacing MUAC with MUACZ, 34% of SAM children fulfilled both criteria, WHZ and MUACZ. MUACZ alone recruited more children with SAM (88%) compared with 46% with WHZ alone. Considering these three indicators together, MUAZ remained the indicator that recruited more children with SAM (85%). WHZ and MUAC showed a moderate agreement [ κ (95% CI) = 0.408 (0.392–0.424)], WHZ and MUACZ a weak agreement [ κ (95% CI) = 0.363(0.347–0.379)] and MUAC and MUACZ a good agreement [ κ (95% CI) = 0.604 (0.590–0.618)]. Conclusion Adjusting MUAC for age increases its ability to recruit children suffering from MAS in our region. Despite this, MUAC remains complementary to WHZ because of their weak concordance.
... There is robust scientific evidence demonstrating the discrepancy that exists between the different anthropometric indicators in the diagnosis of SAM when applying the criteria currently recommended by the WHO (MUAC < 115 mm vs. WHZ < −3 Z-score) [27][28][29]. Indeed, other causes independent of nutritional status may explain the difference between MUAC and WHZ in the selection of children with SAM. MUAC is closely related to muscle mass and increases with age [30]. ...
Article
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The present study aimed to assess the effectiveness and impact on treatment coverage of integrating severe acute malnutrition (SAM) treatment at the health hut level by community health workers (CHWs). This study was a non-randomized controlled trial, including two rural communes in the health district of Mayahi: Maïreyreye (control) and Guidan Amoumoune (intervention). The control group received outpatient treatment for uncomplicated SAM from health facilities (HFs), while the intervention group received outpatient treatment for uncomplicated SAM from HFs or CHWs. A total of 2789 children aged 6–59 months with SAM without medical complications were included in the study. The proportion of cured children was 72.1% in the control group, and 77.2% in the intervention group. Treatment coverage decreased by 8.3% in the control area, while the group of CHWs was able to mitigate that drop and even increase coverage by 3%. This decentralized treatment model of acute malnutrition with CHWs allowed an increase in treatment coverage while maintaining a good quality of care. It also allowed the early inclusion of children in less severe conditions. These results may enhance the Niger Ministry of Health to review the management of SAM protocol and allow CHWs to treat acute malnutrition.
... It is clear now that abandonment of WHZ as a diagnostic criterion for SAM effectively excludes from treatment a large number of children with high risks of morbidity and mortality. 33 The analyses of representative survey data indicate that children with low WHZ only may represent .40% of the SAM caseload in most countries, with higher proportions in high-burden and acute-crisis contexts 3,34 ; increasing the MUAC threshold for admission would increase the number of these children who would be eligible for treatment but would dramatically increase the program target at the expense of specificity. 35 In summary, the weight of evidence suggests that both WHZ and MUAC should be measured in all children evaluated for malnutrition. ...
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Background and objectives: Use of mid-upper arm circumference (MUAC) as a single screening tool for severe acute malnutrition (SAM) assumes that children with a low weight-for-height z score (WHZ) and normal MUAC have lower risks of morbidity and mortality. However, the pathophysiology and functional severity associated with different anthropometric phenotypes of SAM have never been well characterized. We compared clinical characteristics, biochemical features, and health and nutrition histories of nonedematous children with SAM who had (1) low WHZ only, (2) both low WHZ and low MUAC, or (3) low MUAC only. Methods: In Bangladesh, Burkina Faso, and Liberia, we conducted a multicentric cohort study in uncomplicated, nonedematous children with SAM and low MUAC only (n = 161), low WHZ only (n = 138), or a combination of low MUAC and low WHZ (n = 152). Alongside routine anthropometric measurements, we collected a wide range of critical indicators of clinical and nutritional status and viability; these included serum leptin, an adipocytokine negatively associated with mortality risk in SAM. Results: Median leptin levels at diagnosis were lower in children with low WHZ only (215.8 pg/mL; P < .001) and in those with combined WHZ and MUAC deficits (180.1 pg/mL; P < .001) than in children with low MUAC only (331.50 pg/mL). The same pattern emerged on a wide range of clinical indicators, including signs of severe wasting, dehydration, serum ferritin levels, and caretaker-reported health deterioration, and was replicated across study sites. Conclusions: Illustrative of the likely heterogeneous functional severity of the different anthropometric phenotypes of SAM, our results confirm the need to retain low WHZ as an independent diagnostic criterion.
... In children aged 6-59 months, a mid-upper arm circumference of less than 115 mm and severe wasting (Z scores <-3) were both associated with an increased risk of mortality, and are recommended by WHO for identifying severe malnutrition. 23 As a single screening measure, mid-upper arm circumference might be superior to severe wasting because of its simplicity and greater ability to identify children at risk of death. 24,25 Suboptimal breastfeeding practices-defined as less than 6 months of exclusive breastfeeding, and less than 2 years of total breastfeedingare also associated with elevated risks of death from infectious diseases as confirmed in other reviews. ...
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13 years after the first Lancet Series on maternal and child undernutrition, we reviewed the progress achieved on the basis of global estimates and new analyses of 50 low-income and middle-income countries with national surveys from around 2000 and 2015. The prevalence of childhood stunting has fallen, and linear growth faltering in early life has become less pronounced over time, markedly in middle-income countries but less so in low-income countries. Stunting and wasting remain public health problems in low-income countries, where 4·7% of children are simultaneously affected by both, a condition associated with a 4·8-times increase in mortality. New evidence shows that stunting and wasting might already be present at birth, and that the incidence of both conditions peaks in the first 6 months of life. Global low birthweight prevalence declined slowly at about 1·0% a year. Knowledge has accumulated on the short-term and long-term consequences of child undernutrition and on its adverse effect on adult human capital. Existing data on vitamin A deficiency among children suggest persisting high prevalence in Africa and south Asia. Zinc deficiency affects close to half of all children in the few countries with data. New evidence on the causes of poor growth points towards subclinical inflammation and environmental enteric dysfunction. Among women of reproductive age, the prevalence of low body-mass index has been reduced by half in middle-income countries, but trends in short stature prevalence are less evident. Both conditions are associated with poor outcomes for mothers and their children, whereas data on gestational weight gain are scarce. Data on the micronutrient status of women are conspicuously scarce, which constitutes an unacceptable data gap. Prevalence of anaemia in women remains high and unabated in many countries. Social inequalities are evident for many forms of undernutrition in women and children, suggesting a key role for poverty and low education, and reinforcing the need for multisectoral actions to accelerate progress. Despite little progress in some areas, maternal and child undernutrition remains a major global health concern, particularly as improvements since 2000 might be offset by the COVID-19 pandemic.
... Additionally, UNICEF reports that more than 1.5 million children mortality occurred due to severe acute malnutrition every year [2] and 3.5 million children of age 5 years or less with moderate acute malnutrition succumb to death in 2005 [3]. Acute malnutrition is defined by a decrease of two standard deviations (SD) below the WHZ (Weight for Height Z score) [4] while chronic malnutrition, described as stunting, is defined by a decrease of two SD below the HAZ (Height for Age Z score) [5]. ...
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Background: Weight-for-height Z-score (WHZ) and Mid Upper Arm Circumference (MUAC) are both commonly used as acute malnutrition screening criteria. However, there exists disparity between the groups identified as malnourished by them. Thus, here we aim to investigate the clinical features and linkage with chronicity of the acute malnutrition cases identified by either WHZ or MUAC. Besides, there exists evidence indicating that fat restoration is disproportionately rapid compared to that of muscle gain in hospitalized malnourished children but related research at community level is lacking. In this study we suggest proxy measure to inspect body composition restoration responding to malnutrition management among the malnourished children. Methods: The data of this study is from World Vision South Sudan's emergency nutrition program from 2006 to 2012 (4443 children) and the nutrition survey conducted in 2014 (3367 children). The study investigated clinical presentations of each type of severe acute malnutrition (SAM) by WHZ (SAM-WHZ) or MUAC (SAM-MUAC), and analysed correlation between each malnutrition and chronic malnutrition. Furthermore, we explored the pattern of body composition restoration during the recovery phase by comparing the relative velocity of MUAC3 with that of weight gain. Results: As acutely malnourished children identified by MUAC more often share clinical features related to chronic malnutrition and minimal overlapping with malnourished children by WHZ, Therefore, MUAC only screening in the nutrition program would result in delayed identification of the malnourished children. Conclusions: The relative velocity of MUAC3 gain was suggested as a proxy measure for volume increase, and it was more prominent than that of weight gain among the children with SAM by WHZ and MUAC over all the restoring period. Based on this we made a conjecture about dominant fat mass gain over the period of CMAM program. Also, considering initial weight gain could be ascribed to fat mass increase, the current discharge criteria would leave the malnourished children at risk of mortality even after treatment due to limited restoration of muscle mass. Given this, further research should be followed including assessment of body composition for evidence to recapitulate and reconsider the current admission and discharge criteria for CMAM program.
Article
Background: Severe acute malnutrition (SAM) can be diagnosed using weight-for-height Z-score (WHZ) and/or mid-upper arm circumference (MUAC). Although some favor using MUAC alone, valuing its presumed ability to identify children at greatest need for nutritional care, the functional severity and physiological responses to treatment in children with varying deficits in WHZ and MUAC remain inadequately characterized. Objective: We aimed to compare clinical and biochemical responses to treatment in children with 1) both low MUAC and low WHZ, 2) low MUAC- only, and 3) low WHZ-only. Methods: A multicenter, observational cohort study was conducted in children aged 6–59 mo with nonedematous, uncomplicated SAM in Bangladesh, Burkina Faso, and Liberia. Anthropometric measurements and critical indicators were collected 3 times during treatment; metrics included clinical status, nutritional status, viability, and serum leptin, a biomarker of mortality risk in SAM. Results: Children with combined MUAC and WHZ deficits had greater increases in leptin levels during treatment than those with low MUAC alone, showing a 34.4% greater increase on the second visit (95% confidence interval [CI]: 7.6%, 43.6%; P = 0.02) and a 34.3% greater increase on the third visit (95% CI: 13.2%, 50.3%; P = 0.01). Similarly, weight gain velocity was higher by 1.56 g/kg/d in the combined deficit group (95% CI: 0.38, 2.75; P=0.03) compared with children with low MUAC-only. Children with combined deficits had higher rates of iron deficiency and wasting while those with low WHZ alone and combined deficits had higher rates of tachypnea and pneumonia during treatment. Conclusions: Given the comparable treatment responses of children with low WHZ alone and those with low MUAC alone, and the greater vulnerability at admission and during treatment in those with combined deficits, our findings support retaining WHZ as an independent diagnostic and admission criterion of SAM, alongside MUAC. This trial was registered at www.clinicaltrials.gov/study/NCT03400930 as NCT03400930.
Conference Paper
Balanced nutrition is the main source of energy. It is necessary for healthy life of people. Healthy nutrients enable cells to perform their regular activities at pace. Deficiency of proper nutrition while birth causes various complications in further life. These complications include wasting, stunting, edema, mental illness, low immune system, ridged or spoon-shaped nails, brittle, dry hair, and underweight etc. Malnutrition is a condition that occurs when a person consumes a diet that is deficient in one or more major nutrients, or has too many of them. Marasmus, kwashiorkor and intermediate states of marasmus-kwashiorkor are included in the term Protein-Energy Malnutrition (PEM) disorders. PEM is the cause of underweight (low weight for age), stunting (low height for age), and wasting (low weight for height). In India, stunting affects 48% of infants under five years age, wasting affects 20%, and underweight affects 43%. Most children suffering from undernutrition in mild to moderate forms are unnoticed in India, which affects their growth at early ages. Detecting malnutrition at early stage reduces further healthcare cost and improve health outcome. To alleviate the problem of malnutrition, this paper describes a decision tree model for classification of infants being between the ages of 0 and 59 months as normal, acute malnourished or severely malnourished for three categories: Stunting, Wasting and Underweight. In decision tree model, Gini index is adopted as an impurity measure. The accuracy obtained using decision tree for stunting is 82.22%, for wasting 72.23 % and underweight 78.35% using Gini index.
Article
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Background The WHO recommended criteria for diagnosis of sever acute malnutrition (SAM) are weight-for-height/length Z-score (WHZ) of <− 3Z of the WHO2006 standards, a mid-upper-arm circumference (MUAC) of < 115 mm, nutritional oedema or any combination of these parameters. A move to eliminate WHZ as a diagnostic criterion has been made on the assertion that children with a low WHZ are healthy, that MUAC is a “superior” prognostic indicator of mortality and that adding WHZ to the assessment does not improve the prediction of death. Our objective was to examine the literature comparing the risk of death of SAM children admitted by WHZ or MUAC criteria. Methods We conducted a systematic search for reports which examined the relationship of WHZ and MUAC to mortality for children less than 60 months. The WHZ, MUAC, outcome and programmatic variables were abstracted from the reports and examined. Individual study’s case fatality rates were compared by chi-squared analysis and random effects meta-analyses for combined data. Results Twenty-one datasets were reviewed. All the patient studies had an ascertainment bias. Most were inadequate because they had insufficient deaths, used obsolete standards, combined oedematous and non-oedematous subjects, did not report the proportion of children with both deficits or the deaths occurred remotely after anthropometry. The meta-analyses showed that the mortality risks for children who have SAM by MUAC < 115 mm only and those with SAM by WHZ < −3Z only are not different. Conclusions As the diagnostic criteria identify different children, this analysis does not support the abandonment of WHZ as an important independent diagnostic criterion for the diagnosis of SAM. Failure to identify such children will result in their being denied treatment and unnecessary deaths from SAM.
Article
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Background According to WHO childhood severe acute malnutrition (SAM) is diagnosed when the weight-for-height Z-score (WHZ) is <−3Z of the WHO2006 standards, the mid-upper-arm circumference (MUAC) is < 115 mm, there is nutritional oedema or any combination of these parameters. Recently there has been a move to eliminate WHZ as a diagnostic criterion on the assertion that children meeting the WHZ criterion are healthy, that MUAC is universally a superior prognostic indicator of mortality and that adding WHZ to the assessment does not improve the prediction; these assertions have lead to a controversy concerning the role of WHZ in the diagnosis of SAM. Methods We examined the mortality experience of 76,887 6–60 month old severely malnourished children admitted for treatment to in-patient, out-patient or supplementary feeding facilities in 18 African countries, of whom 3588 died. They were divided into 7 different diagnostic categories for analysis of mortality rates by comparison of case fatality rates, relative risk of death and meta-analysis of the difference between children admitted using MUAC and WHZ criteria. Results The mortality rate was higher in those children fulfilling the WHO2006 WHZ criterion than the MUAC criterion. This was the case for younger as well as older children and in all regions except for marasmic children in East Africa. Those fulfilling both criteria had a higher mortality. Nutritional oedema increased the risk of death. Having oedema and a low WHZ dramatically increased the mortality rate whereas addition of the MUAC criterion to either oedema-alone or oedema plus a low WHZ did not further increase the mortality rate. The data were subject to extreme confounding giving Simpson’s paradox, which reversed the apparent mortality rates when children fulfilling both WHZ and MUAC criteria were included in the estimation of the risk of death of those fulfilling either the WHZ or MUAC criteria alone. Conclusions Children with a low WHZ, but a MUAC above the SAM cut-off point are at high risk of death. Simpson’s paradox due to confounding from oedema and mathematical coupling may make previous statistical analyses which failed to distinguish the diagnostic groups an unreliable guide to policy. WHZ needs to be retained as an independent criterion for diagnosis of SAM and methods found to identify those children with a low WHZ, but not a low MUAC, in the community.
Article
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Anthropometric data collected in clinics and surveys are often inaccurate and unreliable due to measurement error. The Body Imaging for Nutritional Assessment Study (BINA) evaluated the ability of 3D imaging to correctly measure stature, head circumference (HC) and arm circumference (MUAC) for children under five years of age. This paper describes the protocol for and the quality of manual anthropometric measurements in BINA, a study conducted in 2016–17 in Atlanta, USA. Quality was evaluated by examining digit preference, biological plausibility of z-scores, z-score standard deviations, and reliability. We calculated z-scores and analyzed plausibility based on the 2006 WHO Child Growth Standards (CGS). For reliability, we calculated intra- and inter-observer Technical Error of Measurement (TEM) and Intraclass Correlation Coefficient (ICC). We found low digit preference; 99.6% of z-scores were biologically plausible, with z-score standard deviations ranging from 0.92 to 1.07. Total TEM was 0.40 for stature, 0.28 for HC, and 0.25 for MUAC in centimeters. ICC ranged from 0.99 to 1.00. The quality of manual measurements in BINA was high and similar to that of the anthropometric data used to develop the WHO CGS. We attributed high quality to vigorous training, motivated and competent field staff, reduction of non-measurement error through the use of technology, and reduction of measurement error through adequate monitoring and supervision. Our anthropometry measurement protocol, which builds on and improves upon the protocol used for the WHO CGS, can be used to improve anthropometric data quality. The discussion illustrates the need to standardize anthropometric data quality assessment, and we conclude that BINA can provide a valuable evaluation of 3D imaging for child anthropometry because there is comparison to gold-standard, manual measurements.
Article
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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). DiscussionRegional 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.
Article
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Background Anthropometric surveys of children are used to assess the nutritional status of a population. World Health Organization (WHO) recommends that either mid-upper-arm circumference (MUAC) or weight-for-height Z-scores (WHZ) are used to assess acute malnutrition prevalence. However, there are reports from several countries that the two criteria identify different children. In order to examine the external validity of these observations we have compared the direction and degree of discrepancy across countries. Methods Anonymous data were collected from 1832 anthropometric surveys from 47 countries with measured children aged from 6 to 59 months and at least 75 malnourished subjects. The prevalence of total acute malnutrition and severe acute malnutrition was calculated using either absolute-MUAC or WHZ (WHO2006 standards). For each country, the total number of children diagnosed as acutely malnourished by either criterion alone or by both criteria were summed from all the surveys conducted in that country. Results In all countries a minority of children were diagnosed as malnourished by both criteria. Both the magnitude and direction of the discrepancy varied dramatically between countries with some having most children diagnosed as malnourished by MUAC and others where nearly all the children were diagnosed by WHZ alone. Eight additional countries with insufficient malnourished children were also analysed and they support the conclusions. Conclusion For all countries examined the discrepancy was not adequately explained by any single hypothesis, such as variation in relative leg to body length. The perceived need for humanitarian intervention can be affected by the measurement chosen to assess the prevalence of malnutrition which will vary from region to region. It is recommended that MUAC measurement be included in all anthropometric surveys and that the two criteria are not alternative measures of the loss of body tissue leading to an increased risk of death, but complementary variables that should both be used independently to guide admission for treatment of malnourished children.
Article
Objective: Severe Acute Malnutrition (SAM) interventions aim to detect and treat children at highest risk of death who benefit most from treatment. SAM services reach less than 20% of affected children worldwide, and innovative policy changes are needed to scale up services. This paper discusses anthropometry to diagnose SAM as one pathway to improve the effectiveness coverage of SAM services. Results: WHO defines SAM by either MUAC <115 mm or WHZ <−3 or the presence of nutritional oedema. Both MUAC and WHZ are proxy indicators of a clinical condition, and neither is a gold standard. Because they measure different characteristics of the same illness, MUAC and WHZ identify different SAM populations that overlap differently in different contexts across and within countries. MUAC is a better predictor of mortality and has the practical advantages of simplicity, reliability and accuracy. Using both indicators independently identifies more children and loses sensitivity to risk of death. Discussion and Conclusion: Based on current evidence and operational and policy considerations, using MUAC only for diagnosing SAM with a countryadapted cut-off could feasibly scale up SAM services and improve coverage to reach the millions of missed children. Meanwhile, continued research on the biomedical consequences and policy implications of this approach, as well as innovations such as system dynamics modeling, may contribute to the evidence.
Article
Objective To evaluate the predictive ability of mid-upper arm circumference (MUAC) for detecting severe wasting (weight-for-height Z -score (WHZ) <−3) among children aged 6–59 months. Design Cross-sectional survey. Setting Rural Uttar Pradesh, India. Subjects Children ( n 18 456) for whom both WHZ ( n 18 463) and MUAC were available. Results The diagnostic test accuracy of MUAC for severe wasting was excellent (area under receiver-operating characteristic curve = 0·933). Across the lower range of MUAC cut-offs (110–120 mm), specificity was excellent (99·1–99·9 %) but sensitivity was poor (13·4–37·2 %); with higher cut-offs (140–150 mm), sensitivity increased substantially (94·9–98·8 %) but at the expense of specificity (37·6–71·9 %). The optimal MUAC cut-off to detect severe wasting was 135 mm. Although the prevalence of severe wasting was constant at 2·2 %, the burden of severe acute malnutrition, defined as either severe wasting or low MUAC, increased from 2·46 to 17·26 % with cut-offs of <115 and <135 mm, respectively. An MUAC cut-off <115 mm preferentially selected children aged ≤12 months (OR=11·8; 95 % CI 8·4, 16·6) or ≤24 months (OR=23·4; 95 % CI 12·7, 43·4) and girls (OR=2·2; 95 % CI 1·6, 3·2). Conclusions Based on important considerations for screening and case detection in the community, modification of the current WHO definition of severe acute malnutrition may not be warranted, especially in the Indian context.
Article
Mid-upper-arm circumference (MUAC) and weight-for-height (WHZ) are both used as diagnostic criteria for severe acute malnutrition (SAM). We have shown that the majority of children who satisfy one criterion do not satisfy the other in all the countries examined. The direction and degree of this discordance varies dramatically from country to country without a satisfactory explanation. These findings have not been disputed, but the logical consequences and conclusions are criticised in the accompanying paper by Briend et al. We dispute Briend et al’s criticisms and present arguments: 1) that all-cause mortality ROC curves from community studies are not definitive evidence in favour of MUAC-only programs; 2) that studies of series of patients should not be dismissed as irrelevant; 3) that children with a low WHZ are not healthy ; 4) that the reason for the discrepancy is not simply due to body shape; 5) that the papers quoted in our previous publication have been misrepresented; 6) that the suggestion that simply increasing the cut-off point for MUAC in an attempt to encompass all the children with a SAM by WHZ-only is not a viable option; and, 7) that the discrepancy presents a threat to current therapeutic programs . Up to 45% of the 6 to 59 month old SAM children in the community with a WHZ below -3Z score have a MUAC which is above 115mm. These children are malnourished, suffer and need treatment no matter whether they have low MUAC or not, they also respond excellently to treatment and can be salvaged. The reasons for the discrepancy are secondary to the main point that WHZ children suffer and need treatment which is denied by a MUAC- only program. Death is not the only adverse outcome of SAM, the other negative outcomes are important and need to be addressed. It is our contention that MUAC-only programs are acceptable in countries where the majority of GAM cases are diagnosed by MUAC, in countries where the majority of GAM cases are only identified by WHZ, MUAC-only programs are not acceptable if the majority of children at risk are to be treated. Coverage assessed by MUAC is below acceptable levels in nearly all countries because those with a low WHZ are then excluded from screening, diagnosis and treatment and are thus not counted. Denial of their risk presents a real threat to these children and is unethical. MUAC only programs are addressing a section of the malnourished population, are to be encouraged and scaled up where appropriate. WHZ measurement is not in competition with such programs, is complementary and should be retained as a diagnostic criterion until a satisfactory alternative is found to identify and treat the children that are now being excluded from treatment.