Optimal screening of children with acute malnutrition requires a change in current WHO guidelines as MUAC and WHZ identify different patient groups

Arnaud Laillou, Sophonneary Prak, Richard de Groot, Sophie Whitney, Joel Conkle, Lindsey Horton, Sam Oeurn Un, Marjoleine A Dijkhuizen, Frank T Wieringa, Arnaud Laillou, Sophonneary Prak, Richard de Groot, Sophie Whitney, Joel Conkle, Lindsey Horton, Sam Oeurn Un, Marjoleine A Dijkhuizen, Frank T Wieringa

Abstract

Background: Timely treatment of acute malnutrition in children <5 years of age could prevent >500,000 deaths annually. Screening at community level is essential to identify children with malnutrition. Current WHO guidelines for community screening for malnutrition recommend a Mid Upper Arm Circumference (MUAC) of <115 mm to identify severe acute malnutrition (SAM). However, it is currently unclear how MUAC relates to the other indicator used to define acute malnutrition: weight-for-height Z-score (WHZ).

Methods: Secondary data from >11,000 Cambodian children, obtained by different surveys between 2010 and 2012, was used to calculate sensitivity and ROC curves for MUAC and WHZ.

Findings: The secondary analysis showed that using the current WHO cut-off of 115 mm for screening for severe acute malnutrition over 90% of children with a weight-for-height z-score (WHZ) <-3 would have been missed. Reversely, WHZ<-3 missed 80% of the children with a MUAC<115 mm.

Conclusions: The current WHO cut-off for screening for SAM should be changed upwards from the current 115 mm. In the Cambodian data-set, a cut-off of 133 mm would allow inclusion of >65% of children with a WHZ<-3. Importantly, MUAC and WHZ identified different sub-groups of children with acute malnutrition, therefore these 2 indicators should be regarded as independent from each other. We suggest a 2-step model with MUAC used a screening at community level, followed by MUAC and WHZ measured at a primary health care unit, with both indicators used independently to diagnose severe acute malnutrition. Current guidelines should be changed to reflect this, with treatment initiated when either MUAC <115 mm or WHZ<-3.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. ROC curve of the MUAC…
Figure 1. ROC curve of the MUAC score in against WHZ
Figure 2. ROC curve of the MUAC…
Figure 2. ROC curve of the MUAC score in against WHZ
Figure 3. Two-step screening procedure for severe…
Figure 3. Two-step screening procedure for severe acute malnutrition at community level.
Figure 4. MUAC-for-Age Z-scores according to the…
Figure 4. MUAC-for-Age Z-scores according to the gender (boys and girl) from WHO anthropometric database in comparison to a single cut-off of 13.3 cm.

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