Variance in number of children admitted to OTP using MUAC < 11.cm and WHZ <-3SD

Hi,

I would like to come back the post as there has been an article in the September 2010 FEX on the programming in Cambodia using both WHZ and MUAC for the same reasons.
I see the point of not including W/H in the active screening process, but think that W/H should be an admission criteria for children presenting themselves directly to the centers, either because of sickness or other reasons.
Or should admission criteria be really restricted to MUAC only and such children, if MUAC above 11.5 but W/H below -3, be turned away?

Are there new studies now clearly indicating mortality risk of MUAC versus W/H under WHO standards. What I have found in a quick research all refers back to NCHS. As well I would like to know if the studies mentioned elsewhere looking at MUAC only for discharge have already lead to some results?

Sorry, a lot of questions.

In our own programs, we use MUAC and/or WHZ at the community and facility level. If a child meets either or both, he is admitted, so children who don't meet both are not excluded. If it's too complicated to have WHZ at the community level, it seems this could still apply using MUAC and/or WHZ at the facility level.

This suggestion of using WFH and / or MUAC comes back again and again. It is based on the assumption that by using WFH you pick up some high risk children missed by WFH as both identify different children.

To test whether this approach makes sense, I went back with former colleagues to data we collected in rural Senegal in the 80's on the relationship between anthropometry and mortality based on a 6 month community follow up with very few children being treated. In those days, referral to the capital, 200 km away was the best we could propose.

We found in this reanalysis that the MUAC ROC curve was constantly above the WFH one, even when the new WHO standard was used. We then plotted the points WFH < -3 and/or MUAC < 115 mm. These two points were both below the MUAC ROC curve. Using WFH < -3 or MUAC < 115 mm indeed increased sensitivity, but this was at the expense of specficity. MUAC < 120 mm had about the same specificity level as WFH < -3 or MUAC < 115 but had a higher sensitivity.

Conclusion: using both diagnostic criteria is more complicated and no more effective than MUAC alone. If a higher sensitivity is needed, better use a higher MUAC cut off and forget WFH.

This study is submitted to a peer review journal. Hope it will be available soon.

Remark: all this is related to dectection of children with a high risk of death.

Hi everyone,

It looks like we will be removing W/H from identification criteria at the health center in Cambodia because of difficulty in measuring and time constraints. We will only use MUAC at community and health center.

Andre, I look forward to reading your study. Did you disaggregate by age? For me, it's difficult to interpret much of the work done on the risk of mortality because MUAC selects younger children here.

I'm left wondering does MUAC show equal or more risk for mortality when compared to W/H in children <5 years simply because younger children have a higher mortality risk; and if age does influence this, what is mortality risk using MUAC compared to W/H or even no criteria for children < 24 months.

On a related topic, we are now integrating treatment for SAM into IMCI. I'm in touch with colleagues in Ethiopia. Does anyone know of another country where this integration has happened?

Dear Joel,

We did not analyse the data by age. In practice, you don't separate children by age either when deciding which child should get treatment. You have to select for treatment children of different ages and different nutritional status pooled together.

MUAC used with a fixed cut off does select younger children everywhere. This may explain why it is better in identifying high risk children, but so what ? Let's be pragmatic, we want something effective to identify high risk children (and who respond to treatment), whatever the reason.

MUAC is clearly related to muscle mass, something which is important for survival. See: Wolfe RR. The underappreciated role of muscle in health and disease. Am J Clin Nutr. 2006 Sep;84(3):475-82. Freely available at: http://www.ajcn.org/content/84/3/475.full.pdf+html

Whether age or the muscle effect is the most relevant to determine risk in relation to MUAC remains an open question. Maybe these interpretation are not really opposed, as body proportions, and in particular the percentage of muscle in body weight, increases with age. Young children and malnourished children have something in common in terms of body composition.

Hi All

Thanks for the invaluable information and discussion. Just to add on the discussion, in some of the countries where we undertake CMAM programmes such as South Sudan, the national protocol recommends to use the following as admission criteria WHZ and MUAC. Hence, screening may be done using MUAC but admission should be based on either. As stated by Mark Myatt this affects the coverage of the programme but on the other hand, there is no much that could be done since MoH national protocol should also be followed. Thus, in this situation what will you advice?

Regards,

Admissions into OTP/SC should be done by either, MUAC and/or WHZ. If one of the criteria is met, the child should be admitted. If MUAC is used for screening at community level but admission at the health facility is based on WHZ only, mothers will increasingly refuse to bring their SAM (by MUAC) children for treatment due to the negative feedback spreading fast. The distance to the health facilities is often large, mothers time is limited, the workload already high. If referred based on MUAC, the admission of the child has to happen. This requires accurate MUAC screening at community level, transparent referral criteria, a close by treatment facility, and use of the same SAM criteria at communtiy and health facility level. However if equipment and time allows, WHZ should be used for admision at health facility level (preferably during routine health interventions/ IMCI consultations) in addition. During coverage surveys it is most likely that a number of missed out cases will be SAM by WHZ only, but having been screened by community volunteers with a MUAC above the SAM cut-off point. However using these admission protocols the most critical children will have the best chance of being detected and referred due to MUAC best predicting a high risk of mortality.