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The optimal mid-upper-arm circumference cutoffs to screen severe acute malnutrition in Vietnamese children.

ABSTRACT: Severe acute malnutrition (SAM) remains a main cause of mortality among children under five years old. Vietnam needs further study to establish the optimal mid-upper-arm circumference (MUAC) cutoff for improving the accuracy of the MUAC indicator in screening SAM children aged 6-59 months. A survey was conducted at all 16 subdistricts across four provinces in Northern Midlands and mountainous areas. The data of 4,764 children showed that an optimal MUAC cutoff of 13.5 cm would allow the inclusion of 65% of children with weight-for-height z-scores (WHZs) below -3SD. A combination of MUAC and WHZ may achieve a higher impact on therapeutic feeding programs for SAM children. The MUAC cutoff of 13.5 cm (65% sensitivity and 72% specificity) should be used as the cutoff for improving and/or preventing SAM status among children under 5 in the Midlands and mountainous areas in Vietnam.

SUBMITTER: Hai TT

PROVIDER: S-EPMC7109525 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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The optimal mid-upper-arm circumference cutoffs to screen severe acute malnutrition in Vietnamese children.

Hai Tran Thi TT Bardosono Saptawati S Wiradnyani Luh Ade Ari LAA Hop Le Thi LT Ngan Hoang T Duc HTD Phuong Huynh Nam HN

AIMS public health 20200323 1

Severe acute malnutrition (SAM) remains a main cause of mortality among children under five years old. Vietnam needs further study to establish the optimal mid-upper-arm circumference (MUAC) cutoff for improving the accuracy of the MUAC indicator in screening SAM children aged 6-59 months. A survey was conducted at all 16 subdistricts across four provinces in Northern Midlands and mountainous areas. The data of 4,764 children showed that an optimal MUAC cutoff of 13.5 cm would allow the inclusio ...[more]

PMID: 32258199

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Project description:BackgroundWeight gain is routinely monitored to assess hydration and growth during treatment of children with complicated severe acute malnutrition (SAM). However, changes in weight and mid-upper arm circumference (MUAC) gain velocities over time are scarcely described. We assessed weight and MUAC gain velocities in 6-59 mo-old children with complicated SAM by treatment phase and edema status.MethodsThis was a prospective study, nested in a randomized/probiotic trial ( ISRCTN16454889 ). Weight and MUAC gain velocities were assessed by treatment phase and edema at admission using linear mixed-effects models.ResultsAmong 400 children enrolled, the median (IQR) age was 15.0 (11.2;19.2) months, 58% were males, and 65% presented with edema. During inpatient therapeutic care (ITC), children with edema vs no edema at admission had negative weight gain velocity in the stabilization phase [differences at day 3 and 4 were - 11.26 (95% CI: - 20.73; - 1.79) g/kg/d and - 13.09 (95% CI: - 23.15; - 3.02) g/kg/d, respectively]. This gradually changed into positive weight gain velocity in transition and eventually peaked at 12 g/kg/d early in the rehabilitation phase, with no difference by edema status (P > 0.9). During outpatient therapeutic care (OTC), overall, weight gain velocity showed a decreasing trend over time (from 5 to 2 g/kg/d), [difference between edema and non-edema groups at week 2 was 2.1 (95% CI: 1.0;3.2) g/kg/d]. MUAC gain velocity results mirrored those of weight gain velocity [differences were - 2.30 (95% CI: - 3.6; - 0.97) mm/week at week 1 in ITC and 0.65 (95% CI: - 0.07;1.37) mm/week at week 2 in OTC].ConclusionsWeight and MUAC gain velocities among Ugandan children with complicated SAM showed an increasing trend during transition and early in the rehabilitation phase, and a decreasing trend thereafter, but, overall, catch-up growth was prolonged. Further research to establish specific cut-offs to assess weight and MUAC gain velocities during different periods of rehabilitation is needed.

Project description:BACKGROUND:A stubborn persistence of child severe acute malnutrition (SAM) and continued gaps in program coverage have made identifying methods for expanding detection, diagnosis, and treatment of SAM an urgent public health need. There is growing consensus that making mid-upper arm circumference (MUAC) use more widely accessible among caregivers and community health workers (CHWs) is an important next step in further decentralizing SAM care and increasing program coverage, including the ability of CHWs to treat uncomplicated SAM in community settings. METHODS:We conducted a systematic review to summarize published and operational evidence published since 2000 describing the use of MUAC for detection and diagnosis of SAM in children aged 6-59 months by caregivers and CHWs, and of management of uncomplicated SAM by CHWs, all outside of formal health care settings. We screened 1,072 records, selected 43 records for full-text screening, and identified 22 studies that met our eligibility criteria. We extracted data on a number of items, including study design, strengths, and weaknesses; intervention and control; and key findings and operational lessons. We then synthesized the qualitative findings to inform our conclusions. The issue of treating children classified as SAM based on low weight-for-height, rather than MUAC, at household level, is not addressed in this review. FINDINGS:We found evidence that caregivers are able to use MUAC to detect SAM in their children with minimal risk and many potential benefits to early case detection and coverage. We also found evidence that CHWs are able to correctly use MUAC for SAM detection and diagnosis and to provide a high quality of care in the treatment of uncomplicated SAM when training, supervision, and motivation are adequate. However, the number of published research studies was small, their geographic scope was narrow, and most described intensive, small-scale interventions; thus, findings are not currently generalizable to public-sector health care systems. CONCLUSIONS:Scaling up the use of MUAC by caregivers and CHWs to detect SAM in household and community settings is a promising step toward improving the coverage of SAM detection, diagnosis, and treatment. Further research on scalability, applicability across a wider range of contexts, coverage impact, and cost is needed. The primary use of MUAC for SAM detection should also be explored where appropriate.

Project description:Debate for a greater role of mid-upper arm circumference (MUAC) measures in nutritional programming continues, but a shift from therapeutic feeding programs admitting children using MUAC and/or weight-for-height Z (WHZ) to a new model admitting children using MUAC only remains complicated by limited information regarding the clinical profile and response to treatment of children selected by MUAC vs. WHZ. To broaden our understanding of how children identified for therapeutic feeding by MUAC and/or WHZ may differ, we aimed to investigate differences between children identified for therapeutic feeding by MUAC and/or WHZ in terms of demographic, anthropometric, clinical, and laboratory and treatment response characteristics.Using secondary data from a randomized trial in rural Niger among children with uncomplicated severe acute malnutrition, we compared children that would be admitted to a therapeutic feeding program that used a single anthropometric criterion of MUAC< 115 mm vs. children that are admitted under current admission criteria (WHZ< -3 and/or MUAC< 115 mm) but would be excluded from a program that used a single MUAC< 115 mm admission criterion. We assessed differences between groups using multivariate regression, employing linear regression for continuous outcomes and log-binomial regression for dichotomous outcomes.We found no difference in terms of clinical and laboratory characteristics and discharge outcomes evaluated between children that would be included in a MUAC< 115 mm therapeutic feeding program vs. children that are currently eligible for therapeutic feeding but would be excluded from a MUAC-only program.A single anthropometric admission criterion of MUAC < 115 mm did not differentiate well between children in terms of clinical or laboratory measures or program outcomes in this context. If nutritional programming is to use a single MUAC-based criterion for admission to treatment, further research and program experience can help to identify the most appropriate criterion in a broad range of contexts to target children in most urgent need of treatment.

Project description:BACKGROUND/OBJECTIVES:Accurate, early identification of acutely malnourished children has the potential to reduce related child morbidity and mortality. The current World Health Organisation (WHO) guidelines classify non-oedematous acute malnutrition among children under five using Mid-Upper Arm Circumference (MUAC) or Weight-for-Height Z-score (WHZ). However, there is ongoing debate regarding the use of current MUAC cut-offs. This study investigates the diagnostic performance of MUAC to identify children aged 6-24 months with global (GAM) or severe acute malnutrition (SAM). SUBJECTS/METHODS:Cross-sectional, secondary data from a community sample of children aged 6-24 months in Niger were used for this study. Children with complete weight, height and MUAC data and without clinical oedema were included. Using WHO guidelines for GAM (WHZ < -2, MUAC < 12.5 cm) and SAM (WHZ < -3, MUAC < 11.5 cm), the sensitivity (Se), specificity (Sp), predictive values, Youden Index and Receiver Operating Characteristic (ROC) curves were calculated for MUAC when compared with the WHZ reference criterion. RESULTS:Of 1161 children, 23.3% were diagnosed with GAM using WHZ, and 4.4% with SAM. Using current WHO cut-offs, the Se of MUAC to identify GAM was greater than for SAM (79 vs. 57%), yet the Sp was lower (84 vs. 97%). From inspection of the ROC curve and Youden Index, Se and Sp were maximised for MUAC < 12.5 cm to identify GAM (Se 79%, Sp 84%), and MUAC < 12.0 cm to identify SAM (Se 88%, Sp 81%). CONCLUSIONS:The current MUAC cut-off to identify GAM should continue to be used, but when screening for SAM, a higher cut-off could improve case identification. Community screening for SAM could use MUAC < 12.0 cm followed by appropriate treatment based on either MUAC < 11.5 cm or WHZ < -3, as in current practice. While the practicalities of implementation must be considered, the higher SAM MUAC cut-off would maximise early case-finding of high-risk acutely malnourished children.

Project description:BackgroundCommunity health workers (CHWs) are recommended to screen for acute malnutrition in the community by assessing mid-upper arm circumference (MUAC) on children between 6 and 59 months of age. MUAC is a simple screening tool that has been shown to be a better predictor of mortality in acutely malnourished children than other practicable anthropometric indicators. This study compared, under program conditions, mothers and CHWs in screening for severe acute malnutrition (SAM) by color-banded MUAC tapes.MethodsThis pragmatic interventional, non-randomized efficacy study took place in two health zones of Niger's Mirriah District from May 2013 to April 2014. Mothers in Dogo (Mothers Zone) and CHWs in Takieta (CHWs Zone) were trained to screen for malnutrition by MUAC color-coded class and check for edema. Exhaustive coverage surveys were conducted quarterly, and relevant data collected routinely in the health and nutrition program. An efficacy and cost analysis of each screening strategy was performed.ResultsA total of 12,893 mothers and caretakers were trained in the Mothers Zone and 36 CHWs in the CHWs Zone, and point coverage was similar in both zones at the end of the study (35.14 % Mothers Zone vs 32.35 % CHWs Zone, p = 0.9484). In the Mothers Zone, there was a higher rate of MUAC agreement (75.4 % vs 40.1 %, p <0.0001) and earlier detection of cases, with median MUAC at admission for those enrolled by MUAC <115 mm estimated to be 1.6 mm higher using a smoothed bootstrap procedure. Children in the Mothers Zone were much less likely to require inpatient care, both at admission and during treatment, with the most pronounced difference at admission for those enrolled by MUAC < 115 mm (risk ratio = 0.09 [95 % CI 0.03; 0.25], p < 0.0001). Training mothers required higher up-front costs, but overall costs for the year were much lower ($8,600 USD vs $21,980 USD.).ConclusionsMothers were not inferior to CHWs in screening for malnutrition at a substantially lower cost. Children in the Mothers Zone were admitted at an earlier stage of SAM and required fewer hospitalizations. Making mothers the focal point of screening strategies should be included in malnutrition treatment programs.Trial registrationThe trial is registered with clinicaltrials.gov (Trial number NCT01863394).

Dataset Information

The optimal mid-upper-arm circumference cutoffs to screen severe acute malnutrition in Vietnamese children.

Publications

The optimal mid-upper-arm circumference cutoffs to screen severe acute malnutrition in Vietnamese children.

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