Severely malnourished children with a low weight-for-height have similar mortality to those with a low mid-upper-arm-circumference: II. Systematic literature review and meta-analysis.
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ABSTRACT:
SUBMITTER: Grellety E
PROVIDER: S-EPMC6138903 | biostudies-other | 2018 Sep
REPOSITORIES: biostudies-other
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Severely malnourished children with a low weight-for-height have similar mortality to those with a low mid-upper-arm-circumference: II. Systematic literature review and meta-analysis.
Grellety Emmanuel E Golden Michael H MH
Nutrition journal 20180915 1
<h4>Background</h4>The WHO recommended criteria for diagnosis of sever acute malnutrition (SAM) are weight-for-height/length Z-score (WHZ) of <- 3Z of the WHO<sub>2006</sub> 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 ...[more]
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Project description: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.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.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.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.
| S-EPMC6138885 | biostudies-other
Project description: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.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.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.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.
| S-EPMC6138898 | biostudies-other
Project description:ObjectiveTo evaluate the performance of mid-upper arm circumference (MUAC) to identify thinness in the late adolescence period (aged 15-19 years) in Ethiopia.DesignWe conducted a school-based cross-sectional study. The receiver operating characteristics curve was used to examine the validity of MUAC compared with BMI Z-score to identify adolescents with thinness (BMI Z-score <-2 sd).SettingsFifteen high schools (grade 9-12) located in Addis Ababa, Ethiopia.ParticipantsA total of 851 adolescent (456 males and 395 females) were included in the study.ResultsThe prevalence of thinness and severe thinness among high-school adolescents in Addis Ababa was 9·5 % (95 % CI 7·7, 11·7 %). The overall AUC for MUAC against BMI Z-score <-2 SD was 0·91 (95 % CI 0·88, 0·93). The optimal MUAC cut-offs to identify thinness were 23·3 cm for males and 22·6 cm for females. These cut-off points give high sensitivity and specificity for both males (a sensitivity of 87·9 % and a specificity of 75·9 %) and females (a sensitivity of 100 % and a specificity 88·2 %).ConclusionsMUAC has a comparable level of accuracy with BMI Z-score to identify thinness in adolescents aged 15-19 years. Hence, MUAC could be used as an alternative tool for surveillance and screening of thinness among adolescents aged 15-19 years. The optimum cut-off proposed by this study may incorrectly include a large number of adolescents when used in a relatively well-nourished population. In this situation, it would be necessary to choose a cut-off with greater positive predictive value.
| S-EPMC10195468 | biostudies-literature
Project description:The authors examined the relationship of maternal anthropometry to fetal growth and birth weight among 1005 human immunodeficiency virus (HIV)-infected women in Lilongwe, Malawi, who consented to enrollment in the Breastfeeding, Antiretrovirals, and Nutrition Study (www.thebanstudy.org). Anthropometric assessments of mid-upper arm circumference (MUAC), arm muscle area (AMA), and arm fat area (AFA) were collected at the baseline visit between 12 and 30 weeks' gestation and in up to 4 follow-up prenatal visits. In longitudinal analysis, fundal height increased monotonically at an estimated rate of 0.92 cm/wk and was positively and negatively associated with AMA and AFA, respectively. These latter relationships varied over weeks of follow-up. Baseline MUAC, AMA, and AFA were positively associated with birth weight (MUAC: 31.84 g/cm(2), 95% confidence interval [CI], 22.18-41.49 [P < .01]; AMA: 6.88 g/cm(2), 95% CI, 2.51-11.26 [P < .01]; AFA: 6.97 g/cm(2), 95% CI, 3.53-10.41 [P < .01]). In addition, MUAC and AMA were both associated with decreased odds for low birth weight (LBW; <2500 g) (MUAC: odds ratio [OR] = 0.85, 95% CI, 0.77-0.94 [P < .01]; AMA: OR = 0.95, 95% CI, 0.91-0.99 [P < .05]). These findings support the use of MUAC as an efficient, cost-effective screening tool for LBW in HIV-infected women, as in HIV-uninfected women.
| S-EPMC3753683 | biostudies-literature
Project description:BACKGROUND: Low Birth Weight (LBW) is one of the major risk factor for death in early life. However, little is known about predictors of LBW in sub-Saharan Africa. Therefore, the aim of this study was to measure the incidence and determinants of LBW in a rural population of Ethiopia. METHODS: An observational cohort study on pregnant women was conducted from December 2009 to November 2010. During the study period 1295 live birth were registered and the weights of 956 children were measured within 24 hours after birth. Socio-demographic, economic, maternal and organizational factors were considered as a predicators of LBW, defined as birth weight below 2500g. Logistic regression was used to analyze the data, odds ratio (OR) and confidence intervals (CI) are reported. RESULT: The incidence of LBW was 28.3%. It is significantly associated with poverty [OR 2.1; 95% CI: 1.42, 3.05], maternal Mid Upper Arm Circumference (MUAC) less than 23 cm [OR 1.6; 95% CI: 1.19, 2.19], not attending ANC [OR 1.6; 95% CI: 1.12, 2.28], mother's experience of physical violence during pregnancy [OR 1.7; 95% CI: 1.12, 2.48], and longer time to walk to health facility [OR 1.6; 95% CI: 1.11, 2.40]. CONCLUSION AND RECOMMENDATION: The incidence of LBW was high in Kersa. Babies born to women who were poor, undernourished, experienced physical violence during pregnancy and who had poor access to health services were more likely to be LBW in this part of the country. In this largely poor community where ANC coverage is low, to reduce the incidence of LBW, it is essential to improve access for maternal health care. The involvement of husbands and the community at large to seek collective action on LBW is essential.
| S-EPMC3386987 | biostudies-other
Project description:ObjectiveIn this secondary analysis of data from an intervention trial, we assessed the performance of Mid Upper Arm Circumference (MUAC) as a predictor of mortality in children aged 6-59 months from Delhi, India, one year after their initial MUAC measurements were taken. Additionally, we assessed MUAC as an absolute value and MUAC z-scores as predictors of risk of mortality.MethodsIn the trial, children were screened using MUAC prior to referral to the study clinic. These children were revisited a year later to ascertain their vital status. Baseline MUAC and MUAC z-scores were used to categorize children as severely (MUAC <115 mm, MUAC z-score <-3SD) or moderately (MUAC 115 to <125 mm, MUAC z-score <-2SD) malnourished. The proportion of malnutrition, risk of mortality, relative risk estimates, positive predictive value and area under the curve (AUC) by MUAC and MUAC z-scores were calculated.ResultsIn the resurvey, the first 36159 children of the 48635 in the initial survey were contacted. Of these, vital status of 34060 (94.2%) was available. The proportion of severe malnutrition by MUAC (<115 mm) was 0.5% with an associated mortality of 4.7% over a one year period and an attributable mortality of 13% while the proportion of the severe malnutrition by MUAC z-score (<-3SDwas 0.9% with an associated mortality of 2.2%.ConclusionsMUAC is a significant predictor of subsequent mortality in under-five children. In settings where height measurement is not feasible, MUAC can be used as a screening tool for identifying severely malnourished children for management.
| S-EPMC5983511 | biostudies-literature
Project description:Random upper arm circumference (RUAC) is frequently used for malnutrition screening among children aged 6-59 months. However, inadequate evidence exists regarding its agreement with mid upper arm circumference (MUAC). This study examined diagnostic concordance between RUAC and standard MUAC measurements and tested RUAC's ability for screening malnutrition among children aged 6-59 months. A cross-sectional study was conducted from April 30 to May 30/2015 in Ethiopia. Data were taken from a sample of 819 children aged 6-59 months with a simple random sampling technique. The data were analyzed using SPSS version 22 software. The kappa agreement level, sensitivity, and specificity were calculated. The receiver operating curve was prepared to determine the optimal cutoff RUAC for the sensitivity and specificity. With National Center for Health Statistics (NCHS) cutoff (12 cm), the performance of RUAC measurements in terms of sensitivity was low (44%). The kappa agreement level between the two measurements was 0.551 (p value < 0.001). With the new WHO cutoff (12.5 cm), however, RUAC was improved in validity (sensitivity 81%), specificity 96.9%, and kappa agreement level (K = 0.807; p < 0.001).
| S-EPMC8032539 | biostudies-literature
Project description:ObjectiveTo investigate the association between mid-upper arm circumference (MUAC), calf circumference (CC) and all-cause mortality in a Chinese population.DesignProspective cohort study.SettingEight long-term care facilities in central Taiwan.ParticipantsA total of 329 residents age 60 years and older (median 79.0 years, range 60-101; 139 men, 190 women) were enrolled.MethodsAnthropometrics and metabolic parameters were measured at the time of enrolment to the study. Mean MUAC and CC were 24.2±3.4 cm and 27.5±4.3 cm, respectively. Mortality data were obtained from the Department of Health in Taiwan.Main outcome measureTo identify the association between all-cause mortality and MUAC or CC.ResultsThere were 255 deaths during the 7-year follow-up period. After adjusting for age, sex, cigarette smoking, betel nut chewing, alcohol use, Karnofsky Performance Status Scale score, serum albumin level, hypertension and diabetes mellitus, subjects in the highest tertile of MUAC (27.8±2.2 cm) and CC (32.1±2.6 cm) had a significantly lower mortality rate than did subjects in the lowest tertile (MUAC 20.6±1.7 cm; CC 22.8±1.9 cm). The adjusted HR for all-cause mortality in the highest versus lowest MUAC tertile was 0.64 (95% CI 0.45 to 0.90). The adjusted HR for all-cause mortality in the highest versus lowest CC tertile was 0.51 (95% CI 0.35 to 0.74).ConclusionsMUAC and CC are negative predictors for all-cause mortality in older Chinese adults living in long-term care facilities. Participants with higher MUAC and CC had lower all-cause mortality.
| S-EPMC5942455 | biostudies-literature
Project description: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.
| S-EPMC7109525 | biostudies-literature
Project description:Background Three different diagnostic criteria are used to identify children aged 6 to 59?months with acute malnutrition: weight-for-height (WHZ), middle upper arm circumference (MUAC) and bilateral pitting oedema. Prevalence of malnutrition from surveys is among the most-used decision support data, however not all diagnostic criteria are used to calculate need, creating a mismatch between programme planning and implementation. With this paper, we investigate if such discrepancies are observed in Mozambique. Methods Population-based nutritional anthropometric surveys from 45 districts in Mozambique conducted by the Technical Secretariat for Food Security and Nutrition (SETSAN) and UNICEF between 2017 and 2019 were analysed. We used Cohen’s kappa coefficient to measure inter-rater agreement between WHZ and MUAC, Spearman’s rank-order coefficient to assess the correlation, binary logistic regression to investigate factors influencing WHZ and MUAC diagnostic classification. We compared acute malnutrition caseload estimates by WHZ, MUAC and oedema to caseloads from combined prevalence estimates. Results WHZ and MUAC rarely agree on their diagnostic classification (??=?0.353, ??<?0.001) and results did not vary by province. We found positive correlation between WHZ and MUAC (rho?=?0.593, ??<?0.0001). Binary logistic regression explained 3.1% of variation in WHZ and 12.3% in the MUAC model. Girls (AOR?=?1.6, ??<?0.0001), children <?24?months (AOR?=?5.3, ? <?0.0001) and stunted children (AOR?=?3.5, ??<?0.0001) influenced the MUAC classification. In the WHZ model, children <?24?months (AOR?=?2.4, ??<?0.0001) and stunted children (AOR?=?1.7, ??<?0.0001) influenced the classification, sex had no effect. Caseload calculations of global acute malnutrition by WHZ and/oedema-only and by MUAC and/oedema-only yielded less children than caseload calculations using the combined prevalence estimates. Similarly, caseload calculations for SAM by WHZ and/oedema-only and SAM by MUAC and/oedema-only yielded less children than the respective combined prevalence calculations. Conclusions Given the discrepancy in diagnostic classification between WHZ and MUAC in Mozambique, using either one alone for calculating burden underestimates the real number of children in need of treatment and negatively affects nutrition programme planning. We recommend that use of the combined prevalence estimates, based on the three diagnostic criteria of WHZ, MUAC and oedema, be officially adopted. Further analysis is needed to detail the programmatic impact of this change.
| S-EPMC7542767 | biostudies-literature