MUAC tapes

Here is an article from 1971 describing the use of MUAC (MUAC/H) in the Biafran Crisis of the last 1960's. Jelliffe described the use of MUAC in the late 1950's and had a purpose designed fibre-glass tape in 1966. Normative MUAC/A thresholds were developed from Polish data (healthy children) by Napoleon Wolanski in the early 1960's and these "year constant standards" were used by Jelliffe in 1966 and 1967 to create threshold at the 10th percentile. I can search out references if needed. Adnam Shakir - an Iraqi paediatrician - and David Morley used tapes made from old x-rays films in (I think) the early 1970's. This type of MUAC tape is also known as the "Shakir Strip". It had colour bands like the modern tape (this was I think Shakir's innovation) and was used (as we do now) by CHWs to do case-finding in the community. This was but was a wrap-around tape rather than an insertion tape as was the tape described by Jelliffe in 1966. I do not have an orginal Shakir Strip in my collection but I do have one from HelpAge International (see this photo).

This image: is taken from: Jelliffe DB (1966), The assessment of the nutritional status of the community, WHO Monograp No. 53 Zerfaz (1975) developed a variety of insertion tapes. Some of these tapes are of novel design allowing (e.g.) the tape to be used as a survey data collection instrument and growth monitoring. The motivation for the development of the insertion was to simplify use and to reduce error. Zerfaz can be rightly called the co-inventor of the modern MUAC strap which is an instertion tape (Zerfaz) with colour banding (Shakir).

Some additional information. The Shakir tape, as far as I remember, was described for the first time in a letter to the Lancet. I think the reference is: Shakir A, Morley D. Letter: Measuring malnutrition. Lancet. 1974 Apr 20;1(7860):758-9. (I have no access to this reference and cannot check it). At that time, the idea was to use MUAC to estimate the degree of malnutrition on the (wrong) assumption (made by Jelliffe a few years earlier) that MUAC does not grow much between 12 to 60 months of age. So it was thought, MUAC could be used to assess nutritional status even when age was not known. At that time, the cut off were much higher than today, I think the original Shakir strip had 125 and 140 mm as limits between different colours. These cut off were chosen to fit with the classifications of malnutrition based on weight-for-age used at that time. Zerfas did introduce the insertion tape in 1975, a really brilliant idea. A few years later, Bairagi from Bangladesh was the first to show with ROC curves that MUAC, without correction for age or height was at least as good as good as other indicators to assess the risk of death. See: Bairagi R. On validity of some anthropometric indicators as predictors of mortality. Am J Clin Nutr. 1981 Nov;34(11):2592-4. This finding was later confirmed by many others (including myself) in other settings and led to the use of MUAC to detect children with a high risk of death in need of treatment. Cut-off were lowered as the objective changed from measuring malnutrition to identify high risk children. Cut off of 110 mm and more recently to 115 mm were then adopted for CMAM programmes.

The circumferential measure most used as an alternative birthweight or birthweight for gestational age is neonatal chest circumference using the nipples as a locator. I have a slight involvement with a project in West Africa using a knotted string used by TBAs to refer low CC neonates to clinics.