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Key questions regarding MUAC only programming - towards a research agenda

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Mark Myatt

Consultant Epideomiologist

Frequent user

5 Oct 2015, 11:41

I have started this thread in the hope that we can come together there to work out what we need to do to move forward with an informed debate on issues around MUAC-only programming and the appropriate treatment of children with MUAC > 115 mm and WHZ < -3.

I will start the ball rolling ...

(1) I think it may be useful to look the issue of MUAC and WHZ with additional data on body shape. Available evidence for WHZ in children and BMI in adults suggest that both are strongly influenced by body shape so that healthy individuals in some populations (notably the Sahel and Horn of Africa bust also in South and South-East Asian populations and Australasia) may be classified as being wasted and in need of nutritional support. We can address this data from cross-sectional surveys of standard design collecting age, sex, weight, height, MUAC, sitting height, chest circumference, and other measures to be decided. We might want to do quite a few of these.

(2) We need to decide the intensity of treatment required by those children with WHZ < -3 with a MUAC > 115 mm (WHZ + / MUAC -). This is a similar situation to what to do with the opposite discordancy (i.e. WHZ- / MUAC +) in young and / or stunted children that faced CTC / CMAM programming about ten years ago. In that case we had the luck of stumbling upon a natural experiment that demonstrated that the children in question did rather badly in terms of weight change, MUAC change, and survival when admitted to SFP compared to when admitted to OTP. The current question on what to do with WHZ + / MUAC - children could, I think, be answered with a small trial in which these children are admitted to a lower intensity program such as TSFP and followed closely. I think we might need two discordant arms. One with discordant children selected in clinics and treated for (e.g.) infection and another with children selected in the community. I think the outcomes of interest will be death in a 3 month follow-up and MUAC < 115 mm in a 3 month follow-up (i.e. so we don't end-up just delaying essential care).

(3) MUAC only programming is much more than just admitting using MUAC (and oedema). Questions exist around (1) the ability to use MUAC to decide discharge particularly around the lowest MUAC threshold that can safely be used, (2) How well MUAC respond to treatment and to episodes of illness during treatment and whether it is practical and safe to use MUAC to monitor response to treatment, (3) what is being gained (i.e. fat or muscle) as MUAC changes in response to treatment, (4) How well does MUAC respond to treatment in young and stunted children.

I think that the questions in (1) need fieldwork (old vanilla SMART surveys will not help here) and the questions in (2) need a properly design study that is designed to be replicated in many settings (analysis of existing program data will not help here). The questions in (3) can (in part) be answered using clinical data from MUAC only programs.

This is just my list of question / methods. I offer it as a starting point and not to close down discussion. Please feel free to add your own ideas and to offer constructive criticism.

While I am doing taking the initiative ... I think we might want to think of an agenda for this thread so that we move from questions / methods to protocols and onto funding, fieldwork, analysis, articles, &c.

Let us stop bickering and move forward on these important issues.


Frequent user

6 Oct 2015, 14:43

Thanks Mark to open this discussion.

A new element: Mark Manary’s group just published a trial from Sierra Leone comparing an integrated protocol with a standard one. The tested integrated protocol gives the same treatment to SAM and MAM children with different RUTF doses in relation to MUAC. See:

Maust A, Koroma AS, Abla C, Molokwu N, Ryan KN, Singh L, Manary MJ. Severe and Moderate Acute Malnutrition Can Be Successfully Managed with an Integrated Protocol in Sierra Leone. J Nutr. 2015 Sep 30. pii: jn214957

The integrated protocol tested by this group is actually a MUAC only protocol.

The approach is elegant, it makes sense, I am sure it will attract attention by its simplicity and its impact. The conclusion is that the integrated MUAC based protocol works better. I am sure this is the way forward, and this kind protocol, maybe with some variations in the RUTF dosage or type of product, and also with detection of MAM/SAM by mothers, is likely to become the “standard” in the few years to come, especially if repeated in other settings and showing similar results.

So this paper reinforces the impression that MUAC-only programmes is the way to go. However, it does not directly address the question of relevance of WFH as additional criteria as both groups differ in other aspects than just patient selection. But we can build on that to propose a protocol which can directly test whether adding WFH is of any use. I would see something like:

Group 1: integrated MUAC only protocol as proposed in the Sierra Leone paper

MUAC < 115 RUTF 200 kcal/kg/day
MUAC >115 < 125 : RUTF 75 kcal/day

Group 2: standard approach with WFH

Patients selected by MUAC < 125 mm

If WFH > -3 same protocol as above
MUAC < 115 RUTF 200 kcal/kg/day
MUAC >115 < 125 : RUTF 75 kcal/day

If WFH < -3, RUTF 200 kcal/kg/day till WFH > -2

Main outcome: ideally, mortality. Else recovery at 3 mo assessed by MUAC > 125 mm.

There should be a cost analysis, as the WFH protocol will be more expensive to run (more training, more measuring equipment).

We can also attempt to fine tune the design. As described above, group 2 will receive slightly more RUTF than group 1 and can get higher weight gains just for that. We can increase the dose in group 1 in the 115-120 mm to balance the RUTF dose between the two groups.

Mark Myatt

Consultant Epideomiologist

Frequent user

7 Oct 2015, 09:38

In this program design (as you have it above) we would use only MUAC for screening / case-finding in the community and at clinics. WHZ is used only for deciding clinical pathways inside the program:

  MUAC < 125 and WHZ < -3    High intensity
  MUAC < 125 and WHZ < -2    Low intensity

I think this is a good idea as we keep the advantages of MUAC while not finding and recruiting only very few low WHZ children.

I think we do need to consider practicability. Since W/H is only possible at some clinic sites (and CMAM scale-up aims at all clinic sites) we would have to have a program that, in some centres, admitted and decided clinical pathways using only MUAC.

I think that MUAC > 125 mm can be used as the discharge criteria. Data from Malawi (in press) suggest that this is safe. It seems likely that we could monitor response to treatment using MUAC. There is some evidence (in press) showing this may be possible but this would need operationalisation (i.e. we think it can be done but have to work out how to do it).

Sameh Al-Awlaqi

Public Health and Nutrition Consultant

Normal user

14 Feb 2019, 14:24

Hello folks,

Here is a very interesting piece of work by Grellety E and Golden MH:




Sameh Al-Awlaqi

Public Health and Nutrition Consultant

Normal user

14 Feb 2019, 14:29

Not sure if the previous link worked. Below is a new one just in case:

and the title is:

"Severely malnourished children with a low weight-for-height have a higher mortality than those with a low mid-upper-arm-circumference: I. Empirical data demonstrates Simpson’s paradox"

For the attention of ENN colleagues: I tried to use the [url] thingy for the previous link but it did not work. Thoughts appreciated. Cheers, Sam


Frequent user

14 Feb 2019, 16:36

Dear Sameh,

Grellety and Golden have a point in saying that MUAC < 115 mm fails to identify all children with a high risk of death. This has been known for years. But there are more efficient ways than using weight-for-height to detect these additional high risk children, either to increase the MUAC threshold (1) or to use weight-for-age (2) in addition to MUAC. None of these options are examined in the Grellety and Golden paper.

This paper is based on samples of children selected for treatment programmes. This approach is unreliable to make statements about community screening as this type of samples is subject to the Berksonian bias, i.e. these samples are not representative of what happens in the community (3).

1. Briend A, Maire B, Fontaine O, Garenne M. Mid-upper arm circumference and weight-for-height to identify high-risk malnourished under-five children. Matern Child Nutr. 2012;8:130–3.
2. Myatt M, Khara T, Dolan C, Garenne M, Briend A. Improving screening for malnourished children at high risk of death: a study of children aged 6-59 months in rural Senegal. Public Health Nutr. 2018;1–10.
3. Berkson J. Limitations of the application of fourfold table analysis to hospital data. Int J Epidemiol. 2014;43:511–5.

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