Key questions regarding MUAC only programming - towards a research agenda

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.

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).