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Variance in number of children admitted to OTP using MUAC < 11.cm and WHZ <-3SD

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 11 replies.

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Daniel Muhinja

Normal user

3 Jul 2010, 14:31

Since 2008, we have been screening and admitting children to outpatient therapeutic program using MUAC 11.0; in June 2009 we adopted MUAC< 11.5 as per the new WHO guidelines. However, we are expected to begin making admissions using WH Scores and MUAC. Before we begin implementation, I would be glad to know if there will be significant increase in OTP caseload after adoption of WHZ scores. Between MUAC and WHZ which one captures more children to OTP? am worried we could just require more staff due to extra workload of measuring children without any significant increase in caseload.* note this is among pastoral communities in Kenya

Mark Myatt

Brixton Health

Frequent user

3 Jul 2010, 22:29

My STRONG ADVICE is to NOT use WHZ for admission (or for anything at all). Experiences with programs that use MUAC have repeatedly shown that programs that use W/H and MUAC for case-finding, referral, and admission tend to have low coverage and low impact. This has been repeatedly observed over the past decade and was even clear in the CTC research program. Unless you are extremely careful, the effect on your case-load of introducing WHZ will be to reduce case-load. If we are to pretend that there are no practical implications of using WHZ and that MUAC with WHZ may capture more children. How many more is difficult to answer since W/H is strongly effected by body shape. Amongst sedentary agrarians or populations living at high altitudes or populations living at low temperatures the effect of adding WHZ will be very small. Amongst pastoralists with high milk consumption and in populations living in high temperatures (e.g. Afar) then the effect may be very large. Amongst Somali pastoralists you may see a 500% increase in case-numbers. Note that many of these cases are not "true cases" but older children with long legs. I think the most likely effect will be to reduce case-load through "the problem of rejected referrals". So ... be very careful about how you deal with rejected referalls. See: http://www.ncbi.nlm.nih.gov/pubmed/20002705 http://www.ncbi.nlm.nih.gov/pubmed/19085192 For more information. I hope this helps.

Anonymous 585

CMN

Normal user

6 Apr 2011, 06:23

Hi, I would like to come back the post as there has been an article in the September 2010 FEX on the programming in Cambodia using both WHZ and MUAC for the same reasons. I see the point of not including W/H in the active screening process, but think that W/H should be an admission criteria for children presenting themselves directly to the centers, either because of sickness or other reasons. Or should admission criteria be really restricted to MUAC only and such children, if MUAC above 11.5 but W/H below -3, be turned away? Are there new studies now clearly indicating mortality risk of MUAC versus W/H under WHO standards. What I have found in a quick research all refers back to NCHS. As well I would like to know if the studies mentioned elsewhere looking at MUAC only for discharge have already lead to some results? Sorry, a lot of questions.

Anonymous 118

Nutrition Advisor

Normal user

6 Apr 2011, 17:50

In our own programs, we use MUAC and/or WHZ at the community and facility level. If a child meets either or both, he is admitted, so children who don't meet both are not excluded. If it's too complicated to have WHZ at the community level, it seems this could still apply using MUAC and/or WHZ at the facility level.

Mark Myatt

Brixton Health

Frequent user

6 Apr 2011, 20:06

The issue is one of keeping W/H in its proper place. What has happened in some CMAM programs is that W/H takes over because it is seen (very wrongly) as the superior measure. This results in cases with MUAC < 115 mm being sent away because they have a WHZ > -3. This is very damaging to coverage. This is an unintended consequence. You add W/H because you don't want to exclude children but the negative effect that this has on coverage means that you effectively exclude many more children. Be careful. A note on "sickness" : Peripheral muscle is preferentially catabolised during infection. This means that most cases of wasting due to infection will have low MUAC. A note on body-shape : W/H is strongly effected by body shape so WHZ < 3 means different things in different places. MUAC is more universal. Discordancy usually occurs when you are working in populations with low SSR where the prognostic value of W/Z is lowest. Studies of mortality risk are no longer possible since we now have very efficacious, very safe, and high coverage treatment protocol. A study would require (e.g.) finding children with MUAC < 115 and / or W/H < -3 and doing nothing. We can't do that. We have to work with the data that we have. We could, I suppose, get the datasets and recalculate WHZ using WGS and redo the analysis. I wonder of the data are available for this. I know of no study of MUAC for discharge that has presented high quality follow-up data. All indications are that MUAC > 124 mmm is probably a safe discharge threshold.

André BRIEND

Frequent user

7 Apr 2011, 06:56

This suggestion of using WFH and / or MUAC comes back again and again. It is based on the assumption that by using WFH you pick up some high risk children missed by WFH as both identify different children. To test whether this approach makes sense, I went back with former colleagues to data we collected in rural Senegal in the 80's on the relationship between anthropometry and mortality based on a 6 month community follow up with very few children being treated. In those days, referral to the capital, 200 km away was the best we could propose. We found in this reanalysis that the MUAC ROC curve was constantly above the WFH one, even when the new WHO standard was used. We then plotted the points WFH < -3 and/or MUAC < 115 mm. These two points were both below the MUAC ROC curve. Using WFH < -3 or MUAC < 115 mm indeed increased sensitivity, but this was at the expense of specficity. MUAC < 120 mm had about the same specificity level as WFH < -3 or MUAC < 115 but had a higher sensitivity. Conclusion: using both diagnostic criteria is more complicated and no more effective than MUAC alone. If a higher sensitivity is needed, better use a higher MUAC cut off and forget WFH. This