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Discharge criteria when using MUAC for admission

This question was posted the Management of wasting/acute malnutrition forum area and has 3 replies.

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Anonymous 3651

Nutrition Specialist/UNICEF

Normal user

19 Apr 2016, 11:39

Ethiopia has been using the old cut off of 110 mm (11cm) for admission of children with SAM and the discharge was based on target gain as most of the facilities (health posts) don't do height/length measurement.

Now we are revising our guideline for management of acute malnutrition as per latest global recommendation (WHO 2013). It is stated that the discharge of children admitted with MUAC should be once they reach 125 mm (12.5 cm) and this would take long time and means children would stay in the program for more than 8 weeks which is the country uses now. Is there any specific recommendation or experience on this. What would be the implication? Is there a better and successful way....? What if a TSFP program is in the area? Can the kids be referred there?

Mark Myatt

Frequent user

19 Apr 2016, 13:15

I assume that you mean admission below 115 mm and discharge above 125 mm.

Length of stay in the program is influenced by the discharge threshold but is also influenced by:

(1) Severity of wasting at admission. Admission at or close to the admission threshold is associated with short lengths of stay, high cure rates, and high coverage.

(2) Compliance by the provider. Programs that can provide the full CTC/CMAM protocol without RUTF stockouts and with good monitoring so that (e.g.) second line antimicrobials are given when indicated tend to have shorter lengths of say,

(3) Compliance by the beneficiary. You might encourage this by positive deviant peer-educators. RUTF sharing is often a problem. Counselling can reduce sharing. A protection ration can also work.

Addressing these issues will shorten lengths of stay.

Having longer lengths of stay can increase crowding at centres. This can be controlled by moving from weekly to two-weekly visits for recovering cases (i.e. those cases not meeting admission criteria and discharge criteria ... 115 <= MUAC < 125).

Having longer lengths of stay can increase program costs. This can be addressed by reducing RUTF rations for recovering children (work from Sierra Leone shows this to be safe).

If you have a well-functioning TSFP and you have a good interface between TSFP and OTP (i.e. so that no referred case gets lost and relapsing cases get returned to OTP quickly) then referral of recovering cases (e.g. MUAC >= 115 mm) can be done.

I hope this is of some use.

Shewangizaw SA Ashenafi

Nutrition program manager

Normal user

19 Apr 2016, 13:53

Hello Dear’s
As you said Ethiopia was using discharge target weight for all under-five children admitted with MUAC but currently research’s conducted in Africa including Ethiopia, indicates there is no significant difference between MUAC and weight gain while the child is getting appropriate treatments, This study demonstrates a close relationship between MUAC and weight change during recovery from SAM under both research and operational field conditions. Furthermore, changes in both MUAC and weight are observed to occur similarly and rapidly during episodes of illness occurring during treatment with no lag effect on the part of MUAC. This presents the possibility for children undergoing outpatient treatment for SAM to be monitored using MUAC as an alternative to weight. Further research would be required to develop a tool which can be deployed safely and enable MUAC to be used as the sole anthropocentric measure for admission, monitoring of recovery and discharge. Even though this study doesn’t recommend MUAC as means of discharge , as the MUAC and weight change are not significant still we can use MUAC as discharge criteria which is MUAC > 12.5CM for two consecutive weeks. Currently we are using MUAC as discharge criteria in south Sudan. http://archpublichealth.biomedcentral.com/articles/10.1186/s13690-015-0103-y
For further reference you can use the link above.
I think it can help.
Thanks

Paul

Technical expert

5 May 2016, 18:08

Hi,
The article referred to above does not make any recommendation regarding MUAC or weight based discharge criteria but merely looks at the relationship between MUAC and weight changes during recovery.

A soon to be published article in the same journal reviews the safety and practicability of MUAC discharge > 12.5cm.

In short the more malnourished the child is on admission then the longer it will take to recover. This time can be shortened by investing in good case finding and early admission to treatment. The median length of stay for all cases we found in the Malawian context was approximately 49 days which is not so different from other criteria and other contexts.

As a rough approximation, a child with a MUAC > 11cm will recover in a median time of about 6 weeks while if they have a MUAC <10cm it will be approximately double that.

In terms of 'success' it depends what you mean. The MUAC > 12.5cm criterion has been demonstrated to be more appropriate than others (e.g. proportional weight gain) since the most severely malnourished children get the most treatment, see:

Dale NM, Myatt M, Prudhon C, Briend A. Using mid-upper arm circumference to end treatment of severe acute malnutrition leads to higher weight gains in the most malnourished children. PLoS One. 2013;8:e55404.

There has also been some concern that the criterion may be unsuitable for short children (i.e. < 65cm on admission) but we did not find that to be the case.

Relapse rates were comparable to other discharge criteria used in CMAM programmes and all of the children with negative outcomes at 3 months following discharge as cured (i.e. they died or relapsed) also had weight for height well above -1 z-score on discharge.

If you invest in good case finding and early admission you are more likely to achieve shorter lengths of stay and higher cure rates. If you have good follow up of absentees this will improve recovery rate since attendance rate was found to be linked to chances of non-recovery. The 'success' of a criterion is not only to be judged by the threshold but also by other operational factors.

I hope this helps,
Paul

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