Hi Mark, thanks for this. You beat me to it.
Nancy, your post raises some very important issues regarding the multiple deficits we see in malnutrition. All forms of malnutrition indicate a compromised physiological state whether that is measured by wasting, stunting or underweight, and all of these measures point to an increased mortality risk when the measures fall below ‘normal’ ranges.
You indicated that MUAC should be used with caution in stunted children because the stunted child is likely to be underweight rather than wasted and that treating such a child (stunted with a low MUAC) will lead to obesity.
The study in Malawi cited by Mark suggested the opposite. Children with a low MUAC that were also stunted (H/A < -2z) were able to achieve the MUAC discharge criterion (> 12.5cm) and all were < +2z by weight for height and weight for age and the majority were below median by both measures. The triceps skinfold for age (WHO standards) and the arm fat index (constructed from other study data) were also normal for both stunted and non-stunted children.
The study also cited other work that had looked at markers for ‘metabolic syndrome’ and indicated that the use of RUTF does not contribute to that risk. After 10 weeks of treatment, leptin levels were 7 times lower than the threshold predicting metabolic syndrome and were lower than those of normally nourished children.
The absence of obesity or any effect on markers for metabolic syndrome following treatment with RUTF suggests that the links between treatment for SAM and later life obesity needs to be considered alongside other factors not directly related to the treatment of SAM per se.
With regards to the use of physical appearance as a diagnostic criterion. WHO indicate that “Evidence does not support using visible severe wasting as a stand-alone criterion for children who are less than 5 years of age”.
https://apps.who.int/iris/bitstream/handle/10665/95584/9789241506328_eng.pdf?ua=1
One study concluded that ‘visible wasting’ identified only 50% of children with SAM defined by anthropometric criteria and concluded that measuring MUAC and oedema should be a routine part of assessment for all children admitted to hospital
https://www.who.int/bulletin/volumes/89/12/11-091280/en/
and in another that nutritional monitoring during hospitalisation should be continued
https://www.tandfonline.com/doi/full/10.1080/16070658.2017.1322825
On the treatment of dehydration of children identified with SAM, this should be conducted cautiously according to the various rehydration protocols, rather than treatment being contingent on whether the child was admitted by MUAC or weight for height.