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RELACION PERIMETRO BRAQUIAL, P/T Y COMORBILIDAD: TRATAMIENTO

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 8 replies.

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Spencer Rivadeneira

pediatra

Normal user

30 Sep 2019, 00:14

Buenas noches.

En un paciente con diarrea y deshidratación,cuyo puntaje Z para P/T está entre -1 y -2 DE, con perímetro braquial < 11.5 cm (riesgo de muerte por desnutrición), el abordaje de reposición de líquidos y el inicio de alimentación deben realizarse como si se tratara una desnutrición aguda severa? o prevalece la puntuación  P/T sobre el perímetro braquial en esos valores.

GRACIAS

Automatic translation:

Good evening,

In a patient with diarrhoea and dehydration, whose Z-score for W / H is between -1 and -2 SD, with MUAC <11.5 cm (risk of death due to malnutrition), should the fluid replacement approach and the start of feeding be performed as if treating severe acute malnutrition? or should the W / H score prevail over the MUAC at those values

Thank you

Paul

Technical expert

30 Sep 2019, 09:14

Hi Spencer,

MUAC and weight for height are independent criteria for admission and treatment. If the child has a MUAC of < 11.5cm then treat for severe acute malnutrition irrespective of the weight for height.

Cheers

Paul

Job

Nutrition Activity Manager-CMAM/MSF

Normal user

30 Sep 2019, 16:30

Hi,

Can you confirm the age of the patient first before any advice? if less than 6 months then avoid MUAC measurement but use W/H z score and manage accordingly. If 6-59 then do MUAC and if <115mm then manage accordingly. Above 5 years avoid MUAC and W/H. Use BMI/Age z scores to score the malnutrition. Also manage diarrhea and dehydration accordingly. Hope this helps.

André BRIEND

Frequent user

2 Oct 2019, 13:44

In response to Job, below the age of 6 months, WFH is not good to select high risk childen. MUAC and Weight-for-age are much better. See review below:

https://www.ennonline.net/mamicasedetectionreview

Paul

Technical expert

2 Oct 2019, 14:34

Thanks Andre,

I would also add in response to Job that you are correct that I assumed that the child was aged 6-59 months. It seemed a direct question that had a direct answer. Advice on the assumption that the child may be aged less than 6 months should be more complete. Even if the WFH is >-2, advice should make reference to other non-anthropometric criteria as recommended by WHO and the studies highlighted by Andre.

It is not correct to give blanket advice that we should avoid MUAC over the age of 5 years. MUAC is used for pregnant and lactating women and although not internationally agreed, there are cut offs that have been implemented in some contexts across the entrire age range from 5 years to adult. For example,

https://www.ennonline.net/fex/54/cutoffpointsadolescentssyria

Recent studies have also indicated that MUAC for age is as effective as BMI for age in assessing mortality risk in older children and adolescents. 

https://www.bmj.com/content/358/bmj.j3423

Paul

Nancy

Nutrition officer

Normal user

2 Oct 2019, 17:37

When using MUAC the only caution is if the child is stunted or not. Stunted children tend to have a normal WHZ score but their WAZ score could indicate stunting and thus stunted children are risk of getting obesity with use of suppliments. 

But a MUAC of 11.5 and the visibility of malnutrition( a child with SAM can also be identified by their physical presentation) should help the concerned to give fluids using IMAM guidelines. 

Mark Myatt

Epidemiologist at Brixton Health

Frequent user

3 Oct 2019, 09:48

I think the obesity issue may be a myth based on some "back of the envelope" physiological modelling and an assumption that stunted children with low MUAC have normal weight for height.

See this article which addresses the issue with evidence from a SAM treatment program. This work shows a tendency for low MUAC cases to be stunted but does not find treatment with RUTF until MUAC exceeded 125 mm for two weeks associated with excess adiposity by a number of measures. The study would be easy to replicate in other settings using data that is already available in program databases.

Paul

Technical expert

3 Oct 2019, 09:56

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. 

Kevin PHELAN

Nutrition advisor, ALIMA

Normal user

3 Oct 2019, 10:08

With regards to children with MAM, we found that:

"Short children with low MUAC do not gain excessive fat during supplementation. With these data, we support a recommendation for policy change to include all children ≥6 months with low MUAC in supplementary feeding programs, regardless of length."

Full article here:

https://www.ncbi.nlm.nih.gov/m/pubmed/30143567/

Cheers

Kevin

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