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Do we need to reconsider the CMAM admission and discharge criteria?; an analysis of CMAM data in South Sudan

This question was posted the Prevention and treatment of severe acute malnutrition forum area and has 2 replies.

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Anonymous 6714

FONDA

Normal user

22 Apr 2020, 10:00

You can find the paper through the link below  and is also attached. please help share with others.

https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-08657-x

Abstract

Background

Weight-for-height Z-score (WHZ) and Mid Upper Arm Circumference (MUAC) are both commonly used as acute malnutrition screening criteria. However, there exists disparity between the groups identified as malnourished by them. Thus, here we aim to investigate the clinical features and linkage with chronicity of the acute malnutrition cases identified by either WHZ or MUAC. Besides, there exists evidence indicating that fat restoration is disproportionately rapid compared to that of muscle gain in hospitalized malnourished children but related research at community level is lacking. In this study we suggest proxy measure to inspect body composition restoration responding to malnutrition management among the malnourished children.

Methods

The data of this study is from World Vision South Sudan’s emergency nutrition program from 2006 to 2012 (4443 children) and the nutrition survey conducted in 2014 (3367 children). The study investigated clinical presentations of each type of severe acute malnutrition (SAM) by WHZ (SAM-WHZ) or MUAC (SAM-MUAC), and analysed correlation between each malnutrition and chronic malnutrition. Furthermore, we explored the pattern of body composition restoration during the recovery phase by comparing the relative velocity of MUAC3 with that of weight gain.

Results

As acutely malnourished children identified by MUAC more often share clinical features related to chronic malnutrition and minimal overlapping with malnourished children by WHZ, Therefore, MUAC only screening in the nutrition program would result in delayed identification of the malnourished children.

Conclusions

The relative velocity of MUAC3 gain was suggested as a proxy measure for volume increase, and it was more prominent than that of weight gain among the children with SAM by WHZ and MUAC over all the restoring period. Based on this we made a conjecture about dominant fat mass gain over the period of CMAM program. Also, considering initial weight gain could be ascribed to fat mass increase, the current discharge criteria would leave the malnourished children at risk of mortality even after treatment due to limited restoration of muscle mass. Given this, further research should be followed including assessment of body composition for evidence to recapitulate and reconsider the current admission and discharge criteria for CMAM program.

Paul

Technical expert

23 Apr 2020, 17:36

Hi Anonymous,

Thank you for posting an interesting article. It is worth noting initially that the paper relates to data on South Sudanese children and that findings should not be extrapolated given the potential geographical variability in the ratios of children identified by MUAC or WHZ. 

The paper raises several issues that are worthy of critical discussion, however given its focus in the abstract I would like to highlight some of the conjectures regarding the recovery of lean vs. fat mass during recovery and the conclusions subsequently drawn. 

The paper's findings based on estimations of relative velocities of MUAC3 vs. weight gain suggest that initial recovery is marked predominatly by increases in fat mass, that the child remains at risk of mortality following recovery due to lack of recovery of muscle mass and, by extrapolation that the discharge criteria should be changed.

However it is worth noting that loss of fat and low leptin levels also contribute to mortality risk, therefore the deposition of fat during and after recovery from SAM should not be viewed as wasted growth nor as somehow impeding recovery by impeding the growth of lean mass. 

Contrary to the posted abstract, a recently published paper by Kangas et al (March 2020) suggests that following treatment of SAM children with RUTF, there was recovery of lean mass (fat free mass index was not different from community controls at recovery) and that at recovery fat mass was deficient. 

https://www.clinicalnutritionjournal.com/article/S0261-5614(20)30102-3/fulltext 

I have data (unpublished) that tracked the recovery of children admitted with SAM into a CMAM programme in Malawi. We measured MUAC and mid upper arm triceps skinfold thickness in SAM children during treatment  with RUTF. We compared changes in the arm fat index with MUAC during treatment and found that for many individuals there is indeed a relatively rapid increase in arm fat index relative to MUAC at the beginning of treatment. However, the changes were variable between individuals with some not showing any rapid 'catch up' at the start of treatment. The data also suggest that arm fat index reaches an asymptote during recovery for some individuals while for others it continues on a steady trajectory up to the point of recovery. As yet the data has not been disaggregated by age, however the changing energy cost of fat deposition from 0-2 years of age possibly contribute to this variability in the recovery trajectory. 

We also looked at changes in the cross sectional area of muscle and fat during treatment. While the data needs more detailed analysis, it suggests that the cross sectional area of both lean and fat mass in the upper arm both change over the entire treatment period and that the changes are generally well correlated.  However, the relative increases of muscle and fat cross sectional areas in the upper arm also varies between individuals. While I have not analysed the data fully and so have not drawn any conclusions, I would suggest that the hypothesis of fat deposition impeding lean mass deposition, particularly during initial recovery,  is suspect.

The relapse of children following cure from SAM is a complex phenomenon. It would appear logical that if children were treated for longer (i.e. beyond the current discharge criteria) they would go on to gain more fat and lean mass and be more resilient to relapse. However I don't think the paper provides adequate evidence that recovered children remain at high risk of mortality following recovery primarily due to inadequate lean mass gain. Other studies have indicated low relapse / mortality rates following recovery at current recommended discharge criteria.

Discussions of the use of weight for height vs. MUAC and the expansion of MUAC criteria have been debated elsewhere. Whatever your view on this, the potential increase in treatment costs through expansion of the admission / discharge criteria may, depending on funding, also limit the number of children that can be treated and should be decided on a case by case basis rather than as a general recommendation. 

I think there is some caution needed in the interpretation of the data presented in the paper and, as the paper concludes, further research is necessary into body composition during and after treatment for SAM.

Paul

Anonymous 6714

FONDA

Normal user

24 Apr 2020, 05:44

Thanks paul and as you rightly say its a very interesting article giving insights into a different way of looking at CMAM admission and discharge criteria and also provides grounds for further research

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