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Borderline MUAC and Z-score measurements

This question was posted the Prevention and treatment of moderate acute malnutrition forum area and has 9 replies. You can also reply via email – be sure to leave the subject unchanged.

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Martin Kumbe

Normal user

16 Feb 2012, 15:11

What is the most appropriete practical decision should one make when confronted with cases of borderline MUACs and Z-scores of 11.5cm and <2 SD respectively in nutrition emergencies where health and food security circumstances are fragile? Do we have many cases of this kind in programs or these are exceptions?

Mark Myatt

Consultant Epideomiologist

Frequent user

16 Feb 2012, 16:57

I am not sure what you are asking.

< 2? I think you mean "< -2" or "WHZ < -2" ... that depends on where you are since W/H means different things in different places.

MUAC = 115 mm ... I'd admit them to CMAM in the setting you describe.

Martin Kumbe

Normal user

18 Feb 2012, 16:58

I gree the question is not well put. Let me rephrase to prompt appropriete responses:

What is the most appropriete practical decision should one make when confronted with cases of MUAC measurements that fall exactly on 115mm and WHZ falling exactly on =<-2 respectively in nutrition emergencies where health and food security circumstances are fragile? Should such cases be admited in OTP or SFP? and if admitted into SFP, what are the chances that such cases would deteriorate? Do we have many cases of this kind in programs or these are exceptions?

Martin Kumbe

Normal user

18 Feb 2012, 16:58

I gree the question is not well put. Let me rephrase to prompt appropriete responses:

What is the most appropriete practical decision should one make when confronted with cases of MUAC measurements that fall exactly on 115mm and WHZ falling exactly on =<-2 respectively in nutrition emergencies where health and food security circumstances are fragile? Should such cases be admited in OTP or SFP? and if admitted into SFP, what are the chances that such cases would deteriorate? Do we have many cases of this kind in programs or these are exceptions?

Martin Kumbe

Normal user

18 Feb 2012, 16:58

I gree the question is not well put. Let me rephrase to prompt appropriete responses:

What is the most appropriete practical decision should one make when confronted with cases of MUAC measurements that fall exactly on 115mm and WHZ falling exactly on =<-2 respectively in nutrition emergencies where health and food security circumstances are fragile? Should such cases be admited in OTP or SFP? and if admitted into SFP, what are the chances that such cases would deteriorate? Do we have many cases of this kind in programs or these are exceptions?

Mark Myatt

Consultant Epideomiologist

Frequent user

18 Feb 2012, 17:08

Speaking personally ... I'd probably pull the MUAC strap a little tighter or make this a "discretionary admission" ("visible severe wasting" is useful for this).

I have nothing to say about using W/H apart from pointing out that WHZ < -2 is very much less severe than MUAC < 115 mm (one we might call MAM and the other we might call SAM).

Bijoy SARKER

Action Contre La Faim | Action Against Hunger

Normal user

18 Feb 2012, 17:37

This is probably a case of younger children aged 6-23 months. If the child's height is =65 cm then i'm totally agree with Mark Myatt. Opposite things are also happening with older children aged 24-59 months. Where MUAC is the only admission criteria, lots of these older children are not coming into the program though their W/H Z-scores are well below -2SD because of their higher arm circumference. Therefore, it is better to keep the both W/H and MUAC option in the nutrition intervention program.

André BRIEND

Frequent user

20 Feb 2012, 08:24

Dear Bijoy,

Many programmes combine weight-for-height and MUAC as admission criteria as you suggest in order not to miss any SAM child. The effect of using these two criteria to select high risk children however, is not what most would expect. With this approach, you do increase sensitivity (ie ability to detect high risk children) but you decrease specificity (ie you detect even more children who are not at risk). We have shown this in a recent paper. See :

Briend A, Maire B, Fontaine O, Garenne M. : Mid-upper arm circumference and weight-for-height to identify high-risk malnourished under-five children. Matern Child Nutr. 2012 Jan;8(1):130-3.

A review of this paper is available in the last Field Exchange issue. See :

http://www.ennonline.net/pool/files/fex/fieldexchange42.pdf p 16

The same observation was made in a recent study based on hospital data. See:

Mogeni P, Twahir H, Bandika V, Mwalekwa L, Thitiri J, Ngari M, Toromo C, Maitland K, Berkley JA. Diagnostic performance of visible severe wasting for identifying severe acute malnutrition in children admitted to hospital in Kenya. Bull World Health Organ. 2011 Dec 1;89(12):900-6

Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3260901/pdf/BLT.11.091280.pdf

So, you are better off in increasing MUAC cut-off rather than using WFH as additional criteria.

Pascale Delchevalerie

Nutrition Advisor MSF Belgium

Normal user

20 Feb 2012, 09:08

Hello,
In context where food security is low, if you want to prevent MAM children to fall in SAM, you can increase your admission criteria to MUAC < 120 mm (as mortality risk is still higher between 115 and 120 mm). With this cut-off, you have also more chance to catch SAM children > 2 years old.

Alexandra Rutishauser-Perera

International Medical Corps

Normal user

20 Feb 2012, 09:33

Personnally, i would say that it depends on the national protocols of the country you are working with , if you implement directly the treatment of malnutrition or if you support the MoH and of the agreements you might have with the agencies supplying your nutrition products.

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