Nutr Res Pract.  2019 Jun;13(3):247-255. 10.4162/nrp.2019.13.3.247.

Performance of mid-upper arm circumference to diagnose acute malnutrition in a cross-sectional community-based sample of children aged 6–24 months in Niger

• Marshall S
• Monárrez-Espino J
• Eriksson A

• KMID: 2453289
• DOI: http://doi.org/10.4162/nrp.2019.13.3.247

Abstract

BACKGROUND/OBJECTIVES
Accurate, early identification of acutely malnourished children has the potential to reduce related child morbidity and mortality. The current World Health Organisation (WHO) guidelines classify non-oedematous acute malnutrition among children under five using Mid-Upper Arm Circumference (MUAC) or Weight-for-Height Z-score (WHZ). However, there is ongoing debate regarding the use of current MUAC cut-offs. This study investigates the diagnostic performance of MUAC to identify children aged 6-24 months with global (GAM) or severe acute malnutrition (SAM).
SUBJECTS/METHODS
Cross-sectional, secondary data from a community sample of children aged 6-24 months in Niger were used for this study. Children with complete weight, height and MUAC data and without clinical oedema were included. Using WHO guidelines for GAM (WHZ <−2, MUAC < 12.5 cm) and SAM (WHZ <−3, MUAC < 11.5 cm), the sensitivity (Se), specificity (Sp), predictive values, Youden Index and Receiver Operating Characteristic (ROC) curves were calculated for MUAC when compared with the WHZ reference criterion.
RESULTS
Of 1161 children, 23.3% were diagnosed with GAM using WHZ, and 4.4% with SAM. Using current WHO cut-offs, the Se of MUAC to identify GAM was greater than for SAM (79 vs. 57%), yet the Sp was lower (84 vs. 97%). From inspection of the ROC curve and Youden Index, Se and Sp were maximised for MUAC < 12.5 cm to identify GAM (Se 79%, Sp 84%), and MUAC < 12.0 cm to identify SAM (Se 88%, Sp 81%).
CONCLUSIONS
The current MUAC cut-off to identify GAM should continue to be used, but when screening for SAM, a higher cut-off could improve case identification. Community screening for SAM could use MUAC < 12.0 cm followed by appropriate treatment based on either MUAC < 11.5 cm or WHZ <−3, as in current practice. While the practicalities of implementation must be considered, the higher SAM MUAC cut-off would maximise early case-finding of high-risk acutely malnourished children.

Keyword

Severe acute malnutrition; anthropometric measures; community screening; diagnosis; Niger

MeSH Terms

Arm*
Child*
Diagnosis
Global Health
Humans
Malnutrition*
Mass Screening
Mortality
Niger*
ROC Curve
Sensitivity and Specificity
Severe Acute Malnutrition

Figure

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  Fig. 1 Study design and eligibility criteria. MUAC, Mid-upper arm circumference; WHO, World Health Organisation

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  Fig. 2 Empirical receiver operating characteristic (ROC) curve for diagnosis of GAM using MUAC. ROC analysis was performed with continuous test variable MUAC against dichotomous criterion variable WHZ (z-score < −2 or > −2) to identify GAM in the total sample, n = 1,161 (AUC 0.89). GAM, Global Acute Malnutrition; MUAC, Mid-upper arm circumference; ROC, Receiver Operating Characteristic; WHZ, Weight-for-height z-score.

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  Fig. 3 Receiver operating characteristic (ROC) curve for diagnosis of SAM using MUAC. ROC analysis was performed with continuous test variable MUAC against dichotomous criterion variable WHZ (z-score < −3 or > −3) to identify SAM in the total sample, n = 1,161 (AUC 0.94). MUAC, Mid-upper arm circumference; ROC, Receiver Operating Characteristic; SAM, Severe Acute Malnutrition; WHZ, Weight-for-height z-score.

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  Fig. 4 Prevalence of GAM and SAM identified using current WHO guidelines and MUAC < 12.0 cm. MUAC < 12.0 cm identified from ROC analysis. ‘Either WHZ or MUAC’ denotes classification of acute malnutrition in one child using either of the indicators alone. ‘Both WHZ and MUAC’ denotes classification of acute malnutrition of one child using both indicators. GAM, Global Acute Malnutrition; MUAC, Mid-upper arm circumference; ROC, Receiver Operating Characteristic; SAM, Severe Acute Malnutrition; WHZ, Weight-for-height z-score.

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  Fig. 5 Screening process for CMAM with SAM MUAC < 12.0 cm. CMAM, Community-based Management of Acute Malnutrition; MUAC, Mid-upper arm circumference; SAM, Severe Acute Malnutrition; WHZ, Weight-for-height z-score.

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