Background: Anthropometric surveys of children are used to assess the nutritional status of a population. World Health Organization (WHO) recommends that either mid-upper-arm circumference (MUAC) or weight-for-height Z-scores (WHZ) are used to assess acute malnutrition prevalence. However, there are reports from several countries that the two criteria identify different children. In order to examine the external validity of these observations we have compared the direction and degree of discrepancy across countries. Methods: Anonymous data were collected from 1832 anthropometric surveys from 47 countries with measured children aged from 6 to 59 months and at least 75 malnourished subjects. The prevalence of total acute malnutrition and severe acute malnutrition was calculated using either absolute-MUAC or WHZ (WHO 2006 standards). For each country, the total number of children diagnosed as acutely malnourished by either criterion alone or by both criteria were summed from all the surveys conducted in that country. Results: In all countries a minority of children were diagnosed as malnourished by both criteria. Both the magnitude and direction of the discrepancy varied dramatically between countries with some having most children diagnosed as malnourished by MUAC and others where nearly all the children were diagnosed by WHZ alone. Eight additional countries with insufficient malnourished children were also analysed and they support the conclusions.

BackgroundCash transfer programs (CTPs) aim to strengthen financial security for vulnerable households. This potentially enables improvements in diet, hygiene, health service access and investment in food production or income generation. The effect of CTPs on the outcome of children already severely malnourished is not well delineated. The objective of this study was to test whether CTPs will improve the outcome of children treated for severe acute malnutrition (SAM) in the Democratic Republic of the Congo over 6 months.MethodsWe conducted a cluster-randomised controlled trial in children with uncomplicated SAM who received treatment according to the national protocol and counselling with or without a cash supplement of US$40 monthly for 6 months. Analyses were by intention to treat.ResultsThe hazard ratio of reaching full recovery from SAM was 35% higher in the intervention group than the control group (adjusted hazard ratio, 1.35, 95% confidence interval (CI) = 1.10 to 1.69, P = 0.007). The adjusted hazard ratios in the intervention group for relapse to moderate acute malnutrition (MAM) and SAM were 0.21 (95% CI = 0.11 to 0.41, P = 0.001) and 0.30 (95% CI = 0.16 to 0.58, P = 0.001) respectively. Non-response and defaulting were lower when the households received cash. All the nutritional outcomes in the intervention group were significantly better than those in the control group. After 6 months, 80% of cash-intervened children had re-gained their mid-upper arm circumference measurements and weight-for-height/length Z-scores and showed evidence of catch-up. Less than 40% of the control group had a fully successful outcome, with many deteriorating after discharge. There was a significant increase in diet diversity and food consumption scores for both groups from baseline; the increase was significantly greater in the intervention group than the control group.ConclusionsCTPs can increase recovery from SAM and decrease default, non-response and relapse rates during and following treatment. Household developmental support is critical in food insecure areas to maximise the efficiency of SAM treatment programs.Trial registrationClinicalTrials.gov, NCT02460848. Registered on 27 May 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-017-0848-y) contains supplementary material, which is available to authorized users.

Objective: The present study was performed to describe the operational implications of using mid-upper arm circumference (MUAC) as a single admission criterion for treatment of severe acute malnutrition in South Sudan. Design: We performed a retrospective analysis of routine programme data of children with severe acute malnutrition aged 6-59 months admitted to a therapeutic feeding programme using weight-for-height Z-score (WHZ) and/or MUAC. To understand the implications of using MUAC as a single admission criterion, we compared patient characteristics and treatment outcomes for children admitted with MUAC < 115 mm (irrespective of WHZ) v. children admitted with WHZ < −3 and MUAC ≥ 115 mm. Results: Of 2205 children included for analysis, 719 (32·6 %) were admitted to the programme with MUAC < 115 mm and 1486 (67·4 %) with WHZ < −3 and MUAC ≥ 115 mm. Children who would have been admitted using a single MUAC < 115 mm criterion were more severely malnourished and more likely to be female and younger. Compared with children admitted with WHZ < −3 and MUAC ≥ 115 mm, children who would have been admitted using MUAC < 115 mm were less likely to recover (54 % v. 69 %) and had higher risk of death (4 % v. 1 %), but responded to treatment with greater weight and MUAC gains. MUAC < 115 mm would have failed to identify 33 % of deaths, while 98 % were identified by WHZ < −3 alone and 100 % by MUAC < 130 mm. Conclusions: The study shows that MUAC < 115 mm identified more severely malnourished children with a higher risk of mortality but failed to identify a third of the children who died. Admission criteria for therapeutic feeding should be adapted to the programmatic context with consideration for both operational and public health implications. Keywords Child malnutrition Mid-upper arm circumferenceWeight-for-height Z-score Admission criteria Community-based management of acute malnutritionAcute malnutrition represents a major cause of childhood morbidity and mortality worldwide. The number of children under the age of 5 years with severe acute malnutrition (SAM) at any time is currently estimated from prevalence data to be nearly 19 million, with the burden or number of incident cases occurring each year presumably higher (1) . SAM contributes to over a million child deaths annually, as children with SAM are estimated to have an approximately ninefold increased risk of death compared with well-nourished children (2,3) . Traditionally, treatment for SAM was conducted exclusively in in-patient settings, an approach that was both costly and limited access to, and impact of, such programmes.In 2007, a new model for the community-based management of acute malnutrition (CMAM) was endorsed by the WHO, UNICEF, World Food Programme and the UN System Standing Committee on Nutrition, in which children with uncomplicated cases of SAM and appetite could be treated on an out-patient basis with the provision of ready-to-use therapeutic foods and weekly or biweekly follow-up (3) . Increasing evidence and operational experience ha...

Objectives This study aims to describe the mortality risk of children in the community who had severe acute malnutrition (SAM) defined by either a mid-upper arm circumference (MUAC) <115mm, a low weight-for-height Z-score (WHZ) <-3 or both criteria. Methods We pooled individual-level data from children aged 6–59 months enrolled in 3 community-based studies in the Democratic Republic of the Congo (DRC), Senegal and Nepal. We estimate the mortality hazard using Cox proportional hazard models in groups defined by either anthropometric indicator. Results In total, we had 49,001 time points provided by 15,060 children available for analysis, summing to a total of 143,512 person-months. We found an increasing death rate with a deteriorating nutritional status for all anthropometrical indicators. Children identified as SAM only by a low MUAC (<115mm) and those identified only by a low WHZ (Z-score <-3) had a similar mortality hazard which was about 4 times higher than those without an anthropometric deficit. Having both a low MUAC and a low WHZ was associated with an 8 times higher hazard of dying compared to children within the normal range. The 2 indicators identified a different set of children; the proportion of children identified by both indicators independently ranged from 7% in the DRC cohort, to 35% and 37% in the Senegal and the Nepal cohort respectively. Conclusion In the light of an increasing popularity of using MUAC as the sole indicator to identify SAM children, we show that children who have a low WHZ, but a MUAC above the cut-off would be omitted from diagnosis and treatment despite having a similar risk of death.

BackgroundIt is often thought that random measurement error has a minor effect upon the results of an epidemiological survey. Theoretically, errors of measurement should always increase the spread of a distribution. Defining an illness by having a measurement outside an established healthy range will lead to an inflated prevalence of that condition if there are measurement errors.Methods and resultsA Monte Carlo simulation was conducted of anthropometric assessment of children with malnutrition. Random errors of increasing magnitude were imposed upon the populations and showed that there was an increase in the standard deviation with each of the errors that became exponentially greater with the magnitude of the error. The potential magnitude of the resulting error of reported prevalence of malnutrition were compared with published international data and found to be of sufficient magnitude to make a number of surveys and the numerous reports and analyses that used these data unreliable.ConclusionsThe effect of random error in public health surveys and the data upon which diagnostic cut-off points are derived to define “health” has been underestimated. Even quite modest random errors can more than double the reported prevalence of conditions such as malnutrition. Increasing sample size does not address this problem, and may even result in less accurate estimates. More attention needs to be paid to the selection, calibration and maintenance of instruments, measurer selection, training & supervision, routine estimation of the likely magnitude of errors using standardization tests, use of statistical likelihood of error to exclude data from analysis and full reporting of these procedures in order to judge the reliability of survey reports.