BackgroundTimely treatment of acute malnutrition in children <5 years of age could prevent >500,000 deaths annually. Screening at community level is essential to identify children with malnutrition. Current WHO guidelines for community screening for malnutrition recommend a Mid Upper Arm Circumference (MUAC) of <115 mm to identify severe acute malnutrition (SAM). However, it is currently unclear how MUAC relates to the other indicator used to define acute malnutrition: weight-for-height Z-score (WHZ).MethodsSecondary data from >11,000 Cambodian children, obtained by different surveys between 2010 and 2012, was used to calculate sensitivity and ROC curves for MUAC and WHZ.FindingsThe secondary analysis showed that using the current WHO cut-off of 115 mm for screening for severe acute malnutrition over 90% of children with a weight-for-height z-score (WHZ) <−3 would have been missed. Reversely, WHZ<−3 missed 80% of the children with a MUAC<115 mm.ConclusionsThe current WHO cut-off for screening for SAM should be changed upwards from the current 115 mm. In the Cambodian data-set, a cut-off of 133 mm would allow inclusion of >65% of children with a WHZ<−3. Importantly, MUAC and WHZ identified different sub-groups of children with acute malnutrition, therefore these 2 indicators should be regarded as independent from each other. We suggest a 2-step model with MUAC used a screening at community level, followed by MUAC and WHZ measured at a primary health care unit, with both indicators used independently to diagnose severe acute malnutrition. Current guidelines should be changed to reflect this, with treatment initiated when either MUAC <115 mm or WHZ<−3.

Background: Anemia is highly prevalent in Cambodian women and children, but data on causes of anemia are scarce. We performed a national micronutrient survey in children and women that was linked to the Cambodian Demographic Health Survey 2014 (CDHS-2014) to assess the prevalence of micronutrient deficiency, hemoglobin disorders and intestinal parasite infection. Methods: One-sixth of households from the CDHS-2014 were selected for a follow-up visit for the micronutrient survey. Households were visited from two weeks to two months after the CDHS-2014 visit. Data on micronutrient status were available for 1512 subjects (792 children and 720 women). Results: Anemia was found in 43% of the women and 53% of the children. Hemoglobin disorders affected >50% of the population, with Hemoglobin-E the most prevalent disorder. Deficiencies of iron (ferritin < 15 g/L), vitamin A (retinol-binding-protein (RBP) < 0.70 mol/L) or vitamin B12 (<150 pmol/L) were not prevalent in the women (<5% for all), whereas 17.8% of the women had low concentrations of folic acid (<10 nmol/L). In the children, the prevalence of iron, vitamin A, vitamin B12 or folic acid deficiency was <10%. Zinc deficiency, hookworm infection and hemoglobinopathy were significantly associated with anemia in children, whereas in the women none of the factors was significantly associated with anemia. Iron deficiency anemia (IDA) was more prevalent in children <2 years, but in older children and women, the prevalence of IDA was <5%. The most prevalent, preventable causes of anemia were hookworm infection and zinc and folic acid deficiency. Over 40% of the anemia was not caused by nutritional factors. Conclusion: The very high prevalence of anemia in Cambodian women and children cannot be explained solely by micronutrient deficiencies and hemoglobin disorders. Micronutrient interventions to improve anemia prevalence are likely to have limited impact in the Cambodian setting. The focus of current interventions to reduce the high prevalence of anemia in children and women should be broadened to include zinc and folic acid as well as effective anti-hookworm measures.

BackgroundEarly identification of children <5 yrs with acute malnutrition is a priority. Acute malnutrition is defined by the World Health Organization as a mid-upper-arm circumference (MUAC) <12.5 cm or a weight-for-height Z-score (WHZ) <-2. MUAC is a simple and low-cost indicator to screen for acute malnutrition in communities, but MUAC cut-offs currently recommended by WHO do not identify the majority of children with weight-for-height Z-score (<-2 (moderate malnourished) or r<-3 (severe malnourished). Also, no cut-offs for MUAC are established for children >5 yrs. Therefore, this study aimed at defining gender and age-specific cut-offs to improve sensitivity of MUAC as an indicator of acute malnutrition.MethodsTo establish new age and gender-specific MUAC cut-offs, pooled data was obtained for 14,173 children from 5 surveys in Cambodia (2011–2013). Sensitivity, false positive rates, and areas under receiver-operator characteristic curves (AUC) were calculated using wasting for children <5yrs and thinness for children ≥5yrs as gold standards. Among the highest values of AUC, the cut-off with the highest sensitivity and a false positive rate ≤33% was selected as the optimal cut-off.ResultsOptimal cut-off values increased with age. Boys had higher cut-offs than girls, except in the 8–10.9 yrs age range. In children <2yrs, the cut-off was lower for stunted children compared to non stunted children. Sensitivity of MUAC to identify WHZ<-2 and <-3 z-scores increased from 24.3% and 8.1% to >80% with the new cut-offs in comparison with the current WHO cut-offs.ConclusionGender and age specific MUAC cut-offs drastically increased sensitivity to identify children with WHZ-score <-2 z-scores. International reference of MUAC cut-offs by age group and gender should be established to screen for acute malnutrition at the community level.

BackgroundThiamine deficiency is thought to be an issue in Cambodia and throughout Southeast Asia due to frequent clinical reports of infantile beriberi. However the extent of this public health issue is currently unknown due to a lack of population-representative data. Therefore we assessed the thiamine status (measured as erythrocyte thiamine diphosphate concentrations; eThDP) among a representative sample of Cambodian women of childbearing age (15–49 y) and their young children (6–69 mo).Methodology/Principle findingsSamples for this cross-sectional analysis were collected as part of a national micronutrient survey linked to the Cambodian Demographic and Health Survey (CDHS) 2014. One-sixth of households taking part in the CDHS were randomly selected and re-visited for additional blood sampling for eThDP analysis (719 women and 761 children). Thiamine status was assessed using different cut-offs from literature.Women were mean (SD) 30 (6) y, and children (46% girls) were 41 (17) mo. Women had lower mean (95% CI) eThDP of 150 nmol/L (146–153) compared to children, 174 nmol/L (171–179; P < 0.001). Using the most conservative cut-off of eThDP < 120 nmol/L, 27% of mothers and 15% of children were thiamine deficient, however prevalence rates of deficiency were as high as 78% for mothers and 58% for children using a cut-off of < 180 nmol/L. Thiamine deficiency was especially prevalent among infants aged 6–12 mo: 38% were deficient using the most conservative cut-off (< 120 nmol/L).Conclusions/SignificanceThere is a lack of consensus on thiamine status cut-offs; more research is required to set clinically meaningful cut-offs. Despite this, there is strong evidence of suboptimal thiamine status among Cambodian mothers and their children, with infants <12 mo at the highest risk. Based on eThDP from this nationally-representative sample, immediate action is required to address thiamine deficiency in Cambodia, and likely throughout Southeast Asia.

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