Potential consequences of expanded MUAC-only programs on targeting of acutely malnourished children and ready-to-use-therapeutic-food allocation: lessons from cross-sectional surveys

Abstract

Background: Some of the recently piloted innovative approaches for the management of acute malnutrition in children use the “expanded MUAC-only” approach, with Mid Upper Arm Circumference (MUAC) <125mm as the sole anthropometric criterion for screening and admission, classification of cases as severe using the 115mm cut-off, and use Ready-to-Use-Therapeutic-Food (RUTF) for the management of both moderate (MAM) and severe (SAM) cases of acute malnutrition. Our study aimed at exploring the potential consequences of this “expanded MUAC-only” program scenario on the eligibility for treatment and RUTF allocation, as compared with the existing WHO normative guidance. Methods: We analyzed data from 550 population representative cross-sectional cluster surveys conducted since 2007. We retrieved all children classified as SAM and MAM according to currently used case definitions, and calculated the proportions of SAM children who would be excluded from treatment, misclassified as MAM, or whose specific risks (because of having both MUAC and weight-for height deficits) would be ignored. We also analyzed the expected changes in the number and demographics (sex, age) of children meant to receive RUTF according to the new approach. Results: We found that approximately one quarter of SAM children would not be detected and eligible for treatment under the “expanded MUAC-only” scenario, and another 20% would be classified as MAM. A further 17% of the total SAM children would be admitted and followed only according to their MUAC or oedema status, while they also present with a severe weight-for height deficit on admission. Considering MAM targeting, about half of the MAM children would be left undetected. This scenario also shows a 2.5 time increase in the number of children targeted with RUTF, with approximately 70% of MAM and 30% of SAM cases among this new RUTF target. Conclusions: This empirical evidence suggests that adoption of “expanded MUAC-only” programs would likely lead to a priori exclusion from treatment or misclassifying as MAM a large proportion of SAM cases, while redirecting programmatic costs in favor of those less in need. It underscores the need to explore other options for improving the impact of programs addressing the needs of acutely malnourished children.

“No weight for height” case detection strategies for therapeutic feeding programs: sensitivity to acute malnutrition and target composition based on representative surveys in humanitarian settings

“…Further, to compare basic demographics of children in SAMall, SAMmuac and Target MUAC+SWAZ, we calculated (1) the proportion of females and (2) the proportion of younger children (aged 6-23 months) in each of these groups. Similar demographic analysis for Expanded MUAC program is reported in our previous manuscript [19].…”

“…Under this approach, screening and admission is based solely on oedema or MUAC, yet at a higher cutoff: all children with a MUAC< 125 mm or oedema would be eligible to a treatment comprising ready-to-use therapeutic food, albeit those presenting a MUAC≥115 mm, at admission or during treatment, would be considered as MAM and would receive a lower dosage [18]. Potential consequences of this approach based on data from recent population representative surveys conducted around the globe were presented in our previous article [19].…”

Does weight-for-height and mid upper-arm circumference diagnose the same children as wasted? An analysis using survey data from 2017 to 2019 in Mozambique

“…Our results are consistent with findings reported by Humphreys et al (2019) [31] in the context of Afghanistan where the Ministry of Public Health acknowledged the differences and adopted the use of the combined prevalence estimates towards more accurate programming [32]. Similarly, consistent with findings reported by Guesdon et., al (2020) [33], our study shows that use of one diagnostic criteria for admission to treatment programmes will Fig. 6 Total number of children (in thousands) in need of treatment using GAM by WHZ only, GAM by MUAC only and cGAM (combined GAM).…”