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) < 125 mm as the sole anthropometric criterion for screening and admission, classification of cases as severe using the 115 mm cutoff, 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 cut-off: 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 ].…”

Anthropometry at discharge and risk of relapse in children treated for severe acute malnutrition: a prospective cohort study in rural Nepal

“…Although the international normative guidance does not endorse the possibility that SAM treatment programs restrict admission to children with MUAC < 115 mm or nutritional edema [8], this proposal has been increasingly promoted and applied [9,10]. As opposed to its consequences on targeting and assessing eligibility to treatment, which have been described and discussed elsewhere [6,[11][12][13], the impacts on discharge have not been analyzed. However, in programs abandoning the assessment of WHZ, MUAC ≥ 125 mm is used as the only restrictive criterion to consider children as cured, irrespective of the WHZ deficits that may be present upon admission.…”

Household‐level water, sanitation and hygiene factors and interventions and the prevention of relapse after severe acute malnutrition recovery: A systematic review

“…For example, all three studies used WHO‐recommended anthropometric measurements to define SAM but used different anthropometric criteria for calculating relapse (e.g., Adegoke et al [ 2021 ] used MUAC only and Altmann et al [ 2018 ] and Erkiso et al [ 2023 ] used MUAC, WHZ and oedema). Although applied in recent years to simplify MAM and SAM treatment guidance, the use of MUAC as the only criterion for SAM identification and admission to OTP may lead to under‐reporting of SAM (Guesdon et al, 2020 ) and thereby SAM relapse. The use of a standardised definition is needed to accurately understand the burden of relapse and determine appropriate postdischarge interventions to improve sustained recovery.…”