Mid-upper arm circumference measurement for severe malnutrition screening in underfives
Abstract
Background Severe malnutrition in Indonesia remains abundant. Severe malnutrition has been assessed by several methods, including mid–upper arm circumference (MUAC) and weight-for-height z-score (WHZ). As a screening method, MUAC is expected to be useful for identifying malnutrition in communities.
Objective To determine whether MUAC measurements can be used for screening severe malnutrition at the community level in Indonesia.
Method A cross-sectional study was conducted in 853 children aged 6 – 59 months who came to an integrated health service post (Posyandu) in Semarang, Central Java. Anthropometric measurements were performed by cadres and researchers and included MUAC and WHZ. Statistical analysis was done by McNemar test; results with P values >0.05 indicated no significant difference. Sensitivity and specificity were determined by 2 x 2 tables. The MUAC cut-off values were determined by receiver-operating characteristic (ROC) curve.
Results Eight hundred fifty-three out of 1,115 children met the inclusion criteria, consisting of 419 (49.1%) boys, with most over the age of 2 years (57.2%). Kappa test revealed good inter-rater reliability in measurements between the cadre and researchers (Kappa=0.726). There were significant differences between MUAC (by cadres) and below red line status as well as WHZ, between MUAC (by researchers) and WHZ, as well as MUAC (by cadre and researchers) with WHZ and height-for-age z-score/HAZ . Sensitivity, specificity, PPV, and NPV of MUAC (by cadre) were 12.5%, 99.9%, 75%, and 97.5%, respectively, while those by the researchers were 16.7%, 99.6%, 57%, and 97.6%, respectively. In this study, MUAC of 14 cm was the best cut-off for severe malnutrition.
Conclusion The MUAC measurement of 14 cm can be used for screening severe malnutrition in underfives at community.
References
Badan Penelitian dan Pengembangan Kementrian Kesehatan RI. Riset Kesehatan Dasar Indonesia 2013. Jakarta: Kemenkes RI; 2013.
Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371:243-60. DOI: 10.1016/S0140-6736(07)61690-0.
Kementrian Kesehatan RI. Pedoman Umum Pengelolaan Posyandu. Jakarta: Kemenkes RI; 2006.
Direktorat Bina Gizi, Direktorat Bina Gizi dan Kesehatan Ibu dan Anak, Kementerian Kesehatan Republik Indonesia. Surat Keputusan Menteri Kesehatan Republik Indonesia No. 1995/Menkes/SK/XII/2010 tentang Standar Antropometri Penilaian Status Gizi Anak. Jakarta: Kemenkes RI; 2011.
World Health Organization, World Food Programme, United Nations System Standing Committee on Nutrition & United Nations Children's Fund (‎‎UNICEF)‎‎. (‎2007)‎. Community-based management of severe acute malnutrition : a joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children's Fund. World Health Organization. [cited 2018 March 30]. Available at: https://apps.who.int/iris/handle/10665/44295
Direktorat Bina Gizi dan Kesehatan Ibu dan Anak Kementerian Kesehatan Republik Indonesia. Pedoman pelayanan anak gizi buruk. Jakarta: Kemenkes RI; 2015.
WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and development. Geneva: World Health Organization, 2006 (312 pages).
Chakraborty R, Bose K, Bisai S. Mid-upper arm circumference as a measure of nutritional status among adult Bengalee male slum dwellers of Kolkata, India: relationship with self-reported morbidity. Anthropol Anz. 2009;67:129–37. DOI: 10.1127/0003-5548/2009/0017.
Bisai S, Bose K. Undernutrition in the Kora Mudi tribal population, West Bengal, India: a comparison of body mass index and mid-upper-arm circumference. Food Nutr Bull. 2009;30:63-7. DOI: 10.1177/156482650903000106.
Myatt M, Khara T, Collins S. A review of methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs. Food Nutr Bull. 2006;27:S7–23. DOI: 10.1177/15648265060273S302.
WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization; 2013.
World Health Organization, United Nation Children's Fund. A Joint Statement by the World Health Organization and the United Nations Children's Fund. WHO child growth standards and the identification of severe acute malnutrition in infants and children. Geneva: WHO; 2009.
Roberfroid D, Hammami N, Lachat C, Prinzo ZW, Sibson V, Guesdon B, et al. Utilization of a mid-upper arm circumference versus weight-for-height in nutritional rehabilitation programmes: a systematic review of evidence. Geneva: World Health Organization;2013. [cited 2018 March 27]. Available at: https://biblio.ugent.be/publication/5700355/file/5700357.pdf
Grellety E, Krause LK, Shams Eldin M, Porten K, Isanaka S. Comparison of weight-for-height and mid-upper arm circumference (MUAC) in a therapeutic feeding programme in South Sudan: is MUAC alone a sufficient criterion for admission of children at high risk of mortality? Public Health Nutr. 2015;18:2575-81. DOI: 10.1017/S136898001500073715.
Laillou A, Prak S, de Groot R, Whitney S, Conkle J, Horton L, et al. Optimal screening of children with acute malnutrition requires a change in current WHO guidelines as MUAC and WHZ identify different patient groups. Plos One. 2014;9:e101159. DOI: 10.1371/journal.pone.0101159.
Fernandez MA, Delchevalerie P, Van Herp M. Accuracy of MUAC in the detection of severe wasting with the new WHO growth standards. Pediatrics. 2010;126:195–201. DOI: 10.1542/peds.2009-2175
Goon DT. Fatness and fat patterning as independent anatomical characteristics of body composition: a study of urban South African children. Iran J Pediatr. 2013;23:423-9. [cited 2018 Maret 28]. Available at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3883372/
Grellety E, Golden MH. Weight-for-height and mid-upper-arm circumference should be used independently to diagnose acute malnutrition: policy implications. BMC Nutr. 2016;2:1-17. DOI 10.1186/s40795-016-0049-7
Victora CG, de Onis M, Hallal PC, Blossner MB, Shrimpton R. Worldwide timing of growth faltering: revisiting implications for interventions. Pediatrics. 2010;125:e473-80. DOI: 10.1542/peds.2009-1519
Dasgupta R, Sinha D, Jain SK, Prasad V. Screening for SAM in the community: is MUAC a simple tool? Indian Pediatr. 2013;50:154–5. DOI: 10.1007/s13312-013-0032-1.
Grijalva-Eternod CS, Wells JC, Girma T, Kæstel P, Admassu B, Friis H, et al. Midupper arm circumference and weight-for-length z scores have different associations with body composition: evidence from a cohort of Ethiopian infants. Am J Clin Nutr. 2015;102:593-9. DOI: 10.3945/ajcn.114.106419.
Maligie M, Crume T, Scherzinger A, Stamm E, Dabelea D. Adiposity, fat patterning, and the metabolic syndrome among diverse youth: the EPOCH study. J Pediatr. 2012;161:875–80. DOI:10.1016/j.jpeds.2012.05.003
Stults-Kolehmainen MA, Stanforth PR, Bartholomew JB, Lu T, Abolt CJ, Sinha R. DXA estimates of fat in abdominal, trunk and hip regions varies by ethnicity in men. Nutr Diabetes. 2013;3:e64. DOI:10.1038/nutd.2013.5
Emergency Nutrition Network, Save the Children United Kingdom, Action Contre la Faim, United Nation High Commissioner for Refugees. Mid upper arm circumference and weight-forheight z-score as indicators of severe acute malnutrition: a consultation of operational agencies and academic specialists to understand the evidence, identify knowledge gaps and to inform operational guidance. Final review paper 2012. [cited 2018 March 29]. Available at: http://www.cmamforum.org/Pool/Resources/ MUAC-WFH-Report-ENN-2013.pdf.
Young H, & Jaspers S. Review of nutrition and mortality indicators for the integrated food security phase classification (IPC) [Internet]. SCN Task Force on Assessment, Monitoring and Evaluation, and The Integrated Food Security Phase Classification (IPC) Global Partners; 2009. [cited 2018 March 30]. Available at : http://www.odi.org/publications/4616-nutrition-mortality-indicators-integrated-food-security-phase-classification-ipc.
Dukhi N, Sartorius B, Taylor M. Mid-upper arm circumference (MUAC) performance versus weight for height in South African children (0–59 months) with acute malnutrition. South African. J Clin Nutr. 2017;30:49-54. DOI: 10.1080/16070658.2016.1255483.
Isanaka S, Guesdon B, Labar AS, Hanson K, Langendorf C, Grais RF. Comparison of clinical characteristics and treatment outcomes of children selected for treatment of severe acute malnutrition using mid upper arm circumference and/or weight-for-height z-score. PLoS One. 2015;10:e0137606. DOI: 10.1371/journal.pone.0137606.
Pusponegoro HD, Wirya IGNW, Pudjiadi AH, Bisanto J, Zulkarnain SZ. Uji diagnostik. In: Sastroasmoro S, Ismael S, editors. Dasar-dasar metodologi penelitian klinis. 5th ed. Jakarta: Sagung Seto; 2014. p. 216-43.
Akobeng AK. Understanding diagnostic tests 1: sensitivity, specificity and predictive values. Acta Paediatr. 2007;96:338–41. DOI: 10.1111/j.1651-2227.2006.00180.x
Mogendi JB, De Steur H, Gellynck X, Saeed HA, Makokha A. Efficacy of mid-upper arm circumference in identification, follow-up and discharge of malnourished children during nutrition rehabilitation. Nutr Res Pract. 2015;9:268-77. DOI: 10.4162/nrp.2015.9.3.268
Briend A, Maire B, Fontaine O, Garenne M. Mid-upper arm circumference and weight-for-height to identify high-risk malnourished under-five children. Matern Child Nutr. 2012;8:130-3. DOI: 10.1111/j.1740-8709.2011.00340.x.
Dairo MD, Fatokun ME, Kuti M. Reliability of the mid upper arm circumference for the assessment of wasting among children aged 12 – 59 months in urban Ibadan, Nigeria. Int J Biomed Sci. 2012;8:140-3. DOI: 10.1371/journal.pone.0101159.
Copyright (c) 2020 Stephanie Adelia, Johannes Capistrano Susanto
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Authors who publish with this journal agree to the following terms:
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Accepted 2020-02-20
Published 2020-02-21
