Safety and practicability of using mid-upper arm circumference as a discharge criterion in community based management of severe acute malnutrition in children aged 6 to 59 months programmes

Abstract

Background: The use of proportional weight gain as a discharge criterion for MUAC admissions to programs treating severe acute malnutrition (SAM) is no longer recommended by WHO. The critical limitation with the proportional weight gain criterion was that children who are most severely malnourished tended to receive shorter treatment compared to less severely malnourished children. Studies have shown that using a discharge criterion of MUAC ≥ 125 mm eliminates this problem but concerns remain over the duration of treatment required to reach this criterion and whether this discharge criterion is safe. This study assessed the safety and practicability of using MUAC ≥ 125 mm as a discharge criterion for community based management of SAM in children aged 6 to 59 months.

Methods: A standards-based trial was undertaken in health facilities for the outpatient treatment of SAM in Lilongwe District, Malawi. 258 children aged 6 to 51 months were enrolled with uncomplicated SAM as defined by a MUAC equal or less than 115 mm without serious medical complications. Children were discharged from treatment as 'cured' when they achieved a MUAC of 125 mm or greater for two consecutive visits. After discharge, children were followed-up at home every two weeks for three months.

Results: This study confirms that a MUAC discharge criterion of 125 mm or greater is a safe discharge criterion and is associated with low levels of relapse to SAM (1.9 %) and mortality (1.3 %) with long durations of treatment seen only in the most severe SAM cases. The proportion of children experiencing a negative outcome was 3.2 % and significantly below the 10 % standard (p = 0.0013) established for the study. All children with negative outcomes had achieved weight-for-height z-score (WHZ) above -1 z-scores at discharge. Children admitted with lower MUAC had higher proportional weight gains (p < 0.001) and longer lengths of stay (p < 0.0001). MUAC at admission and attendance were both independently associated with cure (p < 0.0001). There was no association with negative outcomes at three months post discharge for children with heights at admission below 65 cm than for taller children (p = 0.5798).

Conclusions: These results are consistent with MUAC ≥ 125 mm for two consecutive visits being a safe and practicable discharge criterion. Use of a MUAC threshold of 125 mm for discharge achieves reasonable lengths of stay and was also found to be appropriate for children aged six months or older who are less than 65 cm in height at admission. Early detection and recruitment of SAM cases using MUAC in the community and compliance with the CMAM treatment protocols should reduce lengths of stay and associated treatment costs.

Keywords: Discharge criteria; Mid Upper Arm Circumference (MUAC); Severe Acute Malnutrition (SAM).

Fig. 1

Venn diagram showing anthropometric categories of all admissions

Fig. 2

Flow diagram showing outcomes and exclusions. The study was discontinued at two health centres due to a fall to zero recruitment

Fig. 3

a Box plot describing Attendance rate for ‘cured’ and ‘non-cured’ SAM cases. b: Box plot describing MUAC at admission for ‘cured’ and ‘non-cured’ SAM cases

Fig. 4

a Histogram showing distribution of duration of treatment episode. b: Box plots describing the length of stay for three classes of MUAC at admission c Histogram showing the distribution of proportional weight gains at discharge. d Box plots describing proportional weight gain at discharge for three classes of MUAC at admission

Fig. 5

a Box plot describing length of stay by height at admission for two height classes. b: Box plot describing proportional weight gain by height at admission for two height classes