Determining an optimal case definition using mid-upper arm circumference with or without weight for age to identify childhood wasting in the Philippines

Abstract

In resource-limited areas, where accurate weight-for-height Z-scores are hard to obtain, Mid-Upper Arm Circumference (MUAC) is a simple tool to identify wasted children. MUAC alone, however, may miss identification of many wasted children, leading to untimely intervention and potentially death. Our study aimed to identify the best-performing case definition to detect wasting by Weight-for-Height z-scores (WHZ) in Filipino children aged 6-59 months. We analyzed the 2018-2019 Expanded National Nutrition Survey to assess the diagnostic performance of MUAC cutoffs and a case definition combining MUAC and weight-for-age z-score (WAZ) in identifying moderate and severe wasting compared to the WHZ criterion. The optimal cutoff and case definition was identified as having the highest area under the receiver operating characteristic curve (AUROC). Our findings showed that the current MUAC cutoffs poorly identify severe (sensitivity: 13%; specificity: 99%; AUROC: 0.558) and moderate (sensitivity: 22%; specificity: 96%; AUROC: 0.586) wasting (N = 30,522) in Filipino children. Instead, the optimal MUAC cutoff for severe and moderate wasting were <13.6cm (sensitivity: 62%; specificity: 76%; AUROC: 0.690) and 14.0cm (sensitivity: 80%; specificity: 67%; AUROC: 0.737). There was no effect of sex on MUAC cutoffs, but cutoffs increased with age. We found that the combination of WAZ < -2 or MUAC ≤ 11.7cm (Sensitivity: 80%; Specificity: 80%; AUROC: 0.800) for severe wasting and WAZ < -2 or MUAC ≤ 12.7cm (Sensitivity: 84%; Specificity: 78%; AUROC: 0.810) for moderate wasting significantly improved sensitivity for acceptable decreases in specificity. In summary, implementing alternative case definitions solely based on expanding MUAC insufficiently improves diagnostic accuracy for identifying wasted children by WHZ criteria. Combining WAZ with MUAC could increase the number of eligible children identified and treated by the Philippine Integrated Management of Acute Malnutrition. Further studies are advised to understand the practicality and cost-effectiveness of using the proposed alternative case definitions in the Philippines.

Fig 1. ROC curve of MUAC cutoffs against weight-for height/length Z-scores (moderate wasting).

Fig 2. ROC curve of MUAC cutoffs against weight-for height/length Z-scores (severe wasting).