Skip to main page content
U.S. flag

An official website of the United States government

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Jun;13(3):247-255.
doi: 10.4162/nrp.2019.13.3.247. Epub 2019 May 31.

Performance of mid-upper arm circumference to diagnose acute malnutrition in a cross-sectional community-based sample of children aged 6-24 months in Niger

Sarah K Marshall  1 , Joel Monárrez-Espino  1   2 , Anneli Eriksson  1
Affiliations

Performance of mid-upper arm circumference to diagnose acute malnutrition in a cross-sectional community-based sample of children aged 6-24 months in Niger

Sarah K Marshall et al. Nutr Res Pract. 2019 Jun.

Abstract

Background/objectives: Accurate, early identification of acutely malnourished children has the potential to reduce related child morbidity and mortality. The current World Health Organisation (WHO) guidelines classify non-oedematous acute malnutrition among children under five using Mid-Upper Arm Circumference (MUAC) or Weight-for-Height Z-score (WHZ). However, there is ongoing debate regarding the use of current MUAC cut-offs. This study investigates the diagnostic performance of MUAC to identify children aged 6-24 months with global (GAM) or severe acute malnutrition (SAM).

Subjects/methods: Cross-sectional, secondary data from a community sample of children aged 6-24 months in Niger were used for this study. Children with complete weight, height and MUAC data and without clinical oedema were included. Using WHO guidelines for GAM (WHZ < -2, MUAC < 12.5 cm) and SAM (WHZ < -3, MUAC < 11.5 cm), the sensitivity (Se), specificity (Sp), predictive values, Youden Index and Receiver Operating Characteristic (ROC) curves were calculated for MUAC when compared with the WHZ reference criterion.

Results: Of 1161 children, 23.3% were diagnosed with GAM using WHZ, and 4.4% with SAM. Using current WHO cut-offs, the Se of MUAC to identify GAM was greater than for SAM (79 vs. 57%), yet the Sp was lower (84 vs. 97%). From inspection of the ROC curve and Youden Index, Se and Sp were maximised for MUAC < 12.5 cm to identify GAM (Se 79%, Sp 84%), and MUAC < 12.0 cm to identify SAM (Se 88%, Sp 81%).

Conclusions: The current MUAC cut-off to identify GAM should continue to be used, but when screening for SAM, a higher cut-off could improve case identification. Community screening for SAM could use MUAC < 12.0 cm followed by appropriate treatment based on either MUAC < 11.5 cm or WHZ < -3, as in current practice. While the practicalities of implementation must be considered, the higher SAM MUAC cut-off would maximise early case-finding of high-risk acutely malnourished children.

Keywords: Niger; Severe acute malnutrition; anthropometric measures; community screening; diagnosis.

PubMed Disclaimer

Conflict of interest statement

CONFLICT OF INTEREST: SKM, JME and AE declare that they have no potential conflicts of interests. AE is employed by, and JME is affiliated to Karolinska Institutet. None of the authors received funding or specific salary for this study or publication.

Figures

Fig. 1
Fig. 1. Study design and eligibility criteria.
MUAC, Mid-upper arm circumference; WHO, World Health Organisation
Fig. 2
Fig. 2. Empirical receiver operating characteristic (ROC) curve for diagnosis of GAM using MUAC.
ROC analysis was performed with continuous test variable MUAC against dichotomous criterion variable WHZ (z-score < −2 or > −2) to identify GAM in the total sample, n = 1,161 (AUC 0.89). GAM, Global Acute Malnutrition; MUAC, Mid-upper arm circumference; ROC, Receiver Operating Characteristic; WHZ, Weight-for-height z-score.
Fig. 3
Fig. 3. Receiver operating characteristic (ROC) curve for diagnosis of SAM using MUAC.
ROC analysis was performed with continuous test variable MUAC against dichotomous criterion variable WHZ (z-score < −3 or > −3) to identify SAM in the total sample, n = 1,161 (AUC 0.94). MUAC, Mid-upper arm circumference; ROC, Receiver Operating Characteristic; SAM, Severe Acute Malnutrition; WHZ, Weight-for-height z-score.
Fig. 4
Fig. 4. Prevalence of GAM and SAM identified using current WHO guidelines and MUAC < 12.0 cm.
MUAC < 12.0 cm identified from ROC analysis. ‘Either WHZ or MUAC’ denotes classification of acute malnutrition in one child using either of the indicators alone. ‘Both WHZ and MUAC’ denotes classification of acute malnutrition of one child using both indicators. GAM, Global Acute Malnutrition; MUAC, Mid-upper arm circumference; ROC, Receiver Operating Characteristic; SAM, Severe Acute Malnutrition; WHZ, Weight-for-height z-score.
Fig. 5
Fig. 5. Screening process for CMAM with SAM MUAC < 12.0 cm.
CMAM, Community-based Management of Acute Malnutrition; MUAC, Mid-upper arm circumference; SAM, Severe Acute Malnutrition; WHZ, Weight-for-height z-score.
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

    1. United Nations Children's Fund; World Health Organization; World Bank Group. Levels and Trends in Child Malnutrition, UNICEF - WHO - World Bank Group Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2015.
    1. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-McGregor S, Katz J, Martorell R, Uauy R Maternal and Child Nutrition Study Group. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382:427–451. - PubMed
    1. World Health Organization; United Nations Children's Fund. WHO Child Growth Standards and the Identification of Severe Acute Malnutrition in Infants and Children: a Joint Statement. Geneva: World Health Organization; 2009. - PubMed
    1. World Health Organization. Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children. Geneva: World Health Organization; 2013. - PubMed
    1. 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.