Mid-upper-arm-circumference (MUAC) is used to
detect severe acute malnutrition (SAM) among under-five children in
community settings due to its ease of use. WHO had earlier fixed a
cut-off of 110 mm, but later suggested a new cut-off of 115 mm for
defining SAM based on experience from African countries [1]. However,
there is a paucity of data validating these cut-offs in Indian setting
[2].
A community-based cross-sectional survey was carried
out in four districts of Haryana. In each district, 10% of Sub-centres
(SC) areas were selected randomly with representation from rural, urban
and slum areas according to Probability Proportionate to Size. 40
children were selected from each sub-centre, divided equally from two
randomly selected villages under the Sub-centre. A total of 2466
children in the age group 6 mo-6 years were included in the study.
Anthropometric measurements such as weight (up to nearest 1g, using TARE
function), height (up to nearest 1 mm) and recumbent length in case of
infants (up to nearest 1 mm) were measured using standard equipment and
procedures by graduate level field investigators who were trained in use
of anthropometric equipment [3]. The Mid Upper Arm Circumference (MUAC)
was measured using Shakir’s tape [4]. Nutritional assessment was carried
out using WHO Child Growth Standards according to z-score
classification. Sensitivity, specificity, positive predictive value
(PPV) and negative predictive value (NPV) of MUAC method was calculated
for different cut-offs against weight-for-height Z scores below –3.
Ethical clearance was obtained from the Institute Ethics Committee of
Post Graduate Institute of Medical Education and Research (PGIMER),
Chandigarh. The children diagnosed with SAM were referred to the
district hospital, with follow up by local Auxiliary nurse midwife.
The study population included 1428 (58%) males. The
mean (SD) age of subjects was 29.3 (14.5) months. The mean (SD) weight,
height and MUAC were 10.5 (2.64) kg, 83.1 (10.67) cm, and 14.1 (1.4) cm,
respectively. As compared to the gold standard test, MUAC (<115 mm)
method was found to have a high specificity (96.4%) and NPV (92.2%) but
very low PPV (14.3%) and sensitivity (6.9%). Sensitivity and positive
predictive values were higher when MUAC –3 Z score cut-off was used as
compared to MUAC less than 11.5 cm cut-off (Web
Table I). Prevalence of SAM when computed using WHZ scores
was found to be 3.5% (children below –3 WHZ score), but with MUAC
method, it was found to be 2.3% and 1.8% for children below –3 MUAC
Z-score and children with less than 11.5 cm MUAC, respectively. In this
study, the prevalence of SAM based on WHZ was found to around two times
than those based on a MUAC cut-off of 115 mm. Other studies have
reported that MUAC and WHZ identify different populations of children
with SAM [5,6]. Previous studies have recommended higher cut-off levels
(135 or more, even 155 mm) [7,8].
Contributors: JPT: data analysis,
preparation of the first draft of the manuscript and editing of the
draft. AS: collection of data, analysis of data and editing of
the draft. SP: conceived the idea, supervised data collection and
edited the manuscript.
Funding: National Rural Health Mission of the
Government of Haryana. Competing interests: None stated.
References
1. WHO Child Growth Standards and the Identification
of Severe Acute Malnutrition in Infants and Children. A Joint Statement
by the World Health Organization and the United Nations Children’s Fund.
Geneva: World Health Organization, 2009
2. Shekhar S, Shah D. Validation of mid-upper arm
circumference cut-offs to diagnose severe wasting in Indian children.
Indian Pediatr. 2012;49:496-7.
3. CDC. National Health and Nutrition Examination
Survey (NHANES): Anthropometry Procedures Manual. Atlanta: Centre for
Disease Control; January 2007.
4. Shakir A. Arm circumference in the surveillance of
protein-calorie malnutrition in Baghdad. Am J Clin Nutr.
1975;28:661-5.
5. Ali E, Zachariah R, Shams Z, Vernaeve L, Alders
P, Salio F, et al. Is mid-upper arm circumference alone
sufficient for deciding admission to a nutritional programme for
childhood severe acute malnutrition in Bangladesh? Trans R Soc Trop Med
Hyg. 2013; 107:319-23.
6. WHO child growth standards and the identification
of severe acute malnutrition in infants and children. World Health
Organization and UNICEF, 2009.
7. 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.
8. Kumar R, Aggarwal AK, Iyenger S. Nutritional
status of children: validity of mid-upper arm circumference for
screening undernutrition. Indian Pediatr. 1995;33: 189-96.
9. Hop le T, Gross R, Sastroamidjojo S, Giay T, Schultink
W. Mid-upper-arm circumference development and its validity in
assessment of undernutrition. Asia Pac J Clin Nutr. 1998;7: 65-9.
