Mid Upper Arm Circumference (MUAC) ≥120mm as a simple, safe and effective discharge criterion
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Mid Upper Arm Circumference (MUAC) ≥120mm as a simple, safe and effective discharge criterion in community management of Severe Acute Malnutrition (SAM) in Bihar, India 1 Sakib Burza, 1 Raman Mahajan, 2 Nuria Salse, 2 Cristian Casademont, 1 Elisa Marino 1 MSF – New Delhi, India 2 MSF – Barcelona, Spain Programme Characteristics Summary • In-programme mortality rate <1% • Mean increase in W/H Z-score at discharge 1.59 (CI =1.55-1.62). • 76.2% of children reached W/H≥-2SD at discharge, representing a younger mean admission age (15.3 months) • 2.0% of children remained <-3SD at discharge, representing an older mean age at admission (20.3 months) • No significant difference of admission MUAC between strata (p=0.1) • No significant difference in length-of-stay, stunting, mean MUAC and height increase between strata (p>0.05) Background WHO/UNICEF recommends admission criteria for SAM as MUAC <115mm and/or Weight-for-Height Z-score (WHZ) of <-3SD in children 6-59 months. Although 15% body-weight increase is increasingly accepted as inappropriate for discharge, debate continues regarding the appropriate MUAC and/or W/H cut-offs, with very little evidence available. MUAC is accepted as an effective and simpler method for screening and admitting children with SAM. Its application as a discharge tool will allow feasible upscaling of CMAM in India. MSF program criteria in Bihar Admission criteria: MUAC <115mm +/- oedema Discharge criteria: MUAC ≥120mm + no oedema + good clinical condition Conclusions: When analysing exit W/H, Length Of Stay and Average Weight Gain, MUAC≥120mm discharge demonstrated acceptable programme characteristics. Relapse rates were significantly higher in children with W/H<-3SD at time of discharge but absolute numbers were small (2%), not reflected in mortality and represented an older admission population. Mortality and relapse rates were similar in children attaining MUAC≥125mm and those ≥120 but <125mm at time of discharge. The low prevalence of SAM in 24-59 months age group and high prevalence of severe stunting in Bihar may limit validity in other contexts. Analysis Methodology Long Term Outcomes 1349 of these children were sampled for follow up between 3-18 months post discharge • 76.8% (n=1036) successfully traced • Overall mortality and relapse rates were 0.8% and 4.0% respectively • Higher relapses but similar mortality comparing W/H<3 and ≥-2SD at time of discharge • Relapse and mortality was similar in those children who reached ≥125mm (n=161, 15.5%) compared with ≥120 to <125mm at time of discharge (p>0.5). 2477 children • Admitted with MUAC <115mm • Discharged with MUAC ≥120mm Excluded from analysis: • Oedema (n=8, 0.3%) • Length of stay in program <14 days (n= 95, 3.8%) • Length of stay in program >140 days (n= 71, 2.9%) Included in final analysis: N=2303 Long term outcomes • 1036 children traced 3 - 18 months post discharge • 75% of all children identified traced Weight for Height Z Score at Discharge (SD) (Note all had MUAC ≥120mm) Overall Parameter <-3 (n=45, 2.0%) ≥-3 to <-2 (n=503, 21.8%) ≥-2 (n=1755, 76.2%) N=2303 Mean Age at admission 20.3 (11.5) 18 (9.2) 15.3 (8.0) 16.0 (8.5) Mean WHZ at admission -4.1 (1.1) -3.5 (0.7) -2.9 (0.8) -3.1 (0.8) Mean WHZ at discharge -3.3 (0.3) -2.4 (0.3) -1.2 (0.6) -1.5 (0.8) Mean MUAC at admission (mm) 110.7 (5.6) 110.9 (4.3) 109.2 (6.1) 109.6 (5.8) Average gain in MUAC (mm/day) 0.35 (0.2) 0.35 (0.2) 0.38 (0.2) 0.38 (0.2) Average weight gain (g/kg/day) 3.7 (3.0) 4.0 (3.1) 5.2 (3.2) 4.9 (3.2) Mean % increase in body weight 12.6 (8.8) 14.1 (7.7) 20.5 (12.1) 18.9 (11.6) Mean increase in height (mm/day) 0.39 (0.6) 0.24 (0.4) 0.20 (0.4) 0.22 (0.4) Average length of stay (days) 44.6 (25.7) 46.1 (29.1) 48.0 (28.9) 47.5 (28.9) Mean HAZ at admission (indicator of stunting) -3.3 (2.0) -3.4 (1.5) -3.6 (1.5) -3.6 (1.5) Severe stunting at admission (%) 62.2 60 67.4 65.7
description
Sakib Burza, Raman Mahajan, Nuria Salse, Cristian Casademont and Elisa Marino
Transcript of Mid Upper Arm Circumference (MUAC) ≥120mm as a simple, safe and effective discharge criterion
Mid Upper Arm Circumference (MUAC) ≥120mm as a simple, safe and effective discharge criterion in community management of Severe Acute Malnutrition (SAM) in Bihar, India
1Sakib Burza, 1Raman Mahajan, 2Nuria Salse, 2Cristian Casademont, 1Elisa Marino
1MSF – New Delhi, India 2MSF – Barcelona, Spain
Programme Characteristics Summary • In-programme mortality rate <1% • Mean increase in W/H Z-score at discharge 1.59 (CI =1.55-1.62). • 76.2% of children reached W/H≥-2SD at discharge, representing a younger mean admission age (15.3 months) • 2.0% of children remained <-3SD at discharge, representing an older mean age at admission (20.3 months) • No significant difference of admission MUAC between strata (p=0.1) • No significant difference in length-of-stay, stunting, mean MUAC and height increase between strata (p>0.05)
Background WHO/UNICEF recommends admission criteria for SAM as MUAC <115mm and/or Weight-for-Height Z-score (WHZ) of <-3SD in children 6-59 months. Although 15% body-weight increase is increasingly accepted as inappropriate for discharge, debate continues regarding the appropriate MUAC and/or W/H cut-offs, with very little evidence available.
MUAC is accepted as an effective and simpler method for screening and admitting children with SAM. Its application as a discharge tool will allow feasible upscaling of CMAM in India. MSF program criteria in Bihar Admission criteria: MUAC <115mm +/- oedema Discharge criteria: MUAC ≥120mm + no oedema + good clinical condition
Conclusions: When analysing exit W/H, Length Of Stay and Average Weight Gain, MUAC≥120mm discharge demonstrated acceptable programme characteristics. Relapse rates were significantly higher in children with W/H<-3SD at time of discharge but absolute numbers were small (2%), not reflected in mortality and represented an older admission population. Mortality and relapse rates were similar in children attaining MUAC≥125mm and those ≥120 but <125mm at time of discharge. The low prevalence of SAM in 24-59 months age group and high prevalence of severe stunting in Bihar may limit validity in other contexts.
Analysis Methodology
Long Term Outcomes 1349 of these children were sampled for follow up between 3-18 months post discharge • 76.8% (n=1036) successfully traced • Overall mortality and relapse rates were 0.8% and 4.0% respectively • Higher relapses but similar mortality comparing W/H<3 and ≥-2SD at time of discharge • Relapse and mortality was similar in those children who reached ≥125mm (n=161, 15.5%) compared with ≥120 to <125mm at time of discharge (p>0.5).
2477 children • Admitted with MUAC <115mm • Discharged with MUAC ≥120mm
Excluded from analysis: • Oedema (n=8, 0.3%) • Length of stay in program <14
days (n= 95, 3.8%) • Length of stay in program >140
days (n= 71, 2.9%)
Included in final analysis: N=2303
Long term outcomes • 1036 children traced 3 - 18 months post
discharge • 75% of all children identified traced
Weight for Height Z Score at Discharge (SD) (Note all had MUAC ≥120mm)
Overall
Parameter <-3 (n=45, 2.0%)
≥-3 to <-2 (n=503, 21.8%)
≥-2 (n=1755, 76.2%)
N=2303
Mean Age at admission
20.3 (11.5) 18 (9.2) 15.3 (8.0) 16.0 (8.5)
Mean WHZ at admission
-4.1 (1.1) -3.5 (0.7) -2.9 (0.8) -3.1 (0.8)
Mean WHZ at discharge
-3.3 (0.3) -2.4 (0.3) -1.2 (0.6) -1.5 (0.8)
Mean MUAC at admission (mm)
110.7 (5.6) 110.9 (4.3) 109.2 (6.1) 109.6 (5.8)
Average gain in MUAC (mm/day)
0.35 (0.2) 0.35 (0.2) 0.38 (0.2) 0.38 (0.2)
Average weight gain (g/kg/day)
3.7 (3.0) 4.0 (3.1) 5.2 (3.2) 4.9 (3.2)
Mean % increase in body weight
12.6 (8.8) 14.1 (7.7) 20.5 (12.1) 18.9 (11.6)
Mean increase in height (mm/day)
0.39 (0.6) 0.24 (0.4) 0.20 (0.4) 0.22 (0.4)
Average length of stay (days)
44.6 (25.7) 46.1 (29.1) 48.0 (28.9) 47.5 (28.9)
Mean HAZ at admission (indicator of stunting)
-3.3 (2.0) -3.4 (1.5) -3.6 (1.5) -3.6 (1.5)
Severe stunting at admission (%)
62.2 60 67.4 65.7
