MUAC as admission and/or discharge criteria in nutritional programs

Transcription

1 MUAC as admission and/or discharge criteria in nutritional programs International symposium on Understanding moderate Malnutrition in Children for Effective Interventions Dr Sandra Cohuet 28/05/14, Wien

2 Introduction Scale-up of community-based management of acute malnutrition (CMAM) Different approaches: Children at higher risk of short term mortality Children with excess risk of mid-term and long-term mortality Great variation in Caseload profile: eligibility criteria (age+sex) Capacity to deliver programs

3 Introduction Mid upper arm circumference (MUAC) and weight-forheight z-score (WHZ) used to diagnose SAM Imperfect and independant indicators Used as a proxy to assess nutritional status Do not always identify the same children W/H <-3 SD +/- oedema MUAC<115mm +/- oedema

4 Introduction In 2009, WHO and UNICEF recommended : Both WHZ and MUAC for diagnosis in children 6-59 months of age Percentage weight gain for discharge MUAC used in MSF field operations as single tool Easy to use Facilitates coverage Younger children At higher risk of mortality

5 Uncertainties and debate Strength of evidence to support use of MUAC as single criterion for admission, monitoring and/or discharge Concerns about excluding children with WHZ<-3 and MUAC 115mm

6 Methods Published literature (Pubmed) MSF program experience Indicators collected Recovery Length of stay Defaulter Weight, height, MUAC gain Short term mortality risk

7 Results Reference Country Age range (months) Number of children Myatt, 2006 Ethiopia Gossens, 2009 Burkina Faso Nielsen,2004 Guinea- Bissau Dale, 2013 North Sudan Admission criteria MUAC<110 mm and WHM>70% no oedema Outpatient and SFP MUAC<120 mm and/or Bilateral oedema Outpatient mainly MUAC<130 mm and/or Bilateral oedema Outpatient MUAC<115 mm and/or Bilateral oedema Outpatient Discharge criterion 15% weight gain 15% weight gain MUAC 130 mm MUAC >125 mm MSF-OCP Burkina Faso MUAC<120 mm and/or Bilateral oedema Outpatient mainly MUAC 124 mm MSF-OCBA India MUAC<115 mm and/or Bilateral oedema Outpatient mainly MUAC 120 mm

8 MUAC admission % of weight gain discharge Myatt, 2006 (Ethiopia) Goosens, (Burkina Faso) N MUAC cut off at admission (mm) Cured (%) length of stay (days) Recovery daily MUAC gain (mm/d) MUAC discharge (mm/d) WHZ Discharge (sd) Complications Dead (%) Defaulter (%) 42 <110 (OTP) <110 (SFP) < <

9 MUAC for admission + discharge Nielsen, 2004 (Guinea Bissau) Dale, 2013 (North Sudan) MSF-OCBA (India) MSF-OCP (Burkina Faso) MUAC cut off at admission (mm) Cured (%) length of stay (days) Recovery Weight daily gain (g/kg / /d) MUAC daily gain (mm/d) WHZ discharge (zs) Dead (%) Complications Non Responder (%) Defaulter (%) < / 1000 / d < / 1000 / d <100 NR NR NR < < <

10 42 deaths in total: 31% (13/42) occured in the program among children with z- score<-3 and MUAC>115mm Children potentially excluded: MUAC>115mm + WHZ<-3zs South Sudan MSF-OCP program MUAC<115mm WHZ<-3 & MUAC 115mm (N=787) (N=1526) Nutritional status at admission MUAC (mm) WHO 2006 WHZ Outcomes % % Recovery Death 4 1 Defaulter Response for children cured at discharge (N=704) Mean weight daily gain (g/kg/day) Mean MUAC daily gain, mm/day Length of stay, Days

11 Follow up of children with MUAC>115 mm and WHZ<- 3zs at admission* 158 children recruited in a PHC with WHZ<-3 zs and MUAC>115mm In a Slum in Dhaka, Bangladesh No nutritional intervention 2-weekly prospective follow-up home visits for 3 months Anthropometric evolution, morbidity and mortality monitored * «Is mid-upper arm circumference alone sufficient for deciding admission to a nutritional programme for childhood severe acute malnutrition in Bangladesh?» E.ALI et al. Trans R Soc Trop Med Hyg 2013; 107:

12 Follow up of children with MUAC>115mm and WHZ<- 3zs

13 Main conclusions from available data SAM diagnosed on low MUAC respond adequately Lower MUAC at admission greater MUAC daily gain «It seems acceptable to rely on MUAC as a single assessment tool for case finding and for admission of children with SAM to nutritional programmes» 15% weight gain as discharge criterion: Shortest length of stay in more severely malnourished children Most severely malnourished children being discharged when still malnourished MUAC more coherent discharge criterion

14 Discussion WHO Nutrition Expert Advisory Group (NUGAG) guideline recommends in 2013: percent weight gain should no longer be used as a discharge criterion in nutrition programs children admitted under one criterion are discharged under that same criterion

15 Conclusion Use of MUAC as single criteria of admission and/or discharge: Benefit/Risks Costs Which concrete implications for different stakeholders? MoH NGO UN agencies Further researchs needed