Identification of Acute Malnutrition in Children in Cambodia Requires Both Mid Upper Arm Circumference and Weight-For-Height to Offset Gender Bias of Each Indicator.

Frank Wieringa,Jacques Berger,Arnaud Laillou,Etienne Poirot,Valérie Greffeuille,Ludovic Gauthier,Marjoleine Dijkhuizen,Somphos Som,Chhoun Chamnan

doi:10.3390/nu10060786

Abstract

Malnutrition remains a serious health problem in Cambodia with over 10% of children less than five years of age suffering from acute malnutrition. In addition to the presence of nutritional edema, two indicators are recommended by the World Health Organization for the diagnosis of acute malnutrition: weight-for-height Z-scores (WHZ; with acute malnutrition defined as WHZ < −2 Z-score) and mid-upper arm circumference (MUAC, with acute malnutrition defined as MUAC < 12.5 cm). Earlier, we showed that WHZ and MUAC identified different subgroups of children with acute malnutrition. To explore factors associated with both indicators of acute malnutrition, we analyzed baseline data from a longitudinal study in three provinces in Cambodia: Phnom Penh (capital, urban environment), Kratie (rural province), and Ratanakiri (hilly, rural province). Data was available for 4381 children below 30 months of age. Malnutrition rates were higher in the two rural provinces than in the capital. Although both MUAC and WHZ showed gender bias, with MUAC identifying more girls, and WHZ identifying more boys with acute malnutrition, the gender effect was strongest for MUAC. The gender bias of MUAC diminished with older age, but remained significant up to 30 months of age. Only using both MUAC and WHZ as indicators resulted in gender neutral identification of acute malnutrition. WHZ alone always identified more children with acute malnutrition than MUAC alone. In Phnom Penh, MUAC alone identified only 11% with acute malnutrition in addition to WHZ. To conclude, both MUAC and WHZ showed gender bias in this cohort of Cambodian children. In Cambodia, implementation of a MUAC-only or a WHZ-only program for the identification of acute malnutrition would be unethical as it will lead to many children remaining undiagnosed.

Highlights

Acute malnutrition (AM), which includes both marasmus and kwashiorkor, is still a major health threat in children, associated with a remarkably higher risk for mortality and morbidity
In South-Sudan, mid-upper arm circumference (MUAC) < 11.5 cm failed to identify 1/3 of the children who died of acute malnutrition while admitted to a therapeutic feeding program [7]
Overall prevalence of AM was lower in Ratanakiri (17.2%) than in Kratie (23.5%, P < 0.05)

Summary

Introduction

Acute malnutrition (AM), which includes both marasmus and kwashiorkor, is still a major health threat in children, associated with a remarkably higher risk for mortality and morbidity. An estimated 19 million children are affected by severe acute malnutrition every year, and an estimated 34 million suffer from moderate acute malnutrition [2]. In addition to the presence of nutritional edema, indicating kwashiorkor, the World Health. Organization recommends using either weight-for-height Z scores (WHZ) and/or mid-upper arm circumference (MUAC) for diagnosing acute malnutrition in children above six months of age [4]. Whereas WHZ has been used for several decades in the diagnosis of nutritional status in children, MUAC was introduced in the 1990s as an easier tool to use in field settings [5], and appeared to be a more precise indicator to predict mortality in malnourished children [6]. Acute malnutrition is further distinguished as being severe (WHZ < −3 scores and/or MUAC < 11.5 cm) or moderate

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Conclusion