title: Optimal screening of children with acute malnutrition requires a change in current WHO guidelines as MUAC and WHZ identify different patient groups.
abstract: BACKGROUND
  Timely treatment of acute malnutrition in children <5 years of age could prevent >500,000 deaths annually. Screening at community level is essential to identify children with malnutrition. Current WHO guidelines for community screening for malnutrition recommend a Mid Upper Arm Circumference (MUAC) of <115 mm to identify severe acute malnutrition (SAM). However, it is currently unclear how MUAC relates to the other indicator used to define acute malnutrition: weight-for-height Z-score (WHZ).
  
  
  METHODS
  Secondary data from >11,000 Cambodian children, obtained by different surveys between 2010 and 2012, was used to calculate sensitivity and ROC curves for MUAC and WHZ.
  
  
  RESULTS
  The secondary analysis showed that using the current WHO cut-off of 115 mm for screening for severe acute malnutrition over 90% of children with a weight-for-height z-score (WHZ) <-3 would have been missed. Reversely, WHZ<-3 missed 80% of the children with a MUAC<115 mm.
  
  
  CONCLUSIONS
  The current WHO cut-off for screening for SAM should be changed upwards from the current 115 mm. In the Cambodian data-set, a cut-off of 133 mm would allow inclusion of >65% of children with a WHZ<-3. Importantly, MUAC and WHZ identified different sub-groups of children with acute malnutrition, therefore these 2 indicators should be regarded as independent from each other. We suggest a 2-step model with MUAC used a screening at community level, followed by MUAC and WHZ measured at a primary health care unit, with both indicators used independently to diagnose severe acute malnutrition. Current guidelines should be changed to reflect this, with treatment initiated when either MUAC <115 mm or WHZ<-3.
authors.affiliation: UNICEF, Maternal Child Health and Nutrition section, Phnom Penh, Cambodia.
authors.forename: Arnaud
authors.initials: A
authors.lastname: Laillou
authors.affiliation: National Nutrition Program, Maternal and Child Health Center, Phnom Penh, Cambodia.
authors.forename: Sophonneary
authors.initials: S
authors.lastname: Prak
authors.affiliation: Independent consultant, Phnom Penh, Cambodia.
authors.forename: Richard
authors.initials: R
authors.lastname: de Groot
authors.affiliation: World Food Programme, Phnom Penh, Cambodia.
authors.forename: Sophie
authors.initials: S
authors.lastname: Whitney
authors.affiliation: UNICEF, Maternal Child Health and Nutrition section, Phnom Penh, Cambodia.
authors.forename: Joel
authors.initials: J
authors.lastname: Conkle
authors.affiliation: World Food Programme, Patumwan, Bangkok, Thailand.
authors.forename: Lindsey
authors.initials: L
authors.lastname: Horton
authors.affiliation: UNICEF, Maternal Child Health and Nutrition section, Phnom Penh, Cambodia.
authors.forename: Sam Oeurn
authors.initials: SO
authors.lastname: Un
authors.affiliation: Department of Human nutrition, Copenhagen University, Frederiksberg C, Denmark.
authors.forename: Marjoleine A
authors.initials: MA
authors.lastname: Dijkhuizen
authors.affiliation: Institut de Recherche pour le Développement, UMR 204, IRD/Montpellier1/Montpellier2/SupAgro (NUTRIPASS), Montpellier, France.
authors.forename: Frank T
authors.initials: FT
authors.lastname: Wieringa
mesh_terms: D000208:Acute Disease; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D044342:Malnutrition / Q000175:diagnosis*; D015596:Nutrition Assessment; D012372:ROC Curve; D014944:World Health Organization