Moderate Acute Malnutrition in a Prospective Cohort of Refugee Children: Common, but Often Transient or Unresponsive...

Moderate acute malnutrition (MAM) may be identified using low weight-for-length-z-scores (WLZs) or mid-upper arm circumference (MUAC), but increasingly MUAC alone is used.

This study aims to examine how identification as MAM, using WLZ compared with MUAC, relates to prior and subsequent growth and survival, and to explore a more selective screening approach.

A longitudinal cohort was constructed using routine clinic anthropometric data from 4131 children, monitored monthly in refugee camps in Bangladesh. Children with WLZ >-3 to <-2 or MUAC >115 to <125 mm were identified as MAM and managed with counseling and food supplements.

Between ages 6 and 24 mo, 1586 (38%) children met criteria for MAM (40.3% isolated low MUAC, 41.3% isolated low WLZ, and 18.5% with both). Of these, 44.1% had persistent MAM (low mean values across two 3-mo periods) but 29.3% were transient (screen positive only at 1 measurement point), particularly those identified by WLZ (48.2%). A prior decline in weight-for-age z-score (WAZ) of >0.2 SD was observed in 87.5% of children with low WLZ, compared with 56.0% with low MUAC, who also, on average, showed no gain in WAZ after treatment and were more likely to already be stunted. Children with both, or with persistent MAM were more likely to die than those with no MAM [relative risk both: 3.2; 95% confidence interval: 1.5, 6.8; persistent: 2.51 (1.4, 4.7)]. MUAC-only screening would have missed 25% with persistent MAM.

Screening for MAM identifies a high proportion of children, of whom many have only transient MAM or do not appear to benefit from treatment. A staged approach using increasingly stringent screening criteria could reduce the work of screening and the need for supplementary foods. This approach needs to be formally trialed.