To evaluate the predictive ability of mid-upper arm circumference (MUAC) for detecting severe wasting (weight-for-height Z-score (WHZ) <−3) among children aged 6–59 months.

Cross-sectional survey.

Rural Uttar Pradesh, India.

Children (n 18 456) for whom both WHZ (n 18 463) and MUAC were available.

The diagnostic test accuracy of MUAC for severe wasting was excellent (area under receiver-operating characteristic curve = 0·933). Across the lower range of MUAC cut-offs (110–120 mm), specificity was excellent (99·1–99·9 %) but sensitivity was poor (13·4–37·2 %); with higher cut-offs (140–150 mm), sensitivity increased substantially (94·9–98·8 %) but at the expense of specificity (37·6–71·9 %). The optimal MUAC cut-off to detect severe wasting was 135 mm. Although the prevalence of severe wasting was constant at 2·2 %, the burden of severe acute malnutrition, defined as either severe wasting or low MUAC, increased from 2·46 to 17·26 % with cut-offs of <115 and <135 mm, respectively. An MUAC cut-off <115 mm preferentially selected children aged ≤12 months (OR=11·8; 95 % CI 8·4, 16·6) or ≤24 months (OR=23·4; 95 % CI 12·7, 43·4) and girls (OR=2·2; 95 % CI 1·6, 3·2).

Based on important considerations for screening and case detection in the community, modification of the current WHO definition of severe acute malnutrition may not be warranted, especially in the Indian context.

To characterize the epidemiology of wasting and identify the main predictors of wasting, severe wasting and poor weight-for-height in children.

We analysed a nationally representative sample of 2028 children (Multiple Indicator Survey, 2010).

Royal Kingdom of Bhutan.

Children aged 0–23 months.

Wasting prevalence was significantly higher among infants aged 0–11 months than among children aged 12–23 months (12·0 v. 6·7 %; P=0·004) and among boys than girls (11·0 v. 7·5 %; P=0·04). Children from the Western region had 63 % higher odds of being wasted than children from the Central/Eastern regions (adjusted OR (AOR)=1·63; 95 % CI 1·14, 2·34). Poor feeding practices were among the most significant predictors of wasting and severe wasting. Children who were given prelacteal feeds in the first days of life had 2·5 times higher odds of being severely wasted than those who were not (AOR=2·49; 95 % CI 1·19, 5·19); inadequate complementary feeding in children aged 0–23 months was associated with 58 % higher odds of being wasted (AOR=1·58; 95 % CI 1·02, 2·47) and 2·3 times higher odds of being severely wasted (AOR=2·28; 95 % CI 1·13, 4·58). The association of poor infant feeding practices with wasting and severe wasting was particularly significant in infants (0–11 months).

Programmes for the detection and treatment of severely wasted children need to prioritize very young children (0–11 months), particularly in the Western region. Programmes for the prevention of wasting need to prioritize the improvement of complementary foods and feeding practices in children aged 6–23 months.

To assess the appropriateness of current mid upper-arm circumference (MUAC) cut-offs to identify children with severe acute malnutrition in India.

The analysis concerned 6307 children admitted to nutrition rehabilitation centres (2009–2011) where they received therapeutic care as per guidelines by WHO and the Indian Academy of Pediatrics.

States of Jharkhand, Madhya Pradesh and Uttar Pradesh, India.

Children aged 6–59 months with bilateral pitting oedema or weight-for-height Z-score (WHZ)<−3 or MUAC<115 mm at admission.

Children aged 6–23 months represented ~80 % of the admissions. Among them, the proportion with WHZ<−3 was similar to that with MUAC<115 mm (85·7 % v. 81·8 %); the proportion with MUAC<115 mm whose WHZ was <−3 was 82·6 %; and the proportion with WHZ<−3 whose MUAC<115 mm was 78·8 %. MUAC<115 mm was as effective as WHZ<−3 in identifying 6–59-month-old children with medical complications (32·2 % v. 31·6 %, respectively), the most important risk factor of death among oedema-free children. Furthermore, death rates in children with MUAC<115 mm were higher than in children with WHZ<−3 (0·61 % v. 0·58 %, respectively) and 91 % of the deaths among oedema-free children were deaths of children with MUAC<115 mm.

In populations similar to those included in our analysis, MUAC<115 mm appears to be an appropriate criterion to identify children with severe acute malnutrition who are at a greater risk of medical complications and death, particularly among children 6–23 months old.

To assess the effectiveness of facility-based care for children with severe acute malnutrition (SAM) in malnutrition treatment centres (MTC).

Early detection and treatment of SAM using locally adapted protocols; assessment of programme outcomes, including survival, default, discharge and recovery rates.

All forty-eight MTC in Jharkhand, India.

Children (n 3595) with SAM admitted to MTC (1 July 2009–30 June 2011).

Of children admitted, 55·0 % were girls, 77·7 % were 6–23 months old and 68·6 % belonged to scheduled tribes or castes; 34·4 % had oedema or medical complications. Of the 3418 programme exits, the proportion of children who died was 0·6 % (n 20), the proportion of children who defaulted was 18·4 % (n 628) and the proportion of children discharged was 81·0 % (n 2770). Children's average weight gain was 9·6 (sd 8·4) g/kg body weight per d and their average length of stay was 16·0 (sd 5·7) d. Among the 2770 children who were discharged from the programme, 39·4 % (n 1090) gained 15 % or more of their initial weight while 60·6 % (n 1680) gained less than 15 % of their initial weight.

MTC provide live-saving care for children with SAM as demonstrated by high survival rates. However, the protocols and therapeutic foods currently used need to improve to ensure the recovery of all discharged children. MTC should be reserved for children with complicated SAM; children with uncomplicated SAM should be admitted to a community-based programme for the management of SAM, at a lesser risk to children and a lesser cost to families and the health system.

The present study aimed to compare two situations of endemic malnutrition among <5-year-old African children and to estimate the incidence, the duration and the case fatality of severe wasting episodes.

Secondary analysis of longitudinal studies, conducted several years ago, which allowed incidence and duration to be calculated from transition rates. The first site was Niakhar in Senegal, an area under demographic surveillance, where we followed a cohort of children in 1983–5. The second site was Bwamanda in the Democratic Republic of Congo, where we followed a cohort of children in 1989–92. Both studies enrolled about 5000 children, who were followed by routine visits and systematic anthropometric assessment, every 6 months in the first case and every 3 months in the second case.

Niakhar had less stunting, more wasting and higher death rates than Bwamanda. Differences in cause-specific mortality included more diarrhoeal diseases, more marasmus, but less malaria and severe anaemia in Niakhar. Severe wasting had a higher incidence, a higher prevalence and a more marked age profile in Niakhar. However, despite the differences, the estimated mean durations of episodes of severe wasting, calculated by multi-state life table, were similar in the two studies (7·5 months). Noteworthy were the differences in the prevalence and incidence of severe wasting depending on the anthropometric indicator (weight-for-height Z-score ≤–3.0 or mid upper-arm circumference <110 mm) and the reference system (National Center for Health Statistics 1977, Centers for Disease Control and Prevention 2000 or Multicentre Growth Reference Study 2006).

Severe wasting appeared as one of the leading cause of death among under-fives: it had a high incidence (about 2 % per child-semester), long duration of episodes and high case fatality rates (6 to 12 %).