Academic literature on the topic 'Mid-arm circumference (MAC)'

Background: The incidence of low birth weight babies continues to be high in India at about 30% in contrast to 5-7% in developed countries. Perinatal, neonatal and infant mortality as well as morbidity is associated with low birth weight (LBW) neonates of which, it is the Small for Gestational Age (SGA) neonates that are at increased risk. Henceforth, it becomes important to study the prevalence of SGA babies and to compare various anthropometric measurements among term neonates for assessing as to which of these could be taken as surrogate markers of small for gestational age babies.Methods: It was a cross sectional study conducted over a period of 2 years among 100 term neonates delivered in a private medical college in Puducherry, India.Results: The prevalence of low birth weight babies and small for gestational age was found to be 40% and 30% respectively. Using mid arm circumference as a predictor, the sensitivity, specificity, positive predictive value and negative predictive value of SGA was found to be 100%, 57.14%, 50% and 100% respectively. Using MAC/HC ratio as a predictor, the sensitivity, specificity, positive predictive value and negative predictive value was found to be 46.67%, 100%, 100% and 81.4% respectively.Conclusions: In predicting SGA babies, mid arm circumference has the highest sensitivity whereas MAC/HC ratio has the highest specificity followed by mid arm circumference. Present study concluded that mid arm circumference and ratio of MAC/HC are very helpful in identifying SGA neonates among term neonates.

BMI, mid-arm circumference (MAC) and calf circumference (CC) are anthropometric indicators often included in geriatric health measurement scales. However, their relative effectiveness in predicting long-term mortality risk has not been extensively examined. The present study aimed to evaluate the relative effectiveness of these anthropometrics in predicting long-term mortality risk in older adults. The study prospectively analysed the ability of these indicators in predicting 4-year follow-up mortality risk of a population-representative sample of 4191 men and women, 53 years of age or older in the ‘Survey of Health and Living Status of the Elderly in Taiwan’. Cox regression analyses were performed to evaluate the association of follow-up mortality risk with low ( < 21 kg/m2) or high ( ≥ 27 kg/m2) BMI, low MAC ( < 23·5/22 cm for men/women) and low CC ( < 30/27 cm) respectively, according to Taiwanese-specific cut-off points. Results showed that low CC and low MAC were more effective than low BMI in predicting follow-up mortality risk in 65–74-year-old elderly. But low CC and low BMI were more effective than low MAC in ≥ 75-year-old elderly, and low BMI was more effective than low MAC or low CC in 53–64-year-old persons. High BMI was not effective in predicting mortality risk in any of these age ranges. These results suggest that in elderly adults, CC is more effective than BMI in predicting long-term mortality risk. Thus, more consideration to CC and MAC in designing geriatric health or nutritional measurement scales is recommended.

Background: To know the correlation between birth weight and mid arm circumference (MAC). To test the sensitivity and specificity of cut off limits of MAC for the identification of low-birth-weight babies <2000 gm and <2500 gm.Methods: In this observational study, 300 children were enrolled. Birth weight was measured using electronic weighing scale of accuracy 10 grams within 24 hours of life. Right MAC was measured using non-stretchable tap to the nearest of 0.1 cm at the midpoint between tip of olecranon process of ulna and the acromian process of scapula. Data was analyzed using SPSS. Different cut offs for MAC and their sensitivity, specificity to identify LBW babies <2.5 kg was analyzed through ROC. The study was approved by the institutional ethics committee.Results: MAC highly correlated with weight (p<0.001). A MAC of <10 cm, predicts a birth weight of ≤2500 gm, with a sensitivity of 93% and specificity of 49% MAC of ≤9 cm, predicts a birth weight of ≤2000 gm, with a sensitivity of 95% and specificity of 87%. Regression values were analyzed and formula for detecting birth weight for the given MAC was derived.Conclusions: A positive correlation existed between midarm circumference and birth weight (p<0.001). A cut off value of 10 cm of MAC for identification of low-birth-weight babies weighting ≤2500 gm and 9 cm of MAC for identification of low-birth-weight babies ≤2000 gm with optimum sensitivity and specificity.

Abstract Objectives Malnutrition is common in cirrhosis and is associated with a worse prognosis. This study aimed to evaluate the nutritional status by mid-arm circumference (MAC) and the association between MAC and mortality in patients with decompensated cirrhosis. Methods This is a prospective cohort study performed with hospitalized decompensated cirrhotic patients. Nutritional status was assessed within 72 hours of admission, from April 2017 to April 2018. Patients with values of MAC ≤5th percentile were considered malnourished. Survival over time was estimated using Kaplan-Meier curves and significant predictors of 30-days and long-term mortality were identified using Cox proportional hazards models. Results One-hundred patients with an average age of 60.1 ± 10.3 years were evaluated. Of these, 63% were male. The presence of ascites was the most observed complication with a prevalence of 69%, followed by variceal bleeding in 24% and hepatic encephalopathy in 22%. The median of follow-up time of patients was 11.2 months (range, 2.4–21). Overall mortality was 60% and mortality in 30-days was 16%. Malnourished patients through MAC (30%) were significantly more likely to die in either follow-up of 30-days (Log-rank value: 0.008) and long-term mortality (Log-rank value: 0.001). The 30-days probabilities of survival were 70% in patients malnourished by MAC compared to 90% in patients with MAC values &gt; 5th percentile. In multivariate analysis, after adjustment for age and Child-Pugh score, patients with malnutrition had a higher risk of 30-days mortality (HR: 3.64; 95% CI 1.33–9.95; P = 0.012) and after total period of follow-up (HR: 2.21; 95% CI 1.30–3.73; P &lt; 0.001). Higher values of MAC were associated with a reduced overall mortality risk in 30-days and long-term of 15% and 8%, respectively. Conclusions Malnutrition, assessed by a simple bedside anthropometric parameter, can predict short-term and long-term follow-up mortality risk in patients with decompensated cirrhosis. Therefore, MAC may be an efficacious tool to assess nutritional status and identify patients with a high risk of mortality. Funding Sources This study was supported by a CAPES and FIPE/HCPA scholarship. The sources of funding were not involved in study design; in collection, analysis and interpretation of the data.

Objective Malnutrition is widespread among patients undergoing hemodialysis and is linked to high morbidity and mortality rates. We evaluated the nutritional status and malnutrition markers in patients undergoing hemodialysis in Macao. Methods We performed a cross-sectional analysis of 360 patients in a hemodialysis center. The modified quantitative subjective global assessment (MQSGA), anthropometric indices and related biochemical test data were used to evaluate nutritional status. Results The sample's mean age was 63.47 ± 13.95 years. There were 210 well-nourished (58.3%), 139 mild-to-moderately malnourished (38.6%) and 11 severely malnourished (3.1%) patients. Older patients had a higher incidence of severe malnutrition, but there were no significant differences between diabetic and non-diabetic patients. Mid-arm circumference (MAC); mid-arm muscle circumference; body mass index; triceps skin fold thickness; serum albumin, creatinine and urea; and hemoglobin were all valid for assessing nutritional status. MAC and the serum albumin and creatinine concentrations significantly negatively correlated with MQSGA. Conclusions Malnutrition is commonplace in patients undergoing hemodialysis in Macao, but their nutritional status is not affected by diabetes. Serum creatinine, serum albumin and MAC, and especially pre-dialysis creatinine concentration, represent effective, readily available, and easily remembered screening measures of nutritional status for patients undergoing maintenance dialysis.

Background: Overweight and obesity are two health conditions that contribute to the impaired quality of life. Two parameters of obesity also indicating body composition, body mass index (BMI) and waist circumference (WC), have been used as simple tools to assess abdominal visceral fats. The correlation between both measurements and visceral fats remains unclear.Objective: The study aims at demonstrating that body mass index and waist circumference may reflect visceral fats using bioelectrical impedance analysis in adolescents.Methods: First-year students of the Faculty of Medicine Diponegoro University participated in the study. This cross-sectional study measured BMI, WC, mid-arm circumference (MAC), and visceral fat (VF) of 130 participants. BMI, WC, MAC, and VF were assessed using Omron digital scale, measuring tape, and body impedance analysis, respectively. Spearman test was used for the bivariate analysis while multiple regression was employed to perform multivariate analysis. Significant results were determined if p value <0.05 for the bivariates.Results: The correlation between body mass index and visceral fats showed a strong value with r: 0.794 and p-value=<0.001. The correlation between mid-arm circumference and visceral fats showed r= 0.713 and p value=<0.001. Meanwhile the correlation between waist circumference and visceral fats showed r= 0.655 and p value=<0.001. BMI and WC showed the greatest correlation to VF. The comparison between genders resulted in men having stronger relationships between BMI and VF, and WC and VF.Conclusion: BMI and waist circumference are strongly related to visceral fats based on BIA in medical students.

Malnutrition is common in chronic liver disease. The general objective of this study was to assess severity and nutritional status of cirrhotic patients in Tribhuvan University Teaching Hospital (TUTH). A cross-sectional study was carried out among 88 cirrhotic patients of age group of ≥18 years. Information regarding general profile of patient, Child Turcotte Pugh score (CTP), Model for End Stage Liver Diseases-Na Score ( MELD-Na), Subjective Global Assessment (SGA), Mid Arm Circumference (MAC), Triceps Skin Fold Thickness (TST), Mid Arm Muscle Circumference (MAMC) and Functional Assessment: Handgrip Strength (HGS) was collected. SPSS version 20 was used to analyse data. Majority (56.8%) belonged to CTP grade C, 31.8% belonged to CTP grade B and 11.4% patients belonged to CTP grade A. Majority, 72.7%, 71.6% and 65.9% were malnourished when assessed using SGA, TST and MAC respectively. Majority, 86.4% of the patients had impaired handgrip strength. SGA, TST, MAC and HGS were significantly associated with CTP whereas no any statistically significant association was found between Child-Pugh and MAMC. There was statistically significant difference among the MELD Na means among SGA and HGS classes. The mean MELD Na scores did not significantly differ between among the TST, MAC and MAMC classes. The early diagnosis of the nutritional state and the treatment of malnutrition in cirrhotic patients can contribute to a reduction in the frequency and/or severity of these complications. SGA, TST, MAC and HGS are the non-invasive and easy methods of nutritional assessment of cirrhotic patients to use in regular clinical practice at bed side.

Objective To assess the nutritional status of patients on maintenance hemodialysis by using modified quantitative subjective global assessment (MQSGA) and anthropometric measurements. Method We Conducted a cross sectional descriptive analytical study to assess the nutritional status of fifty four patients with chronic kidney disease undergoing maintenance hemodialysis by using MQSGA and different anthropometric and laboratory measurements like body mass index (BMI), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), triceps skin fold (TSF) and biceps skin fold (BSF), serum albumin, C-reactive protein (CRP) and lipid profile in a government tertiary hospital at Kathmandu, Nepal. Results Based on MQSGA criteria, 66.7% of the patients suffered from mild to moderate malnutrition and 33.3% were well nourished. None of the patients were severely malnourished. CRP was positive in 56.3% patients. Serum albumin, MAC and BMI were (mean + SD) 4.0 + 0.3 mg/dl, 22 + 2.6 cm and 19.6 ± 3.2 kg/m2 respectively. MQSGA showed negative correlation with MAC ( r = −0.563; P = < 0.001), BMI ( r = −0.448; P = < 0.001), MAMC ( r = −0.506; P = < .0001), TSF ( r = −0.483; P = < .0002), and BSF ( r = −0.508; P = < 0.0001). Negative correlation of MQSGA was also found with total cholesterol, triglyceride, LDL cholesterol and HDL cholesterol without any statistical significance. Conclusion Mild to moderate malnutrition was found to be present in two thirds of the patients undergoing hemodialysis. Anthropometric measurements like BMI, MAC, MAMC, BSF and TSF were negatively correlated with MQSGA. Anthropometric and laboratory assessment tools could be used for nutritional assessment as they are relatively easier, cheaper and practical markers of nutritional status.

Introduction: Malnutrition is a common problem in hemodialysis patient, which is associated with increased mortality and morbidity. There is paucity of data regarding the nutritional status of patient on maintenance hemodialysis in developing countries. This study attempts to access nutritional status of patients on hemodialysis in tertiary referral hospital on western region of Nepal and correlate it with biochemical and laboratory parameters.Methods: A total of fifty patients on hemodialysis were evaluated. Nutritional assessment was made by Subjective Global Assessment (SGA) score, anthropometrics [Body Mass Index (BMI), Triceps Skin Fold Thickness (TSF), Mid Arm Circumference (MAC), Mid Arm Muscle Circumference (MAMC) and biochemical tests.Results: The study assessed 50 patients (34 males and 16 females) with mean age of 54 ± 14 years. Seventy eight percent (39) patients had mild to moderate malnutrition. Anthropometric parameters like BMI, TSF, MAC with normal nutrition were significantly higher than in patients with mild to moderate malnutrition. Malnutrition score (MS) by SGA significantly correlated with duration of dialysis. However, serum albumin was not statistically significant.Conclusion: Malnutrition is very common in patients undergoing hemodialysis with SGA having significant correlation with duration of dialysis. Routine nutritional monitoring among such patients are extremely important for diagnosing malnutrition early on, thus preventing complications and reducing the morbidity and mortality rates in this population.

Older adults, especially those acutely ill, are vulnerable to developing malnutrition due to a range of risk factors. The high prevalence and extensive consequences of malnutrition in hospitalised older adults have been reported extensively. However, there are few well-designed longitudinal studies that report the independent relationship between malnutrition and clinical outcomes after adjustment for a wide range of covariates. Acutely ill older adults are exceptionally prone to nutritional decline during hospitalisation, but few reports have studied this change and impact on clinical outcomes. In the rapidly ageing Singapore population, all this evidence is lacking, and the characteristics associated with the risk of malnutrition are also not well-documented. Despite the evidence on malnutrition prevalence, it is often under-recognised and under-treated. It is therefore crucial that validated nutrition screening and assessment tools are used for early identification of malnutrition. Although many nutrition screening and assessment tools are available, there is no universally accepted method for defining malnutrition risk and nutritional status. Most existing tools have been validated amongst Caucasians using various approaches, but they are rarely reported in the Asian elderly and none has been validated in Singapore. Due to the multiethnicity, cultural, and language differences in Singapore older adults, the results from non-Asian validation studies may not be applicable. Therefore it is important to identify validated population and setting specific nutrition screening and assessment methods to accurately detect and diagnose malnutrition in Singapore. The aims of this study are therefore to: i) characterise hospitalised elderly in a Singapore acute hospital; ii) describe the extent and impact of admission malnutrition; iii) identify and evaluate suitable methods for nutritional screening and assessment; and iv) examine changes in nutritional status during admission and their impact on clinical outcomes. A total of 281 participants, with a mean (+SD) age of 81.3 (+7.6) years, were recruited from three geriatric wards in Tan Tock Seng Hospital over a period of eight months. They were predominantly Chinese (83%) and community-dwellers (97%). They were screened within 72 hours of admission by a single dietetic technician using four nutrition screening tools [Tan Tock Seng Hospital Nutrition Screening Tool (TTSH NST), Nutritional Risk Screening 2002 (NRS 2002), Mini Nutritional Assessment-Short Form (MNA-SF), and Short Nutritional Assessment Questionnaire (SNAQ©)] that were administered in no particular order. The total scores were not computed during the screening process so that the dietetic technician was blinded to the results of all the tools. Nutritional status was assessed by a single dietitian, who was blinded to the screening results, using four malnutrition assessment methods [Subjective Global Assessment (SGA), Mini Nutritional Assessment (MNA), body mass index (BMI), and corrected arm muscle area (CAMA)]. The SGA rating was completed prior to computation of the total MNA score to minimise bias. Participants were reassessed for weight, arm anthropometry (mid-arm circumference, triceps skinfold thickness), and SGA rating at discharge from the ward. The nutritional assessment tools and indices were validated against clinical outcomes (length of stay (LOS) >11days, discharge to higher level care, 3-month readmission, 6-month mortality, and 6-month Modified Barthel Index) using multivariate logistic regression. The covariates included age, gender, race, dementia (defined using DSM IV criteria), depression (defined using a single question “Do you often feel sad or depressed?”), severity of illness (defined using a modified version of the Severity of Illness Index), comorbidities (defined using Charlson Comorbidity Index, number of prescribed drugs and admission functional status (measured using Modified Barthel Index; MBI). The nutrition screening tools were validated against the SGA, which was found to be the most appropriate nutritional assessment tool from this study (refer section 5.6) Prevalence of malnutrition on admission was 35% (defined by SGA), and it was significantly associated with characteristics such as swallowing impairment (malnourished vs well-nourished: 20% vs 5%), poor appetite (77% vs 24%), dementia (44% vs 28%), depression (34% vs 22%), and poor functional status (MBI 48.3+29.8 vs 65.1+25.4). The SGA had the highest completion rate (100%) and was predictive of the highest number of clinical outcomes: LOS >11days (OR 2.11, 95% CI [1.17- 3.83]), 3-month readmission (OR 1.90, 95% CI [1.05-3.42]) and 6-month mortality (OR 3.04, 95% CI [1.28-7.18]), independent of a comprehensive range of covariates including functional status, disease severity and cognitive function. SGA is therefore the most appropriate nutritional assessment tool for defining malnutrition. The TTSH NST was identified as the most suitable nutritional screening tool with the best diagnostic performance against the SGA (AUC 0.865, sensitivity 84%, specificity 79%). Overall, 44% of participants experienced weight loss during hospitalisation, and 27% had weight loss >1% per week over median LOS 9 days (range 2-50). Wellnourished (45%) and malnourished (43%) participants were equally prone to experiencing decline in nutritional status (defined by weight loss >1% per week). Those with reduced nutritional status were more likely to be discharged to higher level care (adjusted OR 2.46, 95% CI [1.27-4.70]). This study is the first to characterise malnourished hospitalised older adults in Singapore. It is also one of the very few studies to (a) evaluate the association of admission malnutrition with clinical outcomes in a multivariate model; (b) determine the change in their nutritional status during admission; and (c) evaluate the validity of nutritional screening and assessment tools amongst hospitalised older adults in an Asian population. Results clearly highlight that admission malnutrition and deterioration in nutritional status are prevalent and are associated with adverse clinical outcomes in hospitalised older adults. With older adults being vulnerable to risks and consequences of malnutrition, it is important that they are systematically screened so timely and appropriate intervention can be provided. The findings highlighted in this thesis provide an evidence base for, and confirm the validity of the current nutrition screening and assessment tools used among hospitalised older adults in Singapore. As the older adults may have developed malnutrition prior to hospital admission, or experienced clinically significant weight loss of >1% per week of hospitalisation, screening of the elderly should be initiated in the community and continuous nutritional monitoring should extend beyond hospitalisation.

Les recommandations actuelles de l’OMS séparent les enfants atteints de malnutrition aiguë sévère (MAS) non-œdémateux en trois phénotypes anthropométriques : faible périmètre brachiale (PB) seul ; faible indice poids-taille (IPT) seul ; ou faible PB et ITP. Tous sont éligibles à une réhabilitation nutritionnelle selon les lignes directrices de l’OMS.Cependant, pour des raisons de facilité d’utilisation, et sur la base de données suggérant une surmortalité chez les enfants atteints de MAS diagnostiquée par le seul PB, plusieurs agences et gouvernements considèrent ce dernier critère comme nécessaire et suffisant à l’éligibilité pour une prise en charge de la MAS, excluant de fait les enfants présentant uniquement un faible IPT. Ce changement de paradigme semble prématuré : les liens entre phénotype anthropométrique, retentissement fonctionnelle et risque associés n’ont pas encore été élucidés. En effet, plusieurs ré-analyse de données anciennes montrent que les enfants atteints de MAS inéligibles à une prise en charge sur la base du seul PB (c’est-à-dire les enfants avec uniquement un faible IPT) présentent un risque de décès similaire à ceux éligibles. De plus, ces analyses suggèrent que les enfants présentant simultanément les deux déficits anthropométriques ont un risque de mortalité encore supérieur.Cette thèse vise à décrire et comparer physiopathologie et de la gravité fonctionnelle associée aux phénotypes anthropométriques d’enfants atteints de MAS. En se basant sur l’état actuel des connaissances sur la vulnérabilité chez ces derniers, ces travaux cherchent à répondre à la question suivante : comment les profils de vulnérabilité des enfants atteints de MAS inéligibles à une prise en charge dans le cadre d’un programme basé sur le PB seul (i.e., faible IPT-seul) se comparent-ils aux profils de ceux qui seraient éligibles?Une étude de cohorte multicentrique a été réalisé chez des enfants atteints de MAS sans complications ni œdèmes au Bangladesh, au Burkina Faso, et au Libéria. Les patients ont été inclus de façon équilibré parmi les trois phénotypes anthropométriques. Un large panel de paramètres cliniques et biochimiques indicateurs du statut nutritionnel et de l’état de santé a été recueilli à l’admission à – et à des points clés pendant – la réhabilitation nutritionnelle. Nous avons évalué de nouveaux biomarqueurs de la physiopathologie et de la survie en plus des biomarqueurs conventionnels de l’état de santé et de la dénutrition : la leptine sérique, un paramètre prédictif robuste de mortalité chez les enfants atteints de MAS ; l’abondance isotopique naturelle du carbone et de l’azote (δ13C et δ15N) dans le cheveux, offrant un intéressant historique nutritionnel et métabolique ; la bio-impédancemétrie, une technique mobile et non-invasive pour l’évaluation de la composition corporelle adaptée à une utilisation sur le terrain ; et la mesure de paramètres biochimiques d’inflammation (protéines de la phase aiguë) et de déficience en micronutriments (vitamine A et fer).L’analyse de ces indicateurs ont monté que tous les enfants atteints de MAS, quel que soit leur phénotype anthropométrique, présentent des signes cliniques de dénutrition et des preuves biologiques de déficience en micronutriments—mais avec une hétérogénéité significative sur certains paramètres clés. Les enfants avec un faible IPT seul présentent des anomalies cliniques et biologiques plus sévères que les enfants avec un faible PB seul. Ces résultats montrent également que les enfants avec les deux déficits anthropométriques présentent le risque de morbi-mortalité le plus élevé sur le court terme, et après prise en charge. Ainsi, nos résultats plaident en faveur du maintien de l’IPT comme critère diagnostique indépendant, en accord avec les recommandations de l’OMS. Le développement de méthodes diagnostiques innovantes permettant d’identifier, directement dans la communauté, les enfants présentant un faible IPT doit être une priorité de recherche
Current WHO diagnostic recommendations segregate non-edematous children with severe acute malnutrition (SAM) into one of three anthropometric phenotypes, those with: (1) low mid-upper arm circumference (MUAC) only; (2) low weight-for-height z-score (WHZ) only; or (3) both low MUAC and low WHZ—all of which are eligible for nutritional rehabilitation according to WHO guidelines.But, based on both ease of use and reports purporting higher mortality in SAM identified by MUAC, many agencies and some national governments use only MUAC as the sole diagnostic criterion for admission to therapeutic refeeding programs—disqualifying low WHZ only children from access to treatment. This diagnostic paradigm shift is premature because the links between anthropometric phenotype and functional severity have not yet been clearly delineated. In fact, recent secondary analyses of historic databases have shown that children with SAM that are excluded from treatment within the framework of a MUAC-only program (i.e., low WHZ only) have a similar risk of death as those who are included; moreover, children with both anthropometric deficits (i.e., low MUAC and low WHZ) have a higher risk of death.This dissertation aims to describe and compare the pathophysiology and functional severity associated with the anthropometric phenotypes of children with SAM today. Building on existing comparative work on vulnerability in SAM, it asks: how does the vulnerability profile of children with SAM who are excluded from treatment within the framework of a MUAC-only program (i.e., low WHZ only) compare to the profiles of those children who are included (i.e., low MUAC only and/or both low MUAC and low WHZ)?A multi-centric cohort study was conducted in uncomplicated, non-edematous children with SAM in Bangladesh, Burkina Faso and Liberia. Participants were recruited equally into each of the three anthropometric phenotypes. A wide range of clinical and biochemical indicators of health and nutritional status were collected at admission to, and at key time points throughout, therapeutic refeeding. We assessed emerging biomarkers of pathophysiology and viability in addition to traditional indicators of health status and nutritional deprivation. These included: serum leptin, a robust biochemical predictor of mortality in children with SAM; natural isotopic abundances of carbon and nitrogen (δ13C and δ15N) in hair, promising archives of metabolic status; bio-electric impedance, a portable, non-invasive technique for assessing body composition in the field-setting; and combined biochemical assessment of micronutrient deficiencies (vitamin A and iron) and inflammation (acute phase proteins).Analysis of these indicators demonstrated that all children with SAM (i.e., low WHZ and/or low MUAC) presents with clinical evidence of nutritional deprivation and micronutrient deficiencies, with significant heterogeneities on key criteria. Children with low WHZ only have biochemical and clinical deficits that are more severe than those in children with low MUAC only. These results also indicate that children with both anthropometric deficits have the highest risk of acute and post-discharge death and morbidity. On this basis, low WHZ must be retained as an independent diagnostic criterion, in line with WHO recommendations. Further research is urgently needed to develop innovative diagnostic solutions to identify low WHZ children in the community

This rapid review synthesises the literature on how community-based management of acute malnutrition (CMAM) programmes could be adapted in settings of conflict and fragility. It identifies multiple factors affecting the quality and effectiveness of CMAM services including the health system, community engagement and linkages with other programmes, including education, sanitation, and early childhood development. Family MUAC (Mid-Upper Arm Circumference) is a useful tool to increase community participation and detect early cases of moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) more effectively and less likely to require inpatient care. The literature does not say a lot about m-Health solutions (using mobile devises and applications) in data collection and surveillance systems. Many of the above-mentioned issues are relevant for CMAM programmes in settings of non-emergency, emergency, conflict and fragility. However, there are special circumstance in conflict and fragile settings that need adaptation and simplification of the standard protocols. Because of a broken or partly broken health system in settings of conflict and fragility, local governments are not able to fund access to adequate inpatient and outpatient treatment centres. NGOs and humanitarian agencies are often able to set up stand-alone outpatient therapeutic programmes or mobile centres in the most affected regions. The training of community health volunteers (CHVs) is important and implementing Family MUAC. Importantly, research shows that: Low literacy of CHVs is not a problem to achieve good nutritional outcomes as long as protocols are simplified. Combined/simplified protocols are not inferior to standard protocols. However, due to complexities and low funding, treatment is focused on SAM and availability for children with MAM is far less prioritised, until they deteriorate to SAM. There is widespread confusion about combined/simplified protocol terminology and content, because there is no coherence at the global level.