Response to Briend et al "Low mid-upper arm circumference identifies children with a high risk of death who should be the priority target for treatment"

Mid-upper-arm circumference (MUAC) and weight-for-height (WHZ) are both used as diagnostic criteria for severe acute malnutrition (SAM). We have shown that the majority of children who satisfy one criterion do not satisfy the other in all the countries examined. The direction and degree of this discordance varies dramatically from country to country without a satisfactory explanation. These findings have not been disputed, but the logical consequences and conclusions are criticised in the accompanying paper by Briend et al. We dispute Briend et al’s criticisms and present arguments: 1) that all-cause mortality ROC curves from community studies are not definitive evidence in favour of MUAC-only programs; 2) that studies of series of patients should not be dismissed as irrelevant; 3) that children with a low WHZ are not healthy ;4) that the reason for the discrepancy is not simply due to body shape; 5) that the papers quoted in our previous publication have been misrepresented; 6) that the suggestion that simply increasing the cut-off point for MUAC in an attempt to encompass all the children with a SAM by WHZ-only is not a viable option; and, 7) that the discrepancy presents a threat to current therapeutic programs .Up to 45% of the 6 to 59 month old SAM children in the community with a WHZ below -3Z score have a MUAC which is above 115mm. These children are malnourished, suffer and need treatment no matter whether they have low MUAC or not, they also respond excellently to treatment and can be salvaged. The reasons for the discrepancy are secondary to the main point that WHZ children suffer and need treatment which is denied by a MUAC- only program. Death is not the only adverse outcome of SAM, the other negative outcomes are important and need to be addressed. It is our contention that MUAC-only programs are acceptable in countries where the majority of global acute malnutrition (GAM) cases are diagnosed by MUAC, in countries where the majority of GAM cases are only identified by WHZ, MUAC-only programs are not acceptable if the majority of children at risk are to be treated. Coverage assessed by MUAC is below acceptable levels in nearly all countries because those with a low WHZ are then excluded from screening, diagnosis and treatment and are thus not counted. Denial of their risk presents a real threat to these children and is unethical. MUAC only programs are addressing a section of the malnourished population, are to be encouraged and scaled up where appropriate. WHZ measurement is not in competition with such programs, is complementary and should be retained as a diagnostic criterion until a satisfactory alternative is found to identify and treat the children that are now being excluded from treatment.