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Background: The use of proportional weight gain as a discharge criterion for MUAC admissions to programs treating severe acute malnutrition (SAM) is no longer recommended by WHO. The critical limitation with the proportional weight gain criterion was that children who are most severely malnourished tended to receive shorter treatment compared to less severely malnourished children. Studies have shown that using a discharge criterion of MUAC ≥ 125 mm eliminates this problem but concerns remain over the duration of treatment required to reach this criterion and whether this discharge criterion is safe. This study assessed the safety and practicability of using MUAC ≥ 125 mm as a discharge criterion for community based management of SAM in children aged 6 to 59 months., Methods: A standards-based trial was undertaken in health facilities for the outpatient treatment of SAM in Lilongwe District, Malawi. 258 children aged 6 to 51 months were enrolled with uncomplicated SAM as defined by a MUAC equal or less than 115 mm without serious medical complications. Children were discharged from treatment as 'cured' when they achieved a MUAC of 125 mm or greater for two consecutive visits. After discharge, children were followed-up at home every two weeks for three months., Results: This study confirms that a MUAC discharge criterion of 125 mm or greater is a safe discharge criterion and is associated with low levels of relapse to SAM (1.9 %) and mortality (1.3 %) with long durations of treatment seen only in the most severe SAM cases. The proportion of children experiencing a negative outcome was 3.2 % and significantly below the 10 % standard (p = 0.0013) established for the study. All children with negative outcomes had achieved weight-for-height z-score (WHZ) above -1 z-scores at discharge. Children admitted with lower MUAC had higher proportional weight gains (p < 0.001) and longer lengths of stay (p < 0.0001). MUAC at admission and attendance were both independently associated with cure (p < 0.0001). There was no association with negative outcomes at three months post discharge for children with heights at admission below 65 cm than for taller children (p = 0.5798)., Conclusions: These results are consistent with MUAC ≥ 125 mm for two consecutive visits being a safe and practicable discharge criterion. Use of a MUAC threshold of 125 mm for discharge achieves reasonable lengths of stay and was also found to be appropriate for children aged six months or older who are less than 65 cm in height at admission. Early detection and recruitment of SAM cases using MUAC in the community and compliance with the CMAM treatment protocols should reduce lengths of stay and associated treatment costs.

Background: The objectives of this study were to (i) describe the relationship between weight changes and MUAC changes in children aged between 6 and 59 months during treatment for SAM in CMAM programmes in three country contexts (Malawi, Ethiopia and Bangladesh) admitted using MUAC and (ii) describe the sensitivity of both MUAC and weight to episodes of disease experienced during the SAM treatment episodes in CMAM programmes in three country contexts (Malawi, Ethiopia and Bangladesh) admitted using MUAC., Methods: Data collected under research conditions in Malawi were analysed for the correlation between MUAC and weight changes using the Pearson product-moment correlation coefficient (Pearson's r). Further data from other CMAM programmes implemented under field conditions in Ethiopia and Bangladesh were similarly analysed. The association of growth failure following recent episodes of illness were assessed for MUAC and weight change using a two-by-two table, box-plots and Kruskal Wallis non-parametric rank sum test., Results: MUAC and weight gain acheived over the entire treatment episode were strongly correlated in all three country contexts, Ethiopia (median Pearson's r = 0.816, 95 % CI = 0.782 - 0.845), Malawi (median Pearson's r = 0.843, 95 % CI = 0.802 - 0.876) and Bangladesh (median Pearson's r = 0.725, 95 % CI = 0.663 - 0.777). MUAC and weight changes at each outpatient visit were closely correlated (median Pearson's r = 0.954, 95 % CI = 0.602 - 0.997) under research conditions. The field data from Ethiopia and Bangladesh showed similar correlation (median Pearson's r = 0.945, 95 % CI = 0.685 - 0.998) and (median Pearson's r = 0.939, 95 % CI = 0.705 - 0.994) respectively. MUAC and weight appear to respond rapidly and similarly to episodes of illness reported during outpatient treatment for SAM for MUAC, diarrhoea RR = 1.88 (95 % CI = 1.64 - 2.15), vomiting RR = 1.89 (95 % CI = 1.58 - 2.26), fever RR = 1.57 (95 % CI = 1.36 - 1.82) and cough1.42 (95 % CI = 1.22 - 1.65). Similar relative risks are seen for weight; diarrhoea RR = 2.03 (95 % CI = 1.77 - 2.31), vomiting RR = 2.09 (95 % CI = 1.77 - 2.47), fever RR = 1.76 (95 % CI = 1.53 - 2.03) and cough RR = 1.25 (95 % CI = 1.06 - 1.48)., Conclusions: This study demonstrates a close relationship between MUAC and weight change during recovery from SAM under both research and operational field conditions. Furthermore, changes in both MUAC and weight are observed to occur similarly and rapidly during episodes of illness occurring during treatment with no lag effect on the part of MUAC. This presents the possibility for children undergoing outpatient treatment for SAM to be monitored using MUAC as an alternative to weight. Further research would be required to develop a tool which can be deployed safely and enable MUAC to be used as the sole anthropometric measure for admission, monitoring of recovery and discharge. This development would potentially allow the further decentralisation of the treatment of SAM thus improving programme coverage and child survival.