Objectives This study aims to describe the mortality risk of children in the community who had severe acute malnutrition (SAM) defined by either a mid-upper arm circumference (MUAC) <115mm, a low weight-for-height Z-score (WHZ) <-3 or both criteria. Methods We pooled individual-level data from children aged 6–59 months enrolled in 3 community-based studies in the Democratic Republic of the Congo (DRC), Senegal and Nepal. We estimate the mortality hazard using Cox proportional hazard models in groups defined by either anthropometric indicator. Results In total, we had 49,001 time points provided by 15,060 children available for analysis, summing to a total of 143,512 person-months. We found an increasing death rate with a deteriorating nutritional status for all anthropometrical indicators. Children identified as SAM only by a low MUAC (<115mm) and those identified only by a low WHZ (Z-score <-3) had a similar mortality hazard which was about 4 times higher than those without an anthropometric deficit. Having both a low MUAC and a low WHZ was associated with an 8 times higher hazard of dying compared to children within the normal range. The 2 indicators identified a different set of children; the proportion of children identified by both indicators independently ranged from 7% in the DRC cohort, to 35% and 37% in the Senegal and the Nepal cohort respectively. Conclusion In the light of an increasing popularity of using MUAC as the sole indicator to identify SAM children, we show that children who have a low WHZ, but a MUAC above the cut-off would be omitted from diagnosis and treatment despite having a similar risk of death.
Bibliographical noteFunding: The authors received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
We would like to acknowledge the principal investigators of the original studies: Jan Van den Broeck for the DRC cohort, Michel Garenne for the Senegal cohort, and Keith West for the Nepal cohort. The DRC study was supported by the Centre de Développement Intégrale–Bwamanda, and funding was provided by the Flemish Inter-University Council (Vlaamse Interuniversitaire Raad), the Belgian Administration for Development Cooperation, and the Nutricia Research Foundation. Catherine Schwinger is affiliated to the Centre for Intervention Science in Maternal and Child Health (CISMAC), which is funded by the Research Council of Norway through its Centres of Excellence funding scheme (project number 223269), the University of Bergen (UiB), Norway.