It will be a problem for us to used MUAC for the children less than 6 months because muac is not recoommended for children less than (<-6.)

Dear Anonymous 563, NIPP circles have been designed to include most significant 'at risk' groups of suffering from malnutrition. As the project is a community based initiative, led by volunteers and implemented at a grass roots level, the use of simple and easy screening tools are essential. MUAC is the only simple and relatively easy-to-use anthropometric tool available, that provides us with the ability to screen for at risk individuals. As you correctly point out, there are no current guidelines on the use of MUAC <6mths, but there is research being undertaken and some published information; see: http://www.who.int/bulletin/volumes/90/12/12-109009/en/index.html, in which the study found, using a MUAC cut-off of less than 105mm to be highly specific in selecting infants at a very high risk of death (hazard risk 23 (4.2–122)), and using a MUAC cut-off of less than 110mm illustrated 9.5 times risk of death (hazard risk 9.5 (2.6–35)). As such, and in the absence of current guidelines, we have chosen to use MUAC <11cm with appetite in children 2-6mths as an indicator of MN. Any child without appetite, or where the mother is not producing adequate milk, would be referred to a health facility with IMAM. FYI: rationale for this age range (from 2mths) is based on the rapid rise of MUAC from birth to 2mths (illustrated by scatter plots), after which, most are >11cm. Please note however, that the use of MUAC is merely used as a screening tool to identify HHs with infants that it is thought would benefit from the package of educative and behaviour change support that NIPPs aim to deliver. Families with infants who are flagged as potentially at risk (using this measure), but not severe, are prioritised for inclusion in the circles. The females will receive practical support around breastfeeding / key IYCF messages, plus support for their own improved nutrition, whilst males will focus on ways to support their wives/daughters to undertake these practices. Just because there are no international guidelines available to us as yet, doesn't mean we need to exclude this group from project inclusion. We are eagerly awaiting further developments in this area, as it is possible that infants within this age range with a MUAC <105mm would benefit from a highly intensive therapeutic treatment regime while using >110mm would be ideal in identifying infants at a high risk of death but in a more stable condition, whereby community based support might be appropriate.

WRT "It will be a problem for us to used [sic] MUAC for the children less than 6 months because muac is not recoommended [sic] for children less than (<-6.)" from an anonymous poster (above) ... this is not strictly true. Hatty has posted a link to relevant work (published by the WHO). The main issue is that we do not have proven programming modes (i.e. simple protocols that can be delivered by CHWs and above like we have with CTC / CMAM in older children) for these children. The article suggests that in the absence of proven programming modes we should still do something for young children with MUAC below a specific threshold (i.e. 110 mm) as they are at considerable risk of near term mortality and may benefit from clinical assessment and intervention. The evidence is (IMO) clear and is from an experienced and reputable team (KEMRI, LSHTM) working under strict ethical oversight. We know from experiences in (e.g.) the UK that very young children with poor anthropometry can be "saved". Making this happen took a lot of trial and error and some missteps with complications such as probable iatrogenic retinopathy in pre-term infants. Hatty is surely correct when she states "Just because there are no international guidelines available to us as yet, doesn't mean we need to exclude this group from project inclusion. We are eagerly awaiting further developments in this area, as it is possible that infants within this age range with a MUAC < 105mm would benefit from a highly intensive therapeutic treatment regime while using > 110mm would be ideal in identifying infants at a high risk of death but in a more stable condition, whereby community based support might be appropriate". We cannot learn how to help these children unless we first try to help them. I think that we cannot claim to be running child survival programs and do nothing for children we know to be at high risk of near-term mortality (other than glibly write them off which is the implication of the anonymous statement). Just my tuppence.

Sorry - small error on my part. Where I write, 'it is possible that infants within this age range with a MUAC < 105mm would benefit from a highly intensive therapeutic treatment regime while using > 110mm would be ideal in identifying infants at a high risk of death but in a more stable condition'. The reference to 110mm should read less than <110mm (not greater than).