An interesting observation! I think it overstates the current situation. We do still have some NGOs and local UN offices who love complicated methods (e.g. W/H) which shut mothers out from case-finding and admission decisions. The general drift of CTC/CMAM programming is, however, to involve the mother (and other community members) more and more. A recent advance is in using mothers as the case-finder and locus of control for deciding admission using their own MUAC straps (see [url=http://www.archpublichealth.com/content/73/1/26/abstract]this article[/url] for some information on how this is possible). I do not think we should be complacent. Some agencies and some individuals will continue to resist participatory programming and we need to keep innovating and pushing in this regard.

Dear Mark, You highlight the fundamental importance of mothers being enabled to participate in assessment and decision-making around the care of their children. However, calculating weight for height does not, by definition, shut out mothers from case-finding and admission decisions. The key is the interaction and communication with the mother about what is happening and why, irrespective of the nature of the assessment. Indeed, Massimo found that measuring weight offered an opportunity and time for engagement with a mother. The mother can participate in the actual measurement process, which is a lot more reassuring for both the mother and child, especially for young infants. MUAC's identification of children with higher risk of mortality is a big plus. No doubt it is also a simpler measure to undertake and explain and it is great to see, in recent work, how mothers are being empowered to take charge of this measure (we'll be featuring this in the upcoming issue of Field Exchange). However there is a lack of evidence of what happens to children with low WHZ and 'acceptable' MUAC if not admitted to a treatment programme; our sense from the exchanges on en-net and in Field Exchange, and from the WHZ/MUAC review we did, is that this is the fundamental concern that fuels continued use of WHZ in the context of CMAM. The weight/height discussion is not limited to CMAM programming. It is worth considering too that many countries are still including clinic-based/health post growth monitoring in national programmes, which at least means health staff are thinking about and supporting mothers around growth and nutrition of their children.

Dear Massimo, I work in India where Growth monitoring and Promotion is an important component of the work of the Government Nutrition worker/ Anganwadi worker as she is called. And like you explain they are trained and expected to communicate to the mother in exactly the same way you explained in your post. The Growth chart based on weight for age is easy to understand by the mother. A woman with limited literacy is able to easily understand the upward curve- flattening or a curve which dips downwards. In India many agencies use what are called Community Growth charts where the growth of all children is marked and the chart displayed so that the local community can also clearly understand how many children are growth faltering and which families need special attention. This was all well before the recent re introduction of the MUAC tapes - this is again not uniformly introduced in a large country like India - different states are in different phases of introduction of this tool. In states where there is introduced the worker and the mother are now equally confused - a child who seems to be fine on the W/A chart is now red on the MUAC and it is required that he/she requires urgent attention. CMAM is not yet rolled out in India at scale and hence the option available to such a mother is facility based management where it is available- she is often not able to spare the time to go to the Special Nutrition unit for admission. There is also a lot of scepticism about the Monthly Growth Monitoring itself -there is no clear evidence that it actually serves to improve the situation of the child by alerting the mother- in many states the weighing efficiency i.e the % of children who are weighed monthly of those eligible remains low. In a country like ours where the nutrition emergency is a protracted one and there is not yet a guideline on CMAM, weighing monthly and the Growth chart remain useful simple tools to help mothers understand the growth of their children. I would hesitate in our country to hand out MUAC straps to mothers unless the Government workers themselves and the system itself is prepared to handle these children and in locations where MAM is the major contributor to GAM. There is still not even consensus if W/H or MUAC cutoff should be used to screen children for Acute Malnutrition. We have a long way to go yet.

Evidence is clear regarding screening for disease. To be effective for an individual is has to be done frequently. To be effective at a population level is has to be done to all members of the population at-risk. This high temporal and spatial coverage of screening is not feasible with W/H except in very small and proximate populations. It is certainly not possible for mothers to use W/H. MUAC does not suffer from these problems. We can give each mother (and others) a colour-banded MUAC strap and they can use it as often as they want and they are proximate to the child. The nature of the assessment is key to achieving high spatial and temporal coverage as well as to empowering mothers. If we are to take your assertion at face-value we should be (e.g) using dual-energy x-ray absorptiometry to screen children. Reductio ad absurdum. There is evidence that the discordant (i.e. high MUAC but low W/H) children do better than low MUAC children. W/H is strongly influenced by body shape and linear growth of children is predominantly in the limbs. This means that, in some populations at least, these high MUAC but low W/H children will be the healthiest of children. These are the older "SAM" kids that take a sachet of RUTF and then play football for hours outside the clinic. I have no strong objections to GMP programs but this programming mode has not been as successful as we hoped when it was introduced. I think that this is because faltering seldom leads to meaningful action. Linking GMP with CMAM components such as OTP and SFP does lead to meaningful action.