"Who do you catch?" is a very good question. The answer depends on where you are. In (e.g.) agrarian communities in the Ethiopian highlands you tend to catch much the same group with both indicators. There is a lot of overlap with MUAC tending to select more younger children. Amongst Somali pastoralists you catch different groups with the two indicators. W/H selects very many more older children. This is an example of the body shape issue. The common group is the most wasted younger children although W/H excludes a lot of younger children selected using MUAC. Another good question is "Who are you trying to catch?". If the answer is children at high risk of near term mortality without CMAM services but at low risk of mortality with CMAM services then you want the MUAC group. If the answer is "Children with long legs and, maybe, a bit thin" then you really should take the W/H group. Note : Combing W/H and MUAC does not improve sensitivity. If you want improved sensitivity then increase the MUAC threshold. I reviewed these issues (with colleagued) for CTC / CMAM: Myatt M, Khara T, Collins S, A review of methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs, Food and Nutrition Bulletin, 2006;27(3):S7-S23 You can find this review here: [url]http://www.brixtonhealth.com/FNB_27_3_2006_B.pdf[/url] Any help?

Mark, that is of great help. Now I take a step further and take you to a refugee camp with pastoralists (assuming I can compare ‘your’ Somali people with my refugees). I see high GAM rates with WFH,- let’s say 10% (A) I see much lower GAM rates with MUAC – let’s say 5% (B). (very few kwash cases in the camp). So, following what I learnt from you: In situation A I have older children 3-5 years identified with acute malnutrition. In situation B I have identified more the <2-3 years with acute malnutrition. Now my question: should I be concerned, for whom and why? Following an earlier discussion on ENN-net, we tend to overestimate the pastoralists’ older children as malnourished. This means, the so-called ‘reality’ is that the younger group of which 5% suffer from acute malnutrition is my concern (B); more than the 10% WFH (A) group. And that situation B is closer to reality of acute malnutrition rates than situation A. Am I correct? Thanks to anyone for your reply, which is more than greatly appreciated!

Should you be concerned? Yes. One in twenty children (MUAC) are at elevated risk (i.e. > 1 / 10,000 / day) of mortality. For whom? I would be most concerned at achieving treatment coverage in the low MUAC group and particularly in the group with MUAC below 115 mm. We are lucky that they are easy to find with volunteers using colour-banded MUAC straps. We could treat these in their "homes" using CHWs and avoid crowding at clinic sites. Why? These are children at elevated risk of mortality.

From Jay Berkley: Dear Mija I previously studied this in hospitalised children: [url]http://jama.ama-assn.org/content/294/5/591.long[/url] ‘…skin/hair changes associated with recent kwashiorkor, bipedal edema associated with current kwashiorkor, stunting, subcostal indrawing (pneumonia), no history of seizures, female sex, and younger age were independent associations of having MUAC less than or equal to 11.5 cm rather than WHZ less than or equal to -3…’ In a community setting, I expect MUAC will more often identify: younger, female and kwashiorkor children. I hope that helps Jay