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Mid‐upper arm circumference (MUAC) screening is a simple community‐level method for detecting acute malnutrition. The Family MUAC approach, which trains caregivers to measure their children's MUAC and refer them for treatment, has shown promise, but evidence regarding its impact on malnutrition severity at admission is limited. To address this gap, we conducted a longitudinal study from March to May 2024 in two districts in Eastern Ethiopia, enrolling 360 children aged 6–59 months. We compared children referred by their mothers or caregivers using the Family MUAC (n = 180) with those referred by Health Extension Workers (HEWs) (n = 180). We found that the median MUAC at admission was 119 mm (IQR 116–120) in the mother‐referral group versus 116 mm (IQR 115–119) in the HEWs‐referral group, and the proportion of severe acute malnutrition (MUAC < 115 mm) was lower among caregiver‐referred children (4.2% vs. 18.4%). Multivariable regression analysis showed that mother/caregiver‐referred children had an 80.5% lower risk of severe MUAC at admission [ARR 0.195(0.06, 0.59)] and a 75% reduced likelihood of SAM admission compared to the HEWs‐Referral group (ARR 0.25; 95% CI, 0.148–0.448). The Family MUAC approach significantly reduced the severity of malnutrition at admission. Consequently, this strategy should be expanded and prioritized in national screening programs. Family mid‐upper arm circumference (MUAC) has demonstrated the ability to enhance early detection of acute malnutrition by identifying children with milder forms of wasting at an earlier stage. Consequently, the use of Family MUAC can significantly improve early case identification and has the potential to improve the coverage of treatment services for wasting or acute malnutrition. Summary The median mid‐upper arm circumference (MUAC) at admission was higher in Mother‐Referral (119 mm) versus HEWs‐Referral (116 mm). Severe acute malnutrition (SAM) was lower among caregiver‐referred children (4.2% vs. 18.4%). Multivariable regression showed mother‐referred children had an 80.5% lower risk of severe MUAC at admission and 75% reduced likelihood of SAM admission compared to HEWs‐Referral. Wealth status, household size, proximity to health facilities, caregiver's health‐seeking behavior, and absence of recent illnesses influenced malnutrition severity at admission. Family MUAC significantly reduced malnutrition severity at admission and should be expanded in national screening programs.

Despite frequent use of mid‐upper arm circumference (MUAC) to assess populations in humanitarian settings, no guidance exists about the ranges for excluding implausible extreme outliers (flags) from MUAC data and about the quality assessment of collected MUAC data. We analysed 701 population‐representative anthropometric surveys in children aged 6–59 months from 40 countries conducted between 2011 and 2019. We explored characteristics of flags as well as changes in survey‐level MUAC‐for‐age z‐score (MUACZ) and MUAC means, SD and percentage of flags based on three flagging approaches: ±3 and ±4 MUACZ z‐scores from observed MUACZ survey mean and a fixed interval 100–200 mm of MUAC. Both ±4 and 100–200 flagging approaches identified as flags approximately 0.15% of records; about 60% of all surveys had no flags and less than 1% of surveys had >2% of flags. The ±3 approach flagged 0.6% records in the data set and 3% of surveys had >2% of flags. Plausible ranges (defined as 2.5th and 97.5th percentiles) for SD of MUACZ and MUAC were 0.8–1.2 and 10.5–14.4 mm, respectively. Survey‐level SDs of MUAC and MUACZ were highly correlated (r = 0.68). The average SD of MUACZ was 0.96 using the ±4 flagging approach and 0.94 with ±3 approach. Defining outliers in MUAC data based on the MUACZ approach is feasible and adjusts for different probability of extreme values based on age and nutrition status of surveyed population. In assessments where age is not recorded and therefore MUACZ cannot be generated, using 100–200 mm range for flag exclusion could be a feasible solution. Despite frequent use of mid‐upper arm circumference (MUAC) to assess populations in humanitarian settings, no guidance exists about the ranges for excluding implausible extreme outliers (flags) from MUAC data and about the quality assessment of collected MUAC data. We describe an approach that uses MUAC‐for‐age z‐score(MUACZ) exclusion ranges to identify outliers in MUAC data, with either ±4 or ±3 MUACZ z‐scores from observed MUACZ survey mean. For assessments where age of children is not recorded (such as community‐based MUAC screenings) using a fixed flagging interval of 100–200 mm is a feasible approach. Key messages Mid‐upper arm circumference (MUAC) is routinely used in surveys and screenings to assess nutrition status of pre‐school children in humanitarian settings. To date, there is no guidance on cleaning (detecting implausibly extreme outliers) and assessing quality of MUAC data. Defining flags in MUAC data based on the MUAC‐for‐age z‐score (MUACZ) distribution is feasible and in line with flagging approaches used for other anthropometric indicators. In assessments where age is not recorded and therefore MUACZ cannot be generated, using a fixed range 100–200 mm range for flag exclusion in children aged 6–59 months could be a feasible solution.

A simplified, combined protocol admitting children with a mid‐upper‐arm circumference (MUAC) of <125 mm or oedema to malnutrition treatment with ready‐to‐use therapeutic food (RUTF) uses two sachets of RUTF per day of those with MUAC < 115 mm and/or oedema and one sachet of RUTF per day for those with MUAC 115–<125 mm. This treatment previously demonstrated noninferior programmatic outcomes compared with standard treatment and high recovery in a routine setting. We aimed to observe the protocol's effectiveness in a routine setting at scale, in two health districts of the Central African Republic through an observational cohort study. The pilot enrolled children for 1 year in consortium by the Ministry of Health and nongovernmental partners. A total of 7909 children were admitted to the simplified, combined treatment. Treatment resulted in an 81.2% overall recovery, with a mean length of stay (LOS) of 38.7 days and a mean RUTF consumption of 43.4 sachets per child treated. Among children admitted with MUAC < 115 mm or oedema, 67.9% recovered with a mean LOS of 48.1 days and consumed an average of 70.9 RUTF sachets. Programme performance differed between the two districts, with an overall defaulting rate of 31.1% in the Kouango‐Grimari health district, compared to 8.2% in Kemo. Response to treatment by children admitted with severe acute malnutrition (SAM) by MUAC and SAM by oedema was similar. The simplified, combined protocol resulted in a satisfactory overall recovery and low RUTF consumption per child treated, with further need to understand defaulting in the context. We observed the effectiveness of a simplified, combined, MUAC‐based daily ready‐to‐use therapeutic food dosage for the treatment of acute malnutrition in children under 5 in a routine setting at scale. Our results indicate satisfactory recovery and low RUTFconsumption per child treated. Key messages The simplified, combined protocol with a mid‐upper‐arm circumference (MUAC)‐based ready‐to‐use therapeutic food (RUTF) resulted in a recovery rate that reached SPHERE standards, low length of stay and low RUTF consumption per child among all children treated. Response to treatment was similar among children admitted with severe acute malnutrition (SAM) by oedema and those admitted SAM by MUAC. Contextual factors such as insecurity and stockouts in treatment products affect programme outcomes by increasing defaulting and decreasing recovery rates. The simplified, combined protocol might present an opportunity to treat more children with less product; decentralised delivery should continue to be explored.

Mid‐upper‐arm circumference measurement (MUAC) is a simple, cost‐effective approach to identify wasting in children. The Family MUAC intervention supported community health workers (CHWs) to mentor mothers and child caregivers to measure their children's MUAC at home. Sixty‐four CHWs participated in seven sites in Gauteng and KwaZulu‐Natal (KZN), South Africa. A cross‐sectional survey was conducted to determine caregivers' ability to measure MUAC correctly and regularly. Ten households were randomly selected from household lists provided by each CHW. Fieldworkers collected data about the household, all children aged 6 months to 5 years living there and assessed caregiver's knowledge and skills in MUAC measurement. Data were collected in 521 households (Gauteng 201; KZN 351); 560 mothers/caregivers, (Gauteng 207; KZN 353) and 703 children (Gauteng 235; KZN 468) participated. Gauteng sites were high‐density urban with small families in informal houses with access to water and sanitation, compared to rural KZN with larger households and poor water and sanitation access. Low household income and household food insecurity was the norm across all sites. In KZN a higher proportion of mothers/caregivers had received Family MUAC training compared to Gauteng (256/353; 72.5% vs. 93/270; 34.4%, p < 0001). Most trained mothers/caregivers achieved competency (263/349; 75.3%); this was significantly higher in KZN compared to Gauteng (215/256; 83.9% vs. 48/93; 51.6%; p < 0.001). Mothers/caregivers of 126/703 (17.9%) children recorded MUAC for ≥ 6 months (KZN 116/468, 24.8%; Gauteng 10/235, 4.3%). When designing community‐based interventions for hard‐to‐reach communities it is important to address context‐specific challenges to achieve sustainable high coverage. Summary In low income areas with poor coverage of routine growth monitoring, most mothers and caregivers who had received training and mentoring from community health workers (CHWs) could correctly measure mid‐upper‐arm circumference (MUAC) on their children, demonstrating that household MUAC measurement is feasible. High levels of coverage and sustainability of household MUAC measurements were not achieved for Family MUAC in these hard‐to‐reach communities because of challenges experienced in urban and rural contexts, particularly in high‐density urban sites. Context‐specific challenges should be identified and addressed during implementation of community‐based interventions if high levels of sustainable coverage are to be achieved. Solutions should be developed in partnership with families and communities.

Malnutrition among women is a long‐standing public health concern that has significant adverse consequences on the survival and healthy development of children. Maternal mid‐upper arm circumference (MUAC) could potentially represent a simpler alternative to traditional nutritional indicators. This study aimed to investigate the factors associated with low maternal MUAC (as an indicator of being underweight) and address the research question of whether maternal MUAC is significantly associated with children's nutritional status among poor and very poor households in rural Bangladesh. Data on 5,069 households were extracted from the Suchana programme baseline survey, which was carried out in 80 randomly selected unions (the lowest administrative unit of Bangladesh) in Sylhet and Moulvibazar districts between November 2016 and February 2017. The outcome variables were three child nutritional status indicators: wasting, stunting and underweight. Mothers were classified as underweight if their MUAC was less than 23 cm. Separate multiple logistic regression analyses were used to determine the factors potentially associated with maternal underweight status and explore whether maternal underweight status is significantly associated with children's nutritional status. The prevalence of maternal underweight status was 46.7%, and the prevalence of wasting, stunting and underweight among children under two were 10.5%, 44.4% and 31.9%, respectively. After controlling for various socio‐economic and demographic characteristics, maternal MUAC was significantly associated with children's nutritional status in rural Bangladesh.

The double burden of malnutrition (under- and overnutrition) is a serious public health issue in childhood. The mid-upper arm circumference (MUAC) is a simple tool for screening nutritional status, but studies of the optimal cutoff to define malnutrition are limited. This study aimed to explore the prediction of malnutrition by MUAC in Sri Lankan schoolchildren. The participants were 538 students (202 boys, 336 girls) aged 5–10 years. Spearman’s rank correlation was calculated for MUAC and both body-mass-index-for-age z-score (BAZ) and height-for-age z-score (HAZ). Receiver operating characteristic (ROC) analysis was conducted to assess the ability of MUAC to correctly classify malnutrition, after stratifying for age and birth weight. MUAC correlated significantly with BAZ (r = 0.84) and HAZ (r = 0.35). The areas under the ROC curve for thinness, overweight, obesity, and stunting were 0.88, 0.97, 0.97, and 0.77, respectively. The optimal MUAC cutoff values for predicting thinness and stunting were 167.5 mm and 162.5 mm, respectively; the optimal cutoffs for predicting overweight and obesity were 190.5 mm and 218.0 mm, respectively. These cutoffs differed after stratification by age group and birth weight. Our results confirm MUAC to be a useful tool for monitoring growth in schoolchildren.

Mid‐upper arm circumference (MUAC) < 11.5 cm and weight‐for‐height Z‐score (WHZ) < −3 are used for screening for severe acute malnutrition (SAM). Underweight and concurrent wasting and stunting may better target those at the highest risk of mortality. We compared anthropometric outcomes in children enrolled in a trial of antibiotics for SAM based on categories of baseline anthropometry, including indicators for programme admission (WHZ < −3, MUAC < 11.5) and alternative indicators (weight‐for‐age Z‐score [WAZ] < −3, concurrent wasting and stunting [WHZ < −3 and height‐for‐age Z‐score < −3]). Participants were followed weekly until nutritional recovery and at 8 weeks. We evaluated changes in weight gain (g/kg/day), MUAC, and WHZ in children admitted by admissions criteria (MUAC only, WHZ only, or MUAC and WHZ) and by underweight or concurrent wasting and stunting. Of 301 admitted children, 100 (33%) were admitted based on MUAC only, 41 (14%) WHZ only, and 160 (53%) both MUAC and WHZ, 210 (68%) were underweight and 67 (22%) were concurrently wasted/stunted. Low MUAC and low WHZ children had the lowest probability of nutritional recovery (17% vs. 50% for MUAC‐only and 34% for WHZ‐only). There was no difference in weight gain velocity or WHZ by admissions criteria (WHZ and/or MUAC). Underweight and concurrently wasted/stunted children had lower MUAC and WHZ at 8 weeks compared with those who were not underweight or concurrently wasted and stunted. Children with both low MUAC and low WHZ had the worst outcomes. Relying on MUAC alone may miss children who have poor outcomes. Other indicators, such as WAZ, may be useful for identifying vulnerable children. Weight‐for‐height Z‐score (WHZ) and mid‐upper arm circumference (MUAC) are used for screening for severe acute malnutrition, but alternative indicators such as weight‐for‐age Z‐score (WAZ) may identify children at high risk of mortality. We evaluated anthropometric outcomes in children with severe acute malnutrition by baseline anthropometric status. Children with both low WHZ and MUAC had the worst outcomes, and low WAZ additionally identified children with poor outcomes Key messages Mid‐upper arm circumference (MUAC) and weight‐for‐height Z‐score (WHZ) are currently used for severe acute malnutrition (SAM) screening, but alternative indicators such as weight‐for‐age Z‐score (WAZ) may be additional options. Children admitted to the nutritional program based on both low MUAC and low WHZ had the worst outcomes, including the lowest probability of nutritional recovery and the worst anthropometric outcomes. While MUAC identified most children with SAM, WHZ may provide additional information about poor outcomes beyond MUAC alone. WAZ may be a useful alternative indicator to identify children who would benefit from a therapeutic feeding program without requiring height measurement.

Treatment of acute malnutrition requires novel approaches to improve coverage, reduce costs and improve the efficiency of standard protocols that separate the management of moderate acute malnutrition (MAM) and severe acute malnutrition (SAM). The use of simplified, combined protocols to treat both MAM and SAM has drawn research and policy interest among global, regional and national stakeholders. However, the perspectives of local communities and health care workers regarding the use of protocols to treat acute malnutrition in a routine health care system are generally lacking. This was a cross‐sectional mixed‐methods study aimed at assessing the perceptions of different stakeholders on the use of a simplified, combined protocol in two districts in the Central African Republic. Most of the respondents preferred the simplified, combined protocol over the standard protocol. They generally agreed that the protocol was easy to understand, allowed more children to receive treatment and was effective in treating acute malnutrition. The protocol modifications were well received, including the expanded admission criteria, use of mid‐upper arm circumference (MUAC) only for admission and discharge criteria and reduced and simplified ready‐to‐use therapeutic food quantity to treat MAM and SAM. Some caregivers expressed concern with the use of MUAC only to declare recovery, flagging that underlying illnesses could still be present. The caregivers recommended the provision of other food basket interventions to improve the treatment. The support by caregivers and health care workers on the idea of training community health volunteers to treat acute malnutrition points to the potential of scaling up decentralized treatment to increase coverage in remote areas. The use of the simplified, combined protocol to treat acute malnutrition was well received and supported by most stakeholders involved in implementation. The protocol provided care for children with moderate or severe acute malnutrition (MAM or SAM) within a shorter treatment duration and using a reduced ready‐to‐use therapeutic food dose. Key messages The use of the simplified, combined protocol to treat acute malnutrition received overwhelming support from most stakeholders involved in implementation. Stakeholders were supportive of the use of the protocol to provide care for both severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) children with a shorter length of stay in treatment. Most stakeholders supported the use of mid‐upper arm circumference only for the admission and discharge of children. The majority of stakeholders reported that the ready‐to‐use therapeutic food given for MAM and SAM was sufficient for the child's recovery. The idea of training and equipping community health volunteers to treat acute malnutrition was well supported by caregivers and health care workers and should be explored further.

The associations of lean body mass (LBM) with elevated blood pressure (BP) and hypertension were controversial, and the causalities have never been shown. Mid‐upper arm muscle circumference (MAMC), an easily obtained anthropometric measurement, could provide an accurate estimate for LBM. Therefore, a prospective cohort study in general Chinese residents aiming to find out the relationship between LBM estimated using MAMC and hypertension risk was performed. Eight thousand one hundred eighty‐five eligible participants were included in the baseline analysis, among whom 3442 were subsequently selected into cohort analysis. MAMC was calculated using mid‐upper arm circumference (MUAC) and triceps skinfold thickness (TST). Associations of MAMC with BP values and hypertension prevalence were estimated by linear and logistic regression models. Associations with hypertension incidence were estimated by COX regression models, hazard ratio (HR) and 95% confidence interval (CI) were given. Nonlinear relationship between MAMC and hypertension risk was estimated using restricted cubic spline method. Standardized coefficients of MUAC and TST were compared to estimate their strengths of associations with hypertension. Baseline analysis showed that after adjusted for confounders, the increase of systolic BP per standard deviation (SD) of MAMC were 1.97 mmHg (95%CI: 1.46, 2.48) and 1.63 mmHg (95%CI: 1.10, 2.16) respectively in men and women, and the increases of diastolic BP per SD were 1.58 mmHg (95%CI: 1.23, 1.92) and 1.08 mmHg (95%CI: 0.74, 1.42). Additionally, the association of MAMC with the prevalence of hypertension were also found in both men and women (OR = 1.36, 95%CI: 1.26, 1.47 in men; OR = 1.33, 95%CI: 1.22, 1.44 in women). Cohort analysis showed that MAMC increased the risk of hypertension (HR = 1.10, 95%CI: 1.01, 1.19 for men; HR = 1.15, 95%CI: 1.06, 1.26 for women), and a trend of J‐shaped relationship was found. Additionally, the stronger associations of MUAC with both BP values and hypertension than that of TST were found in both baseline and cohort analyses. Findings in our study implied that we cannot neglect the capacity of LBM in predicting hypertension risk, and LBM estimates should be recommended in general health surveys or examinations.

Aim: To define growth outcomes of a geographically defined population of extremely preterm babies. Population: The EPICure study identified all surviving children in the United Kingdom and Ireland born at ⩽ 25 weeks 6 days gestation between March and December 1995. Of 308 survivors, 283 (92%) were evaluated at 30 months of age corrected for prematurity. Methods: Growth was measured as part of a medical and full neurodevelopmental assessment. Growth parameters were evaluated in relation to other 30 month outcomes and perinatal variables. Results: The children were smaller in each of the five growth measures compared with published population norms: mean (SD) standard deviation scores were −1.19 (1.32) for weight, −1.40 (1.37) for head circumference, −0.70 (1.19) for height, −1.00 (1.38) for body mass index, and −0.75 (0.95) for mid-upper arm circumference. Despite being of average size at birth, children were significantly lighter with smaller head circumferences at the expected date of delivery, compared with population norms, and only weight showed later catch up, by 0.5 SD. Poorer growth was found in children whose parents reported feeding problems and with longer duration of oxygen dependency, as a marker for neonatal respiratory illness. Although severe motor disability was associated with smaller head circumference, overall there was no relation between Bayley scores and head growth. Conclusions: Poor growth in early childhood is common in extremely preterm children, particularly when prolonged courses of systemic steroids have been given for chronic lung disease. Improving early growth must be a priority for clinical care.