Midupper Arm Circumference Outperforms Weight-Based Measures of Nutritional Status in Children with Diarrhea

Background: Undernutrition contributes to 45% of all deaths in children <5 y of age worldwide, with a large proportion of those deaths caused by diarrhea. However, no validated tools exist for assessing undernutrition in children with diarrhea and possible dehydration.

Objective: This study assessed the validity of different measures of undernutrition in children with diarrhea.

Methods: A prospective cohort study was conducted at an urban hospital in Bangladesh. Children <60 mo of age presenting to the hospital rehydration unit with acute diarrhea were eligible for enrollment. Study staff randomly selected 1196 children for screening, of which 1025 were eligible, 850 were enrolled, and 721 had complete data for analysis. Anthropometric measurements, including weight-for-age z score (WAZ), weight-for-length z score (WLZ), midupper arm circumference (MUAC), and midupper arm circumference z score (MUACZ), were calculated pre- and posthydration in all patients. Measurements were evaluated for their ability to correctly identify undernutrition in children with varying degrees of dehydration.

Results: Of the 721 patients with full data for analysis, the median percent dehydration was 4%. Of the 4 measures evaluated, MUAC and MUACZ demonstrated 92-94% agreement pre- and posthydration compared with 69-76% for WAZ and WLZ. Although each 1% change in hydration status was found to change weight-for-age by 0.0895 z scores and weight-for-length by 0.1304 z scores, MUAC and MUACZ were not significantly affected by dehydration status. Weight-based measures misclassified 12% of children with severe underweight and 14% with severe acute malnutrition (SAM) compared with only 1-2% for MUAC and MUACZ.

Conclusions: MUAC and MUACZ were the most accurate predictors of undernutrition in children with diarrhea. WAZ and WLZ were significantly affected by dehydration status, leading to the misdiagnosis of many patients on arrival with severe underweight and SAM. This trial was registered at clinicaltrials.gov as NCT02007733.