Guesdon Benjamin, Couture Alexia, Lesieur Elise, Bilukha Oleg
Action Contre La Faim - France, 14-16 Boulevard Douaumont, 75854, Paris, France.
Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control, 1600 Clifton Road, Atlanta, GA, 30329, USA.
BMC Nutr. 2021 Feb 2;7(1):3. doi: 10.1186/s40795-021-00406-6.
One newly proposed approach to determining eligibility of children aged 6-59 months for therapeutic feeding programs (TFPs) is to use mid-upper arm circumference (MUAC) < 115 mm, bilateral oedema or Weight-for-Age Z-score (WAZ) < - 3 as admission criteria (MUAC+SWAZ). We explored potential consequences of this approach on the eligibility for treatment, as compared with the existing WHO normative guidance. We also compared sensitivity and specificity parameters of this approach for detecting wasted children to the previously described "Expanded MUAC" approach.
We analyzed data from 558 population representative cross-sectional cluster surveys conducted since 2007. We retrieved all children classified as severe acute malnutrition (SAM), moderate acute malnutrition (MAM), and those who are both wasted and stunted (WA + ST), and calculated proportions of previously eligible children who would now be excluded from treatment, as well as proportions of non-malnourished children among those who would become eligible. We also analyzed the expected changes in the number and demographics (sex, age) of the selected populations of children according to the different admission approaches.
Both MUAC+SWAZ and Expanded MUAC case detection approaches substantially increase the sensitivity in detecting SAM, as compared to an approach which restricts detection of SAM cases to MUAC< 115 mm and oedema. Improved sensitivity however is attained at the expense of specificity and would require a very large increase of the size of TFPs, while still missing a non-negligible proportion (20-25%) of the SAM caseload. While our results confirm the sensitivity of the MUAC+SWAZ case detection approach in detecting WA + ST (over 80%), they show, on the other hand, that about half of the additional target detected by using SWAZ criterion will be neither SAM nor WA + ST.
These results suggest that recently promoted approaches to case detection inflate TFPs' targets through the allocation of treatment to large numbers of children who have not been shown to require this type of support, including a significant proportion of non-acutely malnourished children in the MUAC+SWAZ approach. Considering the scarcity of resources for the implementation of TFPs, the rationale of abandoning the use of WHZ and of these alternative case detection strategies need to be critically reviewed.
一种新提出的确定6至59个月儿童是否符合治疗性喂养计划（TFP）资格的方法是，将上臂中部周长（MUAC）<115毫米、双侧水肿或年龄别体重Z评分（WAZ）<-3作为纳入标准（MUAC+SWAZ）。与世界卫生组织现有的规范指南相比，我们探讨了这种方法对治疗资格的潜在影响。我们还将这种检测消瘦儿童的方法的敏感性和特异性参数与之前描述的“扩展MUAC”方法进行了比较。
我们分析了自2007年以来进行的558次具有人群代表性的横断面整群调查的数据。我们检索了所有被归类为重度急性营养不良（SAM）、中度急性营养不良（MAM）以及消瘦且发育迟缓（WA+ST）的儿童，并计算了之前符合条件但现在将被排除在治疗之外的儿童比例，以及那些将符合条件的非营养不良儿童的比例。我们还根据不同的纳入方法分析了选定儿童群体数量和人口统计学特征（性别、年龄）的预期变化。
与将SAM病例检测限制在MUAC<115毫米和水肿的方法相比，MUAC+SWAZ和扩展MUAC病例检测方法在检测SAM方面的敏感性都大幅提高。然而，提高敏感性是以牺牲特异性为代价的，并且这将需要大幅增加TFP的规模，同时仍会遗漏相当比例（20%-25%）的SAM病例。虽然我们的结果证实了MUAC+SWAZ病例检测方法在检测WA+ST方面的敏感性（超过80%），但另一方面，它们表明使用SWAZ标准检测出的额外目标中约有一半既不是SAM也不是WA+ST。
这些结果表明，最近推广的病例检测方法通过将治疗分配给大量未被证明需要此类支持的儿童，包括MUAC+SWAZ方法中相当比例的非急性营养不良儿童，从而夸大了TFP的目标。考虑到实施TFP的资源稀缺，放弃使用WHZ和这些替代病例检测策略的理由需要进行严格审查。
