Berkley, JA

Grijalva-Eternod, CS

Kerac, M

Lelijveld, N

McGrath, M

Mwangome, M

Rogers, E

English

UCL Discovery

LETTER TO THE EDITORLetter to the Editor of the Journal of Nutritional ScienceJournal of Nutritional Science (2023), vol. 12, e26, page 1 of 2 doi:10.1017/jns.2022.99Dear Editor,We are writing in response to the recently published articleJima BR, Hassen HY, Bahwere P and Gebreyesus SH, Diagnostic abil-ity of mid-upper arm circumference-to-length ratio in detecting wastingamong infants aged 1–6 months in Ethiopia, Journal of NutritionalScience, (2022), vol. 11, e23, p1–8.This study addresses an important topic, focusing on smalland nutritionally at-risk infants under 6 months of age (u6m)who are at high risk of wasting(1,2) but for whom there areconsiderable, continued gaps in evidence to inform identifica-tion and management(3). However, we have concerns with thestudy’s premises, which need to be highlighted to avoid con-tinuing replication of an unhelpful methodology. There areconsiderable misconceptions already in this field and thisstudy may risk exacerbating those misunderstandings, causingfurther confusion. We, therefore, present some clarificationshoping readers and future researchers will find them helpful.First, implicit in the study design is an assumption thatweight-for-length (WLZ) is the gold standard for identifyingwasting in infants u6m. This is incorrect. All anthropometricindicators are imperfect proxy measures of malnutrition withdifferent strengths and weaknesses: what matters is how wellthey help identify infants at high risk of mortality and morbid-ity(4). Although low WLZ indeed forms the current WHO2013 case definition for severe malnutrition in infantsu6m(5), there is increasing evidence that it is a poor indicatorof risk in this age group. Other indicators are likely to performbetter, namely weight-for-age (WAZ) and potentiallyunadjusted mid-upper-arm-circumference (MUAC)(6). Theseindicators (along with non-anthropometric criteria) are cur-rently being examined by the WHO in a collaborative pooledanalysis of multiple datasets to explore their predictive valuerelated to functional outcomes (mortality).A second problem is the lack of practical considerations in thestudy’s discussion. MUAC-to-length (MUAC/L) is a complexand problematic measure considering the challenges of accuratelymeasuring length in infants. This makes it a poor, non-viableoption in health and nutrition programmes in low resource set-tings. Length measurement requires a lot of time, training andequipment to measure, it is difficult to do accurately as infants’legs are naturally flexed, and it has the lowest quality data of anyanthropometric measurement(7,8). These factors have been influ-ential in the development of MUAC-only programmes ratherthan those based on WLZ in children aged 6–59 months(9).To improve future research and evidence generation in thisarea, we suggest that the primary aim of future studies onanthropometric measurements for infants u6m should assessrisk of mortality, morbidity or neurodevelopmental out-comes(10,11). Anthropometric recovery is not an end in itselfas mortality risk persists even when weight has beenregained(12). An alternative to ROC curves, which positionWLZ as the gold standard, would be to assess anthropometricoverlap using Venn diagrams(13). Then to explore how differ-ent indicators or combinations of indicators predict mortality/morbidity/development outcomes. Given the age dependenceof MUAC, all such analyses would benefit from stratifying theanalysis into infants aged 0–6 weeks and 7 weeks – 6 months.As immunisations often occur at 6 weeks of age, this thresholdis relatively easy to implement(14,15).We strongly encourage the collection and publication of datawhich examine anthropometry of infants u6m. However, it isessential that the considerable confusion around anthropom-etry is addressed so that all studies can contribute muchneeded evidence to the field. We hope that this short summarygoes some way to bringing clarity and researchers are suitablyinformed and appropriately equipped to produce muchneeded data which will improve the outcomes for infantsu6m, enabling them to not only survive but also thrive.Marko Kerac1, Marie McGrath2, James A. Berkley 3,Carlos S. Grijalva-Eternod1,4, Natasha Lelijveld2,Martha Mwangome3 and Eleanor Rogers2,*© The Author(s), 2023. Published by Cambridge University Press on behalf of The Nutrition Society. This is an Open Access article, distributed underthe terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distributionand reproduction, provided the original article is properly cited.JNSJOURNAL OF NUTRITIONAL SCIENCE1https://doi.org/10.1017/jns.2022.99 Published online by Cambridge University Press1London School of Hygiene and Tropical Medicine, KeppelStreet, London WC1E 7HT, UK2Emergency Nutrition Network, 69 High Street, MarlboroughHouse, Kidlington, Oxfordshire OX5 2DN, UK3Kenya Medical Research Institute (KEMRI)/Wellcome TrustResearch Programme, P.O Box 230, Kilifi, Kenya4UCL Institute for Global Health, 30 Guilford Street, LondonWC1N 1EH, UK*Corresponding author: Eleanor Rogers,email eleanor@ennonline.netReferences1. Kerac M, James PT, McGrath M, et al. (2021) Infant malnutrition inlow-and middle-income countries: assessment and prevalence ofsmall and nutritionally at-risk infants aged under 6 months in 54Demographic & Health Survey datasets. medRxiv.2. Kerac M, Mwangome M, McGrath M, et al. (2015) Management ofacute malnutrition in infants aged under 6 months (MAMI): currentissues and future directions in policy and research. Food Nutr Bull36, S30–S34.3. Angood C, McGrath M, Mehta S, et al. (2015) Research priorities toimprove the management of acute malnutrition in infants aged lessthan six months (MAMI). PLoS Med 12, e1001812.4. Kerac M, McGrath M, Connell N, et al. (2020) ‘Severe malnutrition’:thinking deeply, communicating simply. BMJ Global Health 5, e003023.5. World Health Organisation (2013) Updates on the Management of SevereAcute Malnutrition in Infants and Children (Guideline). Geneva: WHO.6. Hoehn C, Lelijveld N, Mwangome M, et al. (2021) Anthropometriccriteria for identifying infants under 6 months of age at risk of mor-bidity and mortality: a systematic review. Clin Med Insights Pediatr.doi:10.1177/11795565211049904.7. Grijalva-Eternod CS, Kerac M, McGrath M, et al. (2017)Admission profile and discharge outcomes for infants aged lessthan 6 months admitted to inpatient therapeutic care in 10 coun-tries. A secondary data analysis. Matern Child Nutr 13, e12345.doi:10.1111/mcn.12345.8. Mwangome MK, Fegan G, Mbunya R, et al. (2012) Reliability andaccuracy of anthropometry performed by community health work-ers among infants under 6 months in rural Kenya. Trop Med IntHealth 17, 622–629. doi:10.1111/j.1365-3156.2012.02959.x.9. Myatt M, Khara T & Collins S (2006) A review of methods to detectcases of severely malnourished children in the community for theiradmission into community-based therapeutic care programs. FoodNutr Bull 27, S7–23. doi:10.1177/15648265060273S302.10. Mwangome M, Fegan G, Fulford T, et al. (2012) Mid-upper armcircumference at age of routine infant vaccination to identify infantsat elevated risk of death: a retrospective cohort study in theGambia. Bull World Health Organ 90, 887–894.11. Berkley J, Mwangi I, Griffiths K, et al. (2005) Assessment of severemalnutrition among hospitalized children in rural Kenya: compari-son of weight for height and mid upper arm circumference. JAMA294, 591–597.12. Mwangome M, Ngari M, Bahwere P, et al. (2021) Growth monitor-ing and mortality risk in low birthweight infants: a birth cohort studyin Burkina Faso [version 1; peer review: 1 approved with reserva-tions]. Gates Open Res 5. doi:10.12688/GATESOPENRES.13231.2.13. Grijalva-Eternod CS, Beaumont E, Rana R, et al. (2021)Malnutrition in infants aged under 6 months attending communityhealth centres: a cross sectional survey. Nutrients 13, 2489.doi:10.3390/nu13082489.14. Burrell A & Barthorp H (2020) GOAL’s experiences of manage-ment of at-risk mothers and infants (MAMI) in Ethiopia. FieldExchange 62. Available at: https://www.ennonline.net/fex/62/goalexperiencesofmanagement.15. Mwangome M, Fegan G, Fulford T, et al. (2012) Mid-upper armcircumference at age of routine infant vaccination to identifyinfants at elevated risk of death: a retrospective cohort study in theGambia. Bull World Health Organ 90, 887–894. doi:10.2471/BLT.12.109009.2journals.cambridge.org/jnshttps://doi.org/10.1017/jns.2022.99 Published online by Cambridge University Press

Letter to the Editor of the Journal of Nutritional Science

https://discovery.ucl.ac.uk/10166561/1/Grijalva_Letter%20to%20the%20Editor%20of%20the%20Journal%20of%20Nutritional%20Science_AOP.pdf

Letter to the Editor of the Journal of Nutritional Science

Abstract

Similar works

Full text

Available Versions

UCL Discovery