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ROLE OF NEW ANTHROPOMETRIC INDICES, VALIDITY OF MUAC AND WEECH’S FORMULA IN DETECTING UNDER-NUTRITION AMONG UNDER-FIVE CHILDREN IN KARNATAKA

*Department of Community Medicine, A. J. Institute of Medical Sciences, Mangalore575004, Karnataka, India. E-mail of Corresponding Author: krutarth_brahmbhatt@rediffmail.com Abstract Background and Objective: There should be one comprehensive measure or index which can represent the overall prevalence of under-nutrition of all three forms (underweight, wasting and stunting). Composite index of anthropometric failure is one such indicator, proposed by Svedberg. Three new indices namely UI, WI and SI has also been proposed and used. The advantage of use of MUAC is its simplicity. Weech’s formula is an age old formula used by clinicians to identify undernourished children. Material and methods: The study included 171 children under the age of five years, who were referred from the anganwadis of Dakshina Kannada region during the period of January-March 2012. The proportion of underweight, wasting and stunting were calculated according to the new child growth standard of the WHO. CIAF, UI, WI and SI were calculated. Sensitivity, specificity, predictive value and likelihood ratios were calculated for MUAC and Weech’s formula. Results: 58.4% children belonged to category “D” of CIAF. Weech’s formula’s sensitivity in detecting underweight and stunted children was 100% and 96% respectively. Conclusion: Use of CIAF, UI, WI and SI is recommended to present the overall picture of undernutrition among under-five children. Weech’s formula is a sensitive and specific tool to identify to undernourished children.


Introduction
ICDS (Integrated child development services) scheme represents one of the largest and most unique programs for early childhood development in India today. The scheme was launched in the year 1975. India adopted the new WHO child growth standards on 15 th of August 2008 for growth monitoring of children in Anganwadi centers 1 . As per the new WHO growth standards the prevalence of three important indicators of undernutrition namely underweight (low weight for age), wasting (low weight for height) and stunting (low height for age) among under-five children in India is 43%, 20% and 48% respectively. The corresponding figures for the world, with the use of same assessment parameters are 16%, 10 % and 27% respectively 2 . These three indicators overlap -i.e. a child who is underweight, may also be wasted and stunted and other similar combinations of these indicators of under-nutrition are possible. There should be one comprehensive measure or index which can represent the overall prevalence of undernutrition of all three forms (underweight, wasting and stunting). Composite index of anthropometric failure is one such indicator, proposed by Svedberg 3 . In the original model, he suggested six sub-groups of anthropometric failure and one more was added by Nandy et al 4 .
Although CIAF is an useful composite measure, it fails to highlight the individual contribution and importance of underweight, wasting and stunting relative to the overall prevalence of undernutrition 5 . Therefore three new indices namely UI, WI and SI has been proposed and used, which give information on relative significance and severity of the conventional indicators of undernutrition with respect to the total prevalence of under-nutrition 6 . Age independent measurement, which has practical application in screening children between 1-5 years of age, for under-nutrition is MUAC. The advantage of use of MUAC is its simplicity, neither it requires special equipment nor it is difficult to measure and interpret 7 . Most of the anthropometric indicators require use of reference tables, which may not be practically feasible in field studies. Weech's formula is an age old formula used by clinicians to identify under-nourished children 8 . An ideal anthropometric indicator should have a high sensitivity to detect under-nutrition correctly, and high specificity so that government IJBAR (2012) 03 (12) www.ssjournals.com resources and facilities meant for malnourished children may reach only those in need of them. This study was carried out to justify use of new anthropometric indicator-CIAF and three new indices namely UI, WI and SI and to compare the commonly used anthropometric indicators in terms of their sensitivity, specificity and predictive value.

Methodology
The study included 171 children under the age of five years, who were referred from the anganwadis of Dakshina Kannada region during the period of January-March 2012. Mothers of the selected children were interviewed to obtain information on their socio-economic, demographic and health and nutrition-related issues through pretested semi-structured questionnaires. Anthropometric data were obtained in the same manner to minimize the potential sampling errors. Weight of the child was measured in gram with the precision of 100g and height was measured in centimeter with the precision of 0.5cm. For children aged less than two years, weight was calculated by subtracting the weight of the mother from the combined weight of the mother-child pair, and recumbent length was measured with a locally-made wooden stadio-meter. MUAC was measured to the nearest millimetre at the exact midpoint of the left arm using a narrow, flexible, and non-stretchable tape made of plastic 3,4 . Age and the birth weights of children were recorded from the mother. Birth weight ≥ 2.5kg was considered as normal birth weight, < 2.5kg as low birth weight and < 1.5kg as very low birth weight. Immunization status was assessed with the help of immunization card; children, who received all the vaccines, due as per the age, were considered as fully immunized. The proportion of underweight, wasting and stunting were calculated according to the child growth standard of the World Health Organization (WHO) [

Results
Total 171 children, aged 1-5 years were included in the study [ Table 3]. 17 (10%) children had history of acute respiratory tract infections. 126 (73.7%) children received prophylaxis for worm infestation in past six months.
Compared to WHO age and sex specific weight-for-age standards [9]. Compared to WHO age and sex specific height-for-age standards [9].

Discussion
In this study, as per CIAF, 98.2% children were suffering from one or other form of anthropometric failure. This proportion was very high in comparison to other studies 14,15  As per CIAF, 58.4% children belonged to category "D" (stunted, wasted and underweight simultaneously). This is the extra information, we can elicit by the use of CIAF, as we get the information that if the child is underweight whether that child is wasted and stunted also or not. More number of boys than girls belonged to category "D". As the study participants were referred children, this number was higher than studies done in other settings. In a study done by Seetharaman et al., 5.7% children belonged to category "D" of CIAF 15 .
In this study, we calculated the new anthropometric indices namely SI, UI and WI. We compared the values of these indices with other studies. As the denominator includes undernourished children only, we can compare these indices with those from other studies.
[ Table 7]. UI and WI found in this study were highest among all. Four out of six studies reported higher proportion of chronic malnutrition than acute malnutrition among all malnourished children. At national level also we have highest prevalence of stunting followed by underweight and wasting 2 .  18 , the corresponding figures were 100% and 53.8% respectively. We rounded off the age to the IJBAR (2012) 03 (12) www.ssjournals.com nearest quarter of the year in calculating expected weight and height, while in the Haq's study 18 age was taken in completed years. Weech's formula was found as a sensitive tool to identify underweight and stunting among under-five age group children in this study.

Conclusion
In this study we recommend use of Composite index of anthropometric failure (CIAF) to present overall proportion of under-nutrition among under-five children. Use of UI, WI and SI helps in planning and prioritizing the interventions for undernourished children. MUAC can be used as a specific tool to screen children for undernutrition. Weech's formula is a sensitive and specific tool to identify undernourished children in the settings where use of WHO reference tables is not practically feasible.

Limitations
This study was done on 171 referred children.
The catchment area cannot be defined and findings cannot be generalized.