Lay-screeners and use of WHO growth standards increase case finding of hospitalized Malawian children with severe acute malnutrition

Objectives: Strategies to effectively identify and refer children with severe acute malnutrition (SAM) to Nutritional Rehabilitation units (NRU) can reduce morbidity and mortality. Methods: From December 2011 to May 2012, we conducted a prospective study task-shifting inpatient malnutrition screening of Malawian children 6-60 months to lay-screeners and evaluated World Health Organization (WHO) criteria vs. the National Center for Health Statistics (NCHS) guidelines for SAM. Results: Lay-screeners evaluated 3116 children, identifying 368 (11.8%) with SAM by WHO criteria, including 210 (6.7%) who met NCHS criteria initially missed by standard clinician NRU referrals. Overall case finding increased by 56.7%. Mid-upper arm circumference (MUAC) and bipedal edema captured 86% (181/210) NCHS/NRU-eligible children and 89% of those who died (17/19) meeting WHO criteria. Mortality of NCHS/NRU-eligible children was 10 times greater than those without SAM (odds ratio 10.5, 95% confidence interval 5.4-20.6). Conclusions: Ward-based lay-screeners and WHO guidelines identified high-risk children with SAM missed by standard NRU referral. MUAC and edema detected the majority of NRU-eligible children.