A longitudinal study of MUAC as a measure of paediatric malnutrition in Yei, South Sudan: Lessons from a hospital link: Lessons from a hospital link

Author(s): Abigail Sharpe and Simon Struthers

Royal Hampshire County Hospital, Romsey Rd, Winchester, SO22 5DG, UK


Paediatric malnutrition is a significant problem in South Sudan, with rates of wasting up to 22% reported in some areas [1].  Severe acute malnutrition (SAM) is associated with a high mortality [2]. Affected patients require thorough assessment and holistic care including appropriate therapeutic feeding, treatment of associated complications and rehabilitation in order to achieve good outcomes.

Since 2009 there has been an NHS Global Link between Yei Civil Hospital (YCH), Central Equatoria Province and Royal Hampshire County Hospital, Winchester, UK.  It had been noted that there was very minimal provision for malnourished children in the town (total population in Yei was estimated at 185,000 in 2011).  Successive teams from the link therefore assessed the levels of acute paediatric malnutrition in order to supply data to the South Sudanese government and its partners such as UNICEF in order to facilitate decisions as to whether increased provision is warranted.

The measurement used was the Mid-Upper Arm Circumference (MUAC) which is a well-validated indicator of acute malnutrition [3, 4, 5, 6], and is recommended by the World Health Organization (WHO) [7] and the 2009 interim South Sudanese guidelines [8] as a key assessment tool.


Data were collected during three defined periods between 2012 and 2014:

  • Period 1: Oct-Dec 2012 (3 months);
  • Period 2: June 2013 (10 days);
  • Period 3: Oct 2014 (10 days).


MUAC was measured using standardized colour-coded tapes, and by the method described by UNICEF [9] – see Figure 1.

MUAC measurements were collected for all available inpatients and ambulatory care patients aged 6 months to 5 years at YCH, Martha Primary Care Clinic (MPCC), and during mobile clinics (MC) in rural areas over the study periods.  The age and sex of each patient was recorded.  Measurements were categorized using a traffic light system  as shown in Table 1.

All measurements were taken with the verbal consent from a parent, and all results indicating acute malnutrition were flagged to local attending medical staff and explained to the parents. Data from successive years and for each site were compared.

<insert Table 1.>


Table 1. Interpretation of mid-upper arm circumference (MUAC) values for children aged 6 - 59 months [10].

Arm circumference

Colour on tape


>125 mm


No acute malnutrition

≥ 115 to < 125 mm


Moderate acute malnutrition (MAM)

< 115 mm


Severe acute malnutrition (SAM)


Figure 1.  Measuring MUAC. The colour on the tape is orange so the child has moderate acute malnutrition (MAM).  Image reproduced courtesy of UNICEF Ethiopia.


Table 2 shows the nutritional status of the 601 children assessed, and the rate of acute malnutrition by year and site.


Table 2. Number and percent of children according to their MUAC category by year and site.



MUAC category

Total rate of acute malnutrition (MAM + SAM) %

Total rate of SAM



n (%)


n (%)


n (%)



223 (88.8)

20 (8.0)

8 (3.2)




175 (88.4)

16 (8.1)

7 (3.5)




31 (86.1)

4 (11.1)

1 (2.8)






31 (86.1)

4 (11.1)

1 (2.8)


19 (90.5)

1 (4.8)

1 (4.8)



20 (76.9)

3 (11.5)

3 (11.5)




28 (90.3)

3 (9.7)




The data show similar high levels of malnutrition in successive years and different sites, which are concerning and  compare poorly to reported rates of 6 – 9% in neighbouring countries [11, 12, 13].  Data from 2014 show that current rates of acute malnutrition in South Sudan are above 15% - the WHO threshold for nutrition emergencies [14] although the numbers in this year are relatively small. 

At present there are no coordinated programmes in Yei for the management of severe acute malnutrition, and there is no local provision of specialist milks such as F75 and F100, or ready-to-use foods (RUTF) such as Plumpy Nut.  We hope these data can be used to advocate for increased provision for SAM management in Yei, in order to improve mortality and morbidity in the paediatric population there.

The authors would like to thank Cathy Williams, Dr Imelda Heyes and Dr Sally Louden for data collection and doctors and staff at YCH including Dr Denis Zachariah, Dr Issam-Elden Yousif and Dr Kennedy Samuel, and at MPCC for their support of the project.


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