COMPARISON OF MID-UPPER ARM CIRCUMFERENCE

AND WEIGHT-FOR-HEIGHT TO DIAGNOSE SEVERE

ACUTE MALNUTRITION IN AGE GROUP 6-59 MONTHS

PROTOCOL FOR SUBMISSION OF THESIS TO

UNIVERSITY OF DELHI
FOR THE DEGREE OF
DOCTOR OF MEDICINE
(M.D.PAEDIATRICS)
(Session: 2017-2020)

Dr. Abhishek Dixit

Lady Hardinge Medical College and Associated Hospitals

1
(Batch: 2017-2020)

2
 COMPARISON OF MID-UPPER ARM CIRCUMFERENCE
ANDWEIGHT-FOR-HEIGHT TO DIAGNOSE SEVERE ACUTE
MALNUTRITION IN AGE GROUP 6-59 MONTHS

Protocol of thesis to be submitted to the University of Delhi towards partial

fulfillment of the requirement for the Degree of Doctor of Medicine
(Session: 2017-2020)

Student: Dr. Abhishek Dixit ……………………….

(signature)

Supervisor: Dr. Jagdish Chandra ……………………….

Director (signature)
Lady Hardinge Medical College
New Delhi

Co- supervisor: Dr. Praveen Kumar ……………………….

Director Professor (signature)
Department of Paediatrics,
Lady Hardinge Medical College
New Delhi

Head of Department: Dr Virendra Kumar ……………………….

Director Professor and HOD (signature)
Department of Paediatrics
Lady Hardinge Medical College
New Delhi

3
4
 Lady Hardinge Medical College & Smt.S.K.Hospital New Delhi

-​UNDERTAKING​-

I/we agree to abide by ethical guidelines for biomedical research on human subject (As Per
ICMR guidelines) while conducting the research project being submitted for ethical committee
consideration.
1. Project is considered to be absolutely essential for the advancement of knowledge and for
the benefit of all.
2. Only subjects who volunteer for the project will be included. Their informed consent
shall be obtained prior to commencement of the research project and subjects will be kept
fully appraised of all consequences.
3. Privacy and confidentiality of the subjects shall be maintained and without the consent of
the subject, no disclosure will be made.
4. Proper precautions shall be taken so as to minimize risk and prevent irreversible adverse
effects.
5. Professionally competent persons will conduct research.
6. Research will be conducted in a fair, honest, impartial and transparent manner.
Researcher will be accountable for maintaining proper records.
7. Research will be conducted in keeping in view the public interest at large.
8. Research reports, materials and data will be preserved (as per institutional guidelines).
9. Result of research will be made known through scientific publications.
10. Professional and moral responsibilities will be of the researchers, directly or indirectly
connected with the research.
11. Only those drugs, which are approved by the Drug controller of India for a specific
purpose, will be used in the research project.

Signature: Signature:

Supervisor Investigator
Dr. Jagdish Chandra Dr. Abhishek Dixit
Director, MD Student
Lady Hardinge Medical College, Department Of Paediatrics,
New Delhi Lady Hardinge Medical College,
New Delhi

5
 CERTIFICATE FROM INSTITUTION

I, ​Dr Abhishek Dixit​, hereby declare that to the best of my knowledge, no study has been
carried out on the topic- ​Comparison of Mid-Upper Arm Circumference and
Weight-for-Height to Diagnose Severe Acute Malnutrition in age group 6-59 months

Signature:

Name of Candidate: Dr. Abhishek dixit

Department of Paediatrics
Lady Hardinge Medical College and Associated Hospitals
New Delhi-110001

Signature:

Supervisor: Dr. Jagdish Chandra

Director
Lady Hardinge Medical College and Associated Hospitals
New Delhi-110001

Signature

Co- supervisor: Dr. Praveen Kumar

Director- Professor
Department of Paediatrics,
LHMC & Kalawati Saran Children’s Hospital
New Delhi-110001

Signature:

Head of institute: Dr. Jagdish Chandra

Director
Lady Hardinge Medical College and Associated Hospitals
New Delhi-110001

6
 INTRODUCTION 
 
Malnutrition can be defined as the cellular imbalance between supply of nutrients and body’s
demand for them to ensure growth, maintenance, and specific functions. WHO has
recommended to use both Weight for Height Z score and MUAC as independent criteria to
identify children with acute malnutrition​.
Severe acute malnutrition affects nearly 20 million preschool-age children, mostly from the
World Health Organization (WHO) African Region and South-East Asia Region. Malnutrition is
a significant factor in approximately one third of the nearly 8 million deaths in children who are
under 5 years of age worldwide​1​. In children aged 6 months-59 months, Severe Acute
Malnutrition is defined as Weight/Height below -3SD Z score of the median WHO child growth
standards and/or Mid Upper Arm Circumference below 11.5cm and/or presence of bilateral
pedal edema.​2

Globally, 26 million children under 5 years of age suffer from severe acute malnutrition, most of
whom live in South Asia and Sub-Saharan Africa. India alone is home to 31.2% of the severely
wasted children all over the world. According to estimates in 2013, malnutrition affects 8.1
million under-five children, 0.6 million deaths and 24.6 million DALYs. A recent survey
NFHS-4 showed that 7.5 % of children under 5 years of age are severely wasted.​3 ​Moreover,
directly or indirectly, malnutrition contributes to nearly two-thirds of global mortality caused by
pneumonia, diarrhoea, measles and other infections among children under 5 years of age
(under-5s).​3,4 In hospitalized Indian children, malnutrition has been shown to increase the risk of
mortality up to six times in diarrhoea​5,6,7 and up to six times in acute respiratory tract
infections.​8,9
WHO has recommended both Weight for Height (W/H) and Mid Upper Arm Circumference
(MUAC) to be used in programme providing care to children with SAM.​10 However, National
family health surveys have used W/H to identify severely wasted children. In community, based
programmes MUAC is used to identify because it is a simple and low-cost method that can be
applied easily by one person after minimum training and is less susceptible to measurement error

7
than WHZ​11-12. Few recent studies have reported that MUAC and WHZ identify children as
severely wasted inconsistently​13-15​. The extent of overlap and discordance in relation to age and
sex between the different children identified as severely wasted is not well defined for Indian
children. These observed differences often have programmatic implications​16​. If the diagnosis of
severe wasting can be based on the use of both indicators​13,14​, then it will identify total population
of SAM. If correlation is within acceptable range then only MUAC approach in community
based programme will identify SAM children​14​. With these backgrounds, we propose to study
correlation of Mid Upper Arm circumference and weight for height

The gold standard to identify acute malnutrition is weight-for-height z-scores.​11

In contrast to WHZ, MUAC is a simple and low-cost method​4 that can be applied easily by one
person after minimum training​12​ and is less susceptible to measurement error than WHZ.​13

While both indicators are commonly used in programmes providing care for SAM children,
MUAC and WHZ have been shown to identify children as severely wasted inconsistently.​14,15,16

Uncertainty exists however on how MUAC and WHZ relate to each other. Collins et al.
recommended use of MUAC at community level,​17 as MUAC is considered to reflect mortality
risk better than WHZ.​18 Indeed, the World Health Organization recommends MUAC as
independent indicator for admission into therapeutic feeding programs.​19 However, the
specificity of both MUAC and WHZ for detecting children at risk for death have been reported
to be high (95%).​18 In contrast, surprisingly low sensitivities (10%) have been reported for either
MUAC <115 mm and WHZ<-3 SD for predicting death,​18 indicating that actually most children
at risk for dying are not accurately identified by either of these indicators. Moreover, poor
correlations have been reported between MUAC and WHZ-scores.​18,20 Although both indicators
are measuring nutritional status, it is possible, given the low sensitivity, that these two indicators
identify distinctly different sub-sets of children at risk for dying, but fail to cover the complete
spectrum of SAM, each missing a considerable proportion of the children with SAM.

8
Furthermore, the discrepancy between the indicators is shown to vary in different settings.​14-16
The extent of overlap and discordance in relation to age and sex between the different children
identified as severely wasted is not well defined. These observed differences often have
programmatic implications. If the diagnosis of severe wasting is based on the both the indicators
it will require training & supply of equipment. It may unreasonably increase the health care cost
and workload of programmes providing care for SAM. Alternatively, a change in MUAC cut
offs may be explored for better correlation. Single MUAC criterion for admission to
community-based therapeutic programmes may result in missed opportunities to treat a severe
condition.​15

9
 REVIEW OF LITERATURE

Globally, 34 million children under 5 years of age suffer from severe acute malnutrition, a
condition associated with increased risk of mortality and morbidity, most of whom live in South
Asia and Sub-Saharan Africa. India alone is home to 31.2% of the severely wasted children all
over the world. According to IAP guidelines 2013, 8.1 million under 5 children are affected by
malnutrition. 0.6 million deaths and 24.6 million DALYs were attributed to malnutrition. A
recent survey showed that 4.6% of children under 5 years of age are severely wasted.​2

Since 2009, the World Health Organization (WHO) has recommended using weight-for-height
Z-score (WHZ) < -3 and/or mid-upper arm circumference (MUAC) < 115 mm as anthropometric
criteria for admission to therapeutic feeding programs. In recent years, however, the use of
MUAC alone for admission has been increasingly discussed. Many benefits of using MUAC
exist: MUAC is predictive of death, easy to use, acceptable, and linked to community-based
screening methods. However, it is known that MUAC and WHZ select different children for
treatment, complicating a shift from programs currently admitting children using MUAC <115
mm and/or WHZ <-3 to a new model admitting children using MUAC <115 mm only.
Depending on context, up to 63–79% of children currently recommended for therapeutic feeding
with WHZ <-3 and/or MUAC <115 mm would not be eligible if using MUAC <115 mm alone
for admission.

Amare Worku et al in a Study in South Ethiopia concluded that Using secondary data from a
randomized trial in rural Niger among children with uncomplicated severe acute malnutrition,
authors compared children that would be admitted to a therapeutic feeding program that used a
single anthropometric criterion of MUAC<115 mm vs children that are admitted under current
admission criteria (WHZ<-3 and/or MUAC<115 mm) but would be excluded from a program
that used a single MUAC<115 mm admission criterion. They assessed differences between
groups using multivariate regression, employing linear regression for continuous outcomes and
log-binomial regression for dichotomous outcomes. A single anthropometric admission criterion

10
of MUAC < 115 mm did not differentiate well between children in terms of clinical or laboratory
measures or program outcomes in this context. If nutritional programming is to use a single
MUAC-based criterion for admission to treatment, further research and program experience can
help to identify the most appropriate criterion in a broad range of contexts to target children in
most urgent need of treatment.​21

Marion Fiorentino et al from study from Cambodia concluded that optimal cut-off values
increased with age. Boys had higher cut-offs than girls, except in the 8–10.9 yrs age range. In
children <2yrs, the cut-off was lower for stunted children compared to non stunted children.
Sensitivity of MUAC to identify WHZ<-2 and <-3 z-scores increased from 24.3% and 8.1% to
>80% with the new cut-offs in comparison with the current WHO cut-offs.​22

Sheila Isanaka et al from study Comparison of Clinical Characteristics and Treatment Outcomes
of Children Selected for Treatment of Severe Acute Malnutrition Using Mid Upper Arm
Circumference and/or Weight-for-Height Z-Score conducted at Department of Research,
Epicentre, Paris, France Children (n = 4297) aged 6–59 months with validated anthropometric
measures were recruited from a population-based survey conducted in rural southern Ethiopia.
MUAC < 115 mm and WHZ <-3SD were used to define severe wasting as per the World Health
Organization (WHO) classification.
The kappa coefficient was calculated.
There was fair agreement between the MUAC and WHZ definitions of severe wasting in boys
(=0.37) and children younger than 24 months (=0.32) but poor agreement in girls (=0.15) and
children aged 24 months and above (=0.13).​23

Arnaud Laillou et al from study titled Optimal Screening of Children with Acute Malnutrition
Requiring a Change in Current WHO Guidelines as MUAC and WHZ Identify Different Patient
Groups concluded that the secondary analysis showed that using the current WHO cut-off of 115
mm for screening for severe acute malnutrition over 90% of children with a weight-for-height
z-score (WHZ) <3SD would have been missed. Reversely, WHZ <-3SD missed 80% of the

11
children with a MUAC<115 mm. The current WHO cut-off for screening for SAM should be
changed upwards from the current 115 mm. In the Cambodian data-set, a cut-off of 133 mm
would allow inclusion of 65% of children with a WHZ <-3 SD.​24

12
 LACUNAE IN LITERATURE 
 
 
There is no published data on degree of agreement between MUAC and Weight for Height as
criteria for diagnosis of severe acute malnutrition in Indian children.

JUSTIFICATION FOR THE STUDY

- Severe acute malnutrition is important contributor in under-five mortality.

- States like Jharkhand, Odisha, Rajasthan, UP and MP have started piloting Community based
management of SAM.
- It will be useful to determine optimal MUAC for different age and sex which has better
agreement with Weight for Height criteria.

13
RESEARCH QUESTION​:
What is the Degree of agreement between current WHO cutoff of MUAC <115mm and
WEIGHT FOR HEIGHT <-3 SD for severe acute malnutrition in age group 6 months to 59
months.

HYPOTHESIS​:
Patients diagnosed with severe acute malnutrition with independent criteria of MUAC <115mm
and WEIGHT FOR LENGTH <3 SD have kappa coefficient of >0.60.

OBJECTIVES
Primary objective
To determine the Degree of agreement between current WHO cutoff of MUAC < 115mm and
WEIGHT FOR HEIGHT <-3SD for severe acute malnutrition in age group 6 months to 59
months.

Secondary objective
1. To identify optimal cutoffs for children less than 24 months and who are 24 months or older.
2. To identify risk factors for the severe acute malnutrition

14
 METHODOLOGY

Study design: ​Cross-sectional descriptive study.

Period of study: ​The study will be conducted from November 2017 to March 2019.

Place of study: ​Paediatric wards of Kalawati Saran Children’s Hospital, New Delhi.

Study population:
Screening population​: children aged 6-59 months attending outdoor/admitted in Pediatric wards
of Kalawati Saran Children Hospital, New Delhi.
Cases: Children between 6 months to 59 months with Wt for Ht less than -3SD and/or edema of
both feet and/or mid arm circumference less than 115 mm.

Enrolment criteria
A. ​Inclusion criteria​:
- Age :6 month to 59months
- Weight for height less than -3 SD and/or
- Edema of both feet and/or
- Mid arm circumference less than 115mm (in Infants > 6months)
B. ​Exclusion criteria​:
- Child who is on life support
- Child with cerebral palsy/spasticity
- Known neuromuscular disorder
- Bony deformities which can lead to errors

SAMPLE SIZE:
The sample size on this basis of ​κ​ coefficient​25​ is calculated as follows:
A​α​√​Q​01​ + Q​02 +
​ Z​β​ √​
​ Q​A1 +​
​ Q​
​ A2
2

15
N=
κ​1​ – ​κ​2
Here Z ​α​=  Φ​ (1 - ​α​),  where  Φ  ​(·) is the standard normal distribution function taken at
-1 ​

95% CI one tailed study {​Q​0 and Q​1​} are the values from Table for the null hypothesis and
alternative, respectively. Note that K (I = 0 is not excluded from the above discussion).
Z​β​ is taken at 80% power
The sample size calculated by above formula is 520.

Study method:​ following parameters will be recorded:

Age: age of the child will be determined by asking mother or care giver date of birth/age in
completed months
Weight: weight will be measured using electronic digital weighing machine with +/- 10 grams
sensitivity. The child in minimum clothes will be placed on pan of scale so that weight can be
distributed equally about center of the pan. When child will be lying quietly, weight will be
recorded in grams.
Length: Length will be measured in all children less than 2 years of age using an infantometer
with a headboard and sliding foot piece.
Height: A Stadiometer with a vertical back board, a fixed base board and a movable head board
will be to measure height.
If a child aged 2 years or older could not stand, recumbent length will be measured and 0.7 cm
will be subtracted to convert it to height.
Weight for height/length SD score: ​It will be checked using WHO growth reference values for
height and weight for length.
MUAC: it will be measured by marking a point midway between tip of acromian process of
scapula and olecranon process of ulna while child will be asked to hold left arm by the side.
Crossed tape method will be used for measuring circumference.
Pedal edema: ​To check for oedema, foot will be grasped so that it rests in hand with thumb on
top of the foot. Press thumb gently for a few seconds (approx 10 seconds). The child has oedema

16
if a pit (dent) remains in the foot when you lift your thumb. To be considered a sign of severe
acute malnutrition, oedema must appear in both feet.
Informed consent: children fulfilling inclusion criteria and without exclusion criteria will be
enrolled after obtaining written informed consent from parent/caregiver.

STATISTICAL ANALYSIS
A sample size of 520 would be taken for the study. Data would be entered into a predesigned
proforma. The strength of agreement of the ​κ​ coefficient​ values will be categorized as follows:
∙ κ​<0.20, poor
∙ 0.21 < ​κ​< 0.40,fair
∙ 0.41 <​κ​<0.60, moderate
∙ 0.61 < ​κ​<0.80, good
∙ 0.81 < ​κ​< 1.00, excellent​26-29

For the kappa coefficient analysis, we defined severe wasting based on the two anthropometric
indicators as described earlier.
Separate ROC curve for agreement will be drawn for children less than 24 months and more than
24 months
Data will be analysed using EPINFO Open Source freely available Windows statistical software
package.

17
ETHICAL CONSIDERATION
Prior approval from institutional ethics committee will be taken.
Ethical guidelines for biomedical research on human subjects (as per ICMR) will be
followed.
Parents/primary care givers of eligible children will be approached for participation &
subjects will be enrolled only after obtaining informed consent.
Privacy and confidentiality of subjects will be maintained.

18
 REFERENCES

1. United Nations Interagency Group for Child Mortality Estimation. Levels and trends in
child mortality. Report 2012. New York, United Nations Children's Fund, 2012.
2. Ministry of Health and Family Welfare, Government of India. Operational guidelines on
facility based Management of children with severe acute malnutrition. National rural
Health Mission, Ministry of Health and Family Welfare, 2011; New Delhi, India.
3. The Child Health Epidemiology Reference Group (2012) Definitive global childhood
causes of death estimates released by CHERG. Not on track to meet Millennium
Development Goal 4. Available from:
http://www.jhsph.edu/departments/international-health/the-globe/archive/summer2012/ch
ildcauses-of-death.html. Accessed on 5th September 2017.
4. Rice AL, Sacco L, Hyder A, Black RE. Malnutrition as an underlying cause of childhood
deaths associated with infectious diseases in developing countries. Bull World Health
Organ. 2000;78(10):1207-21.
5. Behera SK, Mohapatra SS, Kar S, Das D, Panda C. Incidence and mortality of
hospitalized diarrhoea cases. Part III. Indian Pediatr. 1980;17(7):607-12.
6. Srivastava AK, Bhatnagar JK, Prasad BG, Sharma NL. A clinical and aetiological study
of diarrhoea in hospitalized children at Lucknow. Indian J Med Res. 1973;61(4):596-602.
7. Sachdev HP, Kumar S, Singh KK, Satyanarayana L, Puri RK. Risk factors for fatal
diarrhea in hospitalized children in India. J Pediatr Gastroenterol Nutr. 1991;12(1):76-81.
8. Sehgal V, Sethi GR, Sachdev HP, Satyanarayana L. Predictors of mortality in subjects
hospitalized with acute lower respiratory tract infections. Indian Pediatr.
1997;34(3):213-9.
9. Deivanayagam N, Nedunchelian K, Ramasamy S, Sudhandirakannan, Ratnam SR. Risk
factors for fatal pneumonia: a case control study. Indian Pediatr. 1992;29(12):1529-32.
10. United Nations Development Programme (2006) About MDGs: what they are. Available
from: http://www.unmillenniumproject.org/goals/index.htm. Accessed on 10th Sept.
2017.

19
11. McLaren DS. Letter: Classifying nutritional disease. Am J Clin Nutr. 1974;27(2):105-6.
12. Myatt M, Khara T, Collins S. A review of methods to detect cases of severely
malnourished children in the community for their admission into community-based
therapeutic care programs. Food Nutr Bull. 2006;27(3 Suppl):S7-23.
13. Mwangome MK, Fegan G, Mbunya R, Prentice AM, Berkley JA. Reliability and
accuracy of anthropometry performed by community health workers among infants under
6 months in rural Kenya. Trop Med Int Health. 2012;17:622-9.
14. World Health Organization; United Nations Children’s Fund. WHO Child Growth
Standards and Identification of Severe Acute Malnutrition in Infants and Children: A
Joint statement by the World Health Organization and the United Nations Children’s
Fund; World Health Organization Press: Geneva, Switzerland, 2009. Available from:
http://apps.who.int/iris/bitstream/10665/44129/1/9789241598163_eng.pdf. Accessed on
8th September 2017.
15. Laillou A, Prak S, de Groot R, Whitney S, Conkle J, Horton L, et al. Optimal screening
of children with acute malnutrition requires a change in current WHO guidelines as
MUAC and WHZ identify different patient groups. PLoS One. 2014;9(7):e101159.
16. Berkley J, Mwangi I, Griffiths K, Ahmed I, Mithwani S, English M, Newton C, Maitland
K. Assessment of severe malnutrition among hospitalized children in rural Kenya:
comparison of weight for height and mid upper arm circumference. JAMA.
2005;294(5):591-7.
17. Collins S, Dent N, Binns P, Bahwere P, Sadler K, Hallam A. Management of severe
acute malnutrition in children. Lancet. 2006;368(9551):1992-2000.
18. Briend A, Maire B, Fontaine O, Garenne M. Mid-upper arm circumference and
weight-for-height to identify high-risk malnourished underfive children. Matern Child
Nutr 2012;8(1):130-3.
19. WHO. Guideline: updates on the management of severe acute malnutrition in infants and
children. Geneva: World Health Organization, 2013.

20
20. Dairo MD, Fatokun ME, Kuti M. Reliability of the Mid Upper Arm Circumference for
the Assessment of Wasting among Children Aged 12-59 Months in Urban Ibadan,
Nigeria. Int J Biomed Sci. 2012;8(2):140-3.
21. Tadesse AW, Tadesse E, Berhane Y, Ekström EC. Comparison of mid-upper arm
circumference and weight-for-height to diagnose severe acute malnutrition: a study in
Southern Ethiopia. Nutrients. 2017;9(3). pii: E267.
22. Fiorentino M, Sophonneary P, Laillou A, Whitney S, de Groot R, Perignon M, et al.
Current MUAC Cut-Offs to Screen for Acute Malnutrition Need to Be Adapted to
Gender and Age: The Example of Cambodia. PLoS One. 2016;11(2):e0146442.
23. Isanaka S, Guesdon B, Labar AS, Hanson K, Langendorf C, Grais RF. Comparison of
clinical characteristics and treatment outcomes of children selected for treatment of
severe acute malnutrition using mid upper arm circumference and/or weight-for-height
Z-score. PLoS One. 2015;10(9):e0137606.
24. Laillou A, Prak S, de Groot R, Whitney S, Conkle J, Horton L, et al. Optimal screening
of children with acute malnutrition requires a change in current WHO guidelines as
MUAC and WHZ identify different patient groups. PLoS One. 2014;9(7):e101159.
25. Cantor AB. Sample-Size Calculations for Cohen's Kappa. Psychol Methods 1996;l:150-3
26. Watson PF, Petrie A. Method agreement analysis: A review of correct methodology.
Theriogenology 2010;73:1167-79.
27. Sim J, Wright CC. The kappa statistic in reliability studies: Use, interpretation, and
sample size requirements. Phys Ther. 2005;85:257-68.
28. Viera AJ, Garrett JM. Understanding interobserver agreement: the kappa statistic. Fam
Med. 2005;37:360-63.
29. Landis JR, Koch GG. The measurement of observer agreement for categorical data.
Biometrics 1977;33:159-74.

21
 ANNEXURES 
 
ANNEXURE I PATIENT/CARE-TAKER INFORMATION SHEET

ANNEXURE II CONSENT FORM

ANNEXURE III PATIENT PERFORMA

22
 PATIENT/CARETAKER INFORMATION SHEET 
 
Study title​: Comparison of Mid-Upper Arm Circumference and Weight-for-Height to
Diagnose Severe Acute Malnutrition in age group 6-59 months​.

Name of the investigator:​ Dr. Abhishek Dixit

SUPERVISOR :
Dr. Jagdish Chandra, Director Professor, LHMC and Associated Hospitals.
Dr. Praveen Kumar, Director Professor, LHMC and Associated Hospitals.

Purpose of study :
The purpose of this study is to Comparison of Mid-Upper Arm Circumference and
Weight-for-Height to Diagnose Severe Acute Malnutrition in age group 6-59 months.

Procedure of study:
If you agree for inclusion of your child in the study, your child would be admitted in Pediatric
OPD and wards of Kalawati Saran Children’s Hospital and detailed relevant history and
examination will be done. All information collected in the study shall be fully confidential and
records would be kept secretly.

Benefit from research:

This research will help in better understanding and management of children having severe acute
malnutrition aged 6 months to 5 years.

Confidentiality:
The personal data collected for the purpose of the study will be kept confidential.

Freedom to participate and withdraw:

The participation in this study is completely at your own will and you are free to withdraw your
child from the study at any point of time. At anytime during the course of the study if you wish
to get any information, you are free to contact the investigator.
Dr. Abhishek Dixit: 9582092110
Dr. Jagdish Chandra:
Dr. Praveen Kumar:

23
 रोगी / क
​ े यरटे कर ​सच
ू ना प
​

अ ययन ​शीषक: म ​ य-​ऊपर ​बांह ​के ​प र ध ​और व

​ जन ​के ​ लए ऊ
​ ँ चाई ​क ​तल
ु ना म
​ 6-59 म
​ हन म
​ ​आयु ​वग ​म
गंभीर ​ती क
​ ु पोषण क
​ ा ​ नदान।

अ वेषक क
​ ान
​ ाम: ड
​ ॉअ
​ भषेक द
​ त

पयवे क :
डा. ​जगद श च​ ं , ​ नदे शक ा यापक, ल​ ेडी ह
​ ा डग ​मे डकल ​कॉलेज औ​ र ​सबं ं धत ​अ पताल
डा. ​ वीन कुमार, ​ नदे शक ​ ा यापक, ​लेडी ह​ ा डग म
​ े डकल क
​ ॉलेज औ​ र ​सबं ं धत अ
​ पताल

अ ययन ​का उ ​ दे य:
इस अ
​ ययन ​का ​उ दे य ​म य-​ऊपर ब ​ ांह ​प र ध ​क त ​ ल
ु ना म​ ​है औ
​ र
वज़न क​ े ​ लए ऊ
​ ँ चाई 6-59 म
​ हन म
​ आ
​ यु व ​ गक ​ े ग
​ ंभीर ​ती क​ ु पोषण ​का ​ नदान ​करना।

अ ययन ​क ​ या:
यदआ​ प ​अ ययन म ​ ​अपने ब
​ चे क
​ ोश ​ ा मल ​करने क
​ े ​ लए स
​ हमत ​ह, त
​ ो ​आपके ब
​ चे ​को ​बालवाह ​ओपीडी ​और
कलावती स
​ रन ​ च सअ
​ पताल क ​ े ​वाड और ​ व तत ृ इ​ तहास म
​ ​पर ा ​द ​जाएगी औ​ र ​पर ा क ​ ​जाएगी।

अनसु ध
ं ान स
​ ेल
​ ाभ:
यह ​शोध 6 ​मह ने स
​ े 59 म
​ ह ने त
​ कक
​ ​गंभीर ​ती क
​ ु पोषण व
​ ाले ब
​ च क
​ े ​बेहतर ​समझ ​और ​ बंधन म
​ ​मदद क
​ रे गा।

गोपनीयता:
अ ययन ​के ​उ दे य क
​ े ​ लए ​एक ​ कए ​गए ​ यि तगत ड
​ ट
े ाक
​ ोग
​ ोपनीय ​रखा ​जाएगा।

भाग ​लेने ​और ​वापस ​लेने ​क ​ वतं ता:

इस अ
​ ययन ​म ​भागीदार प ​ रू त​ रह ​से आ
​ पक इ ​ छा स
​ े ​है ​और आ
​ प ​ कसी भ
​ ी ​समय ​अ ययन स ​ ेअ
​ पने ब
​ चे ​को
वापस ल​ ेने क
​ े ​ लए ​ वतं ह ​ । ​ कसी ​भी ​समय अ ​ ययन क ​ े ​दौरान ​य द आ
​ पक​ ोई स
​ च
ू ना ​ ा त ​करना ​चाहते ​ह, त
​ ो
आप अ​ वेषक स ​ े ​सप
ं कक
​ रने क​ े ​ लए ​ वतं ह
​ ।
डा अ भषेक द त: 958209211​0
डा जगद श च
डा वीन कुमार

24
 CONSENT FORM 
 
I _________________________ parent/ guardian of ____________________________ resident
of _____________________________________________________________ hereby declare
that I give my informed consent in the thesis entitled ​“Comparison of Mid-Upper Arm
Circumference and Weight-for-Height to Diagnose Severe Acute Malnutrition in age group
6-59 months”

Dr. Abhishek Dixit has informed me to my full satisfaction, in the language I understand, about
the purpose, nature of the study and various investigations for the study to be carried out. I have
been informed about the duration of the study and the instructions to be followed during the
study period. I give full consent for being enrolled in the above study and I reserve the right to
withdraw my child from the study whenever I wish to without prejudice of my rights to undergo
treatment at Kalawati Saran Children’s Hospital, New Delhi.

______________________
Signature
(Child’s parent/guardian)
Name: Date:

We have witnessed that the child’s parent or guardian has signed the above form in the presence
of his/her free will after understanding its contents.

_______________________
Signature of witness Date:
Name:

_____________________
Signature of investigator Date:
Name:

25
 सहम त ​प

म _________________________ ____________________________ ____________________________

के ​माता-​ पता / अ ​ भभावक _____________________________________________________________ ​के
वारा ​इस ​ कार घ ​ ो षत क
​ रता ​हूं ​ क म
​ "6-59 ​मह न ​क आ ​ यु व​ गम
​ ​गंभीर ​ती क ​ ु पोषण ​का ​ नदान क
​ रने ​के ​ लए
मड-​ऊपर ब ​ ांह ​प र ध ​का व​ जन ​और ऊ ​ ँ चाई ​के ​ लए ​तल
ु ना" ​ना मत थ​ ी सस ​म म
​ ेर स ​ ू चत स
​ हम त ​देता ह
​ ूं ।

डॉ अ
​ भषेक द ​ त ​ने म
​ झ ु ेअ ​ पनी प
​ रू स ​ त
ं िु ट क ​ े ​बारे ​म ​सू चत ​ कया ​है, ज ​ ो ​भाषा ​म स ​ मझता ह ​ ूं , ​इस ​उ दे य ​के
बारे म
​ ,अ​ ययन ​क ​ कृ त ​और अ ​ ययन क ​ े ​ लए ​ व भ न ज ​ ांच क ​ ोप ​ रू ा ​करने ​के ​ लए। अ ​ ययन ​अव ध ​और
अ ययन ​अव ध ​के ​दौरान ​पालन ​ कए ज ​ ाने ​के ​ नदश ​के ब ​ ारे म​ ​मझ ु े ​सू चत ​ कया ​गया ​है। म ​ ​उपरो त अ ​ ययन म ​
नामां कत ​होने ​के ​ लए प ​ ण ू ​सहम त द ​ े ता ह​ ूं औ
​ रज ​ ब ​भी ​जब भ ​ ी ​म क ​ लावती स ​ रन ​ च न ह ​ ॉि पटल, न ​ ई​द ल म ​
इलाज क ​ े ​ लए म
​ ेरे अ
​ धकार ​के ​ तकूल ​ भाव ​डालना ​चाहता ह ​ ूं , त
​ बभ ​ ी ​अपने ब ​ चे क​ ो ​अ ययन से ​वापस ल ​ ेने ​का
अ धकार ​सरु त ​रखता ह ​ ूं ।

______________________
ह ता र
(​ब चे ​के अ
​ भभावक / अ
​ भभावक)
नाम दनांक:

हमने द
​ े खा ​है ​ क ​ब चे ​के म
​ ाता-​ पता ​या अ
​ भभावक ​ने इ
​ सके ​साम य क
​ ोस
​ मझने क
​ े ​बाद ​अपनी ​ वतं ​इ छा क
​ े
उपरो त फ ​ ॉम ​म ह ​ ता र ​ कए ह ​ ।

_______________________
गवाह क
​ े ​ह ता र:
नाम: दनांक:

_____________________
जांचकता क
​ े ह
​ ता र:
नाम: दनांक:

26
 PROFORMA

Date: S. No:

Name: 

Age/Sex: ​ / ​

CR no: 

Address: 



Father’s name: 

Mother’s name: 

Phone number: 

PRESENTING COMPLAINTS:

27
 Y

History of loose motions: If yes, then duration ________________ days

Frequency __________________ (no. of stools in last 24 hours)

1. History of blood in stools

2. History of vomiting
If yes, then duration ________________ days
Frequency __________________ (no. of stools in last 24 hours)
3. History of cough:

If yes, then duration ________________ days

4. History of fever:

History of fast breathingTop fed

Mixed
Exclusive breast feeding
1. Feeding history:What feed given?

(during first 6 months)

2. If top fed then

Cow milk
Katori spoon
Bottle feeding
Mode of feeding

Powder milk
Packaged milk
Type of milk

28
 N

Dilution of milk

If yes, then amount of water used for dilution ________

3. Complementary feeding

When started:

What started:

Immunization history:

BCG
OPV​0 OPV​1 OPV​2 OPV​3 OPV​4 OPV​5
DPT​1 DPT​2 DPT​3 DPTB​1 DPTB​2
HEP B​1 HEP B​2 HEP B​3

Maternal literacy level

Illiterate Y N
Educated upto 5​th Y N
Educated upto 8​th Y N
Educated upto 10​th Y N
Educated upto 12​th Y N
Graduate Y N
Postgraduate Y N

Anthropometry

29
 Y

∙ Weight (kg)

∙ Length/height: (cm)

Z-Score

MUAC: (cm)

Weight for height:

∙ Weight for age:

∙ Pedal oedema:

30