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Module 3: Nutritional Assessment

during Emergencies
 Overview

This module presents the common forms

of malnutrition during emergencies,
importance of nutritional assessment
during emergencies, and the methods
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used in nutritional assessment.

 Learning Objectives
At the end of this module, the participants should
be able to:
1. Identify common forms and causes of
malnutrition during emergencies.
2. Explain the importance of assessing the
nutritional status of individuals during
emergencies.
3. Discuss the different methods of nutritional
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assessment during emergencies (MUAC, W/H).

4. Demonstrate competencies in measuring and
interpreting MUAC, weight, height measurement
results for response planning.
 SESSION 3.1
COMMON FORMS OF MALNUTRITION
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 Malnutrition

• refers to the pathological condition

resulting from
- lack of nutrient (under nutrition), or
- excess of nutrients (over nutrition) or
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- absolute imbalance in nutrient intake

 Types of Malnutrition
• Under nutrition – the condition resulting from
the consumption of inadequate quantity of food
over an extended period of time.

• Over nutrition – the condition resulting from

the consumption of an excessive quantity of
food over an extended period of time.
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• Specific-nutrient deficiency – condition

resulting from a relative or absolute lack of an
individual nutrient.
 Forms of Under-nutrition

Under-nutrition is a consequence of consuming

inadequate quantity of food over an extended
period of time.

It refers to a range of conditions:

• acute malnutrition (wasting/thinness)
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• chronic malnutrition (stunting/shortness)

• micronutrient deficiencies (vitamin A deficiency,
iron deficiency anemia, and iodine deficiency
disorders, etc.)
 Acute malnutrition
• characterized by drastic deterioration of
nutritional status in a short time and that which
relates to present state of nutrition.

• caused by inadequate intake of food and

episodes of infections in the immediate past 3
months and associated with an increased risk of
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morbidity and mortality.

• reversible and can be manifested by muscle

wasting.
 Moderate Acute Malnutrition (MAM)
• characterized by a low weight-for-height
(between less than minus 2 to less than minus
3 z scores of the median growth standards)

• those classified as “wasted”, based on the

revised tables on weight and height
measurements using the WHO Child Growth
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Standards (CGS)

• MUAC is 115 mm (11.5 cm or 4.5 in) to less

than 125 mm (<12.5 cm or <4.9 in).
 Severe Acute Malnutrition (SAM)
• characterized by weight below minus 3 z scores
of the median growth standards

• MUAC is less than 11.5 mm (<11.5 cm. or <4.5

in) and when bilateral pitting edema is present.

• those classified as “severely wasted” (WHO

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Child Growth Standards)

 Clinical Forms of SAM
• Marasmus is a form of severe acute
malnutrition caused by inadequate intake of
energy (calories), Type 2 Nutrients (Nitrogen,
Essential Amino Acids, potassium, Magnesium,
phosphorus, Sulfur, Zinc, Sodium and Chlorine)
with infections and endotoxins.
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• A marasmic child has dry skin, tissue and

muscle wasting and loose skin folds hanging
over the buttocks and armpit.
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 The marasmic child may have folds of
skin on the buttocks and thighs that
make it look as if the child is wearing
“baggy pants.”

Weight-for-age and weight-for-

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length/height are likely to be very low.

 Kwashiorkor
 This is a form of acute malnutrition that
occurs when there is not enough protein in the
diet. It is brought about by deficiencies of Type
1 Nutrients (Iron, Iodine, Copper, Calcium,
Selenium, Thiamine, Riboflavin, Pyridoxine,
Niacin, Folate, Cobalamin and Vitamins A,D,E,K
combined with infections and endotoxins that
result to cell membrane permeability leading to
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edema.

 It is characterized by edema, irritability,

anorexia, dermatitis and enlarged liver with
fatty infiltrates.
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 Marasmic kwashiorkor

refers to a condition where there is a

deficiency of both energy (calories) and
protein and Types 1 & 2 Nutrients. This is
characterized with severe tissue wasting,
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loss of subcutaneous fats, edema,

dehydration and growth retardation.
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 Chronic malnutrition

• most common form of malnutrition and that

which relates to past state of nutrition.

• usually results in stunting and impaired physical

and mental development in children.
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• an irreversible condition.

• stunting of growth is indicated by under/short

height for age(<-2SD).
 Vulnerable Groups during
emergencies

• Low birth weight babies

• 0-59 month old children
• Pregnant and lactating women
• Older people
• People with disabilities
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• People with chronic illnesses

• People with HIV and AIDs
 SESSION 3.2
NUTRITIONAL ASSESSMENT DURING
EMERGENCIES
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 Importance of Nutritional
Assessment

• Malnutrition and infection are intimately related

– a malnourished child is more susceptible to
illness, and a sick child is more likely to become
malnourished

• Malnutrition increases the risk to infections and

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fatal diseases such as malaria, measles,

diarrhea, pneumonia, HIV and AIDS.
 Cycle of Infection and
Undernutrition
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 Moderate acute malnutrition needs to be
addressed to:
• prevent from getting worse
• protect the child’s right to sufficient food,
growth and well-being and to prevent more
serious illness and death

Moderate malnutrition is also significantly cheaper

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to treat than severe malnutrition

• Under nutrition contributes to between 35 and
55 percent of all childhood deaths.
• In serious emergency situations, malnutrition
can account for even more deaths.
 Global distribution of deaths among
children under age 5, by cause, 2010
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 Methods of Nutritional Assessment
• Anthropometric- measurement of variations of
the physical dimension and gross composition of
the human body as in weight, height/length and
left MUAC
• Biochemical- measurement of level of nutrient
and their metabolites using biological specimens
like blood and urine
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• Clinical – physical examination of an individual

for signs suggestive of malnutrition such as
paleness
• Dietary – collection of data on food intake
 Methods of Nutritional Assessment
• Rapid Nutrition Assessment - method of
collecting data in a relatively short period of
time.

• Survey – systematic collection of specific

nutrition indicators to obtain existing nutritional
and nutrition-related problems
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• Nutrition Surveillance – refers to watching

over nutrition in order to make decisions
leading to improvements on nutrition of the
population by providing regular information
about nutrition.
 Rapid Nutrition Assessment
• Refers to the assessment of nutritional status
based on simple anthropometric data:
- MUAC is the circumference of the left upper
arm, measured at the mid-point between the
tip of the shoulder and the tip of the elbow
(olecranon process and the acromium).
- Height/length
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- Weight
- Sex, age and presence of edema
 Rapid Nutrition Assessment
• limited to infants and children of preschool age
(under 5 years of age or U5), who serve to
represent the general population.
• limited to protein-energy malnutrition without
attempting to assess other nutritional
deficiencies. Assessment of other variables can
add workload and may cause unnecessary
delay.
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• conducted monthly until “full normalcy” is

achieved then Operation Timbang (OPT) can be
used.
• Nutrition cluster should lead the assessment
and supervise its conduct.
 Rapid nutrition assessment is important to:

• have a quick snapshot of the nutrition situation

• determine the magnitude and severity of crisis

• determine whether a more detailed assessment

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is required

• serve as initial screening for inclusion in a

selective feeding program
 Nutritional Assessment is conducted

• at the soonest possible time but may not be

feasible or practical during the early stage of
the emergency.

• done in the intermediate and extended phases

since the disaster or emergency may have
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negative effects on the nutritional status

especially of the nutritionally vulnerable
 What to measure during RNA

• Mid-upper-arm circumference or MUAC- the

best measure for 6-59 month-old children for
screening
• Weight and height - the best indicator of
wasting and other nutritional problems
• Height – the best indicator of stunting and
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other nutritional problems

• Bilateral pitting edema – essential indicator
for determining the presence of SAM or
kwashiorkor
 SESSION 3.3
METHODS OF NUTRITIONAL ASSESSMENT
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 How to assess using MUAC

• MUAC- a useful tool in screening acute

malnourished children 6 to 59 months old
during emergencies especially when priority is
given to younger children.

• MUAC- age and sex independent and has been

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based on fixed cut-off point of 12.5 cm.

 MUAC
• can be used in instances where weighing is not
possible.

• simple to take and can be done accurately,

provided the tape is not tightly nor loosely
fitted.
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• tape is very cheap and easily carried and has

special value when weighing scales and/or
length/height boards are not available.
(Guidelines on GMP, 2012)
 Advantages of MUAC
• used for rapid screening of acute malnutrition
from the 6-59 month age range.

• used for identification of severe acute

malnutrition (SAM) during screening at the
community level and admission for treatment at
the health facility.
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• MUAC alone as independent criteria for SAM

was endorsed by WHO.
 Advantages of MUAC
• simple, quick, accurate and inexpensive

• more sensitive

• better indicator of mortality risk associated with

malnutrition than Weight-for-Height. It is
therefore a better measure to identify children
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most in need of treatment.

• less prone to mistakes. Comparative studies

have shown that MUAC is subject to fewer
errors than Weight-for-Height (Myatt et al,
2006).
 • There should be 2 persons involved: the
measurer and assistant/recorder.

• Keep your work at eye-level and sit down when

possible. A very young child can be held during
the procedure by the parent or carer, who
should also remove any clothing that covers the
child’s left arm.
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• Measure MUAC on the left arm hanging freely

by the side using a non-stretch fiberglass tape
 Steps in measuring MUAC
• With the left forearm folded across the body
with palm down, determine the midpoint
between the tip of the acromion process (tip of
the shoulder blade) and the olecranon process
of the ulna (tip of the elbow bone).

• Mark the midpoint with a pen (or hold the tape

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at the point where the midpoint of the arm is

located) and gently position the tape around the
arm, taking care not to hold it too loose or too
tight.

• Take the measurement reading to the nearest

0.1 cm.
 Measurement of Mid-Upper
Arm Circumference (MUAC)

Location of the Midpoint

of the Upper Arm

Acromion
process
on shoulder
blade
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Mid-upper arm Forearm, mid-point

circumference is measured palm down Olecranon
process of
at the midpoint of the upper across
body the ulna
arm and recorded to the
nearest millimeter

Gibson, 1990
 • Make sure that the tape is flat against the skin.
• Read the measurement to the nearest 0.1 cm.
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 How to interpret MUAC

cm SAM MAM NORMAL

11.5 12.5

For Children 6-59 months

RED SAM MUAC < 115 mm (<11.5
cm)
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YELLOW MAM MUAC ≥ 115 mm (>11.5

cm) and < 125 mm (<12.5
cm)

GREEN Normal MUAC ≥ 125 mm (>12.5

cm)
 Assessing using weight for
height/length

• weight for height - widely used nutritional or

anthropometric index, and the best indicator of
wasting.
• recommended for assessment of recent
nutrition, and is especially important for
assessments of nutrition-related humanitarian
emergencies.
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• If measuring weight and height is not possible,

the MUAC could be used as index for screening
preschool children.
 Measuring child’s length/height

• Instruments

- infantometer/length board
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- height board

- microtoise
 Measuring Length/height of less than
2 year old child
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 Using height board for children
2 yrs and older
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 • If a child less than 2 years old will not lie
down for measurement of length,
measure standing height and add 0.7cm
to convert it to length (CGS)

• If a child aged 2 years or older cannot

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stand, measure recumbent length and

subtract 0.7 cm to convert it to height.
(CGS )
 Using microtoise for children
2 yrs and above
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 This is a picture of part of a measuring
tape. The numbers and longer lines
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indicate centimeter markings. The

shorter lines indicate millimeters. The
gray box shows the position of the
footboard when a length measurement
is taken
 Assessing weight for height
• Beam balance
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 Assessing weight for height/length

• Salter scale
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 Assessing weight for height
• Beam balance
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 Demonstration of measuring W/H

• Using the Salter scale

• Using the beam balance

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 Weighing young infants and
struggling children

• Using the beam balance scale and following the

correct weighing procedures, obtain the child's
weight by weighing the mother and the child
together and then weigh the mother alone.

• Subtract the weight of the mother from the

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weight of mother and child to get the child's

weight.

• Record the weight to the nearest 0.1 kg.

 Interpretation of z score values
for weight for length/height
Z-score Nutritional Interpretation
Status
>+3SD Obese The child is obese for
his/her length/height
>+2SD to +3SD Overweight The child is overweight
for his/her length/height
-2SD to +2SD Normal The child’s weight is
within the normal range
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for his/her length/height

<-2SD to -3SD Wasted/Thin The child is wasted/thin
for his/her length/height
<-3SD Severely The child is severely
Wasted wasted for his/her
length/height
 Assessing bilateral pitting edema

• an essential indicator for determining the

presence of SAM or kwashiorkor.

• usually present first in feet, then in

ankles and lower limbs.
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• detected by a definite pit as a result of 3-

second moderate pressure with the
thumb just above the ankle.
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Fighting Hunger Worldwide Weight for Height, Boys and Girls
Fighting Hunger Worldwide Length for Height, Boys and Girls
 Weight for Length/Height, Boys
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 Weight for Length/Height, Girls
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 Key Messages
• Malnutrition should be addressed appropriately
during disasters and emergencies to prevent
serious illness and death.

• Rapid nutrition assessment is used to assess

the nutritional status of children using simple
anthropometric measurements.
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• Nutritional assessment should be done during

the intermediate and extended phases of
emergencies.
 • Timely management of severe acute
malnutrition is a key intervention in
emergencies and could prevent child deaths.

• MUAC is used for rapid screening of acute

malnutrition from the 6-59 month age range
and used for identification of severe acute
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malnutrition (SAM) during screening at the

community level and admission for treatment at
the health facility
 • Depending on a child’s age and ability to stand,
measure the child’s length or height. If the child
is less than two years old, the length is
measured lying down (recumbent) using an
infantometer.

• If the child is more than two years old and

older, the child’s height is measured standing
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upright using a height board or microtoise.

 • if the child less than 2 years old will not lie
down for measurement of length, measure
standing height and add 0.7cm to convert it to
length. If a child aged 2 years and older cannot
stand, measure recumbent length and subtract
0.7cm to convert it to height.
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THANK YOU!