Globally, wasting treatment services admit over 5 million children on a yearly basis, providing lifesaving therapeutic treatment to these high-risk children. Yet only one third of children with wasting receive treatment. Limited geographic coverage means that treatment is just not available in many places. Scaling-up services within countries is essential to ensure that treatment becomes available, especially where wasting is a common condition. Where services are available at local health facilities, children may still not have access due to limited screening, meaning that wasting is not being detected at the community level. In many of these contexts, families are not aware that tools to identify wasting in their child exist, the consequences of untreated wasting, or of the presence of a treatment service.

Empowering families with the tools and know how

One solution to this problem is the Family Middle Upper Arm Circumference (MUAC) approach which aims to make wasting treatment more available and accessible by increasing the frequency and coverage of screening for children suffering from wasting, thereby ultimately detecting more children with wasting for early referral. MUAC bands are cheap, easy to use, colour coded measuring tapes which quickly identify wasting in children under 5. Typically, health workers at facility and community level have been responsible for measuring MUAC of children. However, the Family MUAC approach trains family members on how to use and interpret a MUAC tape. Included in this training is sensitisation on the treatment services available, what to do when wasting is detected and key messaging on infant and young child feeding practices.

Studies have shown that, after training, members of the family are able to accurately measure children’s MUAC. In addition, this approach has led to more frequent screening at home meaning that more children are being measured earlier in their episode of wasting. One study found that where family members had been trained, treatment outcomes were better for the child, likely because the family knows more about the condition and the importance of initiating and finishing treatment. Importantly, Family MUAC is more cost-effective than traditional screening approaches, particularly screening campaigns. Overall, this approach offers a sustainable, low-cost, inclusive approach to screening for child wasting at home.

Mapping the uptake of Family MUAC and responding to COVID-19

The approach was first trialled in rural Niger by ALIMA in 2012, sparking uptake of the approach within the NGO community, with key nutrition actors integrating Family MUAC into their projects and programmes. By 2018, over 1.3 million family members had been trained by 12 different organisations in 26 different countries. Whilst this impressive uptake was promising, many of the Family MUAC interventions remained small-scale and project based, resulting in patchy coverage.

During COVID-19, Family MUAC rose to the forefront of the nutrition response. In most countries, wasting treatment services continued to function as part of the key child survival package of interventions, however, many community outreach activities were halted, including screening. Family MUAC not only ensured that children were still being detected but also facilitated the containment of the virus by reducing contact through shifting screening to the family. Since the COVID-19 pandemic, 39 countries are now implementing the Family MUAC approach, meaning that nearly 50% of all countries implementing wasting treatment are also implementing Family MUAC. The majority of countries implementing Family MAUC are in Africa, though countries in Asia and Latin America are also implementing the approach.

Over the past two years, millions of family members have been trained and are using MUAC tapes to measure their children at home. This twofold increase in countries over the course of the pandemic gives rise to hope that barriers to access for some of the most vulnerable families might be overcome, resulting in more children accessing treatment.

Cementing Family MUAC in policy and planning

It is important now to solidify the great coverage gains of this approach into policy and practice. Certain countries have already integrated Family MUAC into national policy, including several countries in Africa (Burkina Faso, Mali, Mauritania, Niger, Sierra Leone & Sudan) where Family MUAC is present in updated treatment protocols endorsed by the national ministries of health. In Burkina Faso, this policy change has also been complemented by an operational implementation plan to scale-up the approach nationwide. Family MUAC is also part of national policy in Indonesia, where the government has included the approach in the national growth monitoring strategy.

Moving forward, Family MUAC should become a standard component of wasting treatment services. This shift towards integration, at the community level will need to be reflected in both programming and policy at national level. Advocacy to national health ministries is a key avenue to explore to ensure these policy gains at country level. Furthermore, Family MUAC should not only feature as part of wasting service delivery but should be a core component of multi-sectoral child survival and early childhood development programmes. Empowering families to detect wasting at home, with easy to use, cheap MUAC tapes needs to become universal wherever wasting exists.

About the authors:

Sophie Woodhead has over 10 years of experience in the management and implementation of international child development and nutrition interventions. Sophie currently works with UNICEF supporting the area of child wasting treatment services in documentation and technical support. Prior to UNICEF, Sophie worked with national and international NGOs and other UN agencies across countries in Africa and South Asia.

Grace Funnell is a Nutrition Specialist with the UNICEF Nutrition Section in New York where she supports the agency’s strategic goals on wasting and leads the global coordination and implementation of simplified approaches. Prior to joining UNICEF, Grace served as Action Against Hunger USA’s Technical Director.

Competing interests: None

Handling Editor: Neha Faruqui