Protocol 2.2: Compare Evidence Against The Reference Table

The purpose of the IPC Acute Malnutrition  Reference Table is to guide comparison of available evidence against generally accepted international standards and thresholds.

The IPC Acute Malnutrition Reference Table is organized according to the IPC Acute Malnutrition Analytical Framework – i.e. Acute Malnutrition is considered the outcome because it is the outcome of interest in the IPC Acute Malnutrition (Table 36). Immediate, underlying and basic causes of Acute Malnutrition are collectively referred to as contributing factors, so that evidence can be critically evaluated, contextualized and analysed in relation to different severities of Acute Malnutrition (Table 37).

The IPC Acute Malnutrition Reference Table is organized into five severity phases (Phase 1: Acceptable; Phase 2:  Alert; Phase 3: Serious; Phase 4: Critical; and Phase 5: Extremely Critical). Each phase is characterized by a certain level of Acute Malnutrition (Box 83). Additionally, as the phase increases from 1 to 5, increased incidence of diseases, reduction in food consumption, and/or elevated risk of mortality are generally expected.

Each IPC Acute Malnutrition phase is linked to priority response objectives (Box 85). While the IPC Acute Malnutrition Reference Table link response objectives with each phase, it is necessary to conduct a Response Analysis, following the IPC Acute Malnutrition analysis, to determine the specific interventions and activities that are best suited to address Acute Malnutrition in each area of analysis.

Although acute malnutrition outcomes can take on different forms, the most common ones that are globally recognized and used as programme intervention criteria at present are: low WHZ; low MUAC; or the presence of bilateral pitting oedema. In population assessments, children with oedema or low WHZ (i.e. WHZ<-2 standard deviation from the reference) are reported as GAM. Similarly, children with oedema or low MUAC (i.e. MUAC <125mm) are also referred to as GAM.  In the IPC, GAM derived from prevalence of low WHZ or presence of oedema is referenced as GAM based on WHZ, while GAM derived from prevalence of low MUAC or presence of oedema is referenced as GAM based on MUAC.

The IPC recognizes and advocates for the treatment for all forms of acute malnutrition. All children with low MUAC should receive treatment for acute malnutrition together with those who have low WHZ or oedema, since it is the current practice of various partner agencies and governments in different parts of the world. The IPC also acknowledges the efforts of some countries to calculate the number of children who are acutely malnourished by combining GAM based on WHZ, and GAM based on MUAC so as to provide a more inclusive overview of the acute malnutrition situation.

However, global thresholds for GAM based on MUAC are unavailable at present, and reporting on combined prevalence estimates of GAM based on  MUAC and GAM based on WHZ are currently not a standard practice. The IPC urges the nutrition community to work towards developing global standards for a more inclusive approach when assessing Acute Malnutrition by including all forms of Acute Malnutrition.

Working with this vision, but also with the technical limitations, the Acute Malnutrition Reference Table includes globally accepted thresholds for GAM based on WHZ including oedema as well as some preliminary thresholds for GAM based on MUAC including oedema. Because the preliminary thresholds have been developed by the IPC Global Partnership, and authoritative thresholds are still missing, GAM based on MUAC can only be used in the absence of GAM based on WHZ. In exceptional cases when GAM based on MUAC portrays a significantly more severe situation (i.e. GAM based on MUAC is two or more phases higher than GAM based on WHZ), MUAC-based prevalence should be taken into account with a critical review of contributing factors.

The IPC Acute Malnutrition Reference Table is not for review at the country or regional level; however, it may be updated by the IPC Global Partnership, taking into consideration users’ feedback, lessons learned and the latest technical developments, including evidence-based research.