{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,13]],"date-time":"2026-07-13T20:01:15Z","timestamp":1783972875833,"version":"3.55.0"},"reference-count":26,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2021,4,1]],"date-time":"2021-04-01T00:00:00Z","timestamp":1617235200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2021,4,1]],"date-time":"2021-04-01T00:00:00Z","timestamp":1617235200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill & Melinda Gates Foundation","doi-asserted-by":"publisher","award":["OPP1055862"],"award-info":[{"award-number":["OPP1055862"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Pediatr"],"published-print":{"date-parts":[[2021,12]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Weight for length z-score (WLZ)\u2009&lt;\u2009\u2212\u20093 is currently used to define severe acute malnutrition (SAM) among infants. However, this approach has important limitations for infants younger than 6\u2009months of age as WLZ cannot be calculated using WHO growth standards if infant length is &lt;\u200945\u2009cm. Moreover, length for age z-score (LAZ) and weight for length z-score (WLZ) are least reliable measures, with high chances of variation, and less chances of detecting undernutrition in under 6\u2009months infants. The objective of the current analysis was to compare WLZ with WAZ and LAZ in a cohort of Indian infants in predicting the deaths between 6\u2009weeks and 6\u2009months of age.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>The data was from an individually randomized trial conducted in slums of Delhi, India in which infants\u2019 weight and length were measured at 6\u2009weeks of age (at the time of the first immunization visit). Vital status of the infants was documented from 6\u2009weeks to 6\u2009months of age. The sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated for WAZ\u2009&lt;\u2009-3, WLZ\u2009&lt;\u2009-3, and LAZ\u2009&lt;\u2009-3 for deaths between 6\u2009weeks and 6\u2009months of age. The receiver operating characteristics curve was calculated for each of the above anthropometric indicators.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>For deaths occurring between 6\u2009weeks to 6\u2009months of age, the specificity ranged between 85.9\u201395.9% for all three anthropometric indicators. However, the sensitivity was considerably higher for WAZ; it was 64.6% for WAZ\u2009&lt;\u2009-3, 39.1% for LAZ\u2009&lt;\u2009-3, and 25.0% for WLZ\u2009&lt;\u2009-3. WAZ\u2009&lt;\u2009-3 had higher area under curve (0.75; 95% CI: 0.68, 0.82) and hence, better discriminated deaths between 6\u2009weeks and 6\u2009months of age than WLZ\u2009&lt;\u2009-3. The adjusted relative risk (RR 10.6, 95% CI 5.9, 18.9) and the population attributable fraction (PAF 57.9, 95% CI 38.8, 71.0%) of mortality was highest for WAZ\u2009&lt;\u2009-3.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>We found WAZ\u2009&lt;\u2009-3 at 6\u2009weeks of age to be a better predictor of death in the 6\u2009weeks to 6\u2009months of life in comparison to WLZ\u2009&lt;\u2009-3 and LAZ\u2009&lt;\u2009-3 and propose that it should be considered to diagnose SAM in this age group.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12887-021-02629-9","type":"journal-article","created":{"date-parts":[[2021,4,1]],"date-time":"2021-04-01T08:03:07Z","timestamp":1617264187000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Diagnostic measures for severe acute malnutrition in Indian infants under 6\u2009months of age: a secondary data analysis"],"prefix":"10.1186","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0055-6653","authenticated-orcid":false,"given":"Ranadip","family":"Chowdhury","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"family":"Nitika","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tarun Shankar","family":"Choudhary","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sunita","family":"Taneja","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jose","family":"Martines","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nita","family":"Bhandari","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rajiv","family":"Bahl","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2021,4,1]]},"reference":[{"issue":"7","key":"2629_CR1","doi-asserted-by":"publisher","first-page":"224","DOI":"10.1542\/pir.18-7-224","volume":"18","author":"CP Johnson","year":"1997","unstructured":"Johnson CP, Blasco PA. Infant growth and development. Pediatr Rev. 1997;18(7):224\u201342. https:\/\/doi.org\/10.1542\/pir.18-7-224.","journal-title":"Pediatr Rev"},{"key":"2629_CR2","doi-asserted-by":"crossref","unstructured":"Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2102;2012(8):CD003517.","DOI":"10.1002\/14651858.CD003517.pub2"},{"issue":"12","key":"2629_CR3","doi-asserted-by":"publisher","first-page":"887","DOI":"10.2471\/BLT.12.109009","volume":"90","author":"MK Mwangome","year":"2012","unstructured":"Mwangome MK, Fegan G, Fulford T, Prentice AM, Berkley JA. Mid-upper arm circumference at age of routine infant vaccination to identify infants at elevated risk of death: a retrospective cohort study in the Gambia. Bull World Health Organ. 2012;90(12):887\u201394. https:\/\/doi.org\/10.2471\/BLT.12.109009.","journal-title":"Bull World Health Organ"},{"issue":"3","key":"2629_CR4","doi-asserted-by":"publisher","first-page":"515","DOI":"10.1016\/j.jpeds.2012.09.008","volume":"162","author":"SB Vygen","year":"2013","unstructured":"Vygen SB, Roberfroid D, Captier V, Kolsteren P. Treatment of severe acute malnutrition in infants aged <6 months in Niger. J Pediatr. 2013;162(3):515\u201321.e3.","journal-title":"J Pediatr"},{"issue":"4","key":"2629_CR5","doi-asserted-by":"publisher","first-page":"250","DOI":"10.1179\/2046905514Y.0000000158","volume":"34","author":"AJ Prendergast","year":"2014","unstructured":"Prendergast AJ, Humphrey JH. The stunting syndrome in developing countries. Paediatr Int Child Health. 2014;34(4):250\u201365. https:\/\/doi.org\/10.1179\/2046905514Y.0000000158.","journal-title":"Paediatr Int Child Health"},{"issue":"9609","key":"2629_CR6","doi-asserted-by":"publisher","first-page":"340","DOI":"10.1016\/S0140-6736(07)61692-4","volume":"371","author":"CG Victora","year":"2008","unstructured":"Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, et al. Maternal and child undernutrition: consequences for adult health and human capital. Lancet. 2008;371(9609):340\u201357. https:\/\/doi.org\/10.1016\/S0140-6736(07)61692-4.","journal-title":"Lancet."},{"issue":"11","key":"2629_CR7","doi-asserted-by":"publisher","first-page":"1008","DOI":"10.1136\/adc.2010.191882","volume":"96","author":"M Kerac","year":"2011","unstructured":"Kerac M, Blencowe H, Grijalva-Eternod C, McGrath M, Shoham J, Cole TJ, et al. Prevalence of wasting among under 6-month-old infants in developing countries and implications of new case definitions using WHO growth standards: a secondary data analysis. Arch Dis Child. 2011;96(11):1008\u201313. https:\/\/doi.org\/10.1136\/adc.2010.191882.","journal-title":"Arch Dis Child"},{"issue":"4","key":"2629_CR8","doi-asserted-by":"publisher","DOI":"10.1111\/mcn.12866","volume":"15","author":"TS Choudhary","year":"2019","unstructured":"Choudhary TS, Srivastava A, Chowdhury R, Taneja S, Bahl R, Martines J, et al. Severe wasting among Indian infants <6 months: findings from the National Family Health Survey 4. Matern Child Nutr. 2019;15(4):e12866.","journal-title":"Matern Child Nutr"},{"key":"2629_CR9","volume-title":"WHO guidelines: updates on the management of severe acute malnutrition in infants and children","author":"WHO","year":"2013","unstructured":"WHO. WHO guidelines: updates on the management of severe acute malnutrition in infants and children: World Health Organization; 2013."},{"key":"2629_CR10","volume-title":"WHO child growth standards and the identification of severe acute malnutrition in infants and children: a joint statement by the World Health Organization and the United Nations Children\u2019s fund","author":"WHO\/UNICEF","year":"2009","unstructured":"WHO\/UNICEF. WHO child growth standards and the identification of severe acute malnutrition in infants and children: a joint statement by the World Health Organization and the United Nations Children\u2019s fund; 2009."},{"issue":"3","key":"2629_CR11","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0213523","volume":"14","author":"M Mwangome","year":"2019","unstructured":"Mwangome M, Ngari M, Bwahere P, Kabore P, McGrath M, Kerac M, et al. Anthropometry at birth and at age of routine vaccination to predict mortality in the first year of life: a birth cohort study in BukinaFaso. PLoS One. 2019;14(3):e0213523. https:\/\/doi.org\/10.1371\/journal.pone.0213523.","journal-title":"PLoS One"},{"issue":"6","key":"2629_CR12","doi-asserted-by":"publisher","first-page":"1415","DOI":"10.3945\/ajcn.116.149815","volume":"105","author":"M Mwangome","year":"2017","unstructured":"Mwangome M, Ngari M, Fegan G, Mturi N, Shebe M, Bauni E, et al. Diagnostic criteria for severe acute malnutrition among infants aged under 6 mo. Am J Clin Nutr. 2017;105(6):1415\u201323. https:\/\/doi.org\/10.3945\/ajcn.116.149815.","journal-title":"Am J Clin Nutr"},{"issue":"12","key":"2629_CR13","doi-asserted-by":"publisher","first-page":"1340","DOI":"10.1136\/adc.65.12.1340","volume":"65","author":"LD Voss","year":"1990","unstructured":"Voss LD, Bailey BJ, Cumming K, Wilkin TJ, Betts PR. The reliability of height measurement (the Wessex growth study). Arch Dis Child. 1990;65(12):1340\u20134. https:\/\/doi.org\/10.1136\/adc.65.12.1340.","journal-title":"Arch Dis Child"},{"key":"2629_CR14","first-page":"34","volume":"47","author":"M Mwangome","year":"2014","unstructured":"Mwangome M, Berkley J. Measuring infants aged below 6 months: experience from the field. Field Exchange. 2014;47:34.","journal-title":"Field Exchange"},{"issue":"5","key":"2629_CR15","doi-asserted-by":"publisher","first-page":"622","DOI":"10.1111\/j.1365-3156.2012.02959.x","volume":"17","author":"MK Mwangome","year":"2012","unstructured":"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(5):622\u20139. https:\/\/doi.org\/10.1111\/j.1365-3156.2012.02959.x.","journal-title":"Trop Med Int Health"},{"issue":"4","key":"2629_CR16","doi-asserted-by":"publisher","first-page":"474","DOI":"10.1111\/mcn.12124","volume":"10","author":"MK Mwangome","year":"2014","unstructured":"Mwangome MK, Berkley JA. The reliability of weight-for-length\/height Z scores in children. Matern Child Nutr. 2014;10(4):474\u201380. https:\/\/doi.org\/10.1111\/mcn.12124.","journal-title":"Matern Child Nutr"},{"key":"2629_CR17","doi-asserted-by":"publisher","first-page":"146","DOI":"10.1186\/1471-2458-13-146","volume":"13","author":"A Biehl","year":"2013","unstructured":"Biehl A, Hovengen R, Meyer HE, Hjelmesaeth J, Meisfjord J, Gr\u00f8holt E-K, et al. Impact of instrument error on the estimated prevalence of overweight and obesity in population-based surveys. BMC Public Health. 2013;13:146.","journal-title":"BMC Public Health"},{"issue":"4","key":"2629_CR18","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.1001812","volume":"12","author":"C Angood","year":"2015","unstructured":"Angood C, McGrath M, Mehta S, Mwangome M, Lung'aho M, Roberfroid D, et al. Research priorities to improve the management of acute malnutrition in infants aged less than six months (MAMI). PLoS Med. 2015;12(4):e1001812. https:\/\/doi.org\/10.1371\/journal.pmed.1001812.","journal-title":"PLoS Med"},{"key":"2629_CR19","doi-asserted-by":"crossref","unstructured":"WHO\/CHD immunisation-linked vitamin a supplementation study group. Randomised trial to assess benefits and safety of vitamin a supplementation linked to immunisation in early infancy. Lancet. 1998;352(9136):1257\u201363.","DOI":"10.1016\/S0140-6736(98)02487-8"},{"key":"2629_CR20","first-page":"3","volume":"53","author":"DB Jelliffe","year":"1966","unstructured":"Jelliffe DB. The assessment of the nutritional status of the community (with special reference to field surveys in developing regions of the world). Monogr Ser World Health Organ. 1966;53:3\u2013271.","journal-title":"Monogr Ser World Health Organ"},{"key":"2629_CR21","volume-title":"WHO child growth standards: length\/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: methods and development","author":"WHO","year":"2006","unstructured":"WHO. WHO child growth standards: length\/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: methods and development; 2006."},{"key":"2629_CR22","volume-title":"WHO Anthro for personal computers manual: software for assessing growth and development of the world\u2019s children","author":"WHO","year":"2010","unstructured":"WHO. WHO Anthro for personal computers manual: software for assessing growth and development of the world\u2019s children. Geneva: WHO; 2010."},{"key":"2629_CR23","unstructured":"Seed PT, Tobias A. Summary statistics for diagnostic tests. Stata Tech Bull. 2001;10(59):90\u20133."},{"issue":"3","key":"2629_CR24","doi-asserted-by":"publisher","first-page":"837","DOI":"10.2307\/2531595","volume":"44","author":"ER DeLong","year":"1988","unstructured":"DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988;44(3):837\u201345. https:\/\/doi.org\/10.2307\/2531595.","journal-title":"Biometrics."},{"issue":"4","key":"2629_CR25","doi-asserted-by":"publisher","first-page":"458","DOI":"10.1002\/bimj.200410135","volume":"47","author":"R Fluss","year":"2005","unstructured":"Fluss R, Faraggi D, Reiser B. Estimation of the Youden index and its associated cutoff point. Biom J. 2005;47(4):458\u201372. https:\/\/doi.org\/10.1002\/bimj.200410135.","journal-title":"Biom J"},{"key":"2629_CR26","unstructured":"Brady AR. Adjusted population attributable fractions from logistic regression. Stata Tech Bull. 1998;7(42)."}],"container-title":["BMC Pediatrics"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12887-021-02629-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/article\/10.1186\/s12887-021-02629-9\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1186\/s12887-021-02629-9.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,4,1]],"date-time":"2021-04-01T08:06:08Z","timestamp":1617264368000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcpediatr.biomedcentral.com\/articles\/10.1186\/s12887-021-02629-9"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,4,1]]},"references-count":26,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2021,12]]}},"alternative-id":["2629"],"URL":"https:\/\/doi.org\/10.1186\/s12887-021-02629-9","relation":{"has-preprint":[{"id-type":"doi","id":"10.21203\/rs.3.rs-58666\/v2","asserted-by":"object"},{"id-type":"doi","id":"10.21203\/rs.3.rs-58666\/v1","asserted-by":"object"}]},"ISSN":["1471-2431"],"issn-type":[{"value":"1471-2431","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,4,1]]},"assertion":[{"value":"11 August 2020","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"24 March 2021","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"1 April 2021","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The analysis was done based on anonymized data. The primary study was approved by the ethics committee of the All India Institute of Medical Sciences, New Delhi and WHO ethics review committee. The consent form for the primary study also sought written permission from parents to use the information for future research. All parents consented for the same.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare that they have no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"158"}}