Journal of Tropical Pediatrics Advance Access published September 17, 2010

JOURNAL OF TROPICAL PEDIATRICS, VOL. 0, NO. 0, 2010

Evaluation of Mid-upper Arm Circumference in Pre-school

Children: Comparison Between NCHS/CDC-2000 and
WHO-2006 References
by Viviane G. Nascimento,1 Thais Costa Machado,1 Ciro João Bertoli,2 Luiz Carlos de Abreu,1,3 Vitor E. Valenti,3,4 and
Claudio Leone1
1
Departamento de Saúde Materno-Infantil, Universidade de São Paulo (USP), São Paulo, SP, Brazil
2
Departamento de Medicina, Universidade de Taubate´, Taubate´, SP, Brazil

Downloaded from tropej.oxfordjournals.org at Universidade Federal de S?o Paulo on October 12, 2010
3
Departamento de Morfologia e Fisiologia, Faculdade de Medicina do ABC, Santo Andre´, SP, Brazil
4
Departamento de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil

Correspondence: Claudio Leone, Departamento de Saúde Materno-Infantil, Faculdade de Saúde Pública, Universidade de São
Paulo, Avenida Dr Arnaldo 715, Cerqueira Ce´sar 01246-904 São Paulo, SP, Brasil. Tel.: þ55-11-30850240,
E-mail: <cleto@usp.br>

Summary
We aimed to evaluate the classification of arm circumference (AC) in pre-school children by using
National Center for Health Statistics (NCHS/CDC-2000) and World Health Organization
(WHO-2006) references. We evaluated 205 children: weight, height and AC were assessed and the
body mass index (BMI) was calculated. The BMI values were classified into Z-scores by the WHO
referential. The AC was classified into Z-cores by two references, comparing the whole-sample value
and among groups (tercis) of BMI Z-score. The correlation was also evaluated between differences
of AC with BMI Z-score. The WHO referential classified the AC in Z-scores greater than the
NCHS/CDC, which is more specific and less sensitive than the NCHS/CDC for lean children and at
the same time more sensitive and less specific for children with overweight. In conclusion, a significant
difference in the AC classification occurs according to the referential used.

Key words: general paediatrics, international child health, orthopaedics, nutrition, statistics.

Introduction appropriate for growth evaluation. This reference

The arm circumference (AC), also known as brachial
perimeter, has been proposed as an alternative to
select children 5-years old in critical nutritional
state, aiming to identify the risk degree, regardless
of age, gender, weight and height [1, 2]. Its measure-
ment is an important indicator of mortality prognosis
[3–6], especially in cases of severe malnutrition [7].
Recently, in 2006, the World Health Organization
(WHO-2006) estimated new anthropometric param-
eters for children aged between 0 and 60 months,
proposing a reference considered as the most
Funding
Authorship has been granted with the financial
support from FAPESP (Fundação de Amparo à
Pesquisa do Estado de São Paulo, Brazil), # 08/
53142-9.
also includes new values for brachial perimeter
classification [8].
In order to assess nutritional risk in individuals
and populations, researchers compare their data
with measured values of growth reference [9–12].
Besides the reference of WHO-2006 for AC, there is
also the National Center for Health Statistics
(NCHS) USA [7], restated in 2000 by the Centers
for Disease Control (CDC) and available on
5 NutStat Epi-Info software.
In a single set of individuals, the use of different
benchmarks may produce different risk classifica-
tions, and therefore, create values of nutritional
disorders prevalence in communities, which would
derail any evaluations and comparisons over time
and/or between population [13, 14]. At the moment
that we choose to use a particular anthropometry
reference, it is important to know the differences
in risk classification in which it will result when
compared to other references. Therefore, this

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doi:10.1093/tropej/fmq076

investigation was undertaken to evaluate the classifi-
cation of AC in pre-school children by using two
references: NCHS/CDC-2000 and WHO-2006.
Methods
Study population
This analysis is part of a larger cross-sectional study,
which aim was to evaluate, by anthropometric
analysis, growth achieved by a sample of children
aged between 2 and 4 years, who attended at public
nursery schools in Taubaté city, São Paulo, in 2008.
The variables investigated were: weight, height, body
mass index (BMI) and AC. Data collection was
performed at the beginning of the school year. We
excluded children who presented history of chronic
diseases that could influence their growth. The
consent term was sent to all parents or responsible
by the daycare center, which was duly completed and
signed before the start of collection data. This study
was approved by the Ethical Committee in Research
of our University.
In order to calculate the sample size, we used the
following parameters: level of the test significance
 ¼ 5%; test power (1–) ¼ 90% and a minimum
difference between the mean Z-scores estimated by
the two benchmarks of a quarter standard deviation
(0.25), which resulted in a sample size of 170 children.
Taking into account the possibility of any loss of
data, we added 20% to the total number of children
calculated that resulted in a sample of 204 children.
Children were selected from the list of daycare
centers provided by the Department of Education
and Culture of Taubaté in a probabilistic way,
which resulted in a total of 205 children (87 girls
and 118 boys).
Variables evaluation
After obtaining consent from children parents or
responsible, anthropometric data were collected in
the daycare center, according to Lohman et al. [15]
method. The child’s weight was measured by using
the Seca electronic scale with a split of 0.1 g, and
height was measured by stadiometer wall (Seca)
with two meters, centimeters and millimeters subdiv-
ision. The measure of AC was performed with tape
fiberglass extendable using the non-dominant arm of
the child, placing the tape horizontally at the
mid-point between acromion and olecranon. The
measurements were performed by trained profes-
sionals, according to Hauspie technique (2004) [8].
The values of BMI [BMI ¼ weight (kg)/height2 (m)]
in Z-scores were calculated from the reference
values proposed by the WHO (2006) [8]. AC was
classified in Z scores by two benchmarks: the WHO
in 2006 and the reference from the National Center
for Health Statistics (NCHS), USA [7] restated in
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V. G. NASCIMENTO ET AL.
2000 by the CDC [13] and available in the NutStat
Epi-Info software.
Statistical analysis
The comparison of mean AC Z-scores was made by
using paired Student t-test, with a significance level
 ¼ 0.05%. In the analysis of results, we also used the
Pearson correlation coefficient in order to estimate
correlation between the difference between AC
Z-scores (determined by the two references) and the
difference between BMI Z-scores. To calculate
the sample, we used the Power and Sample
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Calculations software (v.3.0.1) and statistical analysis
was performed by Graph Pad Prism (v. 5.0.2).
Results
Mean Z-scores of AC presented a difference of
0.49 Z-scores, the one estimated by the WHO was
the highest (p < 0.0001; Table 1).
Figure 1 shows that the classification by the refer-
ence proposed by WHO in 2006 offsets the estimated
distribution curve to the right, toward higher values
of Z-scores than the observed curve of the NCHS/
CDC-2000 reference, which in turn is much closer to
the theoretically expected normal distribution.
TABLE 1
Comparison of arm circumference (AC) Z-scores in
205 pre-school children according to the reference
used: NCHS/CDC – 2000 and WHO – 2006
Reference Mean Standard Minimum Maximum
deviation
NCHS/CDC – 2000 0.08 1.16 2.26 4.22
WHO 0.57 1.12 2.00 4.01
FIG. 1. Comparison of arm circumference Z-scores
distribution for age in pre-school children according
to the reference used: NCHS/CDC – 2000 and WHO
– 2006. Paired Student t-test; p ¼ 0.0001; AC, arm
circumference.
Journal of Tropical Pediatrics
V. G. NASCIMENTO ET AL.
The differences of mean Z-score in the first, second
and third tertile of BMI were 0.478, 0.539 and 0.453,
respectively, all statistically significant (p < 0.05;
Fig. 2).
Figure 3 displays that there was an inverse
correlation between the differences of Z-scores of
AC and the differences of Z-scores of BMI
(r ¼ 0.2945; p < 0.0001). The regression slope was
0.0301  0.0068 (p < 0.0001).
FIG. 2. Comparison of Z-score distribution of arm
circumference in pre-school children by tertile of
BMI according to the reference used: NCHS/CDC
– 2000 and WHO – 2006. ANOVA followed by
Tukey post-test (*p < 0.05, p < 0.05).
FIG. 3. Correlation of arm circumference Z-scores
estimated from NCHS/CDC – 2000 and WHO–2006
references in pre-school children according to
their BMI Z-scores. Pearson: r ¼ 0.2945 (95%
CI ¼ 0.4146 to 0.1644); p < 0.0001. R2 ¼ 0.08675.
Journal of Tropical Pediatrics
Discussion
The results of this study indicate that when analyzing
AC in pre-school children, depending on the bench-
mark that is used, it may direct to different interpret-
ations regarding the diagnostic of nutritional status.
We suggest that anthropometric assessment alone is
not sufficient for preparation of definitive diagnosis
nutrition; it is just one tool to be considered,
however, in selection situations it may influence
interventions which were adopted as result of the
epidemiological situation.
AC has been considered an important indicator of
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malnutrition, especially during population screening
because it presents good correlation with BMI and it
is an easy measurement to be performed. Although it
was originally proposed primarily for malnutrition
screening [16, 17], AC was also used as an indicator
of nutritional status in general, including in Z-scores
form, in order to control the influence of gender and
age in its interpretation [7, 18, 19].
In order to assess whether AC could be used
for screening of pre-school obese children a previous
investigation [20] studied 1090 children aged between
12 and 59.9 months and proposed cut-off points
for AC for age because they found no advantage
in using the AC/height ratio. These authors also
suggest its use as a more practical method for
screening of pre-school children who are obese due
to the facility and speed of its attainment in that
population.
Besides its use in prevalence surveys of overweight
and obesity risk and for screening populations, the
arm circumference may also be useful for clinical
assessment of nutritional status of critically ill chil-
dren, since it has good correlation with arm muscle
mass and, thus, with the base nutritional condition of
the children [21]. This may be particularly interesting
when it comes to children admitted to intensive care
units, where it is difficult to precisely evaluate other
anthropometric variables due to their critical condi-
tion, or in cases of children with large tumors or with
large edema, which surely contribute to alter their
real weight [21].
Currently, two references that allow the classifi-
cation of arm circumference in Z-scores are available
(including software to make it more accurately), the
NCHS/CDC-2000 and WHO-2006, which were
drawn from different population samples. The
NCHS/CDC-2000 reference corresponds to the
NCHS, 1977, which were developed in the first half
of the 70s, from a study of children fed with formula
and breast milk differently from the standard recom-
mended by WHO. In 2000, the CDC conducted a
review of anthropometric references, including a
new sample of children younger than 3-years old
and modified the mathematical model used for
curves generating and smoothing [13]. On the other
hand, for arm circumference the EpiNut of the
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Epi-Info 3 software continued to be based on data
from NCHS 1977.
In 2006, the WHO published the results of their
multicenter study conducted between 1997 and 2003,
in order to generate new growth curves for evaluation
of children aged between 0 and 60 months; they col-
lected information from approximately 8500 children
from different cultures and ethnicities. The youngest
children (<18-months old) were exclusively breastfed
during the first 4 months of life, recommended by the
WHO. Based on those findings, the WHO sought to
establish what would be a normative pattern of
growth and development of children up to 5-years
old [8].
It is also important to be considered that the
differences between the two references regarding AC
are higher in absolute values of Z-score, when
evaluating children which tend to thinness, a fact
that recommends higher caution in the interpretation
of this indicator in epidemiological situations of high
prevalence of malnutrition. At the same time, this
apparent disadvantage may become an advantage in
epidemiological nutritional transition periods [22, 23]
when a significant increase in prevalence of over-
weight and obesity go through, such as emerging
countries.
We reported that depending on the reference
(NCHS/CDC-2000 and WHO-2006), it may be
directed to distinct interpretations with respect to
nutritional status; both the references are used in
Brazil [20, 24]. We suggest clinical professionals to
consider our data before evaluate clinical status of
the children. Our findings are based on a population
situated in the southeast of the country; it is possible
that different results are found in the north of Brazil.
Thus, future investigations in different areas of Brazil
are necessary to verify if our data are applicable in
different regions of the country.
In conclusion, when analyzing AC in pre-school
children, depending on the reference (NCHS/
CDC-2000 or WHO-2006) it may be directed to
distinct interpretations with respect to nutritional
status.
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