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Children’s Mercy Develops New Tool to Help Combat Malnutrition

MUAC z-score tape quickly identifies malnutrition risk in children across the globe

When Dr. Susan Abdel-Rahman, Children’s Mercy Clinician and Director of Health Care Innovation for the Children’s Mercy Research Institute, was approached by her dietitian colleagues to help develop a quicker and easier way to screen kids for malnutrition – she was up for the challenge.

In response, she invented the MUAC z-score tape that has changed how pediatric malnutrition is evaluated at Children’s Mercy and across the globe thanks, in part, to a collaboration with two local organizations, Hallmark and Children International.

In order to identify and intervene early nutritional challenges of even more children, Abbott Nutrition Health Institute – whose mission is to connect and empower health care professionals around the world through science-based nutrition education and resources – was brought on board to help scale the production and distribution of the MUAC z-score tape worldwide.

To introduce the MUAC z-score tape worldwide, Dr. Abdel-Rahman met with healthcare professionals at the Karolinska Institute in Stockholm, Sweden at the 4th Annual Growth Summit, hosted by Abbott Nutrition Health Institute in February, where she demonstrated how to use this simple and effective malnutrition screening tool to 150 pediatricians, dietitians and clinicians from more than 20 countries around the world.

 “This is an incredible milestone for Children’s Mercy,” said Dr. Abdel-Rahman. “In collaboration with Abbott, we can now deliver nutritional assessment solutions to populations that are otherwise difficult to reach. It also means that we can impact the care of children in our own backyard with restricted access to healthcare resources during this unprecedented pandemic.”

Creating the First-of-its-Kind Malnutrition Measuring Tool

Information about nutritional status in children is routinely obtained from combined weight and length measurements which require calibrated equipment, mathematical calculations and reference charts. The measurement of mid-upper arm circumference (MUAC) is also widely used to evaluate nutritional status and has proven to be a good predictor of malnutrition outcomes. However, the internationally accepted standards are static and do vary by age and gender introducing bias into the classification.

Dr. Abdel-Rahman constructed MUAC growth charts for children 2 months through 18 years of age and used the data to design the first-of-its-kind MUAC z-score tape, an inexpensive, paper-based device that resembles a traditional measuring tape, but also includes age and gender specific color-coded indicators which signal the risk of malnutrition.

Dietitians at Children’s Mercy quickly adopted the MUAC z-score tape and in less than 2 years hit the benchmark for evaluating 10,000 children. “The tape allows us to do a quick screening, and it’s a great tool to show our families,” said Karen Stephens, Assistant Director of Nutrition Services at Children’s Mercy. “It’s much easier for parents to understand when we can say ‘look your child is in the red zone and this is why we’re concerned.’ It’s not just a weight change. They can see that their child’s body is actually decreasing or increasing.”

Labor of Love

Early in development, Dr. Abdel-Rahman’s team printed large sheets of devices on the same tear-resistant paper used in FedEx envelopes and cut each one by hand. “It was very time consuming,” said Dr. Abdel-Rahman. During this time, Dr. Abdel-Rahman was collecting important feedback from her colleagues in Nutrition Services. “Their comments helped us refine the design of the MUAC z-score tape, but the solutions could not be implemented using our current production strategy.”

Collaboration with Hallmark and Children International

The Center for Pediatric Innovation at Children’s Mercy connected Dr. Abdel-Rahman with Hallmark to help streamline production. They also reached out to Children International, a global humanitarian organization that invests in the health, education, empowerment of children, to expand testing of the usability and effectiveness of the MUAC z-score tape beyond the hospital walls.

“Dr. Abdel-Rahman’s work is a great example of how Children’s Mercy is leading pediatric innovation. The Center for Pediatric Innovation’s goal is to expand the impact of such discoveries within Kansas City and across the globe,” said Sallie Guezuraga, Manager, Innovation Solutions at Children’s Mercy. “With the MUAC z-scope tape, we saw a natural fit to connect with Hallmark and Children International, who are global leaders in their respective industries and share missions dedicated to well-being.”

Hallmark Employees Provide Expertise

With thousands of “second-generation” z-score tapes needed to pilot the devices with Children International programs in India and Guatemala, Children’s Mercy collaborated with a company perhaps most known for cards, Hallmark. Their team worked with Dr. Abdel-Rahman to implement design changes, providing time, expertise, materials and intellectual resources. The process included Hallmark’s team of experts from two different departments helping to optimize the color contrast, determine the best material to meet the needs of the Children International’s programs, ensure the printing and cutting met quality standards, determine efficiencies for subsequent and larger production runs, and provide contacts for local, high-quality printers that could meet the unique requirements.

“It was a great opportunity to use our skills and experience to improve a tool that will positively impact the lives of health workers, mothers and children here in Kansas City and across the globe,” said Noeida Kuhnert, supply chain strategy and innovation director, Hallmark. “It was a perfect collaboration that aligned with Hallmark’s vision of making a genuine difference in every life, every day, while supporting a fellow Kansas City company that’s in the business of helping people and one that our founding Hall family supports in many ways.”

Children International Pilots in Guatemala and India

With more devices courtesy of Hallmark, Children International began using the MUAC z-score tape in Guatemala and India. “This was a phenomenal opportunity for Children International to collaborate with two leading Kansas City organizations to deliver a local innovation, to help children around the world,” said Kristen Mallory, the Health and Nutrition Program Officer at Children International. “Malnutrition is prevalent in the global communities where Children International works, and last year more than 6,500 children we serve needed nutrition support. It’s critical that we identify the problem early and put children on a treatment plan.” Mallory says the tape produced positive results in Guatemala and India and has the potential to revolutionize the organization’s nutrition assessment and treatment programs in 10 countries where Children International works.

“Bringing people together to end poverty for good is our vision,” said Susana Eshleman, President and CEO of Children International. “When people join forces with a shared goal to help vulnerable children, we super charge our opportunities to create change. Having seen the promising pilot results for MUAC z-score tape in two of our global communities, we see a bright future for its use … a future where more children receive the critical support they need. We are grateful for this collaboration with Children’s Mercy and Hallmark and for the generous support of everyone involved. MUAC z-score tapes make a better future possible for children and families in Kansas City and around the world who are at risk of losing hope due to poor nutrition.”

Community Support to Help Improve Care Everywhere

None of this would be possible without the generous support from other donors to the hospital that make it possible to distribute these MUAC z-score tape overseas. “This is such an amazing illustration of our community coming together to make an impact on the families and children we serve,” said Jenea Oliver, Vice President of Philanthropy. “Because of the generosity of Hallmark and others, including Black & Veatch, we are able to propel the great work being done at Children’s Mercy to not only benefit children in Kansas City, but many more children around the world. These gifts were the catalyst for moving from cutting the tape by hand to automated production and eventually to mass production – that is truly incredible!”

Ensuring that all familes have access to the best care possible is Dr. Abdel-Rahman’s passion, and with support from Abbott - together they can help create a world of wellbeing for all children around the world.


Dr. Susan Abdel-Rahman is an accomplished researcher and a dedicated, enthusiastic humanitarian. For nearly 20 years, her research has focused on issues affecting children and underserved populations. She has designed and conducted numerous basic and translational studies including clinical trials, which range from single-site studies to large epidemiological investigations. In clinical studies (for which Dr. Abdel-Rahman is the PI), she has enrolled over 25,000 participants many of whom were constituted by racial, ethnic and socioeconomic minorities. The research she has conducted has led to FDA labeling of numerous drugs for children, implementation of global WHO guidelines, development of software that individualizes drug dosing in children, and the invention, patent and FDA clearance of pediatric devices.

Learn more about the Children’s Mercy Research Institute at Children’s Mercy.