Shakir’s Tape: Malnutrition in Children

Shakir’s Tape: Malnutrition in Children – Functions, Parameters, Interpretation, & Clinical Use

Introduction: Why Shakir’s Tape Became a Global Standard

In the early 1970s, Dr. A. Shakir (a British pediatrician working in Baghdad) and Dr. David Morley developed one of the most revolutionary public health tools ever created: a simple, color-coded strip of plastic that could instantly tell a community health worker whether a child was severely or moderately malnourished. Known as the **Shakir’s tape** (or Shakir-Morley tape), this mid-upper arm circumference (MUAC) measuring tape transformed community-based management of acute malnutrition.

Before Shakir’s tape, malnutrition assessment required weighing scales, height boards, and complex calculations of weight-for-height Z-scores—tools that were impractical in remote villages and refugee camps. The genius of Shakir’s design was its simplicity:
– No electricity
– No calculations
– No literacy required
– Color-coded results visible in seconds

Today, even with the newer WHO standardized MUAC tapes, the original Shakir’s tape remains widely used in many countries, especially in South Asia (Pakistan, India, Bangladesh, Afghanistan) and parts of Africa.

What Exactly is Shakir’s Tape?

Shakir’s tape is a **non-stretch, flexible, 1 cm wide plastic strip** marked in millimeters, with three distinctive color zones:

• Length: Usually 26–28 cm with insertion slot design (the “belt-buckle” model) so it can encircle the arm without overlapping errors.

• Material: Durable, washable, non-tear polypropylene.

Many NGOs and governments still print the original Shakir design, so field workers must know which tape they are using.

Functions and Uses of Shakir’s Tape

1. Rapid Screening in Community Settings
• Door-to-door surveys
• Refugee registration points
• Immunization camps
• Disaster and famine response

2. Admission Criteria for Therapeutic Feeding Programs**
• SAM (Red zone) → admitted to inpatient or outpatient therapeutic program (OTP)
• MAM (Yellow zone) → supplementary feeding

3. Monitoring Response to Treatment
• Weekly or bi-weekly MUAC gain (target 1–2 mm/week)

4. Discharge Criteria
• Two consecutive measurements ≥ 12.5 cm + no edema (for original Shakir tape)

5. Early Warning and Surveillance
• Used in sentinel site surveillance for famine early warning systems

All Parameters of Malnutrition Detected or Influenced by Shakir’s Tape

Parameter How Shakir’s Tape Helps Cut-off (Original Shakir) | WHO 2023 Cut-off | Sensitivity/Specificity vs WHZ |
| Global Acute Malnutrition (GAM) | MUAC < 12.5 cm | < 12.5 cm | < 12.5 cm | High sensitivity | | Severe Acute Malnutrition (SAM) | MUAC < 11.5 cm OR bilateral edema | < 11.5 cm | < 11.5 cm | Very high for SAM | | Moderate Acute Malnutrition (MAM) | MUAC 11.5 – 12.5 cm | 11.5 – 12.5 cm | 11.5 – <12.5 cm | Moderate | | Kwashiorkor (edematous malnutrition) | MUAC can be normal or high despite severe disease | Can miss | Can miss | Low sensitivity | | Stunting (chronic) | No direct relation | Not assessed | Not assessed | None | | Underweight | Indirect correlation only | Not direct | Not direct | Weak | Important Limitation: MUAC is excellent for acute wasting but poorly correlated with stunting and can miss children with kwashiorkor who have normal or high MUAC due to edema. Step-by-Step: How to Correctly Measure MUAC with Shakir’s Tape 1. Child age 6–59 months (or height 65–110 cm if age unknown) 2. Child standing or sitting relaxed 3. Identify midpoint between tip of shoulder (acromion) and tip of elbow (olecranon) on the left arm 4. Mark midpoint with pen if needed 5. Arm hanging relaxed (not flexed) 6. Pass tape around arm at midpoint, neither too tight nor loose (should slide but not compress skin) 7. Insert end into buckle slot 8. Read the color in the window or arrow pointer 9. Record result and check for bilateral pitting edema (press both feet/shins for 3 seconds) Advantages of Shakir’s Tape • Extremely cheap (5–10 cents per tape) • Portable, durable, reusable • No training beyond 15 minutes required • High inter-observer reliability (>95%)
• Acceptable to mothers (less invasive than weighing)
• Works in low-literacy settings
• Immediate result – no calculation

Limitations and Criticisms

• Age-dependent: MUAC increases with age, so same cut-off for 6–59 months is not perfect
• Misses some wasted children who have low weight-for-height but MUAC >12.5 cm (especially older children)
• Over-identifies younger children (6–12 months) as malnourished
• Cannot detect kwashiorkor without edema check
• Different cut-offs between old Shakir and new WHO tapes cause confusion

Comparison Table: Shakir’s Tape vs WHO MUAC Tape vs Weight-for-Height

| Method | Severe Cut-off | Moderate Cut-off | Best For | Cost | Training Needed |
| Original Shakir Tape | MUAC < 11.5 cm | 11.5 – 12.5 cm | Rapid community screening | $0.05 | Minimal | | WHO/UNICEF Tape | MUAC < 11.5 cm | 11.5 – <12.5 cm | Global standardization | $0.10 | Minimal | | Weight-for-Height Z | < -3 Z WHZ or edema | -3 to < -2 Z WHZ | Clinical diagnosis & research | $200+ | High | | Bilateral Edema | Present (any grade) = SAM | – | Diagnosing kwashiorkor | Free | Moderate | Current Global Recommendations (2024–2025) • WHO/UNICEF/UNHCR now recommend MUAC < 11.5 cm and/or edema for SAM admission • Many countries (especially in Asia) continue to use • 12.5 cm as the upper green threshold because of historical Shakir tape use • Mother-led MUAC programs (mothers trained to screen their own children) use simplified Shakir-style tapes with huge success in Niger, Mali, and Pakistan Frequently Asked Questions (FAQs) – SEO Optimized Q1. What is the difference between Shakir’s tape and WHO MUAC tape? A: The original Shakir tape uses 12.5 cm as the upper limit for normal (green), while the modern WHO tape uses ≥12.5 cm. Both use <11.5 cm for severe malnutrition. Q2. Is Shakir’s tape still used in 2025? A: Yes! It is still the most common MUAC tape in Pakistan, India, Bangladesh, Afghanistan, Yemen, and many NGO programs because millions were printed decades ago and remain in circulation. Q3. Can Shakir’s tape be used for children under 6 months? A: No. MUAC is validated only for 6–59 months. For infants <6 months, use weight-for-length and clinical signs. Q4. What if a child has edema but MUAC in green zone? A: Any bilateral pitting edema = Severe Acute Malnutrition regardless of MUAC. Edema overrides MUAC result. Q5. Which arm should be measured – left or right? A: Always the **left** mid-upper arm (international standard). Q6. How arate is Shakir’s tape compared to weight-for-height? A: MUAC has >90% sensitivity and specificity for identifying severe wasting in community settings, but it identifies a slightly different (often younger) population than WHZ <-3. Q7. Where can I buy Shakir’s tape? A: UNICEF Supply Division, local manufacturers in Pakistan/India, or NGOs. Price usually $0.05–$0.20 per tape in bulk. Q8. Is 12.4 cm considered moderate or severe on Shakir’s tape? A: On the original Shakir tape, 12.4 cm falls in yellow (11.5–12.5 cm = moderate). On newer WHO tapes, ≥12.5 cm is green, so 12.4 cm is still moderate. Conclusion: The Enduring Legacy of a Simple Strip More than 50 years after its invention, Shakir’s tape remains one of the most cost-effective, life-saving tools in global health. It has screened hundreds of millions of children and helped bring child wasting rates down dramatically in countries that adopted community-based management of acute malnutrition (CMAM). While modern research has led to refined cut-offs and combination approaches (MUAC + edema + WHZ), the original red-yellow-green Shakir tape continues to be the frontline weapon against child malnutrition in the hardest-to-reach places on Earth. For every health worker holding that thin plastic strip in a remote village, Dr. Shakir’s genius lives on: sometimes the simplest innovations save the most lives.

Leave a Reply Cancel reply