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Thahir AIA, Li M, Holmes A, Gordon A. Exploring Factors Associated with Stunting in 6-Month-Old Children: A Population-Based Cohort Study in Sulawesi, Indonesia. Nutrients 2023; 15:3420. [PMID: 37571357 PMCID: PMC10421344 DOI: 10.3390/nu15153420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023] Open
Abstract
Stunting in children under the age of two is a significant global concern, particularly in low- and middle-income countries like Indonesia. Intervention efforts often come too late as many of the underlying causal factors have already occurred earlier. While antenatal multiple micronutrient supplements (MMS) have demonstrated positive effects on pregnancy outcomes, their impact on infant growth in the first six months remains inadequately explored in epidemiological studies. This study aims to identify factors associated with stunting at six months in infants whose mothers received MMS. A population-based cohort study was conducted in four subdistricts of Banggai, Indonesia. Pregnant women were recruited in their third trimester and followed up until their children were six months of age. Validated questionnaires were employed to gather data on social determinants of health and diet, and standardised methods were utilised for anthropometric measurements. Stunting was determined based on the WHO child growth standards. The analysis comprised data from 152 mother-child pairs. The prevalence of stunting during early infancy (first two months) was 18.4%, which decreased to 15.8% in later infancy (at six months). Factors such as small-for-gestational-age (AOR = 11.29; 2.73-46.66), preterm birth (AOR = 6.33; 1.25-31.97), short birth length (AOR = 4.31; 1.11-16.78), maternal mid-upper arm circumference (MUAC) below 23.5 cm, and female infants (AOR = 3.27; 95%CI: 1.04-10.27) were associated with stunting at six months. This study highlights that stunting in the first six months is present at birth, with small-for-gestational-age (SGA) as a strong predictor. In addition, there was a trend to improved growth (-0.30 [-0.79 to 0.18]) in infants born to mothers who received MMS supplementation pre-pregnancy rather than during pregnancy, although it was not statistically significant.
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Affiliation(s)
- Andi Imam Arundhana Thahir
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia;
- Department of Nutrition, Faculty of Public Health, Hasanuddin University, Makassar 90245, Indonesia
| | - Mu Li
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia;
| | - Andrew Holmes
- School of Life and Environmental Science, Faculty of Science, The University of Sydney, Sydney 2006, Australia;
- Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
| | - Adrienne Gordon
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia;
- Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Sydney 2006, Australia
- The Royal Prince Alfred Hospital (RPA), Newborn Care, Sydney Local Health District, Sydney 2050, Australia
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Sadler K, James PT, Bhutta ZA, Briend A, Isanaka S, Mertens A, Myatt M, O'Brien KS, Webb P, Khara T, Wells JC. How Can Nutrition Research Better Reflect the Relationship Between Wasting and Stunting in Children? Learnings from the Wasting and Stunting Project. J Nutr 2023; 152:2645-2651. [PMID: 35687496 PMCID: PMC9839990 DOI: 10.1093/jn/nxac091] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/01/2022] [Accepted: 04/13/2022] [Indexed: 02/02/2023] Open
Abstract
Childhood wasting and stunting affect large numbers of children globally. Both are important risk factors for illness and death yet, despite the fact that these conditions can share common risk factors and are often seen in the same child, they are commonly portrayed as relatively distinct manifestations of undernutrition. In 2014, the Wasting and Stunting project was launched by the Emergency Nutrition Network. Its aim was to better understand the complex relationship and associations between wasting and stunting and examine whether current separations that were apparent in approaches to policy, financing, and programs were justified or useful. Based on the project's work, this article aims to bring a wasting and stunting lens to how research is designed and financed in order for the nutrition community to better understand, prevent, and treat child undernutrition. Discussion of lessons learnt focuses on the synergy and temporal relationships between children's weight loss and linear growth faltering, the proximal and distal factors that drive diverse forms of undernutrition, and identifying and targeting people most at risk. Supporting progress in all these areas requires research collaborations across interest groups that highlight the value of research that moves beyond a focus on single forms of undernutrition, and ensures that there is equal attention given to wasting as to other forms of malnutrition, wherever it is present.
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Affiliation(s)
- Kate Sadler
- Emergency Nutrition Network, Kidlington, United Kingdom
| | | | - Zulfiqar A Bhutta
- Center for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Center of Excellence in Women & Child Health, The Aga Khan University, Karachi, Pakistan
| | - André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
- Center for Child Health Research, Tampere University, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sheila Isanaka
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Epicentre, Paris, France
| | - Andrew Mertens
- Division of Epidemiology & Biostatistics, University of California, Berkeley, USA
| | - Mark Myatt
- Emergency Nutrition Network, Kidlington, United Kingdom
- Brixton Health, Llwyngwril, Gwynedd, Wales, United Kingdom
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA
| | - Patrick Webb
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Tanya Khara
- Emergency Nutrition Network, Kidlington, United Kingdom
| | - Jonathan C Wells
- Great Ormond Street Institute of Child Health (ICH), University College London (UCL), London, United Kingdom
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Dulal S, Prost A, Karki S, Merom D, Shrestha BP, Bhandari B, Manandhar DS, Osrin D, Costello A, Saville NM. Feeding, caregiving practices, and developmental delay among children under five in lowland Nepal: a community-based cross-sectional survey. BMC Public Health 2022; 22:1721. [PMID: 36088374 PMCID: PMC9464411 DOI: 10.1186/s12889-022-13776-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 07/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background Nurturing care, including adequate nutrition, responsive caregiving and early learning, is critical to early childhood development. In Nepal, national surveys highlight inequity in feeding and caregiving practices for young children. Our objective was to describe infant and young child feeding (IYCF) and cognitive and socio-emotional caregiving practices among caregivers of children under five in Dhanusha district, Nepal, and to explore socio-demographic and economic factors associated with these practices. Methods We did a cross-sectional analysis of a subset of data from the MIRA Dhanusha cluster randomised controlled trial, including mother-child dyads (N = 1360), sampled when children were median age 46 days and a follow-up survey of the same mother-child dyads (N = 1352) when children were median age 38 months. We used World Health Organization IYCF indicators and questions from the Multiple Indicator Cluster Survey-4 tool to obtain information on IYCF and cognitive and socio-emotional caregiving practices. Using multivariable logistic regression models, potential explanatory household, parental and child-level variables were tested to determine their independent associations with IYCF and caregiving indicators. Results The prevalence of feeding indicators varied. IYCF indicators, including ever breastfed (99%), exclusive breastfeeding (24-hour recall) (89%), and vegetable/fruit consumption (69%) were common. Problem areas were early initiation of breastfeeding (16%), colostrum feeding (67%), no pre-lacteal feeding (53%), timely introduction of complementary feeding (56%), minimum dietary diversity (49%) and animal-source food consumption (23%). Amongst caregiving indicators, access to 3+ children’s books (7%), early stimulation and responsive caregiving (11%), and participation in early childhood education (27%) were of particular concern, while 64% had access to 2+ toys and 71% received adequate care. According to the Early Child Development Index score, only 38% of children were developmentally on track. Younger children from poor households, whose mothers were young, had not received antenatal visits and delivered at home were at higher risk of poor IYCF and caregiving practices. Conclusions Suboptimal caregiving practices, inappropriate early breastfeeding practices, delayed introduction of complementary foods, inadequate dietary diversity and low animal-source food consumption are challenges in lowland Nepal. We call for urgent integrated nutrition and caregiving interventions, especially as interventions for child development are lacking in Nepal. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13776-8.
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Wells JCK, Marphatia AA, Cortina‐Borja M, Manandhar DS, Reid AM, Saville NM. Associations of maternal age at marriage and pregnancy with infant undernutrition: Evidence from first‐time mothers in rural lowland Nepal. AMERICAN JOURNAL OF BIOLOGICAL ANTHROPOLOGY 2022. [PMCID: PMC9539981 DOI: 10.1002/ajpa.24560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objectives Maternal factors shape the risk of infant undernutrition, however the contributions of age at marriage versus age at pregnancy are rarely disentangled. We explore these issues in a population from lowland rural Nepal, where median ages at marriage and first pregnancy are 15 and 17 years respectively and marriage almost always precedes pregnancy. Methods We analyzed data on first‐time mothers (n = 3002) from a cluster‐randomized trial (2012–2015). Exposures were ages at marriage and pregnancy, categorized into groups. Outcomes were z‐scores for weight (WAZ), length (LAZ), head circumference (HCAZ), and weight‐for‐length (WLZ), and prevalence of wasting and stunting, for neonates (<8 days) and infants (6–12 months). Mixed linear and logistic regression models tested associations of marriage and pregnancy ages with outcomes, adjusting for parental education, household assets, caste, landholding, seasonality, child sex, intervention arm, randomization strata and cluster. Results For neonates, pregnancy <18 years predicted lower LAZ, and <19 years predicted lower WAZ and HCAZ. Results were largely null for marriage age, however early pregnancy and marriage at 10–13 years independently predicted neonatal stunting. For infants, earlier pregnancy was associated with lower LAZ and HCAZ, with a trend to lower WAZ for marriage 10–13 years. Early pregnancy, but not early marriage, predicted infant stunting. Conclusions Early marriage and pregnancy were associated with poorer growth, mainly in terms of LAZ and HCAZ. Associations were stronger for neonatal than infant outcomes, suggesting pregnancy is more susceptible to these stresses. Early marriage and pregnancy may index different social and biological factors predicting child undernutrition.
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Affiliation(s)
- Jonathan C. K. Wells
- Population, Policy and Practice Research and Teaching Department UCL Great Ormond Street Institute of Child Health London UK
| | | | - Mario Cortina‐Borja
- Population, Policy and Practice Research and Teaching Department UCL Great Ormond Street Institute of Child Health London UK
| | | | - Alice M. Reid
- Department of Geography University of Cambridge Cambridge UK
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Fledderjohann J, Channon M. Gender, nutritional disparities, and child survival in Nepal. BMC Nutr 2022; 8:50. [PMID: 35606833 PMCID: PMC9125883 DOI: 10.1186/s40795-022-00543-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 05/09/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This paper examines seemingly contradictory evidence from extant research that son preference is high, but male disadvantage in mortality is increasing in Nepal. To do so, we documented the timing, geographic patterning, and extent of gendered patterns in mortality and feeding practices for children under-five. METHODS We applied pooled multilevel regression models and survival analysis to five rounds of data from Nepal's nationally representative Demographic and Health Surveys (1996-2016). We controlled for potential sociodemographic confounders, including child, maternal, household, and regional correlates, and disaggregated findings by birth order and sibling gender. RESULTS We found evidence of regional variation in mortality, with girls in wealthy urban areas faring the worst in terms of mortality rates. Girls' comparative mortality advantage compared to boys in the neonatal period masks their mortality disadvantage in later periods. Mortality has fallen at a faster rate for boys than girls in most cases, leading to widening of gender inequalities. We also found evidence of female disadvantage in breastfeeding duration, which was linked to higher mortality risks, but no gender disparities in the consumption of other food items. Sibling gender and birth order also mattered for breastfeeding duration: Young girls with older sisters but with no brothers were most disadvantaged. CONCLUSION While we did not find evidence of postnatal discrimination in access to solid and semi-solid foods, girls in Nepal face a disadvantage in breastfeeding duration. Girls with older sisters but no older brothers facing the greatest disadvantage, with risks being particularly concentrated for girls aged 1-4 years. This disadvantage is linked to an increased risk of mortality. To address this, community-based health programs could be expanded to continue targeted healthcare for children beyond 12 months of age, with particular focus on nutrition monitoring and health service provision for girls.
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Affiliation(s)
| | - Melanie Channon
- Department of Social & Policy Sciences, University of Bath, Bath, UK
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Thurstans S, Opondo C, Seal A, Wells JC, Khara T, Dolan C, Briend A, Myatt M, Garenne M, Mertens A, Sear R, Kerac M. Understanding Sex Differences in Childhood Undernutrition: A Narrative Review. Nutrients 2022; 14:nu14050948. [PMID: 35267923 PMCID: PMC8912557 DOI: 10.3390/nu14050948] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 12/27/2022] Open
Abstract
Complementing a recent systematic review and meta-analysis which showed that boys are more likely to be wasted, stunted, and underweight than girls, we conducted a narrative review to explore which early life mechanisms might underlie these sex differences. We addressed different themes, including maternal and newborn characteristics, immunology and endocrinology, evolutionary biology, care practices, and anthropometric indices to explore potential sources of sex differences in child undernutrition. Our review found that the evidence on why sex differences occur is limited but that a complex interaction of social, environmental, and genetic factors likely underlies these differences throughout the life cycle. Despite their bigger size at birth and during infancy, in conditions of food deprivation, boys experience more undernutrition from as early as the foetal period. Differences appear to be more pronounced in more severe presentations of undernutrition and in more socioeconomically deprived contexts. Boys are more vulnerable to infectious disease, and differing immune and endocrine systems appear to explain some of this disadvantage. Limited evidence also suggests that different sociological factors and care practices might exert influence and have the potential to exacerbate or reverse observed differences. Further research is needed to better understand sex differences in undernutrition and the implications of these for child outcomes and prevention and treatment programming.
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Affiliation(s)
- Susan Thurstans
- Department of Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (R.S.); (M.K.)
- Correspondence:
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Andrew Seal
- UCL Institute for Global Health, London WC1E 6BT, UK;
| | - Jonathan C. Wells
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK;
| | - Tanya Khara
- Emergency Nutrition Network, Oxford OX5 2DN, UK; (T.K.); (C.D.)
| | - Carmel Dolan
- Emergency Nutrition Network, Oxford OX5 2DN, UK; (T.K.); (C.D.)
| | - André Briend
- Center for Child Health Research, School of Medicine, Tampere University, 33520 Tampere, Finland;
- Department of Nutrition, Exercise and Sports, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Mark Myatt
- Brixton Health, Llwyngwril, Gwynedd LL37 2JD, Wales, UK;
| | - Michel Garenne
- Institut de Recherche pour le Développement, UMI Résiliences, 93140 Bondy, France;
- Institut Pasteur, Epidémiologie des Maladies Emergentes, 75015 Paris, France
- Senior Fellow, FERDI, Université d’Auvergne, 63000 Clermont-Ferrand, France
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa
| | - Andrew Mertens
- School of Public Health, University of California, Berkeley, CA 94720-7360, USA;
| | - Rebecca Sear
- Department of Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (R.S.); (M.K.)
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; (R.S.); (M.K.)
- Maternal, Adolescent, Reproductive & Child Health Centre (MARCH), London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
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