Determinants of malnutrition in Senegal: individual, household, community variables, and their interaction

Nutritional status of HIV-infected children at Federal University Teaching Hospital, Owerri, Nigeria: A prospective analysis of rural and urban dwellers

Malnutrition is a critical concern among children living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), particularly in regions heavily affected by the HIV epidemic, such as sub-Saharan Africa. In 2019, nearly 2.84 million children under 19 years of age were living with HIV globally, with over 90% residing in sub-Saharan Africa. Concurrently, malnutrition remains prevalent in the region, with approximately 49 million children under the age of 5 experiencing stunting and 149 million suffering from wasting in 2018. This burden of malnutrition is exacerbated by factors such as poverty, food insecurity, and HIV/AIDS, which collectively contribute to adverse health outcomes among affected children. The bidirectional relationship between HIV/AIDS and malnutrition is well-established, with HIV infection increasing the risk of malnutrition and malnutrition worsening the progression of HIV/AIDS. Studies have consistently demonstrated higher rates of stunting, underweight, and wasting among HIV-infected children compared to their uninfected counterparts. Moreover, malnutrition significantly impacts the disease progression, morbidity, and mortality of HIV-infected individuals, further underscoring the importance of addressing this issue in pediatric HIV care. A total of 99 HIV-infected children, aged 2 to 16 years, were consecutively recruited from the pediatric infectious disease clinic of the Federal University Teaching Hospital Owerri. Anthropometric measurements, including weight and height, were obtained using a stadiometer (RGZ-160 England). Weight status was categorized as normal, underweight, overweight, or obese, while height status was classified as stunted, normal, or tall stature. The study participants ranged in age from 2 to 16 years. Approximately 20.2% of the children were underweight, and 6.1% were classified as obese. Stunting was observed in 29.3% of the participants. Notably, all forms of malnutrition, including underweight and overweight, were more prevalent among children residing in rural areas. In addition, stunting was more common among rural dwellers. This study highlights the high prevalence of malnutrition among HIV-infected children attending the pediatric infectious disease clinic at the Federal University Teaching Hospital Owerri. The findings underscore the urgent need for targeted nutritional interventions, particularly in rural areas, to improve the health outcomes of HIV-infected children.

Associated factors of malnutrition status among children and adolescents living with HIV in Tanzania: Individual-level analysis and marginal effect estimation

OBJECTIVES

This study aimed to identify individual-level factors that affect malnutrition outcomes among children and adolescents living with HIV/AIDS in Tanzania.

METHODS

We used data from the National AIDS Control Programme. 70,102 participants aged 5 to 19 years attending care and treatment clinics between January to December 2021 were included. Nutritional assessments were performed by anthropometric measurement. Logistic regression models were used to evaluate risk factors. We further estimated marginal prevalence and adjusted predictions by marginal effects. Supplementary analysis assessed the accuracy of the final fitted model.

RESULTS

Prevalence of malnutrition for stunting, underweight, wasting, and anthropometric failure (CIAF) were 36.0%, 28.9%, 13.0%, and 48.0%, respectively. Several individual-level factors were significant determinants of malnutrition. Boys, participants aged 15-19 years, those switched to second- or third-line antiretroviral therapy (ART), initiated ART at ages of 5-14 years, ART duration less than 3 years, and were in advanced stages of WHO HIV clinical status had increased adjusted odds ratios and marginal prevalence. The larger AUC values for all models implied importance of identified factors accounted for malnutrition.

CONCLUSIONS

On long-term ART, nutritional interventions should be context-specific guidelines to improve growth, especially at ART initiation, ART regimen, and ART duration reckoning with age and sex.

Adolescent pregnancy is associated with child undernutrition: Systematic review and meta-analysis

Adolescent pregnancy is associated with poor fetal growth and development which, in turn, increases the risk of childhood wasting and underweight. However, evidence on how young maternal age affects childhood anthropometry beyond the neonatal period is limited. This systematic review and meta-analysis examined associations between adolescent pregnancy and child wasting and underweight and explored potential underlying social and biological factors. Peer-reviewed literature published in English since 1990 was systematically searched. Eligible studies presented data on wasting and/or underweight in children (≤59 months) born to adolescent mothers (10-19, or ≤24 years where applicable) from low- and middle-income countries. Data extraction used a predefined extraction sheet. Both meta-analysis and qualitative synthesis were performed. Of 92 identified studies, 57 were included in the meta-analysis. The meta-analysis showed that children born to adolescent versus adult mothers were at a higher risk of moderate (odds ratio [OR]: 1.12, 95% confidence interval [CI]: 1.00-1.26 p = 0.04) and severe underweight (OR: 1.21, 95% CI: 1.08-1.35 p < 0.01). Associated risk of wasting was not statistically significant: (OR: 1.05, 95% CI: 0.98-1.12 p = 0.17); severe wasting (OR: 1.16, 95% CI: 0.68-1.96 p = 0.59). These findings were supported by the qualitative synthesis. Evidence on the potential role of biological/social factors was limited, but suggested an intermediary role of maternal nutritional status which warrants further exploration. Particularly in contexts where adolescent pregnancy remains common, interventions to both delay adolescent pregnancy and improve adolescent nutritional status could help reduce the risk of undernutrition in children and contribute to breaking the intergenerational cycle of malnutrition.

Copula Geo-Additive Modeling of Anaemia and Malnutrition among Children under Five Years in Angola, Senegal, and Malawi

Notwithstanding the interventions implemented to address child mortality, anaemia and malnutrition remain a concern for the future of developing countries. Anaemia and malnutrition contribute a high proportion of the causes of childhood morbidity in Africa. The objective of this study is to jointly model anaemia and malnutrition using a copula geo-additive model. This study is a secondary data analysis where a Demographic and Health Survey of 2016 data from Angola, Malawi, and Senegal was used. The descriptive analysis was conducted in SPSS and the copula geo-additive model analysis was performed in R 3.63. The results showed that female children are notably associated with anaemia and a malnourished status (female estimate = 0.144, p-value = 0.027 for anaemia; female estimate = −0.105, p-value = 000 for malnutrition). The probability of each result decreased with an improvement in the mother’s level of schooling. This indicates an urgent requirement for interventions to be implemented by policymakers in order to manage children’s mortality rates. These interventions can include the introduction of educational programs for older adults, children’s dietary programs, and income generation initiatives (starting a small business, etc.). It is hoped that this paper can foster the utilization of copula methodology in this field of science with the use of cross-sectional data.

Age heterogeneities in child growth and its associated socio-demographic factors: a cross-sectional study in India

BACKGROUND

The impacts of socio-demographic and environmental risk factors on child growth have been widely documented. However, it remains unclear whether the impacts of such risk factors on child growth have remained static or changed with child's age. The present study aims to assess the underlying age heterogeneities in child growth and its potential determinants over age in under-five children.

METHODS

Cross-sectional data on child height (measured as height-for-age z-score, i.e., HAZ) and weight (measured as weight-for-age z-score, i.e., WAZ) and potential confounding factors from India's 2015-16 National Family Health Survey (NFHS) were used to construct anthropometric age-profiles by a number of bio-demographic and socioeconomic characteristics. Further, age-interacted multilevel regression analyses were performed to examine differential effects of such/those risk factors on child height and weight by age.

RESULTS

Faltered height and weight growth during first two years of life was noticed in children of all socioeconomic groups studied, albeit with varying magnitude. In case of child's height, factors such as short birth interval, higher birth order, maternal education, household wealth, district level mortality rate have shown strong interaction with child's age during the first 23 months, signifying their age-varying role in different developmental stages of child growth. These factors explain the observed upward and downward shifts in height curve during first two years. Some of these variables (e.g., household wealth) have shown even stronger age interactions after the second birthday of children. For child's weight, interactive effects of most socio-demographic risk factors attenuated parabolically with child's age.

CONCLUSIONS

The impacts of several risk factors, measured at the child, mother, community, and district levels, on child growth indicators varied significantly with the child's age. Nutritional interventions aimed at preventing poor linear growth in children in India should consider these underlying age heterogeneities for growth determinants into account.

Gender differences in nutritional status and determinants among infants (6–11 m): a cross-sectional study in two regions in Ethiopia

Background

A limited number of studies suggest that boys may have a higher risk of stunting than girls in low-income countries. Little is known about the causes of these gender differences. The objective of the study was to assess gender differences in nutritional status and its determinants among infants in Ethiopia.

Methods

We analyzed data for 2036 children (6–11 months old) collected as the baseline for a multiple micronutrient powders effectiveness study in two regions of Ethiopia in March–April 2015. Child, mother, and household characteristics were investigated as determinants of stunting and wasting. Multiple logistic regression models were used separately for boys and girls to check for gender differences while adjusting for confounders. The study is registered at http://www.clinicaltrials.gov/ with the clinical trials identifier of NCT02479815.

Results

Stunting and wasting prevalence is significantly higher among boys compared to girls, 18.7 vs 10.7% and 7.9 vs 5.4%, respectively. Untimely initiation of breastfeeding, not-exclusive breastfeeding at the age of 6 months, region of residence, and low maternal education are significant predictors of stunting in boys. Untimely introduction to complementary food and low consumption of legumes/nuts are significant predictors of stunting in both boys and girls, and low egg consumption only in girls. Region of residence and age of the mother are significant determinants of wasting in both sexes. Analysis of interaction terms for stunting, however, shows no differences in predictors between boys and girls; only for untimely initiation of breastfeeding do the results for boys (OR 1.46; 95%CI 1.02,2.08) and girls (OR 0.88; 95%CI 0.55,1.41) tend to be different (p = 0.12).

Conclusion

In Ethiopia, boys are more malnourished than girls. Exclusive breastfeeding and adequate dietary diversity of complementary feeding are important determinants of stunting in boys and girls. There are no clear gender interactions for the main determinants of stunting and wasting. These findings suggest that appropriate gender-sensitive guidance on optimum infant and young child feeding practices is needed.

Do malnutrition, pre-existing morbidities, and poor household environmental conditions aggravate susceptibility to Coronavirus disease (COVID-19)? A study on under-five children in India

BACKGROUND

The novel Coronavirus disease 2019 (2019-nCoV) outbreak, caused by severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2), has become the worst serious global risk to humanity in the last century and linked with various risk factors.

OBJECTIVE

To find out the risk zone associated with Coronavirus disease among children under-five age using malnourished status, pre-existing morbidity conditions, poor household environmental conditions, and also with case fatality rate (CFR) and active case rate (ACR) of COVID-19 in India.

DATA SOURCES & METHODS

Data was collected from the 4th round of the National Family Health Survey (NFHS)-4, 2015-16, and CFR and ACR of COVID-19 related data collected from the Ministry of Health and Family Welfare (MoHFW) on 18th May 2020. Mean, standard deviation, and Z-score statistical methods have been employed to identify the risk factors zone and Hot Spot analysis (Getis-Ord Gi) has been done.

RESULTS

The states and union territories (UTs) which have a high composite vulnerability score (CVS) of COVID-19 among under-five children are in Meghalaya (CVS = 1), Uttar Pradesh (CVS = 0.93), Jharkhand (CVS = 0.86), Bihar (CVS = 0.74), Madhya Pradesh (CVS = 0.74), and Odisha (CVS = 0.55). The states and UTs which have low composite vulnerability score of COVID-19 among under-five children are in Sikkim (CVS = -0.90), Daman & Diu (CVS = -0.76) Lakshadweep (CVS = -0.74), Kerala (CVS = -0.72), Chandigarh (CVS = -0.71). The COVID-19 high-risk zones (hot spot: 99% Confidence interval [CI]) were observed in Madhya Pradesh, Uttar Pradesh, Jharkhand, Bihar, and Meghalaya states of India, which are spatially high clustered and the low-risk zones (cold spot: 95% CI) were observed in Kerala, Mizoram states of India.

CONCLUSIONS

Well-built public health measures, including rapidly searching in high focus areas and testing of COVID-19, should be performed in vulnerable regions of COVID-19.

Does malnutrition in clubfoot patients affect Ponseti technique and its outcome?

OBJECTIVES

Malnutrition is a crucial health problem predominantly in the developing countries. Malnutrition in children is one of the main risk factors for diseases and mortality. Club foot or congenital talipes equinovarus (CTEV) is the most common form of congenital orthopaedic abnormality. Over the past 20 years, the Ponseti method is considered the gold standard for the treatment of clubfoot. Our objective is to determine the prevalence of malnutrition in clubfoot patients, and its effects on the outcome of Ponseti technique in patients presenting to the Orthopaedic Clinic of tertiary care Hospital in Karachi, Pakistan.

METHOD

The cross-sectional study was conducted from January to December 2018. Total 153 clubfoot patients were treated and the World Health Organization (WHO) classification of weight-for-age index was used to assess the nutritional status of patients, and its impact on outcome of Ponseti technique was recorded and analysed with a P value ≤ .05 as significant.

RESULTS

Of the 153 patients, 112 (79.7%) were found in good nutritional status and 42 (20.6%) were malnourished. The average number of casts per patient and patients requiring 6+ casts in the undernutrition group was higher compared with good nutrition group (45.5% vs 21.42%, respectively). The number of Achilles tenotomy performed in the undernutrition group was also higher (76.4% vs 51.8%).

CONCLUSION

A significant correlation between patients' nutritional status and outcome of the Ponseti technique is found as it influences the number of casts, possible relapse and failure of treatment.

Prevalence and determinants of severity levels of anemia among children aged 6-59 months in sub-Saharan Africa: A multilevel ordinal logistic regression analysis

BACKGROUND

Anemia is a major public health problem affecting more than half of children under the age of five globally. It has serious short- and long-term consequences including growth retardation, impaired motor and cognitive development, and increased morbidity and mortality. Despite anemia is the leading cause of child mortality in sub-Saharan Africa, there is limited evidence on the prevalence and determinants of anemia among under-five children in sub-Saharan Africa. Therefore, this study aimed to investigate the prevalence and determinants of severity levels of anemia among children aged 6-59 months in sub-Saharan Africa.

METHODS

This study was based on the most recent Demographic and Health Survey (DHS) data of 32 sub-Saharan African countries. A total weighted sample of 135,619 children aged 6-59 months was included in the study. Considering the hierarchical nature of DHS data and the ordinal nature of anemia, a multilevel ordinal logistic regression model was applied. Proportional odds assumption was tested by Brant test and it was satisfied (p-value = 0.091). Besides, deviance was used for model comparison. Variables with a p-value ≤0.2 in the bivariable analysis were considered for the multivariable analysis. In the multivariable multilevel proportional odds model, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported for potential determinant factors of severity levels of anemia.

RESULTS

The overall prevalence of anemia among children aged 6-59 months in sub-Saharan Africa was 64.1% [95% CI: 63.9%, 64.4%]. Of which, 26.2% were mildly anemic, 34.9% moderately anemic and 3% severely anemic. Poor maternal education, lower household wealth status, large family size, being male child, multiple births, having fever in the last two weeks, having diarrhea in the last two weeks, higher-order birth, maternal anemia, underweight, wasted, and stunted were significantly associated with increased odds of higher levels of anemia. Whereas, being 24-59 months age, taking drugs for an intestinal parasite, and born from mothers aged ≥ 20 years were significantly associated with lower odds of higher levels of anemia.

CONCLUSION

Severity levels of anemia among children aged 6-59 months in sub-Saharan Africa was a major public health problem. Enhancing maternal education, providing drugs for an intestinal parasite, designing interventions that address maternal anemia, febrile illness, and diarrheal disease, and strengthening the economic status of the family are recommended to reduce childhood anemia. Furthermore, it is better to strengthen the strategies of early detection and management of stunted, wasted, and underweight children to decrease childhood anemia.

Refrigeration and child growth: What is the connection?

Child stunting in Latin America and the Caribbean (LAC) decreased from 22.9% in 1990 to 9.6% in 2017. While stunting rates in the region were falling, access to electricity and refrigeration were on the rise. Despite a large body of evidence surrounding the effects of refrigeration on food consumption, and separately of the importance of food consumption for child health and nutrition, surprisingly few studies explore the potential effects of refrigeration on child nutrition. We studied the relationship between refrigeration and child nutrition outcomes using rich panel data for 1298 low-income households with children younger than 12 months at baseline in El Alto, Bolivia. We estimated the effects of refrigerator ownership on diet and nutrition outcomes using a difference-in-difference approach. Owning a refrigerator was associated with increased food expenditures and improved child nutrition. We found evidence that households that acquired a refrigerator were more likely to buy food that requires refrigeration, and children in households that acquired refrigerators were 0.17 standard deviations taller for their age after 2 years. We also found that refrigeration was associated with a 0.26 standard deviation decline in BMI-for-age, an effect driven by increased height rather than lower weight. These results suggest that refrigeration may play a role in explaining reductions in undernutrition observed in low- and middle-income countries in recent decades.

Drivers of stunting reduction in Senegal: a country case study

BACKGROUND

Senegal has been an exemplar country in the West African region, reducing child stunting prevalence by 17.9% from 1992 to 2017.

OBJECTIVES

In this study, we aimed to conduct a systematic in-depth assessment of factors at the national, community, household, and individual levels to determine the key enablers of Senegal's success in reducing stunting in children <5 y old between 1992/93 and 2017.

METHODS

A mixed methods approach was implemented, comprising quantitative data analysis, a systematic literature review, creation of a timeline of nutrition-related programs, and qualitative interviews with national and regional stakeholders and mothers in communities. Demographic and Health Surveys and Multiple Indicator Cluster Surveys were used to explore stunting inequalities and factors related to the change in height-for-age z-score (HAZ) using difference-in-difference linear regression and the Oaxaca-Blinder decomposition method.

RESULTS

Population-wide gains in average child HAZ and stunting prevalence have occurred from 1992/93 to 2017. Stunting prevalence reduction varied by geographical region and prevalence gaps were reduced slightly between wealth quintiles, maternal education groups, and urban compared with rural residence. Statistical determinants of change included improvements in maternal and newborn health (27.8%), economic improvement (19.5%), increases in parental education (14.9%), and better piped water access (8.1%). Key effective nutrition programs used a community-based approach, including the Community Nutrition Program and the Nutrition Enhancement Program. Stakeholders felt sustained political will and multisectoral collaboration along with improvements in poverty, women's education, hygiene practices, and accessibility to health services at the community level reduced the burden of stunting.

CONCLUSIONS

Senegal's success in the stunting decline is largely attributed to the country's political stability, the government's prioritization of nutrition and execution of nutrition efforts using a multisectoral approach, improvements in the availability of health services and maternal education, access to piped water and sanitation facilities, and poverty reduction. Further efforts in the health, water and sanitation, and agriculture sectors will support continued success.

Maternal and Child Nutrition Status in Rural Communities of Kalalé District, Benin: The Relationship and Risk Factors

BACKGROUND

Double burden of malnutrition (DBM) is an emerging public health concern in urban Benin. However, an understanding of the phenomena in rural areas of the country is lacking.

OBJECTIVES

To assess the prevalence of DBM and to investigate the sociodemographic and dietary characteristics that differentiate DBM from undernourished children only, overweight/obese mothers only, and normal households in Kalalé district.

METHODS

A cross-sectional study was conducted on 426 mother-child pairs: nonpregnant women aged 15 to 49 years and children aged 6 to 59 months. Weight-for-age and height-for-age were used to classify underweight and stunted children, body mass index ≥25 kg/m² to measure overweight/obese mothers, and a 24-hour recall to assess the diet diversity score (DDS).

RESULTS

Overall, 37.6% of children were stunted, 10.1% wasted, and 22.8% underweight, while the rate of overweight/obese mothers was 15.5%. The DBM was present in 6.1% of the households. Overweight/obese mothers' households had better socioeconomic status (SES), greater maternal education, less food insecurity, and a more diversified diet, in contrast with undernourished children households. The DBM households shared several features with undernourished children households, except for a greater (not significant) SES, but had the lowest DDS. Logistical regression revealed that high SES, older age child, DDS, mother education, and ethnicity were associated with DBM.

CONCLUSIONS

The study highlights the importance of addressing the DBM at the community level in rural Benin. However, multicenter studies in various rural parts of the country are needed to substantiate the present results, so that appropriate strategies to reduce the DBM can be planned.

Goal-setting and volitional behavioural change: Results from a school meals intervention with vitamin-A biofortified sweetpotato in Nigeria

Malnutrition, particularly vitamin A deficiency, is a major public health problem in many developing countries. This study investigated whether priming or self-generation of goals, or whether attention to instrumental or experiential goals together with use of a reminder condition or not, promotes dietary behaviour intentions and change. A set of 556 randomly selected children aged 7-12 in Osun state, Nigeria, participated in an four-week intervention and field experiment in which a meal based on orange-fleshed sweetpotato, rich in pro-vitamin A, was introduced on five occasions as a complement to the existing school meal. Baseline intentions, anticipated feelings and repeated measures of post-consumption and experience were assessed. The analyses included a generalised linear mixed model for consumption and a linear mixed model for feelings and experience. The results confirmed that attention to instrumental goals undermines goal pursuit, while a focus on experiential goals increases the persistence of pursuit. Priming of experiential goals should be recommended, especially because this approach evokes positive feelings after eating. There was no evidence of an effect from repeated pairing of goals with the school meal, but use of planning by stating intentions increased the amount eaten. These results have implications for how school meals programmes should be designed to better align personal motivation with behavioural change in relation to dietary health.

Levels and correlates of nutritional status of women of childbearing age in rural Bangladesh

OBJECTIVE

The present study examined the prevalence of and risk factors for malnutrition in a population-based cohort of women of childbearing age in rural Bangladesh.

DESIGN

A cross-sectional study that collected pre-pregnancy weight, height, and data on selected risk factors for nutritional status of women.

SETTING

The study was conducted in Sylhet District of Bangladesh.

SUBJECTS

Study subjects included 13 230 non-pregnant women of childbearing age. Women were classified into underweight (<18·5 kg/m2), normal (18·5-24·9 kg/m2) and overweight/obese (≥25·0 kg/m2) using BMI; and into moderate to severe stunting (<150 cm), mild stunting (150-<155 cm) and normal (≥155 cm) using height. Two multinomial logistic regression models were fitted for BMI: model 1 examined individual and household factors associated with BMI, and model 2 additionally examined the association of community variables. The same analysis was conducted for height.

RESULTS

Prevalence of underweight, overweight/obesity and moderate to severe stunting was 37·0, 7·2 and 48·6 %, respectively. Women's education and household wealth were inversely related to both underweight status and stunting. Underweight rate was significantly lower in the post-harvest season. Women with any education and who belonged to households with higher wealth were more likely to be overweight/obese.

CONCLUSIONS

The study documented high underweight and stunting, and moderate overweight/obesity rates among rural Bangladeshi women; and recommends design and implementation of a multidimensional intervention programme based on individual-, household- and community-level risk factors that can address underweight, stunting and overweight/obesity to improve the nutritional status of women of childbearing age in Bangladesh.

Socioeconomic context of the community and chronic child malnutrition in Colombia

OBJECTIVE

To analyze the influence of the socioeconomic context of the community on chronic child malnutrition in Colombia.

METHODS

We estimated multilevel logistic models using data from the National Demographic and Health Survey in Colombia in 2010. The final sample included 11,448 children under the age of five gathered in 3,528 communities. In addition, we used the Principal Component Analysis with polychoric correlations for the construction of composed indicators of wealth, autonomy of the woman, and the use and access to the health system.

RESULTS

The average level of community wealth was significantly and independently associated with chronic malnutrition in early childhood, more than the socioeconomic status of the household itself. At the individual and household level, the probability of chronic malnutrition was higher for children from mothers with low levels of autonomy and use and access to the health system, mothers who had their first child in adolescence, and mothers who live in homes in the lowest wealth quintiles. In contrast, children from mothers with a body mass index > 25 and with at least secondary education (versus no education) were less likely to suffer from chronic malnutrition.

CONCLUSIONS

Research, programs, and interventions need to take into account the physical, economic, and social context of communities to contribute with the improvement of the nutritional status of early childhood in Colombia.

Individual and community level factors with a significant role in determining child height-for-age Z score in East Gojjam Zone, Amhara Regional State, Ethiopia: a multilevel analysis

Background

In Ethiopia, child undernutrition remains to be a major public health challenge and a contributing factor for child mortality and morbidity. To reduce the problem, it is apparent to identify determinants of child undernutrition in specific contexts to deliver appropriately, targeted, effective and sustainable interventions.

Methods

An agroecosystem linked cross-sectional survey was conducted in 3108 children aged 6–59 months. Multistage cluster sampling technique was used to select study participants. Data were collected on socio-demographic characteristics, child anthropometry and on potential immediate, underlying and basic individual and community level determinants of child undernutrition using the UNICEF conceptual framework. Analysis was done using STATA 13 after checking for basic assumptions of linear regression. Important variables were selected and individual and community level determinants of child height-for-age Z score were identified. P values less than 0.05 were considered the statistical level of significance.

Results

In the intercept only model and full models, 3.8% (p < 0.001) and 1.4% (p < 0.001) of the variability were due to cluster level variability. From individual level factors, child age in months, child sex, number of under five children, immunization status, breast feeding initiation time, mother nutritional status, diarrheal morbidity, household level water treatment and household dietary diversity were significant determinants of child height for age Z score. Also from community level determinants, agroecosystem type, liquid waste disposal practice and latrine utilization were significantly associated with child height-for-age Z score.

Conclusion

In this study, a statistical significant heterogeneity of child height-for-age Z score was observed among clusters even after controlling for potential confounders. Both individual and community level factors, including the agroecosystem characteristics had a significant role in determining child height-for-age Z score in the study area. In addition to the existing efforts at the individual levels to improve child nutritional status, agroecosystem and community WASH related interventions should get more attention to improve child nutritional status in the study area.

Determinants of stunting in children under 5 years in Madagascar

Madagascar is among countries where the prevalence of stunting is dramatically high in under 5 years old children. This study investigated the determinants of child stunting based on the UNICEF framework on the causes of malnutrition. A cutoff at 24 months was used to separate the child population into two groups. By using the latest Demographic and Health Survey (2009), logistic regressions were performed to determine the variables associated with stunting. In 2009, 40.1% of the 1,863 children aged 0-23 months and 53.9% of the 2,911 children aged 24-59 months were stunted contributing to the 48.5% overall stunting prevalence in the sample. Girls were less likely to be stunted (adjusted odds ratio with confidence interval [AOR] = 0.69 [0.55-0.88] and 0.84 [0.72-0.97], p < 0.01) than boys; the risk of stunting increased with age. Regarding underlying predictors, increased maternal height was associated with lower odds of stunting in both age groups (AOR = 0.75 [0.68-0.83] and 0.69 [0.61-0.77], p < 0.001). Children living in households using iodized salt (>15 ppm) had lower risk of stunting in the younger group (AOR = 0.76 [0.61-0.94], p < 0.05). Children living in urban areas were less likely to be stunted in both age groups (AOR = 0.67 [0.51-0.88] and 0.73 [0.59-0.90] respectively, p < 0.01]. Region of residence was also a significant basic factor for stunting. This study contributes to the understanding of the determinants of child stunting in Madagascar. The results confirmed the need for specific interventions for each of the two age groups.

'Mommy, I miss daddy'. The effect of family structure on children's health in Brazil

This paper studies the relationship between single motherhood and children's height-for-age z-scores in Brazil. In order to isolate the causal effect between family structure and children's condition, we estimate an econometric model that uses male preference for firstborn sons and local sex ratios to instrument the probability of a woman becoming a single mother. Our results have a local average treatment effect interpretation (LATE). We find that children being raised by a single mother (whose marital status is affected by a firstborn girl and a low sex ratio) have a height-for-age z-score that is lower than that of children of similar characteristics that cohabit with both progenitors. We claim that the increasing trend of single motherhood in Brazil should be of concern in health policy design.

Influence of Schistosoma mansoni and Hookworm Infection Intensities on Anaemia in Ugandan Villages

BACKGROUND

The association of anaemia with intestinal schistosomiasis and hookworm infections are poorly explored in populations that are not limited to children or pregnant women.

METHODS

We sampled 1,832 individuals aged 5-90 years from 30 communities in Mayuge District, Uganda. Demographic, village, and parasitological data were collected. Infection risk factors were compared in ordinal logistic regressions. Anaemia and infection intensities were analyzed in multilevel models, and population attributable fractions were estimated.

FINDINGS

Household and village-level predictors of Schistosoma mansoni and hookworm were opposite in direction or significant for single infections. S. mansoni was found primarily in children, whereas hookworm was prevalent amongst the elderly. Anaemia was more prevalent in individuals with S. mansoni and increased by 2.86 fold (p-value<0.001) with heavy S. mansoni infection intensity. Individuals with heavy hookworm were 1.65 times (p-value = 0.008) more likely to have anaemia than uninfected participants. Amongst individuals with heavy S. mansoni infection intensity, 32.0% (p-value<0.001) of anaemia could be attributed to S. mansoni. For people with heavy hookworm infections, 23.7% (p-value = 0.002) of anaemia could be attributed to hookworm. A greater fraction of anaemia (24.9%, p-value = 0.002) was attributable to heavy hookworm infections in adults (excluding pregnant women) as opposed to heavy hookworm infections in school-aged children and pregnant women (20.2%, p-value = 0.001).

CONCLUSION

Community-based surveys captured anaemia in children and adults affected by S. mansoni and hookworm infections. For areas endemic with schistosomiasis or hookworm infections, WHO guidelines should include adults for treatment in helminth control programmes.

Evidence of a Double Burden of Malnutrition in Urban Poor Settings in Nairobi, Kenya

Background

Many low- and middle-income countries are undergoing a nutrition transition associated with rapid social and economic transitions. We explore the coexistence of over and under- nutrition at the neighborhood and household level, in an urban poor setting in Nairobi, Kenya.

Methods

Data were collected in 2010 on a cohort of children aged under five years born between 2006 and 2010. Anthropometric measurements of the children and their mothers were taken. Additionally, dietary intake, physical activity, and anthropometric measurements were collected from a stratified random sample of adults aged 18 years and older through a separate cross-sectional study conducted between 2008 and 2009 in the same setting. Proportions of stunting, underweight, wasting and overweight/obesity were dettermined in children, while proportions of underweight and overweight/obesity were determined in adults.

Results

Of the 3335 children included in the analyses with a total of 6750 visits, 46% (51% boys, 40% girls) were stunted, 11% (13% boys, 9% girls) were underweight, 2.5% (3% boys, 2% girls) were wasted, while 9% of boys and girls were overweight/obese respectively. Among their mothers, 7.5% were underweight while 32% were overweight/obese. A large proportion (43% and 37%%) of overweight and obese mothers respectively had stunted children. Among the 5190 adults included in the analyses, 9% (6% female, 11% male) were underweight, and 22% (35% female, 13% male) were overweight/obese.

Conclusion

The findings confirm an existing double burden of malnutrition in this setting, characterized by a high prevalence of undernutrition particularly stunting early in life, with high levels of overweight/obesity in adulthood, particularly among women. In the context of a rapid increase in urban population, particularly in urban poor settings, this calls for urgent action. Multisectoral action may work best given the complex nature of prevailing circumstances in urban poor settings. Further research is needed to understand the pathways to this coexistence, and to test feasibility and effectiveness of context-specific interventions to curb associated health risks.

Prevalence and risk factors of undernutrition among antiretroviral-therapy-naïve subjects aged under 5 years old in Makurdi, Nigeria: a retrospective study

Background

Undernutrition is common in human immunodeficiency virus (HIV) infection and it contributes significantly to its morbidity and mortality. However, as far as we are aware, few studies have described the risk factors of undernutrition among HIV-infected Nigerian children. The study reported here aimed to determine the prevalence and risk factors of undernutrition among HIV-infected, antiretroviral therapy (ART)-naïve children aged under 5 years old in Makurdi, Nigeria.

Methods

A retrospective, cross-sectional study was undertaken at the Federal Medical Centre, Makurdi, between June 2010 and June 2011. Logistic regression modelling was used to determine the risk factors of undernutrition.

Results

Data on 182 HIV-infected children (88 males and 94 females), aged between 6 weeks and 59 months were studied. The prevalence of undernutrition was 12.1%, 33.5%, and 54.4% for underweight, wasting, and stunting, respectively. In multivariate regression analyses, being female (adjusted odds ratio [AOR] 0.292, 95% [confidence interval] CI 0.104–0.820, P=0.019), the child’s caregiver being on ART (AOR 0.190, 95% CI 0.039–0.925, P=0.04), and the absence of tuberculosis in the child (AOR 0.034, 95% CI 0.003–0.357, P=0.005) were independently protective against underweight. Subjects who were exclusively breastfed in the first 6 months of life were protected from stunting (AOR 0.136, 95% CI 0.032–0.585, P=0.007). No factor impacted significantly on wasting in multivariate analyses.

Conclusion

Undernutrition among HIV-infected, ART-naïve children aged under 5 years old may be reduced if programmatic interventions are guided toward early initiation of ART among eligible HIV-infected caregivers and the promotion of HIV/tuberculosis coinfection control efforts. Also, the importance of exclusive breastfeeding in reducing undernutrition cannot be overemphasized.

The relationship between BMI and dietary intake of primary school children from a rural area of South Africa: The Ellisras longitudinal study

OBJECTIVES

To investigate the relationship between dietary intake and BMI of primary school children from a rural area of South Africa cross-sectionally. Both under and over nutrition remain major health problems in South Africa. In rural areas, where especially undernutrition leads to child morbidity and mortality, determinants should be detected.

METHODS

Data was used from 825 children (421 boys, 404 girls), aged 6-12 years, participating in the Ellisras Longitudinal Growth study. Height and weight were measured in accordance with the protocol of the International Society for the Advancement of Kinanthropometry. Internationally recommended cut-off points for body mass index (BMI) were used. Dietary intake was measured using the 24 h recall method. In general, boys and girls from Ellisras had dietary intake levels lower than or according to dietary guidelines.

RESULTS

A singular linear regression model showed a significant association between monounsaturated fat and BMI. The multiple model demonstrated that total fat (B = 0.05, CI: 0.019-0.082), monounsaturated fat (B = -0.093, CI: -0.160 to -0.026) and polyunsaturated fat (B = 0.056, CI: 0.09-0.02) predict BMI.

CONCLUSION

This study supports previous findings about BMI and dietary trends in rural areas of South Africa. Despite low fat intake of the subjects, this macronutrient appeared to predict BMI most strongly. More research is needed; however, to further examine how healthy their lifestyle is nowadays with respect to diet and into what extent the nutrition transition has reached this area.

COMMUNITY SOCIOECONOMIC CONTEXT AND ITS INFLUENCE ON INTERMEDIARY DETERMINANTS OF CHILD HEALTH: EVIDENCE FROM COLOMBIA

Intermediary determinants are the most immediate mechanisms through which socioeconomic position shapes health inequities. This study examines the effect of community socioeconomic context on different indicators representing intermediary determinants of child health. In the context of Colombia, a developing country with a clear economic expansion, but one of the most unequal countries in the world, two categories of intermediary determinants, namely behavioural and psychosocial factors and the health system, are analysed. Using data from the 2010 Colombian Demographic and Health Survey (DHS), the results suggest that whilst the community context can exert a greater influence on factors linked directly to health, in the case of psychosocial factors and parent's behaviours, the family context can be more important. In addition, the results from multilevel analysis indicate that a significant percentage of the variability in the overall index of intermediary determinants of child health is explained by the community context, even after controlling for individual, family and community characteristics. These findings underline the importance of distinguishing between community and family intervention programmes in order to reduce place-based health inequities in Colombia.

Anthropometric measurements by ethnicity in Colombia, 1965-1990

We analyzed the evolution of height in Colombia of cohorts born in the period 1965-1990 by ethnic groups. We found that Afro-Colombian men and women were the tallest: 6cm taller than indigenous people and 2cm taller than the rest of the population. We also found that the height gap between Afro-Colombians and others decreased during the period under study by 0.7cm for both men and women. While improvements were noticeable among the Afro-Colombians and those who chose not to be classified by ethnicity, in the case of the indigenous population only female cohorts registered an average-height increase of 1.5cm. Moreover, we found that indigenous Colombians were more likely than other ethnic groups to experience an increase in biological well-being as a consequence of an improvement in their socio-economic status, thereby reducing the average-stature gap between them and the rest of the population by 2.1 and 3.6cm for men and women, respectively.

Effect of a school feeding programme on nutritional status and anaemia in an urban slum: a preliminary evaluation in Kenya

To reduce malnutrition and improve child survival, school feeding programmes have been established in many parts of Africa, although prevalence of child malnutrition and anaemia remains high, especially in urban slums. The objective of this study is to evaluate the effect of a school feeding programme in the slums of Nairobi (Kenya) on anaemia and nutritional status, together with an investigation for socioeconomic determinants that may overrule this effect. Sixty-seven children at the St. George primary school in Kibera participated in the school feeding programme for 1 year and data concerning anaemia rate, nutritional status and socioeconomic status were collected during a medical health check. Data were compared with a control group of children attending the same school, of the same age and with the same gender distribution without participation in a feeding programme. Data were analyzed with statistical software (SPSS 17.0). Children participating in the school feeding programme were less stunted (p = 0.02) and wasted (p = 0.02) than children in the control group, and levels of anaemia were lower (p = 0.01). Having no father (p = 0.01) and living in small families (p = 0.003) overruled the effect of the feeding programme. Also, the higher the mother's education, the more wasting was seen (p = 0.04) despite participation in the programme. The programme reduced anaemia and malnutrition and has improved child growth in our study group greatly, but we found that education level of the mother, family size and absence of a father overruled the effect of the school feeding programme. Because sample size of our study is small, we encourage further large-scaled research on reviewing programmatic interventions to develop optimal feeding strategies and improve nutritional status of children.

Maternal HIV infection and other factors associated with growth outcomes of HIV-uninfected infants in Entebbe, Uganda

Objective

To assess the associations between maternal HIV infection and growth outcomes of HIV-exposed but uninfected infants and to identify other predictors for poor growth among this population.

Design

Within a trial of de-worming during pregnancy, the cohort of offspring was followed from birth. HIV status of the mothers and their children was investigated and growth data for children were obtained at age 1 year. Length-for-age, weight-for-age and weight-for-length Z-scores were calculated for each child; Z-scores <−2 were defined as stunting, underweight and wasting, respectively.

Setting

The study was conducted in Entebbe municipality and Katabi sub-county, Uganda.

Subjects

The sample consisted of 1502 children aged 1 year: HIV-unexposed (n 1380) and HIV-exposed not infected (n 122).

Results

Prevalence of stunting, underweight and wasting was 14·2 %, 8·0 % and 3·9 %, respectively. There was evidence for an association between maternal HIV infection and odds of being underweight (adjusted OR = 2·32; 95 % CI 1·32, 4·09; P = 0·006) but no evidence for an association with stunting or with wasting. Young maternal age, low maternal education, low birth weight, early weaning and experiencing a higher number of episodes of malaria during infancy were independent predictors for stunting and underweight. A higher number of living children in the family was associated with wasting.

Conclusions

Maternal HIV infection was associated with being underweight in HIV-exposed uninfected infants. The success of programmes for prevention of mother-to-child HIV transmission means that an increasing number of infants will be born to HIV-infected women without acquiring HIV. Therefore, viable nutritional interventions need to be identified for this population.

Exploring the paradox: double burden of malnutrition in rural South Africa

BACKGROUND

This article is a review of the PhD thesis by Elizabeth Kimani-Murage that explores the double burden of malnutrition in rural South Africa. This is in the context of a worryingly rapid increase in obesity and obesity-related diseases in low- and middle-income countries (LMICs) including South Africa, and in the wake of on-going nutrition transition and lifestyle changes in these countries.

OBJECTIVE

To understand the profiles of malnutrition among children and adolescents in a poor, high HIV prevalent, transitional society in a middle-income country.

METHODS

A cross-sectional growth survey was conducted in 2007 targeting 4,000 children and adolescents aged 1-20 years. In addition, HIV testing was carried out on children aged 1-5 years and Tanner pubertal assessment among adolescents aged 9-20 years.

RESULTS

The study shows stunting at an early age and adolescent obesity, particularly among girls, that co-exists in the same socio-geographic population. The study also shows that HIV is an independent modifiable risk factor for poor nutritional outcomes in children and makes a significant contribution to nutritional outcomes at the individual level. Significant predictors of undernutrition at an early age, documented at individual, household, and community levels, include child's HIV status, age and birth weight, maternal age, age of household head, and area of residence. Significant predictors of overweight/obesity and risk for metabolic disease during adolescence, documented at individual and household levels include child's age, sex, and pubertal development, household-level food security, socio-economic status, and household head's highest education level.

CONCLUSIONS

The combination of early stunting and adolescent obesity raises critical concerns in the wake of the rising public health importance of metabolic diseases in LMICs. This is because, both paediatric obesity and adult short stature are risk factors for metabolic syndrome and metabolic diseases in adulthood. Clearly, policies and interventions to address malnutrition in this and other transitional societies need to be double-pronged and gender-sensitive.

Child Health in the Sundarbans: How Far Do Mutually Reinforcing Shocks Act As Contextual Determinants?

Childhood chronic under-nutrition and common childhood illness are highly prevalent in the delta region of the Sundarbans of West Bengal, India. The present work tested the hypothesis—frequent climatic shock is likely to predispose chronic and transient health shocks through behavioural responses of households in the presence of inaccessibility, inadequacy and acceptability barriers which act in the economy as long wave shocks. The work is based on a household and facility survey; primary data was collected in 19 blocks of the Sundarbans. The results highlight that transient climatic shock make child health worse through the pathway of chronic poverty, low resilience, physical and social barriers to health-seeking as well as ineffective service delivery systems. Further in-depth research is required to understand multiple vulnerabilities, related to coping of households and ways to improve the service delivery mechanism to have healthy children in the Sundarbans in the near future.

Water accessibility and child health: use of the leave-out strategy of instruments

This paper investigates the leave-out strategy of instruments by using the leave-out community ratio of household access to in-yard water sources and community water infrastructure as instruments for hours in fetching water time, and the data on disease symptoms. The results show that community-level access to clean water is significantly associated with both water-relevant and irrelevant disease symptoms, which suggests that the correlation between community-level access to clean water and child health is at least partially due to endogenous project placement potentially with respect to unobserved community wealth. The paper concludes that the OLS estimates have a potential endogeneity bias problem and that IV estimates under this strategy is subject to endogenous project placement and is not valid. A policy implication of this study is that careful attention should be paid to both self-selection and endogenous project placement in studying the effect of water accessibility on child health.

Nutritional status and HIV in rural South African children

BACKGROUND

Achieving the Millennium Development Goals that aim to reduce malnutrition and child mortality depends in part on the ability of governments/policymakers to address nutritional status of children in general and those infected or affected by HIV/AIDS in particular. This study describes HIV prevalence in children, patterns of malnutrition by HIV status and determinants of nutritional status.

METHODS

The study involved 671 children aged 12-59 months living in the Agincourt sub-district, rural South Africa in 2007. Anthropometric measurements were taken and HIV testing with disclosure was done using two rapid tests. Z-scores were generated using WHO 2006 standards as indicators of nutritional status. Linear and logistic regression analyses were conducted to establish the determinants of child nutritional status.

RESULTS

Prevalence of malnutrition, particularly stunting (18%), was high in the overall sample of children. HIV prevalence in this age group was 4.4% (95% CI: 2.79 to 5.97). HIV positive children had significantly poorer nutritional outcomes than their HIV negative counterparts. Besides HIV status, other significant determinants of nutritional outcomes included age of the child, birth weight, maternal age, age of household head, and area of residence.

CONCLUSIONS

This study documents poor nutritional status among children aged 12-59 months in rural South Africa. HIV is an independent modifiable risk factor for poor nutritional outcomes and makes a significant contribution to nutritional outcomes at the individual level. Early paediatric HIV testing of exposed or at risk children, followed by appropriate health care for infected children, may improve their nutritional status and survival.

Exploring the meaning of context for health: Community influences on child health in South India

Much research attention has been devoted to community context and health. Communities are often defined as residential spaces, such as neighborhoods, or as social groupings, such as caste in India. Using data from a group of tea estates in South India, we attempt to address important methodological challenges in the identification of neighborhood effects on child health. We find significant neighborhood effects for weight for age at age one, including a protective role for community-level women's education, but none for birth weight. In contrast to the usual pattern in rural India, caste disparities in child health are also eliminated in this setting.

Child nutrition in Mozambique in 2003: the role of mother's schooling and nutrition knowledge

This paper is a study of the determinants of the anthropometric status of preschool children in Mozambique. Using the 2003 Demographic and Health Survey, we provide insights into two main explanatory factors: the mother's schooling and the mother's nutrition knowledge. Rather than treating the mother's schooling as a black box, we analyze its interaction with the mother's nutrition knowledge and household wealth in order to elucidate the mechanisms underlying their ultimate effect on child height. The estimates obtained through instrumental variable regression show that the direct effect of the mother's schooling is large but that the rate at which it increases declines as her educational level rises. Primary education seems to be a key to enhance the mothers' general knowledge, which then improves the allocation of resources in regard to children's well-being and the care for the child. A higher educational level attained by the mother is likely to play only a minimal and indirect role in her child's nutrition, by expanding her economic opportunities. This is because more educated mothers have also more qualified and time-consuming jobs, which reduces the time spent for childcare. Mothers with higher levels of nutrition knowledge, acquired primarily outside of school, are able to choose a more diversified diet for their children and, broadly speaking, to utilize food more effectively. Based on a second technique, the instrumental variable quantile regression, we are able to draw a double conclusion: that mothers' nutrition knowledge contributes to height increases among extremely deprived children, and that mothers' formal education and household wealth are slightly more important for relatively well-off children.

Nutritional status of children in India: household socio-economic condition as the contextual determinant

BACKGROUND

Despite recent achievement in economic progress in India, the fruit of development has failed to secure a better nutritional status among all children of the country. Growing evidence suggest there exists a socio-economic gradient of childhood malnutrition in India. The present paper is an attempt to measure the extent of socio-economic inequality in chronic childhood malnutrition across major states of India and to realize the role of household socio-economic status (SES) as the contextual determinant of nutritional status of children.

METHODS

Using National Family Health Survey-3 data, an attempt is made to estimate socio-economic inequality in childhood stunting at the state level through Concentration Index (CI). Multi-level models; random-coefficient and random-slope are employed to study the impact of SES on long-term nutritional status among children, keeping in view the hierarchical nature of data.

MAIN FINDINGS

Across the states, a disproportionate burden of stunting is observed among the children from poor SES, more so in urban areas. The state having lower prevalence of chronic childhood malnutrition shows much higher burden among the poor. Though a negative correlation (r = -0.603, p < .001) is established between Net State Domestic Product (NSDP) and CI values for stunting; the development indicator is not always linearly correlated with intra-state inequality in malnutrition prevalence. Results from multi-level models however show children from highest SES quintile posses 50 percent better nutritional status than those from the poorest quintile.

CONCLUSION

In spite of the declining trend of chronic childhood malnutrition in India, the concerns remain for its disproportionate burden on the poor. The socio-economic gradient of long-term nutritional status among children needs special focus, more so in the states where chronic malnutrition among children apparently demonstrates a lower prevalence. The paper calls for state specific policies which are designed and implemented on a priority basis, keeping in view the nature of inequality in childhood malnutrition in the country and its differential characteristics across the states.

The economic and nutrition transition in Equatorial Guinea coincided with a double burden of over- and under nutrition

We assess trends in children's nutritional status in Equatorial Guinea, a country in socioeconomic transition. Nationally representative samples were conducted in 1997, at the start of the economic take off, and again in 2004. Children aged 0-60 months were included in the surveys (N=436, 552). Both surveys included a sociodemographic, dietary and health questionnaire, and anthropometric measurements from which height-for-age (HAZ); weight-for-age (WAZ) and weight-for-height (WHZ) Z-scores were calculated. Between 1997 and 2004, the prevalence of child overweight for all children increased from 21.8% to 31.7%, especially in urban areas (from 18.2% to 29.4%, p=0.01). Stunting prevalence among children >or=2 years old decreased (from 57.9% to 45.3%, p<0.02), but for all age groups remained very high (34.7% overall, 46.5% rural and 28.5% urban in 2004). The economic take off in Equatorial Guinea appeared to coincide with substantial increases in the prevalence of child overweight whereas the prevalence of stunting decreased even if it remained high. The results suggest that the country is undergoing a nutrition transition and acquiring the concomitant double burden of under and over nutrition.

Why no adult stunting penalty or height premium? Estimates from native Amazonians in Bolivia

Among adults of industrial nations, growth stunting (<-2 SD height Z score) is associated with worse indicators of adult well-being (e.g., income). Does adult stunting also inflict private costs in traditional societies? Adult stunting penalties or height premiums might only emerge when traditional societies modernize. Here we estimate the association between adult stunting and indicators of adult well-being using data from a panel study in progress among the Tsimane', a foraging-farming society of native Amazonians in Bolivia. Subjects included 248 women and 255 men >or=age 22 measured annually during 5 consecutive years (2002-2006). Nine outcomes (wealth, monetary income, illness, access to credit, mirth, schooling, math skills, plant knowledge, forest clearance) were regressed separately against a stunting dummy variable and a wide range of control variables. We found no significant association between any of the indicators of own well-being and adult stunting. Additional analysis showed that stunting bore an association only with poorer mid-arm muscle area. Height premiums and stunting penalties, though evident and marked in modern societies, might not be common in all traditional societies.

Is undernutrition a risk factor for sensorineural hearing loss in early infancy?

The present cross-sectional study set out to determine the nutritional status of infants aged 0–3 months with the WHO Multicentre Growth Reference (WHO-MGR) and examine the relationship between undernutrition and congenital or early-onset sensorineural hearing loss (CESHL) rarely reported for developing countries. The nutritional status of all infants attending community-based clinics for routine Bacille de Calmette-Guérin (BCG) immunisation from July 2005 to December 2006 was determined by weight-for-age, weight-for-length and BMI-for-age based on the WHO-MGR. Hearing loss status was determined by tympanometry, auditory brainstem response (ABR) and visual response audiometry after a two-stage screening with transient evoked otoacoustic emissions and automated ABR. The relationship between nutritional status and CESHL were explored after adjusting for potentially confounding maternal and infant characteristics using multivariable logistic regression analyses. Of the 3386 infants who completed the hearing evaluation protocol, seventy-one were confirmed with hearing loss (>30 dB hearing level). More than one-third (37·9 %) of all infants and over half (54·9 %) of those with CESHL were undernourished by at least one measure of growth. Stunting (35·3 %) was the most prevalent nutritional deficit in infants with CESHL. In the final logistic model, infants with any undernourished physical state were significantly likely to have CESHL (OR 1·67; 95 % CI 1·03, 2·77) and of a severe-to-profound degree (OR 3·92; 95 % CI 1·38, 11·17) compared with infants without any undernourishment. Prospective studies to establish the full spectrum of the relationship between undernutrition and CESHL, particularly in resource-poor countries, are therefore warranted.