WHO 2006 child growth standards: implications for the prevalence of stunting and underweight-for-age in a birth cohort of Gabonese children in comparison to the Centers for Disease Control and Prevention 2000 growth charts and the National Center for Health Statistics 1978 growth references

Accuracy of international growth charts to assess nutritional status in children and adolescents: a systematic review

Abstract Objective: To verify, through a systematic review, the accuracy of nutritional assessment in children and adolescents using the length/height-for-age and BMI-for-age growth charts of the Centers for Disease Control and Prevention (CDC) (2000), the World Health Organization (WHO) (2006/2007) and the International Obesity Task Force (IOTF) (2012). Data source: We selected articles from the databases Medical Literature Analysis and Retrieval System Online (MEDLINE), through PubMed, National Library of Medicine and The National Institutes of Health (NIH), Scientific Electronic Library Online (SciELO) and Virtual Health Library (VHL). The following descriptors were used for the search: “Child”, “Adolescent”, “Nutritional Assessment”, “Growth Chart”, “Ethnic Groups”, “Stature by age”, “Body Mass Index”, “Comparison”, “CDC”, “WHO”, and “IOTF”. The selected articles were assessed for quality through the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies of the NIH. Data synthesis: Thirty-three studies published between 2007 and 2020 were selected and, of these, 20 presented good quality, 12 presented fair quality and one presented poor quality. For children under five years old, the WHO length/height-for-age growth charts were shown appropriate for children from Argentina, South Africa, Brazil, Gabon, Qatar, Pakistan and the United States. For those five years old and older, the WHO BMI-for-age growth charts were accurate for the Brazilian and Canadian populations, while the IOTF growth charts were accurate for the European populations. Conclusions: There are difficulties in obtaining international growth charts for children from 5 years old and older that go along with a long period of growth, and which include genetic, cultural and socioeconomic differences of multiethnic populations who have already overcome the secular trend in height.

CTRP3 and serum triglycerides in children aged 7-10 years

INTRODUCTION

The prevalence of obesity-related disorders has been steadily increasing over the past couple of decades. Diseases that were once only detected in adults are now prevalent in children, such as hyperlipidemia. The adipose tissue-derived hormonal factor C1q TNF Related Protein 3 (CTRP3) has been linked to triglyceride regulation especially in animal models. However, the relationship between circulating CTRP3 levels and obesity-related disorders in human subjects is controversial. CTRP3 can circulate in different oligomeric complexes: trimeric (<100 kDa), middle molecular weight (100-300 kDa), and high molecular weight (HMW) oligomeric complexes (>300 kDa). Previous work has identified that it is not the total amount of CTRP3 present in the serum, but the specific circulating oligomeric complexes that appear to be indicative of the relationship between CTRP3 and serum lipids levels. However, this work has not been examined in children. Therefore, the purpose of this study was to compare the levels of different oligomeric complexes of CTRP3 and circulating lipid levels among young children (aged 7-10 years).

METHODS

Morphometric data and serum samples were collected and analyzed from a cross-sectional population of 62 children of self-identified Hispanic origin from a community health center, between 2015 and 2016. Serum analysis included adiponectin, insulin, leptin, ghrelin, glucagon, C-reactive peptide, triglyceride, cholesterol, IL-6, TNF, and CTRP3. Correlation analyses were conducted to explore the relationships between CTRP3 and other biomarkers.

RESULTS

Total CTRP3 concentrations were significantly positively correlated with total cholesterol and HDL cholesterol. Whereas, HMW CTRP3 was not significantly associated with any variable measured. Conversely, the middle molecular weight (MMW) CTRP3 was negatively correlated with triglycerides levels, and very low-density lipoprotein (VLDL), insulin, and body mass index (BMI). The negative correlations between MMW CTRP3 and triglycerides and VLDLs were particularly strong (r2 = -0.826 and -0.827, respectively).

CONCLUSION

Overall, these data indicate that the circulating oligomeric state of CTRP3 and not just total CTRP3 level is important for understanding the association between CTRP3 and metabolic diseases. Further, this work indicates that MMW CTRP3 plays an important role in triglyceride and VLDL regulation which requires further study.

Why under five children are stunted in Pakistan? A multilevel analysis of Punjab Multiple indicator Cluster Survey (MICS-2014)

BACKGROUND

Pakistan is facing a serious problem of child under-nutrition as about 38% of children in Pakistan are stunted. Punjab, the largest province by population and contributes high gross domestic product (GDP) share in economy has reported 27% moderately and 10% severely stunted children of less than 5 years. Thus, this study aims at examining the determinants of stunting (moderate and severe) at different level of hierarchy empirically in Punjab province of Pakistan.

METHODOLOGY

Data for this study is coming from Punjab Multiple Indicators Cluster Survey (MICS-2014), used two-stage, stratified cluster sampling approach. Sub-national level data covering urban and rural areas were used for this study consists of 25,067 children less than 5 year's ages, from nine administrative divisions and 36 districts of Punjab province of Pakistan. Descriptive statistics and multilevel hierarchical models were estimated. Multilevel data analyses have an advantage because it provides robust standard error estimates and helps in finding variation in the data at various levels.

RESULTS

Punjab has a stunting prevalence of about 27% moderately and 10% severely stunted children of less than 5 years. The results depict that increasing the age of the child, increasing birth order, illiterate mothers and fathers, lack of sanitation facilities and being poor are associated significantly with the likelihood of moderate and severe stunting. Surprisingly, there is a gender bias in stunting in Punjab, Pakistan and being a girl child is more likely associated with moderate and severe stunting, which shows the patriarchal nature of the society and a substantial prevalence of gender bias in household resource allocations.

CONCLUSION

This outcome of our analysis points towards targeting not only households (focus on girls) but also their families and communities.

Trajectory of vitamin D, micronutrient status and childhood growth in exclusively breastfed children

This study aimed to compare the trajectory of serum 25(OH)D, micronutrient levels, and anthropometric measurements between exclusively breastfed and mixed-fed children. This is a prospective cohort study. Anthropometric measurements of the children were obtained during scheduled clinical visits. Tests for 25(OHD), ferritin, zinc and complete blood count were performed yearly until 3 years of age. Clinical records and questionnaires on dietary habits were obtained. The results showed that despite official recommendations on vitamin D/iron supplements for breastfed children, less than 10% of our exclusively breastfed children received regular supplements. Thus, after 1 year, the odds for having iron deficiency anemia and vitamin D insufficiency were 9 [95% CI, 4-19] and 6 [95% CI, 2-16], respectively. Longitudinal follow-up showed the prevalence of iron deficiency to decrease from 34% at 1 year to 2% at age 3 years. However, the prevalence of vitamin D insufficiency remained persistently high throughout the first three years of life (60% at 1 to 44% at 3 years). Very few children had zinc deficiency. Anthropometric measurements showed exclusively breastfed children to have lower mean z-scores for body weight and height when compared to mixed-fed children after 12 months. In conclusion, children who were exclusively breastfed for longer than 4 months without proper supplement were more likely to have transient iron deficiency anemia and persistent vitamin D insufficiency. Their growth became relatively slower after infancy. Whether this was associated with underlying inadequate serum vitamin D and iron level remains an important issue to be explored.

Inadequate management of complementary foods contributes to the risk of aflatoxin exposure and low nutrition status among children

Early exposure to aflatoxins through complementary food is linked to impaired growth in childhood. The current study assessed the household’s practices on management of complementary foods in relation to the risk of aflatoxin exposure and poor nutritional status among infant and young children in Tanzania. A cross-sectional study of complementary feeding practices, aflatoxin exposure and nutritional status was conducted to 101 infants and young children aged between 6-23 months in Dodoma region of Tanzania. The intake of complementary food was estimated by using repeated 24 h dietary recall. Flour used as complementary food was sampled from each of the 101 families and aflatoxins were analysed using high-performance liquid chromatography. A deterministic approach was used to estimate dietary exposure of aflatoxins in the complementary foods. Anthropometric measurements were taken and rates of stunting, underweight and wasting estimated according to the WHO standard procedures. Multivariate logistic regression analysis was used to assess the association between feeding practices and aflatoxin exposure or the growth performance among subjects. The average consumption of complementary flour was 118 g per child per day and 52% of the flours contained groundnuts. AFB1 was detected in 42.5% of the flour and levels ranged from 0.3 to 2,128.0 μg/kg (mean 228.11±49.84 μg/kg). Dietary exposures of aflatoxin B1 ranged from 0.1 to 23,172.81 ng/kg body weight per day (mean 1,337±392.5 ng/kg). Of the subjects, 40.4% (95% CI; 29.8; 50.9) were stunted and significant association was found between stunted growth and dietary exposure of AFB1 (adjusted odd ratio (AOR)=5.9; 95% CI: 0.019-0.028). Early introduction of cereal-and groundnut-based complementary foods in Tanzania is associated with high risk of aflatoxin exposure and impaired growth in children. There is need to integrate aflatoxin management measures in the guidelines for Infant and Young Children Feeding of Tanzania.

Assessment of a Nutritional Rehabilitation Model in Two Modern Broilers and Their Jungle Fowl Ancestor: A Model for Better Understanding Childhood Undernutrition

This article is the first in a series of manuscripts to evaluate nutritional rehabilitation in chickens as a model to study interventions in children malnutrition (Part 1: Performance, Bone Mineralization, and Intestinal Morphometric Analysis). Inclusion of rye in poultry diets induces a nutritional deficit that leads to increased bacterial translocation, intestinal viscosity, and decreased bone mineralization. However, it is unclear the effect of diet on developmental stage or genetic strain. Therefore, the objective was to determine the effects of a rye diet during either the early or late phase of development on performance, bone mineralization, and intestinal morphology across three diverse genetic backgrounds. Modern 2015 (Cobb 500) broiler chicken, 1995 Cobb broiler chicken, and the Giant Jungle Fowl were randomly allocated into four different dietary treatments. Dietary treatments were (1) a control corn-based diet throughout the trial (corn-corn); (2) an early phase malnutrition diet where chicks received a rye-based diet for 10 days, and then switched to the control diet (rye-corn); (3) a malnutrition rye-diet that was fed throughout the trial (rye-rye); and (4) a late phase malnutrition diet where chicks received the control diet for 10 days, and then switched to the rye diet for the last phase (corn-rye). At 10 days of age, chicks were weighed and diets were switched in groups 2 and 4. At day 20 of age, all chickens were weighed and euthanized to collect bone and intestinal samples. Body weight, weight gain, and bone mineralization were different across diet, genetic line, age and all two- and three-way interactions (P < 0.05). Overall, Jungle Fowl were the most tolerant to a rye-based diet, and both the modern and 1995 broilers were significantly affected by the high rye-based diet. However, the 1995 broilers consuming the rye-based diet appeared to experience more permanent effects when compared with the modern broiler. The results of this study suggest that chickens have a great potential as a nutritional rehabilitation model in human trials. The 1995 broilers line was an intermediate genetic line between the fast growing modern line and the non-selected Jungle Fowl line, suggesting that it would be the most appropriate model to study for future studies.

Early and Late Postnatal Accelerated Growth Have Distinct Effects on Metabolic Health in Normal Birth Weight Infants

Accelerated growth in postnatal life in low birth weight infants has been associated with insulin resistance and metabolic syndrome-related disorders in later life. Postnatal accelerated growth in also common in normal birth weight infants, but little is known about the impact on metabolic health. In a prospective cohort study of 203 term normal birth weight infants, we evaluated the impacts of accelerated (Δweight Z score > 0.5) or decelerated (Δweight ΔZ < -0.5) growth during early (0-3 months) and late (3-12 months) postnatal life on metabolic health indicators at age 1-year. The primary outcomes were homeostasis model assessment of insulin resistance (HOMA-IR), β-cell function [homeostasis model assessment of β-cell function (HOMA-β)], and fasting plasma lipids. Adjusting for maternal, paternal, and infant characteristics, accelerated growth during the first 3 months of life was associated with a 41.6% (95% confidence interval 8.9-84.2%) increase in HOMA-β, and a 8.3% (0.7-15.4%) decrease in fasting plasma total cholesterols, and was not associated with HOMA-IR in infants at age 1-year. Accelerated growth during 3-12 months was associated with a 30.9% (3.3-66.0%) increase in HOMA-IR and was not associated with HOMA-β. Neither accelerated nor decelerated growth was associated with fasting plasma triglycerides, high-density lipoprotein or low-density lipoprotein cholesterol concentrations in infants at age 1-year. Accelerated growth during early postnatal life may be beneficial for β-cell function, but during late postnatal life harmful for insulin sensitivity in normal birth weight infants.

Growth monitoring as an early detection tool: a systematic review

Growth monitoring of apparently healthy children aims at early detection of serious underlying disorders. However, existing growth-monitoring practices are mainly based on suboptimal methods, which can result in delayed diagnosis of severe diseases and inappropriate referrals. We did a systematic review to address two key and interconnected questions underlying growth monitoring: which conditions should be targeted, and how should abnormal growth be defined? We systematically searched for studies reporting algorithms for growth monitoring in children and studies comparing the performance of new WHO growth charts with that of other growth charts. Among 1556 identified citations, 69 met the inclusion criteria. Six target conditions have mainly been studied: Turner syndrome, coeliac disease, cystic fibrosis, growth hormone deficiency, renal tubular acidosis, and small for gestational age with no catch-up after 2 or 3 years. Seven algorithms to define abnormal growth have been proposed in the past 20 years, but their level of validation is low, and their overall sensitivities and specificities vary substantially; however, the Grote and Saari clinical decision rules seem the most promising. Two studies reported that WHO growth charts had poorer performance compared with other existing growth charts for early detection of target conditions. Available data suggest a large gap between the widespread implementation of growth monitoring and its level of evidence or the clinical implications of early detection of serious disorders in children. Further investigations are needed to standardise the practice of growth monitoring, with a consensus on a few priority target conditions and with internationally validated clinical decision rules to define abnormal growth, including the selection of appropriate growth charts.

Effect of Antihelminthic Treatment on Vaccine Immunogenicity to a Seasonal Influenza Vaccine in Primary School Children in Gabon: A Randomized Placebo-Controlled Trial

BACKGROUND

Helminth infections are a major public health problem, especially in the tropics. Infected individuals have an altered immune response with evidence that antibody response to vaccination is impaired. Hence, treatment of helminth infections before vaccination may be a simple intervention to improve vaccine immunogenicity. In the present study we investigated whether a single-dose antihelminthic treatment influences antibody responses to a seasonal influenza vaccine in primary school children living in Gabon, Central Africa.

METHODS

In this placebo-controlled double-blind trial conducted in Gabon the effect of a single-dose antihelminthic treatment with 400 mg albendazole versus a placebo one month prior to immunization with a seasonal influenza vaccine was investigated. Antiviral antibody titers against all three vaccine strains were assessed by haemagglutination inhibition (HI) test at baseline (Day 0; vaccination) and four weeks (Day 28) as well as 12 weeks (Day 84) following vaccination. Vaccine-specific memory B-cell response was measured at Day 0 and Day 84 by vaccine-specific Enzyme-linked Immunospot (ELISpot) assay. The trial is registered with the Pan African Clinical Trials Registry (PACTR) (PACTR201303000434188).

RESULTS

98 school children aged 6-10 years were randomly allocated to receive either antihelminthic treatment or placebo and were vaccinated one month after the treatment. The prevalence of helminths at baseline was 21%. Vaccine-specific HI titers against at least one of the three vaccine strains increased at Day 28 and Day 84 in all participants. HI titers against both influenza A strains as well as memory B-cell response were modestly higher in the antihelminthic treated group compared to the placebo group but the difference was not statistically significant. Total but not specific IgA was elevated in the antihelminthic treated group compared to the control group at Day 28.

CONCLUSION

In our setting antihelminthic treatment had no significant effect on influenza vaccine immunogenicity. A trend towards better antiviral and vaccine immunogenicity in the antihelminthic treated group encourages studies to be conducted with alternative treatment schedules or in populations with a higher helminth burden.

Pattern and characteristics of growth faltering in early infancy in an urban sub-Saharan African setting

OBJECTIVE

To determine the pattern of and factors associated with changes in nutritional status in early infancy in a resource-poor setting.

METHODS

A cohort study in Lagos, Nigeria, in which the nutritional status at birth was compared with status at the first postnatal check-up routinely scheduled for 6-8 weeks based on the World Health Organization's multicenter growth reference and the Centers for Disease Control and Prevention 2000 growth charts. Factors associated with improved, worsened or steady nutritional status at follow-up based on z-scores for weight-for-age, length-for-age and weight-for-length were determined with multinomial regression analysis.

RESULTS

The mean length-for-age and weight-for-length based on the Centers for Disease Control and Prevention for the 445 full-term singletons studied were higher than the corresponding World Health Organization's multicenter growth reference values at birth and at follow-up, while mean weight-for-age was lower at birth but higher subsequently. Some 20.7% of infants were undernourished by at least one nutritional measure initially, which declined to 16.4% at follow-up. Also 8.1% of the infants remained undernourished, 8.3% became undernourished, and 5.6% became well-nourished at follow-up. Low birthweight full-term infants were significantly likely to remain undernourished (p < 0.001) or become well-nourished (p < 0.001) at follow-up while the offspring of elderly mothers (p = 0.024) or first-time mothers (p = 0.036) had an elevated risk of remaining undernourished by at least one measure at follow-up.

CONCLUSIONS

Many infants are likely to exhibit individual nutritional changes at variance with the overall/summary trend. Those whose nutritional status is likely to deteriorate or remain poor require timely intervention to minimize the risk of subsequent developmental delays/deficits from early infancy.

Variations in estimates of underweight, stunting, wasting, overweight and obesity in children from Argentina comparing three growth charts

OBJECTIVE

To compare estimates of underweight, stunting, wasting, overweight and obesity based on three growth charts.

DESIGN

Cross-sectional study to estimate weight-for-age, length/height-for-age and weight-for-height comparing the 2006 WHO Child Growth Standards ('the WHO standards'), the 1977 National Center for Health Statistics (NCHS) international growth reference ('the NCHS reference') and the 1987 Argentine Pediatric Society Committee of Growth and Development reference ('the APS reference'). Cut-off points were defined as mean values ±2 s d. Epi-Info software version 6·0 (Centers for Disease Control and Prevention) was used for statistical evaluations (χ 2, P ≤ 0·05).

SETTING

Greater La Plata conurbation, Buenos Aires, Argentina.

SUBJECTS

A total of 2644 healthy, full-term children from 0 to 5 years of age.

RESULTS

Prevalence of underweight was higher with the WHO standards than with the other references up to the first 6 months. For the rest of the ages, prevalence was lower with the WHO standards. Stunting prevalence was higher with the WHO standards at all ages. Prevalence of wasting was higher with the WHO standards compared with the NCHS reference up to the first 6 months and lower at 2-5 years of age. Overweight and obesity prevalences were higher with the WHO standards at all ages.

CONCLUSIONS

The new WHO standards appear to be a solid and reliable tool for diagnosis and treatment of nutritional diseases, also being the only one built with infants fed according to WHO recommendations. Therefore, our results support the decision of the National Ministry of Health about the utilization of the new WHO standards to monitor the nutritional status of Argentinean children aged less than 5 years.

Socioeconomic disparities and the familial coexistence of child stunting and maternal overweight in Guatemala

The double burden of malnutrition, defined here as households with a stunted child and an overweight mother (SCOM), is a growing problem in Guatemala. We explored the magnitude of SCOM and the identification of socio-economic factors associated with this malnutrition duality. From the 2000 Living Standards Measurement Study from Guatemala, we obtained a sample of 2492 households with pairs of children 6-60 months and their mothers (18-49 years) and estimated the prevalence of SCOM. Economic characteristics of this sample were assessed with the Concentration Index (CI). Results revealed higher prevalence of child stunting, but a lower prevalence of maternal overweight among the poor compared to the rich households. Economic inequality in child stunting was greater than economic inequality in maternal overweight (CI=-0.22 vs. +0.14). SCOM pairs were more prevalent among the poor and middle SES groups as compared to the rich households. A multivariate logistic regression model showed that SCOM was more likely to occur in households from the middle consumption quintile than in those from the first quintile (odds ratio=1.7). The findings reported here add new insights into the complex phenomenon observed in households with both extremes of the malnutrition continuum, and support the need for the identification of economic, social and biological interventions aimed at, on the one hand, the prevention of this duality of the malnutrition in those households where it is still non-existent, and on the other hand, to deter or correct the economic, social and biological environments where those mother-child dyads are already affected by such phenomena.

Performance of WHO growth standards on Indian children with growth related disorders

OBJECTIVE

To assess performance of WHO 2006 standards on anthropometric measurements of children referred for growth related disorders to a speciality pediatric clinic in Pune, India, from June 2006 through June 2010.

METHODS

Data presented in this study were collected retrospectively from case records of all children from birth to 60 mo (n=1840, mean age 2.7±1.3 y) who presented with growth related disorders; healthy age and sex matched children were recruited as controls (n=824, mean age 2.8±1.2 y). Children were divided as per their clinical diagnosis into eight different groups: growth hormone deficiency, bone disorders, syndromic short stature, familial short stature, hypothyroidism, nutritional and systemic disorder, other endocrinopathies and overgrowth disorders. Anthropometric parameters for all study subjects were converted to standard deviation scores (SD scores) using the WHO Anthro 2005.

RESULTS

Mean height SD scores of children with growth related disorders were significantly lower than that of the controls, while that of the tall children were significantly higher (p<0.05). All children who were clinically very short were below the 1st percentile, while none of the children with overgrowth or normal children were classified as stunted. Weight for height SD scores of children with nutritional and systemic disorders were the lowest, while those for the obese children were the highest.

CONCLUSIONS

The present results suggest that the WHO 2006 growth standards classify children with growth disorders appropriately and the classification is in concordance with the clinical assessment. They provide health practitioners in a clinical setting with an effective tool to assess growth of children.

Height, weight and BMI percentiles and nutritional status relative to the international growth references among Pakistani school-aged children

Background

Child growth is internationally recognized as an important indicator of nutritional status and health in populations. This study was aimed to compare age- and gender-specific height, weight and BMI percentiles and nutritional status relative to the international growth references among Pakistani school-aged children.

Methods

A population-based study was conducted with a multistage cluster sample of 1860 children aged five to twelve years in Lahore, Pakistan. Smoothed height, weight and BMI percentile curves were obtained and comparison was made with the World Health Organization 2007 (WHO) and United States' Centers for Disease Control and Prevention 2000 (USCDC) references. Over- and under-nutrition were defined according to the WHO and USCDC references, and the International Obesity Task Force (IOTF) cut-offs. Simple descriptive statistics were used and statistical significance was considered at P < 0.05.

Results

Height, weight and BMI percentiles increased with age among both boys and girls, and both had approximately the same height and a lower weight and BMI as compared to the WHO and USCDC references. Mean differences from zero for height-, weight- and BMI-for-age z score values relative to the WHO and USCDC references were significant (P < 0.001). Means of height-for-age (present study: 0.00, WHO: -0.19, USCDC: -0.24), weight-for-age (present study: 0.00, WHO: -0.22, USCDC: -0.48) and BMI-for-age (present study: 0.00, WHO: -0.32, USCDC: -0.53) z score values relative to the WHO reference were closer to zero and the present study as compared to the USCDC reference. Mean differences between weight-for-age (0.19, 95% CI 0.10-0.30) and BMI-for-age (0.21, 95% CI 0.11-0.30) z scores relative to the WHO and USCDC references were significant. Over-nutrition estimates were higher (P < 0.001) by the WHO reference as compared to the USCDC reference (17% vs. 15% overweight and 7.5% vs. 4% obesity) while underweight and thinness/wasting were lower (P < 0.001) by the WHO reference as compared to the USCDC reference (7% vs. 12% underweight and 10% vs. 13% thinness). Significantly lower overweight (8%) and obesity (5%) prevalence and higher thinness grade one prevalence (19%) was seen with use of the IOTF cut-offs as compared to the WHO and USCDC references. Mean difference between height-for-age z scores and difference in stunting prevalence relative to the WHO and USCDC references was not significant.

Conclusion

Pakistani school-aged children significantly differed from the WHO and USCDC references. However, z score means relative to the WHO reference were closer to zero and the present study as compared to the USCDC reference. Overweight and obesity were significantly higher while underweight and thinness/wasting were significantly lower relative to the WHO reference as compared to the USCDC reference and the IOTF cut-offs. New growth charts for Pakistani children based on a nationally representative sample should be developed. Nevertheless, shifting to use of the 2007 WHO child growth reference might have important implications for child health programs and primary care pediatric clinics.

Child mortality as predicted by nutritional status and recent weight velocity in children under two in rural Africa

WHO has released prescriptive child growth standards for, among others, BMI-for-age (BMI-FA), mid-upper arm circumference-for-age, and weight velocity. The ability of these indices to predict child mortality remains understudied, although growth velocity prognostic value underlies current growth monitoring programs. The study aims were first to assess, in children under 2, the independent and combined ability of these indices and of stunting to predict all-cause mortality within 3 mo, and second, the comparative abilities of weight-for-length (WFL) and BMI-FA to predict short-term (<3 mo) mortality. We used anthropometry and survival data from 2402 children aged between 0 and 24 mo in a rural area of the Democratic Republic of Congo with high malnutrition and mortality rates and limited nutritional rehabilitation. Analyses used Cox proportional hazard models and receiver operating characteristic curves. Univariate analysis and age-adjusted analysis showed predictive ability of all indices. Multivariate analysis without age adjustment showed that only very low weight velocity [HR = 3.82 (95%CI = 1.91, 7.63); P < 0.001] was independently predictive. With age adjustment, very low weight velocity [HR = 3.61 (95%CI = 1.80, 7.25); P < 0.001] was again solely retained as an independent predictor. There was no evidence for a difference in predictive ability between WFL and BMI-FA. This paper shows the value of attained BMI-FA, a marker of wasting status, and recent weight velocity, a marker of the wasting process, in predicting child death using the WHO child growth standards. WFL and BMI-FA appear equivalent as predictors.

Prevalence, pattern and risk factors for undernutrition in early infancy using the WHO Multicentre Growth Reference: a community-based study

This cross-sectional study set out to determine the prevalence, pattern and risk factors for undernutrition during early infancy in a setting with substantial non-hospital births against the backdrop of limited evidence on nutritional status in the first three months of life based on an exclusively breast-fed reference population. Undernutrition based on z-scores below -2 for weight-for-age, height/length-for-age and body-mass-index-for-age among infants (0-3 months) attending clinics for routine Bacille de Calmette-Guérin (BCG) immunisation in Lagos, Nigeria from July 2005 to March 2008 was determined using current World Health Organisation's Multicentre Growth Reference (WHO-MGR). Maternal and infant factors associated with undernutrition were explored with multivariable logistic regression analyses. Of the 5888 full-term infants enrolled 51% were born outside hospital and 99.4% were exclusively breast-fed. 811 (13.8%) were underweight (weight-for-age), 1802 (30.8%) were stunted (height/length-for-age) and 579 (10.0%) were wasted (body-mass-index-for-age). Altogether, 3635 (61.6%) infants were not undernourished while 192 (3.3%) were undernourished by all three nutritional measures. Intrauterine growth restriction was a significant contributor to undernutrition. Maternal age, multiple pregnancies and gender were associated with all nutritional indices. Additionally, maternal education, ownership/type of residence, parity, antenatal care, place of delivery and hyperbilirubinaemia were predictive of underweight, stunting and wasting. We conclude that undernutrition is prevalent in the first three months of life in this population and can be detected early at routine immunisation clinics shortly after birth. Maternal/perinatal history offers valuable predictors in resource-poor communities where the majority of births occur outside hospital.