Piecing together the stunting puzzle: a framework for attributable factors of child stunting

Age- and height-dependent bias of underweight and overweight assessment standards for children and adolescents

Background

Precision in evaluating underweight and overweight status among children and adolescents is paramount for averting health and developmental issues. Existing standards for these assessments have faced scrutiny regarding their validity. This study investigates the age and height dependencies within the international standards set by the International Obesity Task Force (IOTF), relying on body mass index (BMI), and contrasts them with Japanese standards utilizing the percentage of overweight (POW).

Method

We scrutinized a comprehensive database comprising 7,863,520 children aged 5-17 years, sourced from the School Health Statistics Research initiative conducted by Japan's Ministry of Education, Culture, Sports, Science, and Technology. Employing the quantile regression method, we dissected the structure of weight-for-height distributions across different ages and sexes, quantifying the potentially biased assessments of underweight and overweight status by conventional criteria.

Results

Applying IOFT criteria for underweight assessment revealed pronounced height dependence in males aged 11-13 and females aged 10-11. Notably, a discernible bias emerged, wherein children in the lower 25th percentile were classified as underweight five times more frequently than those in the upper 25th percentile. Similarly, the overweight assessment displayed robust height dependence in males aged 8-11 and females aged 7-10, with children in the lower 25th percentile for height deemed obese four or five times more frequently than their counterparts in the upper 25th percentile. Furthermore, using the Japanese POW criteria for assessment revealed significant age dependence in addition to considerably underestimating the percentage of underweight and overweight cases under the age of seven. However, the height dependence for the POW criterion was smaller than the BMI criterion, and the difference between height classes was less than 3-fold.

Conclusion

Our findings underscore the intricacies of age-dependent changes in body composition during the growth process in children, emphasizing the absence of gold standards for assessing underweight and overweight. Careful judgment is crucial in cases of short or tall stature at the same age, surpassing sole reliance on conventional criteria results.

Statistical modelling of determinants of child stunting using secondary data and Bayesian networks: a UKRI Global Challenges Research Fund (GCRF) Action Against Stunting Hub protocol paper

INTRODUCTION

Several factors have been implicated in child stunting, but the precise determinants, mechanisms of action and causal pathways remain poorly understood. The objective of this study is to explore causal relationships between the various determinants of child stunting.

METHODS AND ANALYSIS

The study will use data compiled from national health surveys in India, Indonesia and Senegal, and reviews of published evidence on determinants of child stunting. The data will be analysed using a causal Bayesian network (BN)-an approach suitable for modelling interdependent networks of causal relationships. The model's structure will be defined in a directed acyclic graph and illustrate causal relationship between the variables (determinants) and outcome (child stunting). Conditional probability distributions will be generated to show the strength of direct causality between variables and outcome. BN will provide evidence of the causal role of the various determinants of child stunning, identify evidence gaps and support in-depth interrogation of the evidence base. Furthermore, the method will support integration of expert opinion/assumptions, allowing for inclusion of the many factors implicated in child stunting. The development of the BN model and its outputs will represent an ideal opportunity for transdisciplinary research on the determinants of stunting.

ETHICS AND DISSEMINATION

Not applicable/no human participants included.

Impact of indoor Air Pollution on the Linear growth of children in Jimma, Ethiopia

BACKGROUND

Stunting in children is the term for reduced linear growth and development, which is frequently brought on by a persistently inadequate diet, recurrent infections and chronic diseases or poor health conditions. Apart from the classic covariates of stunting, which include diet and illness, the relative contribution of household air pollution to chronic nutrition conditions is least studied. Hence, this study is conducted to investigate the impact of household air pollution on the linear growth of under-five children in Jimma town, Ethiopia.

METHODS

A prospective cohort study was employed to collect data from 280 under-five children who lived in households using solid fuel (exposed group, n = 140) and clean fuel (unexposed group, n = 140). Height-for-age Z scores were compared in both groups over a 12-month follow-up period. The difference in differences estimators were used for comparison of changes in the height-for-age Z scores from baseline to end line in exposed and non-exposed groups. The independent effect of the use of solid fuels on height-for-age Z scores was analyzed through a multivariable linear regression model. Statistical Significances were declared at P < 0.05 and 95% CI level.

RESULTS

In an unadjusted model (Model 1), compared with the clean fuel type, the mean difference in the height-for-age Z score of children in households using solid fuel was lower by 0.54 (-0.54, 95% CI -0.97, -0.12, P = 0.011). The beta coefficient remained negative after adjusting for age and sex (Model 2 -0.543, 95% CI -1.373, -0.563) and sociodemographic variables (Model 3: -0.543, 95% CI -1.362, -0.575). In the final model (Model 4), which adjusted for wealth quantile, dietary practice, water, sanitation and hygiene status and household food insecurity access scale, the beta coefficient held the same and significant (beta: -0.543, 95% CI -1.357, -0.579, P < 0.001). Higher HAZ scores were observed among female child (β: = 0.48, 95%CI: 0.28, 0.69), Child with father attended higher education (β: = 0.304 95%CI: 0.304, 95% CI 0.19, 0.41) as compared to male gender and those who did not attend a formal education, respectively. In contrast, child living in households with poor hygiene practices had lower HAZ score (β: -0.226, 95% CI: -0.449, -0.003), P < 0.001.

CONCLUSIONS

Exposure to indoor air pollution was inversely related to linear growth. Furthermore, sex, educational status and hygiene were found relevant predictors of linear growth. In such a setting, there is a need to step up efforts to design and implement public education campaigns regarding the health risks associated with exposure to household air pollution. Promoting improvements to kitchen ventilation and the use of improved cooking stoves, which will help to mitigate the detrimental effects of indoor air pollution on child growth impairment and its long-term effects.

Age-appropriate feeding practices and their association with undernutrition among children aged 6-23 months in aspirational districts of India: a multinomial analysis

'Health and nutrition' is one among the five areas covered by the Aspirational District Programme in India, which aims to achieve the Sustainable Development Goals (SDGs). The reduction of undernutrition in under-five children has remained a major focus of the SDGs, especially at the ages of 6-23 months as this affects child development. This study used National Family Health Survey 2015-16 data to examine appropriate feeding practices and their associations with undernutrition among children aged 6-23 months in the 124 aspirational districts of India. Multinomial logistic regression analysis was used to analyse the association between feeding practices and undernutrition, adjusting for covariates. A total of 13,851 children aged 6-23 months were included in the analysis. Child nutritional outcomes, and children receiving the recommended minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD), were poorer in the aspirational compared with non-aspirational districts. However, the proportions of children who continued to breastfed, i.e. currently breastfeeding and the proportion of children who were receiving appropriate breastfeeding, i.e. receiving complementary feeding, in addition to breast milk, were higher in the aspirational districts. Appropriate breastfeeding and MDD were found to be associated negatively with undernutrition. While the continuation of breastfeeding increased the odds of children being undernourished, appropriate breastfeeding lowered the odds. The significant predictors of undernourishment among the study children were the child being male, of higher birth order, older and of smaller than average birth size; mother's lower educational level, mother's lower BMI of mothers and being a teenage mother; and poor household drinking water, sanitation facilities and lower economic status. This study suggests that educating mothers, especially illiterate and poor mothers, about appropriate breastfeeding and dietary diversity could help prevent and reduce child undernutrition in the aspirational districts of India.

Dietary diversity, food insecurity and the double burden of malnutrition among children, adolescents and adults in South Africa: Findings from a national survey

Childhood stunting remains a global public health problem. Many stunted children live in the same household as overweight or obese adults (the so-called double burden of malnutrition), evidence that quality as well as quantity of food is important. In recent years, food security measurement has shifted away from anthropometry (e.g., stunting) to experiential measures (e.g., self-reported hunger). However, given the continued problem of stunting, it is important that national surveys identify malnutrition.

Objectives

To examine the associations between a variety of food security indicators, including dietary diversity, with adult, child (0-4 years) (5-9 years) and adolescent (10-17 years) anthropometry. To estimate the prevalence of double burden households.

Methods

The study utilized cross-sectional data from the South African National Income Dynamics Survey NIDS (2008). We examined the associations between five food security indicators and anthropometry outcomes. The indicators were adult and child hunger in the household, self-reported household food sufficiency, food expenditure>60% of monthly expenditure and household dietary diversity. Multinomial and logistic regression models were employed to examine the associations with adult BMI categories and children's stunting and BMI.

Results

The prevalence of stunting was 18.4% and the prevalence of wasting and overweight was 6.8 and 10.4%, respectively. Children <5 and adolescents with medium dietary diversity were significantly more likely to be stunted than children with high dietary diversity. Among children <5, child hunger and medium dietary diversity were significantly associated with wasting. None of the food security indicators were associated with stunting in children aged 5-9. Among stunted children, 70.2% lived with an overweight or obese adult. Among adults, increased dietary diversity increased the risk of overweight and obesity.

Conclusion

Dietary diversity can be used as a proxy for poor nutritional status among children <5 years and adolescents but the relationship between dietary diversity and adult obesity is more complex. Given the double burden of malnutrition in many low- and middle-income countries, indicators of dietary quality remain important. These tools can be further refined to include an extra category for processed foods. Given the relative simplicity to collect this data, national surveys would be improved by its inclusion.

Basic determinants of child linear growth outcomes in sub-Saharan Africa: a cross-sectional survey analysis of positive deviants in poor households

Childhood malnutrition is a significant public health problem confronting countries across the globe. Although there is evidence of a downward trend in undernutrition globally, sub-Saharan Africa did not experience significant improvement in the past decades. This study investigated the basic determinants of linear growth among children living in poor households. We analysed a nationally representative sample of children aged 0–59 months (N = 24,264). The study countries were Ghana, Kenya, the Democratic Republic of Congo (DRC), Nigeria, and Mozambique. The child’s height-for-age Z-scores (HAZ), categorised into HAZ > − 2 standard deviations (SD) (not stunted) and HAZ < − 2 SD (stunted) was the outcome variable of interest. We used logistic regression as our analytical strategy. In DRC, Ghana, Kenya and Nigeria, maternal years of schooling was associated with positive linear growth among children living in poor households. In Ghana and DRC, four antenatal visits had a positive effect on better linear growth, while in Nigeria, healthy maternal body mass index (kg/m²) had a positive effect on child's linear growth. The putative socio-demographic determinants investigated in our study can promote the linear growth of children living in poor households. Interventions aimed at fostering linear growth among children living in poverty should focus on enhancing these factors.

Effectiveness of an integrated agriculture, nutrition-specific, and nutrition-sensitive program on child growth in Western Kenya: a cluster-randomized controlled trial

BACKGROUND

Stunting rates remain unacceptably high in many regions, including sub-Saharan Africa. Agricultural programs have led to increased yields and household incomes but showed limited success in improving nutritional status.

OBJECTIVES

We assessed whether linear growth could be improved through a potentially scalable, integrated program adding nutrition-specific and nutrition-sensitive components to an existing agricultural program.

METHODS

In this cluster-randomized controlled trial in rural Western Kenya, we randomized children aged 6-35 months from farming families to an agricultural intervention without (control group) or with a bundle of interventions (intervention group), including distribution of micronutrient powders (MNP), poultry to increase egg consumption, seeds of greens and onions, and soap and chlorine solution, as well as provision of monthly behavior change trainings. The primary outcome was the change in height-for-age z-score (HAZ) over 2 years of follow-up. We assessed safety through active morbidity and passive adverse event monitoring. We conducted an intention-to-treat analysis, followed by per-protocol and prespecified subgroup analyses.

RESULTS

From March to April 2018, we enrolled 1927 children from 126 clusters (control, 942 children in 63 clusters; intervention, 985 children in 63 clusters). Data on HAZ were available for 1672 (86.6%) children after 2 years. Adherence was >80% for use of MNP, chlorine, and greens and receipt of soap, and ∼40% for egg and red onion consumption. The intention-to-treat analysis indicated a greater change in HAZ over 2 years in the intervention group (adjusted effect size, 0.11; 95% CI: 0.02-0.19). We found a slightly stronger effect in the per-protocol analysis (adjusted effect size, 0.15; 95% CI: 0.06-0.24). Dietary diversity and consumption of iron-rich foods were improved in the intervention group, and reported instances of fever, lower respiratory tract infections, and diarrheal episodes were lower in the intervention group.

CONCLUSIONS

This study found a modest improvement in linear growth, indicating the need for multiple, integrated interventions to achieve benefits. The trial was registered with clinicaltrials.gov as NCT03448484.

Pre-pregnancy dietary pattern is associated with newborn size: results from ProcriAr study

Babies born small-for-gestational age (SGA) have an increased risk of mortality, morbidity and adverse functional consequences. Studies suggest that pre-pregnancy maternal diet may influence newborns' size. This study aimed to determine whether maternal pre-pregnancy dietary patterns (DP) are associated with delivering SGA newborns in the ProcriAr Cohort Study, Sao Paulo-Brazil. Pre-pregnancy DP of 299 women were investigated using factor analysis with principal component's estimation, based on intake reported on a validated 110-item FFQ. Newborns were classified as SGA if their weight and/or length, adjusted by gestational age and sex, were below the 10th percentile of the INTERGROWTH-21st standards. Multivariate Poisson regression modelling with robust error variance was performed to examine associations between the different DP (in quintiles) and SGA. In a model adjusted by maternal sociodemographic and health behaviours, women who scored in the highest quintile of the DP 'Snacks, sandwiches, sweets and soft drinks' (in relation to the women who scored in the lowest quintile) were significantly more likely to deliver SGA babies (relative risk 1·92; 95 % CI 1·08, 3·39). This study verified that women's pre-pregnancy dietary behaviour characterised by an energy-dense nutrient-poor food intake was a risk factor for delivering SGA newborns. Investments in education and improved access to healthful food and nutritional information before pregnancy should be prioritised due to their potential positive impact on child health. However, further studies are warranted to identify specific metabolic pathways that may be underlying these associations.

Infant Anthropometry and Growth Velocity Before 6 Months are Associated with Breastfeeding Practices and the Presence of Subclinical Mastitis and Maternal Intestinal Protozoa in Indigenous Communities in Guatemala

BACKGROUND

The possibility that maternal health status and breastfeeding practices contribute to growth faltering before 6 mo is underexplored.

OBJECTIVES

This longitudinal study investigated whether indicators of subclinical mastitis (SCM) and breast inflammation, maternal fecal-oral contamination, and/or breastfeeding practices were associated with infant anthropometry or growth velocity before 6 mo.

METHODS

Indigenous Mam-Mayan mother-infant dyads (n = 140) were recruited. Breast milk was collected at early (<6 wk) and established (4-6 mo) lactation when maternal and infant anthropometry were measured. Milk Na:K ratio as an indicator of SCM and concentrations of 4 proinflammatory cytokines were measured. Maternal stool samples were examined for the presence of intestinal parasites including nonpathogenic protozoa (Endolimax nana, Iodamoeba bütschlii, Entamoeba coli, Blastocystis hominis). Questionnaires characterized breastfeeding and hygiene practices. Multiple linear regression identified factors associated with infant growth attainment [weight-for-age z-score (WAZ), length-for-age z-score (LAZ), and head circumference-for-age z-score (HCAZ)] and growth velocity (expressed as change per day from early to established lactation). Multiple logistic regression identified factors associated with increased odds of underweight, stunting, and low head circumference at both lactation stages.

RESULTS

A higher Na:K ratio, individual nonpathogenic protozoa, and specific breastfeeding and hygiene practices were associated with impaired growth before 6 wk and at 4-6 mo in exclusively breastfed infants. Growth velocity for weight was inversely associated with Entamoeba coli but cranial growth was associated positively with Iodamoeba bütschlii whereas feeding colostrum in early lactation was protective and decreased the odds of an HCAZ < -2 SD. Finally, the presence of SCM in early lactation increased the likelihood of both WAZ < -2 SD and LAZ < -2 SD by 6 wk.

CONCLUSIONS

Prevention of SCM can improve early infant weight, but measures that promote the feeding of colostrum and reduce exposure to fecal-oral contamination might be required to minimize infant growth faltering in breastfed infants.

Prevalence and determinants of stunting among preschool and school-going children in the flood-affected areas of Pakistan

Stunting is a significant public health problem in low- and middle-income countries. This study assessed the prevalence of stunting and associated risk factors of stunting among preschool and school-going children in flood-affected areas of Pakistan. A cross-sectional study was conducted by visiting 656 households through multi-stage sampling. Respondent's anthropometric measurements, socio-demographic information and sanitation facilities were explored. A logistic regression model was used to determine determinants of stunting, controlling for all possible confounders. The overall prevalence of stunting in children was 40.5%, among children 36.1% boys and 46.3% of girls were stunted. The prevalence of stunting in under-five children was 50.7%. Female children (OR=1.35, 95% CI:0.94-2.0), children aged 13-24 months (OR=6.5, 95% CI: 3.0-13.9), mothers aged 15-24 years (OR=4.4, 95% CI: 2.6-7.2), joint family (OR=2.1, 95% CI: 1.4-3.0) did not have access to improved drinking water (OR=3.3, 95% CI: 1.9-5.9), and the toilet facility (OR=2.8, 95% CI, 1.9-4.3), while the children from district Nowshera (OR=1.7, 95% CI: 0.9-3.2) were significantly (P<0.05) associated in univariate analysis. The regression model revealed that child age, maternal age, family type, quality of water, and toilet facility, were the significant (P<0.05) factors contributing to child stunting in the flood-hit areas. Identification of key factors might be helpful for policymakers in designing comprehensive community-based programs for the reduction of stunting in flood-affected areas. In disasters such as flood, the detrimental consequences of the stunting problem could be even more on children. Evidence-based education and care must be provided to the families in the flood-affected regions to reduce the stunting problem. The determinants of stunting should be targeted by making comprehensive policies regarding proper nutrition, livelihood, clean water, and sanitation facilities in flood-hit regions.

Do Early Infant Feeding Practices and Modifiable Household Behaviors Contribute to Age-Specific Interindividual Variations in Infant Linear Growth? Evidence from a Birth Cohort in Dhaka, Bangladesh

BACKGROUND

Causes of infant linear growth faltering in low-income settings remain poorly understood. Identifying age-specific risk factors in observational studies might be influenced by statistical model selection.

OBJECTIVES

To estimate associations of selected household factors and infant feeding behaviors within discrete age intervals with interval-specific changes in length-for-age z-scores (LAZs) or attained LAZ, using 5 statistical approaches.

METHODS

Data from a birth cohort in Dhaka, Bangladesh (n = 1157) were analyzed. Multivariable-adjusted associations of infant feeding patterns or household factors with conditional LAZ (cLAZ) were estimated for 5 intervals in infancy. Two alternative approaches were used to estimate differences in interval changes in LAZ, and differences in end-interval attained LAZ and RRs of stunting (LAZ < -2) were estimated.

RESULTS

LAZ was symmetrically distributed with mean ± SD = -0.95 ± 1.02 at birth and -1.00 ± 1.04 at 12 mo. Compared with exclusively breastfed infants, partial breastfeeding (difference in cLAZ: -0.11; 95% CI: -0.20, -0.02) or no breastfeeding (-0.30; 95% CI: -0.54, -0.07) were associated with slower growth from 0 to 3 mo. However, associations were not sustained beyond 6 mo. Modifiable household factors (smoking, water treatment, soap at handwashing station) were not associated with infant growth, attained size, or stunting. Alternative statistical approaches yielded mostly similar results as conditional growth models.

CONCLUSIONS

The entire infant LAZ distribution was shifted down, indicating that length deficits were mostly caused by ubiquitous or community-level factors. Early-infant feeding practices explained minimal variation in early growth, and associations were not sustained to 12 mo of age. Statistical model choice did not substantially alter the conclusions. Modifications of household hygiene, smoking, or early infant feeding practices would be unlikely to improve infant linear growth in Bangladesh or other settings where growth faltering is widespread.

Campylobacter infection and household factors are associated with childhood growth in urban Bangladesh: An analysis of the MAL-ED study

The dual burden of enteric infection and childhood malnutrition continues to be a global health concern and a leading cause of morbidity and death among children. Campylobacter infection, in particular, is highly prevalent in low- and middle-income countries, including Bangladesh. We examined longitudinal data to evaluate the trajectories of change in child growth, and to identify associations with Campylobacter infection and household factors. The study analyzed data from 265 children participating in the MAL-ED Study in Mirpur, Bangladesh. We applied latent growth curve modelling to evaluate the trajectories of change in children's height, as measured by length-for-age z-score (LAZ), from age 0-24 months. Asymptomatic and symptomatic Campylobacter infections were included as 3- and 6-month lagged time-varying covariates, while household risk factors were included as time-invariant covariates. Maternal height and birth order were positively associated with LAZ at birth. An inverse association was found between increasing age and LAZ. Campylobacter infection prevalence increased with age, with over 70% of children 18-24 months of age testing positive for infection. In the final model, Campylobacter infection in the preceding 3-month interval was negatively associated with LAZ at 12, 15, and 18 months of age; similarly, infection in the preceding 6-month interval was negatively associated with LAZ at 15, 18, and 21 months of age. Duration of antibiotic use and access to treated drinking water were negatively associated with Campylobacter infection, with the strength of the latter effect increasing with children's age. Campylobacter infection had a significant negative effect on child's growth and this effect was most powerful between 12 and 21 months. The treatment of drinking water and increased antibiotic use have a positive indirect effect on linear child growth trajectory, acting via their association with Campylobacter infection.

Do domestic animals contribute to bacterial contamination of infant transmission pathways? Formative evidence from Ethiopia

Child stunting is associated with poor water, sanitation and hygiene (WASH), partly due to the effect of infection on intestinal nutrient absorption. WASH interventions, however, show little effect on growth. A hypothesis is that bacterial contamination of hands and floors from domestic animals and their faeces, and subsequent ingestion via infant hand-to-mouth behaviours, may explain this. This formative study used microbial testing and survey and observational data from 20 households in Ethiopia to characterise principle bacterial transmission pathways to infants, considering WASH facilities and practices, infant behaviours and animal exposure. Microbial swabbing showed the contamination of hands and floor surfaces from thermotolerant coliform bacteria. Animal husbandry practices, such as keeping animals inside, contributed significantly (all p < 0.005). There was no evidence that latrine facilities mitigated contamination across infant (p = 0.76) or maternal (p = 0.86) hands or floor surfaces (p = 0.36). This small study contributes to the evidence that animal faeces are an important source of domestic bacterial contamination. The results imply that interventions aiming to reduce pathogen transmission to infants should think beyond improving WASH and also consider the need to separate infants and animals in the home. Intervention studies will be required to determine whether this reduces infant infection and improves linear growth.

Anthropometry before Day 46 and Growth Velocity before 6 Months of Guatemalan Breastfed Infants Are Associated with Subclinical Mastitis and Milk Cytokines, Minerals, and Trace Elements

BACKGROUND

Subclinical mastitis (SCM) is an inflammatory condition of the mammary gland, but its association with human milk composition and infant growth is not well described.

OBJECTIVES

We investigated whether SCM, milk cytokines, and/or estimated intakes of milk minerals and trace elements were associated with infant anthropometry or growth velocity before 6 mo.

METHODS

Breast milk was collected from Mam-Mayan mothers (n = 114) at both early (2-46 d) and established (4-6 mo) lactation. Concentrations of 9 elements (sodium, potassium, calcium, magnesium, copper, iron, manganese, selenium, zinc) analyzed by inductively-coupled plasma mass spectrometry were used to estimate infants' daily intakes. Concentrations of 4 cytokines were measured. Milk concentrations and infants' estimated elemental intakes and anthropometric measurements during early and established lactation were compared by SCM status. Multiple regression was used to identify factors associated with infant growth attainment (<46 d) for infant weight- (WAZ), length- (LAZ), and head circumference-for-age (HCAZ) and weight-for-length (WLZ) z scores and with growth velocity (expressed as Δ/d) from early to established lactation.

RESULTS

SCM prevalence was higher in early (30%) than established (10%) lactation. Breast milk of SCM mothers had higher cytokine concentrations and higher magnesium in early and higher selenium concentrations in both early and established lactation (Padj < 0.0121). At day 46, regression models showed inverse associations of SCM with WLZ and IL-1β with LAZ (Padj < 0.0150). In contrast, linear growth velocity was positively associated with IL-1β measured in early lactation (Padj < 0.0124), whereas cranial growth velocity was positively associated with IL-8 measured during established lactation ( Padj < 0.0124).

CONCLUSIONS

Despite a high prevalence of inadequate intakes, only infants' intake of milk magnesium during early lactation was associated with linear growth velocity in breastfed infants <6 mo. Evidence shows that SCM, breast-milk cytokines, and infants' estimated intakes of select elements are independently associated with growth attainment and growth velocity during lactation.

A framework for targeting water, sanitation and hygiene interventions in pastoralist populations in the Afar region of Ethiopia

Globally, many populations face structural and environmental barriers to access safe water, sanitation and hygiene (WASH) services. Among these populations are many of the 200 million pastoralists whose livelihood patterns and extreme environmental settings challenge conventional WASH programming approaches. In this paper, we studied the Afar pastoralists in Ethiopia to identify WASH interventions that can mostly alleviate public health risks, within the population's structural and environmental living constraints. Surveys were carried out with 148 individuals and observational assessments made in 12 households as part of a Pastoralist Community WASH Risk Assessment. The results show that low levels of access to infrastructure are further compounded by risky behaviours related to water containment, storage and transportation. Additional behavioural risk factors were identified related to sanitation, hygiene and animal husbandry. The Pastoralist Community WASH Risk Assessment visually interprets the seriousness of the risks against the difficulty of addressing the problem. The assessment recommends interventions on household behaviours, environmental cleanliness, water storage, treatment and hand hygiene via small-scale educational interventions. The framework provides an approach for assessing risks in other marginal populations that are poorly understood and served through conventional approaches.

Health Considerations for Immigrant and Refugee Children

Immigrant and refugee children are at increased risk for physical, developmental, and behavioral health challenges. This article provides an overview of physical, developmental, and behavioral health considerations for immigrant and refugee children within an ecological framework that highlights family, community, and sociocultural influences. Experiences and exposures relevant to immigrant and refugee children are discussed. Clinical pearls are provided for topics of chronic disease, nutrition, infectious disease, developmental screening, and mental health assessment. Interdisciplinary and community partnerships are emphasized as a means to decrease barriers to care and facilitate family navigation of complex social, educational, and health care systems.

Nutritional profile of Syrian refugee children before resettlement

BACKGROUND

The year 2015 marked the highest number of refugees globally and included record numbers of Syrians moving to neighboring countries. Half of the Syrians were children aged ≤18 years. Our study sought to examine undernutrition and overnutrition among a group of Syrian refugee children who underwent medical screening by IOM for resettlement.

METHODS

This is a retrospective review of Syrian refugee children aged 6 to 59 months from January 1, 2015 to December 31, 2016. The World Health Organization (WHO) Stata package computed Z-scores based on available weight and height data. Prevalence estimates of undernutrition (wasting and stunting) and overnutrition (overweight and obesity) were made using WHO standards. Multivariate analysis was used to determine the factors associated with wasting, stunting, and overnutrition, adjusting for age, sex, family size, and country of health assessment.

RESULTS

A total of 14,552 Syrian refugee children aged 6 to 59 months underwent health assessments in Jordan (43·1%), Lebanon (38·8%), Turkey (7·0%), Greece (6·7%), Egypt (2·4%), and Iraq (2·1%). Overall, this group of Syrian refugee children had a low prevalence of wasting (< 5%) and stunting (< 10%), and high prevalence of overweight or obese (10.6%). Differences were observed in the prevalence of wasting by country of health assessment. In the multiple regression analysis, the prevalence of stunting and overnutrition decreased with increasing age, and being male was associated with overnutrition but not wasting and stunting.

CONCLUSIONS

Findings revealed an overall low prevalence of undernutrition among this group of Syrian children assessed, although prevalence varied by age group. This low prevalence may reflect the effectiveness, as well as expose possible gaps, of refugee nutrition programs or interventions in countries of asylum. Further studies are recommended to evaluate other possible contributors to malnutrition in this refugee group.

Path analyses of risk factors for linear growth faltering in four prospective cohorts of young children in Ghana, Malawi and Burkina Faso

Stunting prevalence is an indicator of a country’s progress towards United Nations’ Sustainable Development Goal 2, which is to end hunger and achieve improved nutrition. Accelerating progress towards reducing stunting requires a deeper understanding of the factors that contribute to linear growth faltering. We conducted path analyses of factors associated with 18-month length-for-age z-score (LAZ) in four prospective cohorts of children who participated in trials conducted as part of the International Lipid-Based Nutrient Supplements Project in Ghana (n=1039), Malawi (n=684 and 1504) and Burkina Faso (n=2619). In two cohorts, women were enrolled during pregnancy. In two other cohorts, infants were enrolled at 6 or 9 months. We examined the association of 42 indicators of environmental, maternal, caregiving and child factors with 18-month LAZ. Using structural equation modelling, we examined direct and indirect associations through hypothesised mediators in each cohort. Out of 42 indicators, 2 were associated with 18-month LAZ in three or four cohorts: maternal height and body mass index (BMI). Six factors were associated with 18-month LAZ in two cohorts: length for gestational age z-score (LGAZ) at birth, pregnancy duration, improved household water, child dietary diversity, diarrhoea incidence and 6-month or 9-month haemoglobin concentration. Direct associations were more prevalent than indirect associations, but 30%–62% of the associations of maternal height and BMI with 18-month LAZ were mediated by LGAZ at birth. Factors that were not associated with LAZ were maternal iron status, illness and inflammation during pregnancy, maternal stress and depression, exclusive breast feeding during 6 months post partum, feeding frequency and child fever, malaria and acute respiratory infections. These findings may help in identifying interventions to accelerate progress towards reducing stunting; however, much of the variance in linear growth status remained unaccounted for by these 42 individual-level factors, suggesting that community-level changes may be needed to achieve substantial progress.

Infant growth faltering linked to subclinical mastitis, maternal faecal-oral contamination, and breastfeeding

Infant growth faltering occurs in breastfed infants <6 months of age. The possibility that maternal health status contributes to this growth faltering is underexplored. We investigated whether (a) subclinical mastitis (SCM), an asymptomatic inflammation of the breast, (b) maternal intestinal nematode and protozoan infections, indicators of faecal-oral contamination, or (c) poor breastfeeding practices increased the odds of stunting (length-for-age z-score < -2SD), underweight (weight-for-age z-score < -2SD), or low head circumference (head circumference-for-age z-score < -2SD) in breastfed infants in rural indigenous communities in Guatemala. Mother-infant dyads (n = 105) were subdivided into those with and without SCM (milk Na:K ratio > 0.6). Maternal and infant anthropometry were measured at the time of breast milk collection. Maternal stool samples were examined for the presence of intestinal nematodes and protozoa. Questionnaires were used to characterize breastfeeding practices (exclusivity and frequency) and support, hygiene (latrine use and household faucet), and infant diarrhoea. SCM occurred in 14% of women and was associated with increased odds of infant stunting (odds ratio [OR] = 4.3; confidence interval [CI] [1.1, 15.8]), underweight (OR = 9.2; CI [1.8, 48.0]), and low head circumference (OR = 15.9; CI [2.6, 96.9]). Maternal pathogenic protozoa and nematodes were uncommon (<4%), but nonpathogenic protozoa were common (e.g., Entamoeba coli [39%]). Entamoeba coli increased the likelihood (OR = 3.3; CI [1.02, 10.6]) of low head circumference, whereas higher breastfeeding frequency lowered its odds (OR = 0.74, CI [0.56, 0.97]). Prevention of SCM may improve early infant growth, but public health measures that increase breastfeeding frequency and reduce faecal-oral contamination may be required to minimize low head circumference.

Association of intestinal pathogens with faecal markers of environmental enteric dysfunction among slum-dwelling children in the first 2 years of life in Bangladesh

OBJECTIVE

Environmental Enteric Dysfunction (EED) can be assessed by faecal biomarkers such as Myeloperoxidase (MPO), Neopterin (NEO) and Alpha-1 anti-trypsin (AAT). We aimed to test the association of intestinal pathogens with faecal markers of EED among slum-dwelling children in first 2 years of life.

METHODS

The MAL-ED birth cohort data of Bangladesh site were used to conduct this analysis. Multivariable analyses using Generalized Estimating Equations (GEE) were performed to test the association between intestinal pathogens and faecal markers of EED.

RESULTS

Giardiasis, ascariasis and trichuriasis were the most frequent parasitic infections and Campylobacter spp., Enteroaggregative Escherichia coli (EAEC) and Enterotoxigenic Escherichia coli (ETEC) were the common bacterial pathogens observed in stool samples of the children. Overall, 71%, 97% and 58% of stool samples were above values considered normal in non-tropical settings for MPO, NEO and AAT respectively. Giardiasis was found to be significantly associated with MPO (Coefficient = 0.55; 95% CI = 0.15, 0.95; P-value = 0.008) and AAT concentrations (Coefficient = 0.34; 95% CI = 0.04, 0.63; P-value = 0.03). A significant association was found between trichuriasis and NEO (Coefficient = 0.90; 95% CI = 0.19, 1.61; P-value = 0.01). Trichuriasis (Coefficient = 1.71; 95% CI = 0.32, 3.11; P-value = 0.02) and giardiasis (Coefficient = 1.51; 95% CI = 0.79, 2.23; P-value <0.001) were significantly associated with EED score. Children with EAEC had significantly higher MPO concentrations (Coefficient = 0.33; 95% CI = 0.06, 0.61; P-value = 0.02).

CONCLUSION

The study results imply the importance of intestinal pathogens in contributing to intestinal inflammation and increased intestinal permeability in young children.

Comparative Models of Biological and Social Pathways to Predict Child Growth through Age 2 Years from Birth Cohorts in Brazil, India, the Philippines, and South Africa

Background

Early growth faltering accounts for one-third of child deaths, and adversely impacts the health and human capital of surviving children. Social as well as biological factors contribute to growth faltering, but their relative strength and interrelations in different contexts have not been fully described.

Objective

The aim of this study was to use structural equation modelling to explore social and biological multidetermination of child height at age 2 y in longitudinal data from 4 birth cohort studies in low- and middle-income countries.

Methods

We analyzed data from 13,824 participants in birth cohort studies in Brazil, India, the Philippines, and South Africa. We used exploratory structural equation models, with height-for-age at 24 mo as the outcome to derive factors, and path analysis to estimate relations among a wide set of social and biological variables common to the 4 sites.

Results

The prevalence of stunting at 24 mo ranged from 14.0% in Brazil to 67.7% in the Philippines. Maternal height and birthweight were strongly predictive of height-for-age at 24 mo in all 4 sites (all P values <0.001). Three social-environmental factors, which we characterized as "child circumstances," "family socioeconomic status," and "community facilities," were identified in all sites. Each social-environmental factor was also strongly predictive of height-for-age at 24 mo (all P values <0.001), with some relations partly mediated through birthweight. The biological pathways accounted for 59% of the total explained variance and the social-environmental pathways accounted for 41%. The resulting path coefficients were broadly similar across the 4 sites.

Conclusions

Early child growth faltering is determined by both biological and social factors. Maternal height, itself a marker of intergenerational deprivation, strongly influences child height at 2 y, including indirect effects through birthweight and social factors. However, concurrent social factors, many of which are modifiable, directly and indirectly contribute to child growth. This study highlights opportunities for interventions that address both biological and social determinants over the long and short term.