A review of the evidence linking child stunting to economic outcomes

Effect of maternal post-natal Balanced Energy Protein supplementation and infant Azithromycin on infant growth outcomes- An Open-label randomized controlled trial

BACKGROUND

Maternal undernutrition is a direct risk factor for infant growth faltering.

OBJECTIVE

We evaluated the effect of postnatal Balanced Energy Protein (BEP) supplementation in lactating women and Azithromycin (AZ) in infants on infant growth outcomes.

DESIGN

A randomized controlled superiority trial of lactating mother-newborn dyads was conducted in Karachi, Pakistan. Mothers intending to breastfeed their newborns with mid-upper arm circumference of less than 23 cm and live infants between 0-6 days of life were randomly assigned to one of three arms in a 1:1:1 ratio. Lactating mothers in the control arm received standard-of-care counseling on exclusive breastfeeding, nutrition, infant immunization and health promotion plus iron-folate supplementation until the infant was 6 months of age. In intervention arm 1, mothers additionally received two 75-gram sachets of BEP per day, while in intervention arm 2 along with the standard-of-care and BEP, the infant also received one dose of Azithromycin (at 20 mg per kilogram) at 42 days of life. The primary outcome was infant length velocity at 6 months. The total sample size was 957 (319 in each arm).

RESULTS

From August 1, 2018 to May 19, 2020, 319 lactating mother-newborn dyads were randomized in each arm, and the last follow-up was completed on November 20, 2020. The mean difference in length velocity (cm per month) between BEP alone and control was 0.01 (95% CI: -0.03, 0.06), BEP plus AZ and control was 0.08 (95% CI:0.03,0.13) and between BEP+AZ and BEP alone was 0.06 (95% CI: 0.01, 0.11). There were 1.46% (14/957) infant deaths in the trial, and 17.9% (171/957) non-fatal events (injectable treatment and/or hospitalizations) were recorded.

CONCLUSION

Postnatal maternal BEP supplementation and infant AZ administration could modestly improve infant growth outcomes at 6 months, suggesting potential benefits in simultaneously addressing maternal and infant undernutrition.

CLINICAL TRIAL DATA

This trial is registered on ClinicalTrials.gov NCT03564652 on June 21, 2018.

Prevalence of childhood stunting and determinants in low and lower-middle income African countries: Evidence from standard demographic and health survey

INTRODUCTION

Undernutrition poses a significant global public health challenge, adversely affecting childhood cognitive and physical development while increasing the risk of disease and mortality. Stunting, characterized by impaired growth and development in children due to insufficient psychological stimulation, frequent infections, and inadequate nutrition, remains a critical issue. Although economic growth alone cannot fully address the prevalence of stunting, there exists a robust correlation between a country's income level and childhood stunting rates. Countries with higher incomes tend to have lower rates of childhood stunting. Notably, while childhood stunting is declining worldwide, it remains persistent in Africa. Consequently, this study aims to assess the prevalence of childhood stunting and its determinants in low- and lower-middle-income African countries.

METHOD

This study conducted a secondary analysis of standard demographic and health surveys in low- and lower-middle-income African countries spanning the period from 2010 to 2022. The analysis included a total sample of 204,214 weighted children under the age of five years. To identify the determinants of stunting, we employed a multilevel mixed-effect model, considering the three levels of variables. The measures of association (fixed effect) were determined using the adjusted odds ratio at a 95% confidence interval. Significance was declared when the association between the outcome variable and the explanatory variable had a p-value less than 0.05.

RESULT

In low and lower-middle-income African countries, 31.28% of children under five years old experience stunting, with a 95% confidence interval ranging from 31.08% to 31.48%. The results from a multilevel mixed-effect analysis revealed that 24 months or more of age of child, male gender, low and high birth weight, low and high maternal BMI, no and low maternal education, low household wealth index, multiple (twin or triplet) births, rural residence, and low income of countries were significantly associated with childhood stunting.

CONCLUSION

Stunting among children under five years of age in low- and lower-middle-income African countries was relatively high. Individual, community, and country-level factors were statistically associated with childhood stunting. Equally importantly, with child, maternal, and community factors of stunting, the income of countries needs to be considered in providing nutritional interventions to mitigate childhood stunting in Africa.

Adolescents' height and cognitive ability in China

Cognitive ability, as an early human capital, has always been an important research object in modern education and labor economics. Despite growing awareness of the importance of height in individual growth and development, there are few empirical studies on height and cognitive ability. Using the data from the China Education Panel Survey, this paper examined the impact of height on the cognitive ability of adolescents and explored the reasons behind the Chinese pursuit of height growth and the potential impact mechanism. In this paper, comprehensive analysis ability was taken as the representative of cognitive ability. The empirical results showed that height was positively correlated with cognitive ability. From the perspective of the influence mechanism, the hypothesis that height reflected self-esteem, health, non-cognitive ability, and other influences on cognitive ability was excluded. To correct the errors that endogenous problems may cause, we used the PSM method and "age at first menstruation " and "age at first wet dream" as instrumental variables to correct them. The results showed that height still affected cognitive ability, with taller people having higher cognitive ability.

Childhood growth during recovery from acute illness in Africa and South Asia: a secondary analysis of the childhood acute illness and nutrition (CHAIN) prospective cohort

Background

Growth faltering is well-recognized during acute childhood illness and growth acceleration during convalescence, with or without nutritional therapy, may occur. However, there are limited recent data on growth after hospitalization in low- and middle-income countries.

Methods

We evaluated growth following hospitalization among children aged 2-23 months in sub-Saharan Africa and South Asia. Between November 2016 and January 2019, children were recruited at hospital admission and classified as: not-wasted (NW), moderately-wasted (MW), severely-wasted (SW), or having nutritional oedema (NO). We describe earlier (discharge to 45-days) and later (45- to 180-days) changes in length-for-age [LAZ], weight-for-age [WAZ], mid-upper arm circumference [MUACZ], weight-for-length [WLZ] z-scores, and clinical, nutritional, and socioeconomic correlates.

Findings

We included 2472 children who survived to 180-days post-discharge: NW, 960 (39%); MW, 572 (23%); SW, 682 (28%); and NO, 258 (10%). During 180-days, LAZ decreased in NW (-0.27 [-0.36, -0.19]) and MW (-0.23 [-0.34, -0.11]). However, all groups increased WAZ (NW, 0.21 [95% CI: 0.11, 0.32]; MW, 0.57 [0.44, 0.71]; SW, 1.0 [0.88, 1.1] and NO, 1.3 [1.1, 1.5]) with greatest gains in the first 45-days. Of children underweight (<-2 WAZ) at discharge, 66% remained underweight at 180-days. Lower WAZ post-discharge was associated with age-inappropriate nutrition, adverse caregiver characteristics, small size at birth, severe or moderate anaemia, and chronic conditions, while lower LAZ was additionally associated with household-level exposures but not with chronic medical conditions.

Interpretation

Underweight and poor linear growth mostly persisted after an acute illness. Beyond short-term nutritional supplementation, improving linear growth post-discharge may require broader individual and family support.

Funding

Bill & Melinda Gates FoundationOPP1131320; National Institute for Health ResearchNIHR201813.

Effect of maternal serum albumin level on birthweight and gestational age: an analysis of 39200 singleton newborns

Background

Serum albumin plays a pivotal role in regulating plasma oncotic pressure and modulating fluid distribution among various body compartments. Previous research examining the association between maternal serum albumin levels and fetal growth yielded limited and inconclusive findings. Therefore, the specific influence of serum albumin on fetal growth remains poorly understood and warrants further investigation.

Methods

A retrospective study involved 39200 women who had a singleton live birth at a tertiary-care academic medical center during the period from January 2017 to December 2020. Women were categorized into four groups according to the quartile of albumin concentration during early pregnancy: Q1 group, ≤41.0 g/L; Q2 group, 41.1-42.6 g/L; Q3 group, 42.7-44.3 g/L and Q4 group, >44.3 g/L. The main outcome measures were mid-term estimated fetal weight, birthweight and gestational age. Multivariate linear and logistic regression analysis were performed to detect the independent effect of maternal serum albumin level on fetal growth after adjusting for important confounding variables.

Results

In the crude analysis, a significant inverse correlation was found between early pregnancy maternal serum albumin levels and fetal growth status, including mid-term ultrasound measurements, mid-term estimated fetal weight, birthweight, and gestational age. After adjustment for a number of confounding factors, mid-term estimated fetal weight, birthweight, and birth height decreased significantly with increasing albumin levels. Compared to the Q2 group, the Q4 group had higher rates of preterm birth (aOR, 1.16; 95% CI, 1.01-1.34), small-for-gestational-age (aOR, 1.27; 95% CI, 1.11-1.45) and low birthweight (aOR, 1.41; 95% CI, 1.18-1.69), and lower rate of large-for-gestational-age (aOR, 0.85; 95% CI, 0.78-0.94). Moreover, to achieve the optimal neonatal outcome, women with higher early pregnancy albumin levels required a greater reduction in albumin levels in later pregnancy stages.

Conclusions

A higher maternal serum albumin level during early pregnancy was associated with poor fetal growth, with the detrimental effects becoming apparent as early as the mid-gestation period. These findings provided vital information for clinicians to predict fetal growth status and identify cases with a high risk of adverse neonatal outcomes early on.

An analysis of the dual burden of childhood stunting and wasting in Myanmar: a copula geoadditive modelling approach

OBJECTIVE

To analyze the spatial variation and risk factors of the dual burden of childhood stunting and wasting in Myanmar.

DESIGN

Analysis was carried out on nationally representative data obtained from the Myan-mar Demographic and Health Survey conducted during 2015-2016. Childhood stunting and wasting are used as proxies of chronic and acute childhood undernutrition. A child with standardized height-for-age Z score (HAZ) below -2 is categorized as stunted while that with a weight-for-height Z score (WHZ) below -2 as wasted.

SETTING

A nationally representative sample of households from the 15 states and regions of Myanmar.

PARTICIPANTS

Children under the age of five (n 4162).

RESULTS

Overall marginal prevalence of childhood stunting and wasting were 28.9% (95% CI 27.5, 30.2) and 7.3% (95% CI 6.5, 8.0) while their concurrent prevalence was 1.6% (95% CI 1.2, 2.0). The study revealed mild positive association between stunting and wasting across Myanmar. Both stunting and wasting had significant spatial variation across the country with eastern regions having higher burden of stunting while southern regions having higher prevalence of wasting. Child age and maternal weight-for-height Z score had significant non- linear association with both stunting and wasting while child gender, ethnicity and household wealth quintile had significant association with stunting.

CONCLUSION

The study provides data-driven evidence about the association between stunting and wasting and their spatial variation across Myanmar. The resulting insights can aid in the formulation and implementation of targeted, region-specific interventions towards improving the state of childhood under-nutrition in Myanmar.

Social determinants of child malnutrition outcomes: Evidence from CHNS in China

China is committed to reduce child malnutrition outcomes (CMO) rates to less than 5 % by 2030 in order to meet the Sustainable Development Goal (SDG). Yet, this is still an enormous challenge for China, particularly in disadvantaged areas, due to regional and urban-rural disparities. Using China Health and Nutrition Survey (CHNS) data from 1991 to 2015 and fixed-effect models, this study investigates the social determinants of stunting (n = 4012) measured by height-for-age z score (HAZ) and wasting (n = 4229) measured by weight-for-height z score (WHZ) in children under the age of five. According to the empirical findings, the significant social determinants of child stunting encompassed whether the child is insured (p < 0.01), maternal education level (primary school (p < 0.01) low middle school (p < 0.01); vocational school (p < 0.01)), maternal employment status (p < 0.05), mother's average working days (p < 0.05), average household per capita income (p < 0.01), household asset index (p < 0.01), urbanization index living in a community (medium (p < 0.05); higher (p < 0.01); highest (p < 0.01)) and living regions (west (p < 0.01); northeast (p < 0.05)). Children's maternal employment status (p < 0.05), mother's average working days (p < 0.05), living areas (p < 0.05) and living regions (central (p < 0.01); west (p < 0.01); north-east (p < 0.05)) are the significant factors impacting child wasting. Furthermore, the interaction impact between maternal employment and have one additional working day per week is positive. To attain SDGs, the Chinese government should priorities lowering stunting and wasting among 5-year-olds in the western region, particularly in impoverished regions. Also, it is possible to develop tailored policies for the growth and development of children under the age of five by addressing pertinent socio-economic factors.

The Planetary Child Health & Enterics Observatory (Plan-EO): a protocol for an interdisciplinary research initiative and web-based dashboard for mapping enteric infectious diseases and their risk factors and interventions in LMICs

Background

Diarrhea remains a leading cause of childhood illness throughout the world that is increasing due to climate change and is caused by various species of ecologically sensitive pathogens. The emerging Planetary Health movement emphasizes the interdependence of human health with natural systems, and much of its focus has been on infectious diseases and their interactions with environmental and human processes. Meanwhile, the era of big data has engendered a public appetite for interactive web-based dashboards for infectious diseases. However, enteric infectious diseases have been largely overlooked by these developments.

Methods

The Planetary Child Health and Enterics Observatory (Plan-EO) is a new initiative that builds on existing partnerships between epidemiologists, climatologists, bioinformaticians, and hydrologists as well as investigators in numerous low- and middle-income countries. Its objective is to provide the research and stakeholder community with an evidence base for the geographical targeting of enteropathogen-specific child health interventions such as novel vaccines. The initiative will produce, curate, and disseminate spatial data products relating to the distribution of enteric pathogens and their environmental and sociodemographic determinants.

Discussion

As climate change accelerates there is an urgent need for etiology-specific estimates of diarrheal disease burden at high spatiotemporal resolution. Plan-EO aims to address key challenges and knowledge gaps by making rigorously obtained, generalizable disease burden estimates freely available and accessible to the research and stakeholder communities. Pre-processed environmental and EO-derived spatial data products will be housed, continually updated, and made publicly available to the research and stakeholder communities both within the webpage itself and for download. These inputs can then be used to identify and target priority populations living in transmission hotspots and for decision-making, scenario-planning, and disease burden projection.

Study registration

PROSPERO protocol #CRD42023384709.

The Planetary Child Health & Enterics Observatory (Plan-EO): a protocol for an interdisciplinary research initiative and web-based dashboard for mapping enteric infectious diseases and their risk factors and interventions in LMICs

Background

Diarrhea remains a leading cause of childhood illness throughout the world that is increasing due to climate change and is caused by various species of ecologically sensitive pathogens. The emerging Planetary Health movement emphasizes the interdependence of human health with natural systems, and much of its focus has been on infectious diseases and their interactions with environmental and human processes. Meanwhile, the era of big data has engendered a public appetite for interactive web-based dashboards for infectious diseases. However, enteric infectious diseases have been largely overlooked by these developments.

Methods

The Planetary Child Health and Enterics Observatory (Plan-EO) is a new initiative that builds on existing partnerships between epidemiologists, climatologists, bioinformaticians, and hydrologists as well as investigators in numerous low- and middle-income countries. Its objective is to provide the research and stakeholder community with an evidence base for the geographical targeting of enteropathogen-specific child health interventions such as novel vaccines. The initiative will produce, curate, and disseminate spatial data products relating to the distribution of enteric pathogens and their environmental and sociodemographic determinants.

Discussion

As climate change accelerates there is an urgent need for etiology-specific estimates of diarrheal disease burden at high spatiotemporal resolution. Plan-EO aims to address key challenges and knowledge gaps by making rigorously obtained, generalizable disease burden estimates freely available and accessible to the research and stakeholder communities. Pre-processed environmental and EO-derived spatial data products will be housed, continually updated, and made publicly available to the research and stakeholder communities both within the webpage itself and for download. These inputs can then be used to identify and target priority populations living in transmission hotspots and for decision-making, scenario-planning, and disease burden projection.

Study registration

PROSPERO protocol #CRD42023384709.

Spatiotemporal variations in mean height of 17-year-old students born in 1957-2002 across 47 Japanese prefectures: Evidence from School Health Surveys

This paper examines the secular trends and variations in mean height of 17-year-old students born in 1957-2002 across 47 prefectures in Japan. Mean height is consistently lower in southwest prefectures and greater in prefectures in the Greater Tokyo Area and from the south-central area to the north-western area facing Eurasia in the main island. Both the range and the coefficient of variation stay constant in the cohorts born during the 1970s or later, following rapid increases of mean height in the prefectures that initially have the lowest means. A comprehensive policy framework may be needed to address diverse factors affecting the physical growth of adolescents at the subnational level.

Global health burden and cost of lead exposure in children and adults: a health impact and economic modelling analysis

BACKGROUND

Lead exposure is a worldwide health risk despite substantial declines in blood lead levels following the leaded gasoline phase-out. For the first time, to our knowledge, we aimed to estimate the global burden and cost of intelligence quotient (IQ) loss and cardiovascular disease mortality from lead exposure.

METHODS

In this modelling study, we used country blood lead level estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. We estimated IQ loss (presented as estimated loss in IQ points with 95% CIs) in the global population of children younger than 5 years using the blood lead level-IQ loss function from an international pooled analysis. We estimated the cost of IQ loss, which was calculated only for the proportion of children expected to enter the labour force, as the present value of loss in lifetime income from the IQ loss (presented as cost in US dollars and percentage of gross domestic product with a range). We estimated cardiovascular deaths (with 95% CIs) due to lead exposure among people aged 25 years or older using a health impact model that captures the effect of lead exposure on cardiovascular disease mortality that is mediated through mechanisms other than hypertension. Finally, we used values of statistical life to estimate the welfare cost of premature mortality (presented as cost in US dollars and percentage of GDP). All estimates were calculated by World Bank income classification and region (for low-income and middle-income countries [LMICs] only) for 2019.

FINDINGS

We estimated that children younger than 5 years lost 765 million (95% CI 443-1098) IQ points and that 5 545 000 (2 305 000-8 271 000) adults died from cardiovascular disease in 2019 due to lead exposure. 729 million of the IQ points lost (95·3% of the total global IQ loss) and 5 004 000 (90·2% of total) cardiovascular disease deaths due to lead exposure occurred in LMICs. IQ loss in LMICs was nearly 80% higher than a previous estimate. Cardiovascular disease deaths were six times higher than the GBD 2019 estimate. The global cost of lead exposure was US$6·0 trillion (range 2·6-9·0) in 2019, which was equivalent to 6·9% (3·1-10·4) of the global gross domestic product. 77% (range 70-78) of the cost was the welfare cost of cardiovascular disease mortality, and 23% (22-30) was the present value of future income losses from IQ loss.

INTERPRETATION

Our findings suggest that global lead exposure has health and economic costs at par with PM2·5 air pollution. However, much work remains to improve the quality of blood lead level measurement data, especially in LMICs.

FUNDING

The Korea Green Growth Trust Fund and the World Bank's Pollution Management and Environmental Health Program.

Causes and consequences of child growth faltering in low-resource settings

Growth faltering in children (low length for age or low weight for length) during the first 1,000 days of life (from conception to 2 years of age) influences short-term and long-term health and survival1,2. Interventions such as nutritional supplementation during pregnancy and the postnatal period could help prevent growth faltering, but programmatic action has been insufficient to eliminate the high burden of stunting and wasting in low- and middle-income countries. Identification of age windows and population subgroups on which to focus will benefit future preventive efforts. Here we use a population intervention effects analysis of 33 longitudinal cohorts (83,671 children, 662,763 measurements) and 30 separate exposures to show that improving maternal anthropometry and child condition at birth accounted for population increases in length-for-age z-scores of up to 0.40 and weight-for-length z-scores of up to 0.15 by 24 months of age. Boys had consistently higher risk of all forms of growth faltering than girls. Early postnatal growth faltering predisposed children to subsequent and persistent growth faltering. Children with multiple growth deficits exhibited higher mortality rates from birth to 2 years of age than children without growth deficits (hazard ratios 1.9 to 8.7). The importance of prenatal causes and severe consequences for children who experienced early growth faltering support a focus on pre-conception and pregnancy as a key opportunity for new preventive interventions.

The rise and fall of SES gradients in heights around the world

We use data from a large sample of low- and middle-income countries to study the association (or "gradient") between child height and maternal education. We show that the gap in height between high- and low-SES children is small at birth, rises throughout childhood, and declines in adolescence as girls and boys go through puberty. This inverted U-shaped pattern is consistent with a degree of catch-up in linear height among children of low- relative to high-SES families, in partial contrast to the argument that height deficits cannot be overcome after the early years of life. This finding appears to be explained by the association between SES and the timing of puberty and therefore of the adolescent growth spurt: low-SES children start their adolescent growth spurt later and stop growing at later ages as well.

Determinants of meeting the minimum acceptable diet among children aged 6 to 23 months in Bangladesh: Evidence from a national representative cross-sectional study

Background

Minimum acceptable diet (MAD) is a core indicator of infant and child feeding practices (IYCF). Meeting the MAD is essential to enhance the nutritional status of children aged 6-23 months.

Objective

To identify the determinants of meeting the MAD among children aged 6-23 months in Bangladesh.

Methods

The study was based on a secondary dataset of the 2017-2018 Bangladesh Demographic and Health Survey (BDHS 2017-18). Complete (weighted) data from 2,426 children aged 6-23 months were analyzed.

Results

The overall percentage of meeting the MAD was 34.70%, whereas, in terms of urban and rural, it was 39.56% and 32.96%, respectively. Age of the children 9-11 months [Adjusted odds ratio (AOR) = 3.54; 95% CI: 2.33-5.4], 12-17 months [AOR = 6.72; 95% CI: 4.63-9.77], and 18-23 months [AOR = 7.12; 95% CI: 1.72-5.98], the maternal primary [AOR = 1.75; 95% CI: 1.07-2.86], secondary [AOR = 2.3; 95% CI: 1.36-3.89], and higher education [AOR = 3.21; 95% CI: 1.72-5.98], currently working mothers [AOR = 1.45; 95% CI: 1.13-1.79], mothers' access to mass media [AOR = 1.29; 95% CI: 1-1.66], and at least four antenatal care (ANC) from medically skilled providers [AOR = 1.74; 95% CI: 1.39,2.18] were independent determinants of meeting the MAD.

Conclusions

Many children are still far behind in meeting the MAD. Nutritional interventions like improved nutrition recipes, nutrition education and homemade food supplementation, nutritional counseling by home visits, community mobilization, health forums, antenatal and postnatal sessions, and media campaigns on IYCF are needed to meet MAD practice.

Projecting the long-term economic benefits of reducing Shigella-attributable linear growth faltering with a potential vaccine: a modelling study

BACKGROUND

Linear growth is an important outcome of child development with implications for economic productivity. Enteric infections, particularly Shigella, have been linked to linear growth faltering (LGF). However, benefits from potential reductions in LGF are rarely included in economic analyses of enteric infections. We aimed to quantify the economic benefits of vaccination related to reduced Shigella-attributable disease and associated LGF compared with the net costs of a vaccine programme.

METHODS

In this benefit-cost analysis, we modelled productivity benefits in 102 low-income and middle-income countries that had recent stunting estimates available, at least one Shigella-attributable death annually, and available economic data, particularly on gross national income and growth rate projections. We modelled benefits strictly related to linear growth improvements and no other benefits associated with reducing diarrhoeal burden. The effect size in each country was calculated as shifts in height-for-age Z score (HAZ), representing population average changes for preventing Shigella-attributable less-severe diarrhoea and moderate-to-severe diarrhoea separately for children younger than 5 years. Benefits data were calculated per country and combined with estimated net costs of the vaccine programme in the form of benefit-cost ratios (BCRs); BCRs above parity, or $1 in benefits per $1 in costs (with a 10% margin representing borderline results: 1·10:1), were considered cost-beneficial. Countries were aggregated for analysis by WHO region, World Bank income category, and eligibility for support from Gavi, the Vaccine Alliance.

FINDINGS

In the base-case scenario, all regions exhibited cost-beneficial results, with the South-East Asia region and Gavi-eligible countries exhibiting the highest BCRs (21·67 for the South-East Asia region and 14·45 for Gavi-eligible countries), and the Eastern Mediterranean region yielding the lowest BCRs (2·90). All regions exhibited cost-beneficial results from vaccination, except in more conservative scenarios (eg, those assuming early retirement ages and higher discount rates). Our findings were sensitive to assumed returns for increased height, assumptions about vaccine efficacy against linear growth detriments, the anticipated shift in HAZ, and discount rate. Incorporating the productivity benefits of LGF reduction into existing cost-effectiveness estimates resulted in longer-term cost-savings in nearly all regions.

INTERPRETATION

LGF is a secondary outcome of Shigella infection and reduction in LGF is not often quantified as a health or economic benefit of vaccination. However, even under conservative assumptions, a Shigella vaccine only moderately effective against LGF could pay for itself from productivity gains alone in some regions. We recommend that LGF be considered in future models assessing the economic and health impacts of interventions preventing enteric infections. Further research is needed on vaccine efficacy against LGF to inform such models.

FUNDING

Bill & Melinda Gates Foundation, Wellcome Trust.

Impact evaluation of a community nutrition and livelihood program on child nutrition in rural Bangladesh

Given the high prevalence of child undernutrition in Bangladesh, multi-sectoral approaches involving livelihood promotion have potential to mitigate the burden of undernutrition. This study examined the impact of an economic development (ED) program providing poultry assets, gardening skills and saving training added to the Positive Deviant (PD)/Hearth program (PDH/ED), compared to PD/Hearth only (PDH). A total of 1029 children who attended PD/Hearth sessions in September-November 2018 at 6-13 months of age were enrolled in the cohort study in July-August 2019. The cohort, comprised of 532 children in the PDH/ED group and 593 children in the PDH group, was reassessed in November 2020. The program impact on child nutrition, food security, crop production, dietary quality and household income was estimated using a difference-in-differences approach accounting for the sociodemographic differences between PDH/ED and PDH groups. Compared to the PDH group, the PDH/ED group showed increases in child dietary diversity score (DDS) (+0.32), child minimum dietary diversity (13.7 percentage points [pp]), and maternal DDS (+0.28) (all p < 0.05). From 2019 to 2020, the PDH/ED households improved food security by 12.6 pp and diversified crop production (bananas (9.7 pp), papaya (11.1 pp), carrots (3.8 pp) and lemons (5.9 pp)), and increased the proportion of annual income ≥60,000 Taka by 12.4 pp and last month income ≥5000 Taka by 7.8 pp, compared to PDH group (all p < 0.05). However, there was no impact on child nutritional status, morbidity, livestock ownership and total annual/last income. Incorporating an ED program into nutrition programming could benefit food security and dietary diversity in rural Bangladesh.

Income-Nutrition Gradient and Intrahousehold Allocation in Rural Pakistan

OBJECTIVE

To estimate the relationship between household income and child health outcomes for male and female children, aged 0-5 years, in rural Pakistan.

METHOD

The study uses 2014 round of Pakistan Rural Household Panel Survey (PRHPS) and regression analyses to estimate the relationship between household income and child health outcomes for male and female children in rural Pakistan.

RESULTS AND POLICY IMPLICATIONS

We find that increase in income is associated with an increase in child weight-for-age and weight-for-height z-scores, and reduction in the likelihood of a child being underweight or wasted. However, our results suggest that these gains associated with an increase in income are greater for male children as compared to female children. These differences in income-nutrition gradient can be explained by the gender-differences in consumption of health inputs (e.g., food intake, vaccinations, and nutritional supplements) associated with an increase in income. Our results indicate the need for policy instruments that can encourage an equitable resource allocation within households.

Does emigration by itself improve birth weight? Study in European newborns of Indo-Pakistan origin

Objective

Our aim was to evaluate the effect of emigration on fetal birth weight (BW) in a group of pregnant women coming from the Indian subcontinent.

Methods

This was a retrospective study in a mixed population of pregnant women from the Indian subcontinent that either moved to Europe or stayed in their original countries. The influence of emigration along with several pregnancy characteristics: GA at delivery, fetal gender, maternal age, height, weight, body mass index (BMI) and parity on BW was evaluated by means of multivariable linear regression analysis.

Results

According to European standards, babies born to Indo-Pakistan emigrants and babies born to women staying in the Indian subcontinent were similarly small (BW centile 30± 29 and 30.1 ± 28, p<0.68). Multivariable regression demonstrated that emigration by itself did not exert a direct influence on BW (p  = 0.27), being BMI and gestational age at delivery the true determinants of BW (p<0.0001).

Conclusions

Maternal BMI is the most relevant parameter affecting fetal growth regardless of the place of residence.

A cross-sectional analysis of long-term exposure to ambient air pollution and cognitive development in children aged 3-4 years living in 12 low- and middle-income countries

Exposure to ambient air pollution may affect cognitive functioning and development in children. Unfortunately, there is little evidence available for low- and middle-income countries (LMICs), where air pollution levels are highest. We analysed the association between exposure to ambient fine particulate matter (≤2.5 μm [PM_2.5]) and cognitive development indicators in a cross-sectional analysis of children (aged 3-4 years) in 12 LMICs. We linked Demographic and Health Survey data, conducted between 2011 and 2018, with global estimates of PM_2.5 mass concentrations to examine annual average exposure to PM_2.5 and cognitive development (literacy-numeracy and learning domains) in children. Cognitive development was assessed using the United Nations Children's Fund's early child development indicators administered to each child's mother. We used multivariable logistic regression models, adjusted for individual- and area-level covariates, and multi-pollutant models (including nitrogen dioxide and surface-level ozone). We assessed if sex and urban/rural status modified the association of PM_2.5 with the outcome. We included 57,647 children, of whom, 9613 (13.3%) had indicators of cognitive delay. In the adjusted model, a 5 μg/m³ increase in annual all composition PM_2.5 was associated with greater odds of cognitive delay (OR = 1.17; 95% CI: 1.13, 1.22). A 5 μg/m³ increase in anthropogenic PM_2.5 was also associated with greater odds of cognitive delay (OR = 1.05; 95% CI: 1.00, 1.10). These results were robust to several sensitivity analyses, including multi-pollutant models. Interaction terms showed that urban-dwelling children had greater odds of cognitive delay than rural-dwelling children, while there was no significant difference by sex. Our findings suggest that annual average exposure to PM_2.5 in young children was associated with adverse effects on cognitive development, which may have long-term consequences for educational attainment and health.

Decomposing the Intraurban Malnutrition Gap Between Poor and Non-poor Children in Colombia : Decomposing the Intraurban Malnutrition Gap Between Poor and Non-poor Children in Colombia

In Colombia, although it can be said that, on average children living in urban areas have better quality of life than their rural peers, it is also true that within cities, there are high levels of socioeconomic inequality. Our objective is to identify the contribution of the factors that explain the gap in stunting and excess weight between poor and non-poor children under 5 years of age in urban areas of Colombia. We use data from the 2015 National Nutritional Status Survey, and two nonlinear decomposition techniques based on the classical decomposition method developed by Blinder-Oaxaca. With a sample of 6877 observations, the results show that the intraurban gap of stunting between poor and non-poor children in urban areas is 4.8 percentage points. Its main determinants are the mother's educational level (46.5%), affiliation to the health system by the mother (19.4%), and assisted delivery in a medical institution (16.6%). For excess weight, the gap is - 2.1 percentage points, and its main determinants are the mother's educational level (39.2%) and birth attended by a physician (21.8%). This study suggests the coexistence of a double burden of malnutrition (DBM) in children under 5 years of age living in urban areas of Colombia. Stunting is associated with low-income levels while excess weight is associated with higher income levels. The identification of the main determinants of DBM and its relative importance, constitutes a contribution for public policy makers aimed at reducing socioeconomic gaps.

Predictors of stunting among children aged 6-59 months, Zimbabwe

OBJECTIVE

Stunted children have an increased risk of diminished cognitive development, diabetes, degenerative and CVD later in life. Numerous modifiable factors decrease the risk of stunting in children. This study aimed to assess the role of the individual, household and social factors on stunting in Zimbabwean children.

DESIGN

A 1:2 unmatched case-control study.

SETTING

This study was conducted in two predominantly rural provinces (one with the highest national prevalence of stunting and one with the lowest prevalence) in Zimbabwe.

PARTICIPANTS

Data were obtained from the caregivers of 150 children aged between 6 and 59 months with stunting and from the caregivers of 300 children without stunting.

RESULTS

Multiple (39) correlates of stunting were identified. Child's age, birth length, birth weight, and weight-for-age outcome (child-related factors), caregiver's age, maternal HIV status, occupation, and education (parental factors), breast-feeding status, number of meals, and dietary quality (dietary factors), child's appetite, diarrhoeal and worm infection (childhood illnesses), income status, access to safe water, access to a toilet, health clubs and maternal support in infant feeding (household, socio-cultural factors) were all found to be significant predictors of childhood stunting.

CONCLUSION

Nearly all aspects under review from the individual-, household- to social-level factors were significantly associated with childhood stunting. These findings add to the growing body of evidence supporting the WHO stunting framework and strengthen the need to focus interventions on a multi-sectoral approach to effectively address stunting in high prevalence countries.

Ambient temperature during pregnancy and fetal growth in Eastern Massachusetts, USA

Background

Left unabated, rising temperatures pose an escalating threat to human health. The potential effects of hot temperatures on fetal health have been under-explored. Here, we examined the association between prenatal ambient temperature exposure and fetal growth measures in a Massachusetts-based pregnancy cohort.

Methods

We used ultrasound measurements of biparietal diameter (BPD), head circumference (HC), femur length and abdominal circumference (AC), in addition to birthweight (BW), from 9446 births at Beth Israel Deaconess Medical Center from 2011 to 2016. Ultrasound scans were classified into three distinct gestational periods: 16–23 weeks, 24–31 weeks, 32+ weeks; and z-scores were created for each fetal growth measure using the INTERGROWTH-21st standards. We fitted distributed lag models to estimate the time-varying association between weekly temperature and fetal growth, adjusting for sociodemographic characteristics, seasonal and long-term trends, humidity and particulate matter (PM2.5).

Results

Higher ambient temperature was associated with smaller fetal growth measures. The critical window of exposure appeared to be Weeks 1–20 for ultrasound parameters, and high temperatures throughout pregnancy were important for BW. Associations were strongest for head parameters (BPD and HC) in early to mid-pregnancy, AC late in pregnancy and BW. For example, a 5ºC higher cumulative temperature exposure was associated with a lower mean AC z-score of -0.26 (95% CI: -0.48, -0.04) among 24–31-Week scans, and a lower mean BW z-score of -0.32 (95% CI: -0.51, -0.12).

Conclusion

Higher temperatures were associated with impaired fetal growth. This has major health implications given that extreme temperatures are more common and escalating.

Change in stunting and its associated factors among children aged less than 5 years in Ethiopia using Ethiopia Demographic and Health Survey data from 2005 to 2019: a multivariate decomposition analysis

OBJECTIVE

The aim of this study is to assess change in stunting and its associated factors among children aged less than 5 years in Ethiopia using Ethiopia Demographic and Health Survey data from 2005 to 2019.

DESIGN

A community-based cross-sectional study was conducted.

SETTING

The study was conducted in Ethiopia.

PARTICIPANTS

In 2005, 4586 individuals were examined, followed by 10 282 in 2011, 9462 in 2016 and 4937 in 2019.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome of the study was stunting, and the secondary outcome was factors associated with stunting and its change. A multilevel logistic regression model was fitted to identify individual and community-level factors associated with stunting among children aged less than 5 years. Multivariate decomposition analysis was also carried out to assess the role of compositional characteristics and behavioural change for decline in stunting among children aged less than 5 years in Ethiopia.

RESULTS

Over the study period, the prevalence rate of stunting in children aged less than 5 years decreased from 47% to 37% in 2019. Differences in behavioural change among children under the age of 5 years account for 76.69% of the overall decline in stunting prevalence rate in the years 2005-2011, 86.53% in the years 2005-2016, 98.9% in the years 2005-2019, 70.34% in the years 2011-2016 and 73.77% in the years 2011-2019. Behavioural adjustments among breastfed children, diet diversity, place of delivery, ANC follow-up and region have all had a major effect on stunting prevalence rate. The wealth index, parenteral education, child's age in months, length of breast feeding and area were among the compositional change factors.

CONCLUSION

A large percentage of children aged less than 5 years remains stunted in Ethiopia. Stunting was associated with alterations in the compositional and behavioural characteristics of children. Stimulating existing nutritional measures and improving the wealth index will make a significant difference in reducing stunting among Ethiopian children aged less than 5 years.

Trends in associations between socioeconomic development and urban-rural disparity with high blood pressure in Chinese children and adolescents over two decades

This study aimed to assess the association between the trend of urban-rural disparity in high blood pressure (HBP) in Chinese children and adolescents and socioeconomic development. Data on 1,054,602 students aged 7-18 years were obtained from five successive national surveys administered in 29 Chinese provinces in 1995, 2000, 2005, 2010, and 2014. HBP was defined as average measured systolic BP and/or diastolic BP equal to or more than 95th percentile. The socioeconomic indicators at the provincial-level included gross domestic product (GDP) per capita, the Engel coefficient, and urbanization rates. From 1995 to 2014, HBP prevalence in Chinese children and adolescents fluctuated between 6.9% and 9.2%. Rural areas had a higher prevalence of HBP than urban areas, with a diminishing trend in urban-rural disparity from 1995 to 2010 with a reduced OR from 1.45 (95% CI: 1.40-150) in 1995 to 1.09 (1.05-1.12) in 2010, whereas a widening gap in 2014 with OR of 1.23 (1.19-1.26)). A positive association existed between the improvement of socioeconomic indicators and the increase in HBP, which was demonstrated obviously by the Engel coefficient strata. The increases in the urbanization rates were accompanied by a greater increase of HBP in urban than in rural areas. The large urban-rural disparity suggests a priority of HBP control in rural children due to their current and future HBP and cardiovascular disease risks. Socioeconomic development could affect the urban-rural disparity in HBP risk, reflecting the importance of effective policy responses for preventing HBP by avoiding unhealthy lifestyles brought about by rapid economic development.

Assessing public financing for nutrition in Bhutan, Nepal and Sri Lanka

The objective of this study was to assess public financing for nutrition in Bhutan, Nepal and Sri Lanka to identify limitations of available data and to discuss policy implications. A variant of the Scaling Up Nutrition Movement methodology was used. Budget allocations and expenditures for relevant government ministries during 2012-2018 were identified. Nutrition-related line items were tagged using definitions of nutrition-specific and nutrition-sensitive interventions. Data were aggregated by year and calculated in constant United States dollars (USD). Expenditures by year were presented as a proportion of gross domestic product and general government expenditures. The percent utilization of budget allocations and proportion of funding from central government sources were determined. Per capita expenditures on nutrition-specific interventions varied from USD 1.08-8.76 and for nutrition-sensitive interventions varied from USD 20.22-51.20. Nutrition-specific expenditures as a percent of gross domestic product ranged from 0.08% in Sri Lanka in 2017% to 0.34% in Nepal in 2016. The median utilization rate was 64% for nutrition-specific and 84% for nutrition-sensitive interventions. Nutrition-specific funding financed by the central government was 90.7% in Bhutan and 99.4% in Sri Lanka. This study revealed the need to prioritize and invest in evidence-based interventions, including balancing investments in nutrition-specific versus -sensitive interventions. Challenges in estimation of nutrition expenditures and cross-country comparison were also observed, highlighting the need for appropriate nutrition line item tagging and standardized systems for data collection.

Can digitally enabling community health and nutrition workers improve services delivery to pregnant women and mothers of infants? Quasi-experimental evidence from a national-scale nutrition programme in India

Background

India’s 1.4 million community health and nutrition workers (CHNWs) serve 158 million beneficiaries under the Integrated Child Development Services (ICDS) programme. We assessed the impact of a data capture, decision support, and job-aid mobile app for the CHNWs on two primary outcomes—(1) timeliness of home visits and (2) appropriate counselling specific to the needs of pregnant women and mothers of children <12 months.

Methods

We used a quasi-experimental pair-matched controlled trial using repeated cross-sectional surveys to evaluate the intervention in Bihar and Madhya Pradesh (MP) separately using an intention-to-treat analysis. The study was powered to detect difference of 5–9 percentage points (pp) with type I error of 0.05 and type II error of 0.20 with endline sample of 6635 mothers of children <12 months and 2398 pregnant women from a panel of 841 villages.

Results

Among pregnant women and mothers of children <12 months, recall of counselling specific to the trimester of pregnancy or age of the child as per ICDS guidelines was higher in both MP (11.5pp (95% CI 7.0pp to 16.0pp)) and Bihar (8.0pp (95% CI 5.3pp to 10.7pp)). Significant differences were observed in the proportion of mothers of children <12 months receiving adequate number of home visits as per ICDS guidelines (MP 8.3pp (95% CI 4.1pp to 12.5pp), Bihar: 7.9pp (95% CI 4.1pp to 11.6pp)). Coverage of children receiving growth monitoring increased in Bihar (22pp (95% CI 0.18 to 0.25)), but not in MP. No effects were observed on infant and young child feeding practices.

Conclusion

The at-scale app integrated with ICDS improved provision of services under the purview of CHNWs but not those that depended on systemic factors, and was relatively more effective when baseline levels of services were low. Overall, digitally enabling CHNWs can complement but not substitute efforts for strengthening health systems and addressing structural barriers.

Trial registration number

ISRCTN83902145.

Scarring and selection effects on children surviving elevated rates of postneonatal mortality in sub-Saharan Africa

Infants in sub-Saharan Africa face adversity: Infections and undernutrition are major causes of infant deaths and can cause physiological damage with long-lasting adverse scarring effects on the human development of the survivors, for example, in terms of health and education. However, selective mortality of more vulnerable children at very high levels of adversity in early life can leave the surviving population to appear on average healthier. This paper estimated the nonlinear effects of postneonatal mortality rate—a proxy for adversity, particularly infections and undernutrition—in a 50 km radius, occurring over the period of infancy, on the subsequent height-for-age and school attendance of the surviving children. The results indicated that an adverse environment in infancy negatively affected height-for-age at age 1–4 years: At relatively low levels of adversity (at the 10th percentile of postneonatal mortality rate), an additional postneonatal death per 100 person-years decreased height-for-age of the survivors by almost 2% of the mean deficit in height (relative to a common growth standard) when comparing siblings born into different levels of adversity. At high levels of adversity, no effect was found for height-for-age while a small positive association was observed for school attendance at age 7–16 years. The results indicated that selective mortality may have canceled out (or even dominated in the case of school attendance) observable scarring effects following high levels of postneonatal mortality rate in sub-Saharan Africa.

•

Adversity in early life negatively affects human development in sub-Saharan Africa.

•

The postneonatal mortality rate over infancy was used as a proxy for adversity.

•

Elevated adversity in infancy negatively affected height-for-age at age 1–4 years.

•

At high adversity, selective mortality may cancel out observable scarring effects.

Evaluation of the child growth monitoring programme in two Zimbabwean provinces

Background

The child growth monitoring (CGM) programme is an important element of nutrition programmes, and when combined with other child health programmes, it can assist in successful management and control of malnutrition in children.

Aim

This study aimed to assess the extent to which the CGM programme is able to identify instances of childhood malnutrition and how much this contributes towards malnutrition reduction in Zimbabwe.

Setting

The study was conducted in Manicaland and Matabeleland South provinces of Zimbabwe. The two provinces were purposively selected for having the highest and least proportion of children affected by stunting in the country.

Methods

The CGM programme in Zimbabwe was evaluated using the logic model to assess the ability of the programme to identify growth faltering and link children to appropriate care.

Results

Records from 60 health facilities were reviewed. Interviews were conducted with 60 nurses, 100 village health workers (VHWs) and 850 caregivers (300 health facility exit interviews, 450 community based). Nearly all (92%) health facilities visited had functional measuring scales. Twelve health facilities (20%) had no functional height board, with five using warped height boards for measuring children’s height. Less than a quarter (21%) of the children had complete records for weight for age and height for age. A large proportion of children eligible for admission for the management of moderate (83%) and severe malnutrition (84%) were missed.

Conclusion

The CGM programme in Zimbabwe is not well equipped for assessing child height for age and management of children identified with malnutrition, thus failing to timely identify and manage childhood stunting.

Priority setting in early childhood development: an analytical framework for economic evaluation of interventions

Background

Early childhood development (ECD) sets the foundation for healthy and successful lives with important ramifications for education, labour market outcomes and other domains of well-being. Even though a large number of interventions that promote ECD have been implemented and evaluated globally, there is currently no standardised framework that allows a comparison of the relative cost-effectiveness of these interventions.

Methods

We first reviewed the existing literature to document the main approaches that have been used to assess the relative effectiveness of interventions that promote ECD, including early parenting and at-home psychosocial stimulation interventions. We then present an economic evaluation framework that builds on these reviewed approaches and focuses on the immediate impact of interventions on motor, cognitive, language and socioemotional skills. Last, we apply our framework to compute the relative cost-effectiveness of interventions for which recent effectiveness and costing data were published. For this last part, we relied on a recently published review to obtain effect sizes documented in a consistent manner across interventions.

Findings

Our framework enables direct value-for-money comparison of interventions across settings. Cost-effectiveness estimates, expressed in $ per units of improvement in ECD outcomes, vary greatly across interventions. Given that estimated costs vary by orders of magnitude across interventions while impacts are relatively similar, cost-effectiveness rankings are dominated by implementation costs and the interventions with higher value for money are generally those with a lower implementation cost (eg, psychosocial interventions involving limited staff).

Conclusions

With increasing attention and investment into ECD programmes, consistent assessments of the relative cost-effectiveness of available interventions are urgently needed. This paper presents a unified analytical framework to address this need and highlights the rather remarkable range in both costs and cost-effectiveness across currently available intervention strategies.

Differences in nutritional status between rural and urban Yucatec Maya children: The importance of early life conditions

Early‐life conditions shape childhood growth and are affected by urbanization and the nutritional transition. To investigate how early‐life conditions (across the “first” and “second” 1000 days) are associated with rural and urban children's nutritional status, we analyzed anthropometric data from Maya children in Yucatan, Mexico. We collected weight, height and triceps skinfold measures, then computed body mass and fat mass indices (BMI/FMI), in a cross‐sectional sample of 6‐year‐olds (urban n = 72, rural n = 66). Demographic, socioeconomic and early‐life variables (birthweight/mode, rural/urban residence, household crowding) were collected by maternal interview. We statistically analyzed rural‐urban differences in demographic, socioeconomic, early‐life, and anthropometric variables, then created linear mixed models to evaluate associations between early‐life variables and child anthropometric outcomes. Two‐way interactions were tested between early‐life variables and child sex, and between early‐life variables and rural‐urban residence. Results showed that rural children were shorter‐statured, with lower overweight/obesity and cesarean delivery rates, compared to urban children. Household crowding was a negative predictor of anthropometric outcomes; the strongest effect was in boys and in urban children. Birthweight positively predicted anthropometric outcomes, especially weight/BMI. Birth mode was positively (not statistically) associated with any anthropometric outcome. Cesarean delivery was more common in boys than in girls, and predicted increased height in urban boys. In conclusion, urbanization and household crowding were the most powerful predictors of Maya 6‐year‐old anthropometry. The negative effects of crowding may disproportionately affect Maya boys versus girls and urban versus rural children. Early‐life conditions shape Maya children's nutritional status both in the “first” and “second” 1000 days.

Food and nutrient intake of school-aged children in Lebanon and their adherence to dietary guidelines and recommendations

BACKGROUND

Lebanon, an Eastern Mediterranean country, is witnessing a remarkable nutrition transition, and the diets of school-aged children may be amongst those most affected. However, limited studies have examined the food consumption patterns and nutrient adequacy in this age group.

OBJECTIVES

The present study aimed to evaluate the dietary intakes of school-aged children in Lebanon and assess their adherence to nutrition guidelines and recommendations.

METHODS

This study used data for 4-13 y-old children (n = 711) from a national cross-sectional survey conducted in 2014-2015 on a representative sample of Lebanese households with children. Dietary intake was assessed using single 24-h recall method. Estimated food group and nutrient intakes were compared to dietary recommendations and age-specific dietary reference intakes (DRI), including Estimated Average Requirements (EAR) and Acceptable Macronutrient Distribution Range (AMDR). Food group, energy, macro- and micro-nutrient intakes were presented for all children in the sample and stratified by age (4-8 y and 9-13 y) and sex.

RESULTS

Mean energy intake of 4-13-year-old children was 1804 kcal/d. Almost half of the energy was provided by carbohydrates while 12% of children had protein intakes below EAR. Approximately three-quarters of children (4-13 y) exceeded the AMDR for total fat and saturated fats, and a similar proportion over consumed added sugars. The main sources of energy intake (EI) among children were the sweets, sweetened beverages and desserts followed by grains and mixed dishes. No significant differences were noted in %EI from different food groups, by sex, in either age groups. The highest adherence of children to food group recommendations was observed for the grains' food group (47.2-54.4%EI), while the lowest adherence was found for vegetables (3.1-14.1%EI). A high prevalence of vitamin and mineral inadequacies was noted amongst 4-13 y old children for key micronutrients, including vitamin D (99%), calcium (81%), and vitamin A (69.5%). Risk of inadequate micronutrient intakes was significantly increased among the older age group (p-value < 0.05).

CONCLUSION

Nutrient intakes of school-aged children in Lebanon reflect suboptimal nutrition. Educational and public health interventions are needed to promote healthier diets among children and prevent micronutrient deficiencies during this critical phase.

Systematic review to evaluate a potential association between helminth infection and physical stunting in children

Background

Despite considerable public health efforts over the past 20 years, childhood stunting (physical and/or cognitive) levels globally remain unacceptably high—at 22% amongst children under 5 years old in 2020. The aetiology of stunting is complex and still largely unknown. Helminths can cause significant mortality and morbidity and have often been cited as major causative agents for stunting, although their actual role in childhood stunting remains unclear. Our aim was to systematically review the current evidence to help support or refute the hypothesis that helminths cause physical stunting in children.

Methods

Inclusion criteria were as follows: infected with (and/or exposed to) helminths (soil-transmitted helminths, schistosomes or food-borne trematodes), children, pregnant or breastfeeding women as study participants (children included infants 0–1 year old, preschool-age children 1–5 years and school-age children > 5 years old), anthelmintic treatment intervention, stunting-related variables reported (e.g. height, height-for-age z-score, birth weight), helminth infection reported in relation to stunting, any geographic location, any date, peer-reviewed literature only. Exclusion criteria were: non-primary research, study protocols, studies with no new data, non-English language papers and animal (non-human) helminth studies. Seven databases were searched on 28 May 2021. Risk of bias was assessed for included studies and GRADE was used for studies included in RCT subgroup meta-analyses (in preschool-age children and pregnant women). This systematic review was registered with PROSPERO (CRD42021256201).

Results

Eighty studies were included in the analyses. No significant overall evidence was found in support of the hypothesis that helminths cause physical stunting in children, although there was some association with wasting.

Conclusions

Whilst analyses of the available literature to date failed to support a direct association between helminth infection and childhood stunting, there was significant heterogeneity between studies, and many had follow-up periods which may have been too short to detect impacts on growth. Most apparent was a lack of available data from key demographic groups wherein one may predict the greatest association of helminth infection with stunting—notably that of infants, preschool-age children, and pregnant or nursing women. Thus this review highlights the urgent need for further targeted empirical research amongst these potentially most vulnerable demographic groups.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-022-05235-5.

Estimating additional schooling and lifetime earning obtained from improved linear growth in low- and middle-income countries using the Lives Saved Tool (LiST)

Background

Policymakers seeking to prioritize the use of restricted financial resources need to understand the relative costs and benefits of interventions for improving nutritional status. Improved linear growth can lead to increased education attainment and improved economic productivity in low- and middle-income countries (LMICs), though these non-health-related benefits are not reflected in current long-term modelling efforts, including the Lives Saved Tool (LiST). Our objective was to integrate the effects of improved linear growth on non-health related benefit into LiST by estimating subsequent gains in years of schooling and wage earnings. We then estimated the impacts of reaching the Sustainable Development Goals (SDGs) target for stunting in South Asian countries on lifetime productivity.

Methods

In the first step, we used LiST outputs to estimate the improved linear growth due to scaled-up nutrition interventions and used published estimates to quantify the education gain resulting from an increase in height for age z-score (HAZ). In the second step, we used published country-level estimates on economic returns to schooling to quantify the relative gains in wages that children born today will experience because of their additional education attainment in the future. In the last step, we used country-level data on wages to estimate the net present value of future earnings gained due to early childhood growth improvement per birth cohort.

Results

If South Asia countries reach the SDG target by 2025, an estimated 8.6 million years of schooling will be obtained by six birth cohorts of 2020 to 2025. These six birth cohorts will also gain an estimated US$64 893 million in the present value term, at a 5% discount rate, in lifetime earnings. India has the largest expected gain in years of schooling (7367 years) and lifetime earnings (US$59 390 million in present value terms, at a 5% discount rate).

Conclusions

Two non-health-related benefits of improved linear growth – additional years of schooling and lifetime earnings – are added in LiST. Together with LiST costing, users can now conduct both cost-effective and benefit-cost analyses. Using both analyses will provide more comprehensive insights into nutrition interventions' relative costs and benefits.

Child wasting before and after age two years: A cross-sectional study of 94 countries

BACKGROUND

Wasting reflects infections and poor nutrition and affects almost 50 million children at any given time. Wasting comes with immediate risk of mortality and increased risks for long-term negative consequences for development. Children under two are particularly sensitive to undernutrition and infections. We estimated the age patterning in wasting prevalence.

METHODS

We calculated wasting prevalence and used Poisson regression models to estimate prevalence ratios comparing prevalence in children under and over two years using data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 94 mostly low- and middle-income countries, including 804,172 children under five, born to a nationally representative sample of women 15-49 years old. Wasting prevalence was defined as the percentage of children with weight-for-height below -2 z-score from the median of the WHO 2006 growth standard.

FINDINGS

Wasting prevalence for children under two was 14% (95% CI: 13, 14) while it was 9% (95% CI: 9, 9) for children 2-4 years old-leading to a prevalence ratio of 0·66 (95% CI: 0·64, 0·67) in our pooled sample. Prevalence ratios were less than one, indicating lower prevalence in children over two, in 87 countries and statistically significantly lower than one at a 5% level (non-adjusted) in 68 countries. Wasting prevalence was generally lower in children under two for males and females and the wealthiest and poorest households.

INTERPRETATION

Since wasting prevalence was observed to be greater among children 0-2 years, and adverse exposure to undernutrition and infections are particularly harmful and interventions are more effective during the 1000 days from conception until age two, nutrition interventions should ensure coverage of children under two through programmatic measures to increase detection and enrollment in wasting programs.

FUNDING

UNICEF, Nutrition Section, Programme Division in New York.

Childhood Growth and Socioeconomic Outcomes in Early Adulthood Evidence from the Inter-War United States

Childhood malnutrition and its later life effects were important concerns in European and North American social policy in the early twentieth century. However, there have been few studies of the long-term socioeconomic consequences of malnutrition in childhood. We use a unique longitudinal dataset to provide credible causal estimates of the effects of childhood nutrition on early-adult educational and employment outcomes. Our dataset includes 2,499 children in Saint Paul, Minnesota who were weighed and measured in a national children's health survey in 1918/1919 at 0-6 years of age. We observe those same people in the 1920, 1930 and 1940 U.S. censuses allowing us to measure childhood socioeconomic status (1920), adolescent school attendance (1930) and early-adult wages, and employment and educational attainment (1940). Examining variation between biological siblings, we are able to obtain credibly causal estimates of the relationship between childhood stature and weight and later life outcomes, largely canceling out the bias otherwise resulting from their joint correlation with genes and socioeconomic background. Because the initial survey located children within households, we identify the effect of differences in early childhood nutrition from differences between male siblings. Consistent with contemporary evidence from developing countries we find that being taller and heavier in early childhood is associated with better educational and labor market outcomes. Identifying all effects within families to control for socioeconomic background and family structure we find a standard deviation increase in BMI in early childhood was associated with a 3% increase in weekly earnings and that boys who were heavier for their age at the initial survey were 10% less likely to be unemployed in 1940. Taken together, these results confirm the importance of investments in early life health for later-life outcomes.

Economic costs of childhood stunting to the private sector in low- and middle-income countries

BACKGROUND

Stunting during childhood has long-term consequences on human capital, including decreased physical growth, and lower educational attainment, cognition, workforce productivity and wages. Previous research has quantified the costs of stunting to national economies however beyond a few single-country datasets there has been a limited number of which have used diverse datasets and have had a dedicated focus on the private sector, which employs nearly 90% of the workforce in many low- and middle-income countries (LMICs). We aimed to examine (i) the impact of childhood stunting on income loss of private sector workforce in LMICs; (ii) to quantify losses in sales to private firms in LMICs due to childhood stunting; and (iii) to estimate potential gains (benefit-cost ratios) if stunting levels are reduced in select high prevalence countries.

METHODS

This multiple-methods study engaged multi-disciplinary technical advisers, executed several literature reviews, used innovative statistical methods, and implemented health and labor economic models. We analyzed data from seven longitudinal datasets (up to 30+ years of follow-up; 1982-2016; Peru, Ethiopia, India, Vietnam, Philippines, Tanzania, Brazil), 108 private firm datasets (spanning 2008-2020), and many global datasets including Joint Malnutrition Estimates, and World Development Indicators to produce estimates for 120+ LMICs (with estimates up to 2021). We studied the impact of childhood stunting on adult cognition, education, and height as pathways to wages/productivity in adulthood. We employed cloud-based artificial intelligence (AI) platforms, and conducted comparative analyses using three analytic approaches: traditional frequentist statistics, Bayesian inferential statistics and machine learning. We employed labour and health economic models to estimate wage losses to the private sector worker and firm revenue losses due to stunting. We also estimated benefit-cost ratios for countries investing in nutrition-specific interventions to prevent stunting.

FINDINGS

Across 95 LMICs, childhood stunting costs the private sector at least US$135.4 billion in sales annually. Firms from countries in Latin America and the Caribbean and East Asia and Pacific regions had the greatest losses. Totals sales losses to the private sector accumulated to 0.01% to 1.2% of national GDP across countries. Sectors most affected by childhood stunting were manufacturing (non-metallic mineral, fabricated metal, other), garments and food sectors. Sale losses were highest for larger sized private firms. Across regions (representing 123 LMICs), US$700 million (Middle East and North Africa) to US$16.5 billion (East Asia and Pacific) monthly income was lost among private sector workers. Investing in stunting reduction interventions yields gains from US$2 to US$81 per $1 invested annually (or 100% to 8000% across countries). Across sectors, the highest returns were in elementary occupations (US$46) and the lowest were among agricultural workers (US$8). By gender, women incurred a higher income penalty from childhood stunting and earned less than men; due to their relatively higher earnings, the returns for investing in stunting reduction were consistently higher for men across most countries studied.

INTERPRETATION

Childhood stunting costs the private sector in LMICs billions of dollars in sales and earnings for the workforce annually. Returns to nutrition interventions show that there is an economic case to be made for investing in childhood nutrition, alongside a moral one for both the public and private sector. This research could be used to motivate strong public-private sector partnerships to invest in childhood undernutrition for benefits in the short and long-term.

Associations Between Eight Earth Observation-Derived Climate Variables and Enteropathogen Infection: An Independent Participant Data Meta-Analysis of Surveillance Studies With Broad Spectrum Nucleic Acid Diagnostics

Diarrheal disease, still a major cause of childhood illness, is caused by numerous, diverse infectious microorganisms, which are differentially sensitive to environmental conditions. Enteropathogen-specific impacts of climate remain underexplored. Results from 15 studies that diagnosed enteropathogens in 64,788 stool samples from 20,760 children in 19 countries were combined. Infection status for 10 common enteropathogens-adenovirus, astrovirus, norovirus, rotavirus, sapovirus, Campylobacter, ETEC, Shigella, Cryptosporidium and Giardia-was matched by date with hydrometeorological variables from a global Earth observation dataset-precipitation and runoff volume, humidity, soil moisture, solar radiation, air pressure, temperature, and wind speed. Models were fitted for each pathogen, accounting for lags, nonlinearity, confounders, and threshold effects. Different variables showed complex, non-linear associations with infection risk varying in magnitude and direction depending on pathogen species. Rotavirus infection decreased markedly following increasing 7-day average temperatures-a relative risk of 0.76 (95% confidence interval: 0.69-0.85) above 28°C-while ETEC risk increased by almost half, 1.43 (1.36-1.50), in the 20-35°C range. Risk for all pathogens was highest following soil moistures in the upper range. Humidity was associated with increases in bacterial infections and decreases in most viral infections. Several virus species' risk increased following lower-than-average rainfall, while rotavirus and ETEC increased with heavier runoff. Temperature, soil moisture, and humidity are particularly influential parameters across all enteropathogens, likely impacting pathogen survival outside the host. Precipitation and runoff have divergent associations with different enteric viruses. These effects may engender shifts in the relative burden of diarrhea-causing agents as the global climate changes.

Is mother's financial autonomy associated with stunting among children aged 7-35 months: An empirical study from India

Stunting depicts chronic deprivation and is a huge public health problem in several developing countries. Considering the sociocultural and sociodemographic factors of India, we aimed to examine the relationship between maternal autonomy and stunting among children <35 months. We have used the data from the latest round of National Family health survey conducted in 2015-16. The main exposure variable was women's autonomy which are represented in our study by the four dimensions- decision-making, physical mobility, financial autonomy, attitudes towards domestic violence, the main predictor variable was stunting among children. Chi-square analysis, univariate and multivariable binary logistic regression analysis were performed to find the association of childhood stunting and women's autonomy. The results were reported at 5% level of significance. All the autonomy variables have shown a significant association with child stunting at 5% level of significance. The unadjusted odds of stunting were found to be significant with respect to all the four dimensions of autonomy variables except physical autonomy. However, after adjusting for other explanatory factors attenuated these relationships and made them statistically insignificant except for women's economic autonomy (AOR = 0.91; 95% C.I.-(0.85, 0.98)) which was found to be significantly affecting the child's status of stunting. Our study reinforces that maternal autonomy is a significant predictor of childhood stunting. Hence, we recommend that policy makers, while designing interventions and policies, must address the socioeconomic inequalities at the community level while devising ways to improve women's empowerment. As it has far-reaching consequences on the nutrition status of the upcoming generations.

Exposure to PM2.5 during Pregnancy and Fetal Growth in Eastern Massachusetts, USA

BACKGROUND

Prior studies have examined the association between fine particulate matter [PM ≤2.5μm in aerodynamic diameter (PM2.5)] and fetal growth with either limited spatial or temporal resolution.

OBJECTIVES

In this study, we examined the association between PM2.5 exposure during pregnancy and fetal growth measures (ultrasound parameters and birth weight) in a pregnancy cohort using spatiotemporally resolved PM2.5 in Eastern Massachusetts, USA.

METHODS

We used ultrasound measures of biparietal diameter (BPD), head circumference, femur length, and abdominal circumference (AC), in addition to birth weight, from 9,446 pregnancies that were delivered at the Beth Israel Deaconess Medical Center from 2011-2016. We used linear mixed-effects models to examine the associations of PM2.5 in two exposure windows (the first 16 wk of pregnancy and the cumulative exposure up until the assessment of fetal growth) with anatomic scans (ultrasound measures at<24 wk), growth scans (ultrasound measures at≥24wk), and birth weight. All models were adjusted for sociodemographic characteristics, long-term trends, and temperature.

RESULTS

Higher PM2.5 exposure in the first 16 wk was associated with smaller fetal growth measures, where associations were particularly strong for BPD, AC, and birth weight. For example, a 5-μg/m3 increase in PM2.5 was associated with a lower mean BPD z-score of -0.19 (95% CI: -0.31, -0.06) before 24 wk, a lower mean AC z-score of -0.15 (95% CI: -0.28, -0.01) after 24 wk, and a lower mean birth weight z-score of -0.11 (95% CI: -0.20, -0.01). Analyses examining the associations with cumulative PM2.5 exposure up until the assessment of fetal growth produced attenuated associations.

CONCLUSIONS

Higher gestational exposure to PM2.5 was associated with smaller fetal growth measures at levels below the current national standards. https://doi.org/10.1289/EHP9824.

Early childhood stunting and later life outcomes: A longitudinal analysis

Using longitudinal data from four countries-Ethiopia, India, Peru and Vietnam- we show that early childhood stunting is highly persistent as measured by the association between stunting status in early childhood and stunting status at age 15. Stunting in early childhood is associated with lower grade completion by age 22 and has a negative relationship with cognition as measured by math, language and reading scores at ages 8, 12 and 15. Stunting in early childhood is also associated with poorer subjective assessment of a child's health at age 15. Analyzing determinants, we show that lack of preventive care and economic shocks are associated with an increase in the probability of stunting in early childhood.

Stunting among kindergarten children in China in the context of COVID-19: A cross-sectional study

BACKGROUND

The impact of COVID-19 has most likely increased the prevalence of stunting. The study aimed to determine the prevalence of stunting among kindergarten children in the context of coronavirus disease 2019 (COVID-19) in Longgang District, Shenzhen, China, and its risk factors.

METHODS

A cross-sectional study was conducted to identify children from 11 sub districts of 481 kindergartens in the Longgang District of Shenzhen City from May to July 2021. In the context of COVID-19, an online survey was conducted to gather demographic information, height, birth information, and lifestyle. The prevalence of stunting was calculated, and the risk factors were analyzed using binary logistic regression with three stepwise models.

RESULTS

A total of 118,404 subjects were included from May to July 2021, with a response and questionnaire effective rates of 85.75% and 95.03%, respectively. The prevalence of stunting and severe stunting were 3.3% and 0.8%, respectively. Model 3 showed that risk factors for stunting were male sex [odds ratio (OR) = 1.07], low birth weight (OR = 2.02), insufficient sleep time (OR = 1.08), less food intake than their peers (OR = 1.66), slower eating than their peers (OR = 1.16), accompanied by grandparents alone or non-lineal relatives (reference: parents accompanying) (OR = 1.23, 1.51), and children induced to eat (OR = 1.17). Protective factors included only-child status (OR = 0.66), reported high activity (OR = 0.37, 0.26, 0.23), parents with high education levels (father: OR = 0.87, 0.69; mother: OR = 0.69, 0.58), high monthly income per capita of the family (OR = 0.88, 0.74, 0.68), and allowing children to make food choices (OR = 0.82).

CONCLUSION

The stunting rate of children in kindergartens in Longgang District is 3.3%, close to the level of developed countries but higher than the average level of developed cities in China. The relatively high stunting rate in children under 3 years old in 2021 may be associated with the influence of COVID-19. Appropriate policies should be formulated for individuals and families with children to help children establish good living habits and reduce stunting.

Stunting, maternal investment, and early child development in Serbian Roma children aged 36-59 months

Stunting has shown negative associations with poor child developmental indicators. However, in poor ethnic minority populations the evidence for associations of anthropometric growth indicators and child development is limited. This study examined associations between stunting, height for age z scores (HAZ) and other determinants, with Early Child Development (ECD) among children in poor Roma communities. Publicly available data from Multiple Indicator Cluster Surveys for Serbian Roma settlements were used to assess a cohort of 1075 Roma children aged 36-59 months. Indicators of child growth and nutrition included children?s HAZ scores and stunting. ECD assessed physical, learning/cognition, literacy/numeracy and socio-emotional developmental domains. Multiple regressions were used to assess the association between HAZ and stunting with ECD, controlling for maternal and child confounders. Sum score for ECD in Roma children was low, and 18% of children were stunted. After adjusting for potential confounders, HAZ and stunting revealed no significant associations with developmental outcomes. Instead, increasing maternal investment was positively associated with overall ECD score and higher scores in each of the individual developmental domains, except socio-emotional. In a low-resource setting, maternal investment appeared a good predictor of child development: it may buffer against the effects of poverty and stimulate child development.

Neonatal stunting and early childhood caries: A mini-review

The nutritional status of pregnant women greatly determines their newborn outcome. Deficiencies of several micronutrients are associated with stunting in early childhood, affecting health into adulthood. However, apart from the systemic disease that has been a concern so far, fetal undernutrition can also be associated with dental caries in a child's early life, especially since the primary teeth begin to form during the mother's gestation period. The important thing to underline regarding the intrauterine formation of primary teeth is especially in terms of enamel formation. One of the causes of developmental enamel defects that will contribute to the emergence of early childhood caries is the malnutrition of the pregnant mother. This mini-review aims to understand the linkage mechanism behind neonatal stunting to early childhood caries. This concept is expected to generate further research to help prevent both growth stunting and early childhood caries. In addition, with some evidence-based research, the importance of the first dental visit can be further promoted.

Influence of agriculture on child nutrition through child feeding practices in India: A district-level analysis

Malnutrition continues to be a primary concern for researchers and policymakers in India. There is limited scientific research on the effect of agriculture on child nutrition in the country using a large representative sample. To the best of our knowledge, no study has examined the spatial clustering of child malnutrition and its linkage with agricultural production at the district-level in the country. The present study aims to examine agricultural production's role in improving the nutritional status of Indian children through child feeding practices. The nutritional indicators of children from the National Family Health Survey-4 (2015-16) and the agricultural production data for all the 640 districts of India obtained from the District-Wise Crop Production Statistics (2015-16), published by the Ministry of Agriculture, Government of India were used for the analysis. The statistical analysis was undertaken in STATA (version 14.1). ArcMap (version 10.3), and GeoDa (version 1.8) were used for the spatial analysis. The study found a higher prevalence of malnutrition among children who had not received Minimum Meal Frequency (MMF), Minimum Dietary Diversity (MDD), and Minimum Acceptable Diet (MAD). Further, child feeding practices- MMF, MDD, and MAD- were positively associated with high yield rates of spices and cereals. The yield rate of cash crops, on the contrary, harmed child feeding practices. Production of pulses had a significant positive effect on MDD and MAD. Districts with high cereal yield rates ensured that children receive MMF and MAD. There is a significant spatial association between child feeding practices and malnutrition across Indian districts. The study suggests that adopting nutrient-sensitive agriculture may be the best approach to improving children's nutritional status.

Stories of Change in Nutrition in Ghana: a focus on stunting and anemia among children under-five years (2009 – 2018)

The current study aimed to understand why child stunting and anemia (CS&A) rates declined in Ghana between 2009 and 2018, and which priority policies and programs will further improve nutrition outcomes. Trends and potential drivers of stunting (height-for-age z-score < -2.0 SD) and anemia (hemoglobin < 11.0 g/dL), and decomposition analysis of DHS data (2003 to 2014) were conducted. The quantitative evidence was triangulated with Net-Map analysis of nutrition stakeholder relationships and influence, desk review of policies and programs 2009–2019, and in-depth interviews with 25 stakeholders who provided additional insights to explain CS&A trends. Declines in stunting (29.6%) and anemia (14.1%) in children were observed at the national level, but with important subgroup variations. Decomposition analyses identified changes in the household, maternal, and child characteristics (including wealth, use of antenatal services, maternal education, and immunization) as correlates of anemia reduction. Stunting reduction was linked with changes in bed-net utilization, household wealth, and pregnancy care service utilization. Additionally, multiple policies and programs initiated/implemented across multiple sectors were considered potentially relevant to CS&A reduction over time, including those focused on infant and young child feeding, water and sanitation, social protection, and health care access. Initiation/strengthening of these interventions was stimulated by awareness creation and subsequently increased prioritization of stunting. However, program delivery was limited by deficits in government funding, perceived low priority of child anemia, low implementation capacity and coverage, and weak coherence across sectors. Reduced CS&A resulted from improved access to services implemented across multiple sectors, albeit limited by implementation scale and capacity. Further reduction in CS&A requires enhanced multi-sectorally coordinated actions and capacity.

Do Laws Promoting Gender Equity and Freedom from Violence Benefit the Most Vulnerable? A multilevel Analysis of Women's and Adolescent Girls' Experiences in 15 low-and-Middle-Income Countries

In this analysis, we assess whether laws that promote gender equity and freedom from violence are associated with a lower risk of prior-year physical and sexual intimate partner violence (IPV) among adolescent girls and adult women (AGW) and whether these laws protect more and less vulnerable AGW equally. We included all 15 countries that administered the Domestic Violence Module in a Demographic and Health Survey since 2015. The primary exposure was a validated, country-level index of laws on violence against women and girls (LoVI). A multilevel approach was used to model five forms of violence (prior-year partner physical, sexual, physical or sexual violence and prior-year non-partner physical violence or sexual violence) among ever-partnered, non-widowed adolescent girls 13–19 years (n = 6691) and women 20–49 years (n = 119 343). Across countries, partner physical violence ranged from 0% to 33% and sexual violence from 0% to 23%. Laws on marital rape, child marriage and sexual harassment were negatively associated with prior-year physical and sexual IPV for women and girls. Comprehensive domestic violence legislation was unrelated to girls’ experiences of prior-year physical or prior-year sexual IPV. No interaction was observed between LoVI component laws and a score meant to capture adolescent vulnerability. Three of the four LoVI component laws had consistent, negative associations with partner violence for girls and women, but negative associations were stronger for women than girls. Thus, while laws promoting gender equity and freedom from violence are generally protective, they may be more so for women than adolescent girls. Future research should explore the impact of gender equitable laws on women’s and adolescent girls’ experiences of violence, and countries may consider more comprehensive legal protections against violence for adolescent girls.

Indirect effects of the SARS CoV-2 pandemic on the prevalence of breastfeeding: Modeling its impact

INTRODUCTION

Breastfeeding has a protective effect against acute respiratory and diarrheal infections. There are psychological and social effects due to physical isolation in the population in the mother-child group.

OBJECTIVE

To assess the impact on infant mortality due to a decrease in the prevalence of breastfeeding during 2020 due to the physical isolation against the SARS CoV-2 (COVID-19) pandemic in Colombia.

MATERIALS AND METHODS

We used the population attributable risk approach taking into account the prevalence of breastfeeding and its potential decrease associated with the measures of physical isolation and the relative risk (RR) of the association between exclusive breastfeeding and the occurrence of acute infection consequences in the growth (weight for height) of children under the age of five through a mathematical modeling program.

RESULTS

We found an increase of 11.39% in the number of cases of growth arrest in the age group of 6 to 11 months with a 50% decrease in breastfeeding prevalence, as well as an increase in the number of diarrhea cases in children between 1 and 5 months of age from 5% (5.67%) on, and an increased number of deaths in children under 5 years (9.04%) with a 50% decrease in the prevalence of exclusive breastfeeding.

CONCLUSIONS

A lower prevalence of breastfeeding has an impact on infant morbidity and mortality in the short and medium-term. As a public health policy, current maternal and childcare strategies must be kept in order to reduce risks in the pediatric population.

Magnitude of Stunting and Associated Factors among Adolescent Students in Legehida District, Northeast Ethiopia

BACKGROUND

Undernutrition including stunting particularly at an adolescent stage was not emphasized by various intervention strategies in the Ethiopian context. Assessing the magnitude and potential risk factors of undernutrition is thus helpful for policymakers to design appropriate intervention strategies. Hence, this study was aimed at assessing the magnitude of stunting and associated factors among adolescent students in Legehida district, Northeast Ethiopia.

METHODS

A school-based cross-sectional study was conducted among 424 adolescent students from February 15th to March 15th, 2018. A stratified sampling followed by a simple random sampling technique was used to select the study participants. A pretested, structured, and self-administered questionnaire was used to collect the required data. Height was measured by using a portable stadiometer and the height-for-age (HFA) z-score was calculated as an indicator of stunting. SPSS version 25 and WHO AnthroPlus software were applied to analyze the data. A multivariable logistic regression analysis was performed to identify factors associated with adolescent stunting. Statistical significance was determined at a p value of <0.05 and association was described by using an odds ratio at a 95% confidence interval.

RESULTS

A total of 406 adolescent students (with a response rate of 95.7%) participated in the study. The magnitude of stunting among adolescent students in this study was 24.9% (95% CI: 24.6%-35.3%).

CONCLUSIONS

Stunting among adolescent students was significantly associated with being male [AOR = 2.1; 95% CI: 1.73-5.90], meal frequency (<3/day) [AOR = 4.6; 95% CI: 2.61-8.24], infrequent handwashing practice [AOR = 3.6; 95% CI: 1.30-9.40], absence of latrine facility (AOR = 5.51; 95% CI: 3.03-9.9), and consumption of unsafe water [AOR = 2.8; 95% CI: 1.35-6.19]. Hence, conducting routine nutrition screenings and assessments, promotion of proper food intake, and emphasis on nutrition education and counseling are needed to be strengthened.

Economic Evaluations of Child Nutrition Interventions in Low- and Middle-Income Countries: Systematic Review and Quality Appraisal

Economic evaluation is crucial for cost-effective resource allocation to improve child nutrition in low and middle-income countries (LMICs). However, the quality of published economic evaluations in these settings is not well understood. This systematic review aimed to assess the quality of existing economic evaluations of child nutrition interventions in LMICs and synthesize the study characteristics and economic evidence. We searched 9 electronic databases, including MEDLINE, with the following concepts: economic evaluation, children, nutrition, and LMICs. All types of interventions addressing malnutrition, including stunting, wasting, micronutrient deficiency, and overweight, were identified. We included economic evaluations that examined both costs and effects published in English peer-reviewed journals and used the Drummond checklist for quality appraisal. We present findings through a narrative synthesis. Sixty-nine studies with diverse settings, perspectives, time horizons, and outcome measures were included. Most studies used data from sub-Saharan Africa and South Asia and addressed undernutrition. The mortality rate, intervention effect, intervention coverage, cost, and discount rate were reported as predictors among studies that performed sensitivity analyses. Despite the heterogeneity of included studies and the possibility of publication bias, 81% of included studies concluded that nutrition interventions were cost-effective or cost-beneficial, mostly based on a country's cost-effectiveness thresholds. Regarding quality assessment, the studies published after 2016 met more criteria than studies published before 2016. Most studies had well-stated research questions, forms of economic evaluation, interventions, and conclusions. However, reporting the perspective of the analyses, justification of discount rates, and describing the role of funders and ethics approval were identified as areas needing improvement. The gaps in the quality of reporting could be improved by consolidated guidance on the publication of economic evaluations and the use of appropriate quality appraisal checklists. Strengthening the evidence base for child malnutrition across different regions is necessary to inform cost-effective investment in LMICs. Trial registration: PROSPERO CRD42020194445.

Poverty and childhood malnutrition: Evidence-based on a nationally representative survey of Bangladesh

BACKGROUND

Malnutrition contributes to children's morbidity and mortality, and the situation undermines the economic growth and development of Bangladesh. Malnutrition is associated with lower levels of education that decrease economic productivity and leads to poverty. The global burden of malnutrition continues to be unacceptably high amid social and economic growth, including in Bangladesh. Therefore, identifying the factors associated with childhood malnutrition and poverty is necessary to stop the vicious cycle of malnutrition leaded poverty.

METHODS

The study utilized the 2017-18 Bangladesh Demographic and Health Survey (BDHS), accumulating 7,738 mother-child pairs. Associations between potential risk factors and nutritional status were determined using chi-square tests, and multivariate logistic regression models were utilized on significant risk factors to measure their odds ratio (OR) with their 95% confidence intervals (CI).

RESULTS

The prevalence of moderate and severe wasting was 7.0% and 1.8%, respectively, whereas the prevalence of moderate and severe stunting was 19.2% and 8.0%, while 16.4% and 3.6% of children were moderately and severely underweight. Children from the poorest and poor households were suffering from at least one form of malnutrition. Adjusted ORs were estimated by controlling socio-economic and demographic risk factors, such as poor maternal body mass index, parents' lower education level, use of unhygienic toilet, child age in months, and recent experience of diarrhea and fever. The pattern was almost similar for each malnutrition status (i.e., stunting, underweight, and wasting) in the poorest and poor households.

CONCLUSION

Bangladesh achieved the Millennium Development Goals, focusing primarily on health-related indicators and working to achieve the Sustainable Development Goals. Even considering this success, the prevalence of malnutrition and poverty in same household remains relatively high compared to other developing countries. Therefore, the study recommends the implementation of nationwide systematic measures to prevent poverty and malnutrition.