Intergenerational influences on child growth and undernutrition

Maternal selenium deficiency was positively associated with the risk of selenium deficiency in children aged 6-59 months in rural Zimbabwe

There is growing evidence showing the existence of selenium (Se) deficiency among women and children in sub-Saharan Africa. Unfortunately, the key drivers of Se deficiency are not clearly understood. This study assessed the determinants of Se deficiency among children aged 6-59 months and Women of Reproductive Age (WRA), in Zimbabwe. This cross-sectional biomarker study was conducted in selected districts in rural Zimbabwe (Murewa, Shamva, and Mutasa). Children aged 6-59 months (n = 683) and WRA (n = 683), were selected using a systematic random sampling approach. Venous blood samples were collected, processed, and stored according to World Health Organization (WHO) guidelines. Plasma selenium concentration was measured using inductively coupled plasma-mass spectrometry (ICP-MS). Anthropometric indices were assessed and classified based on WHO standards. Demographic characteristics were adapted from the Zimbabwe Demographic Health Survey standard questionnaire. Multiple logistic regression analysis showed that children whose mothers were Se deficient were 4 times more likely to be Se deficient compared to those whose mothers were Se adequate (OR = 4.25; 95% CI; 1.55-11.67; p = 0.005). Girl children were 3 times more likely to be Se deficient compared to boys (OR = 2.84; 95% CI; 1.08-7.51; p = 0.035). Women producing maize for consumption were 0.5 times more likely to be Se deficient than non-producers (OR = 0.47; 95% CI; 0.25-0.90; p = 0.022). The risk of Se depletion in children was amplified by maternal deficiency. Therefore, initiation of maternal multiple micronutrient supplementation from preconception through lactation is beneficial to both children and women.

Preoperative Malnutrition Increases Risk of In-Hospital Mortality, Major Infection, and Longer Intensive Care Unit Stay After Ventricular Septal Defect Closure

BACKGROUND

High energy requirements and poor feeding can lead to growth failure in patients with ventricular septal defect (VSD), but effects of preoperative malnutrition on surgical outcomes are poorly understood, especially in low-resource settings.

METHODS AND RESULTS

We analyzed a cohort of children <5 years of age undergoing VSD closure at 60 global centers participating in the International Quality Improvement Collaborative for Congenital Heart Disease, 2015 to 2020. We calculated adjusted odds ratios (ORs) for in-hospital death and major infection and adjusted coefficients for duration of intensive care unit stay for 4 measures of malnutrition: severe wasting (weight-for-height Z score, <-3), moderate wasting (-3

CONCLUSIONS

Malnutrition was associated with mortality, infection, and longer intensive care unit stay in a global cohort of children undergoing VSD closure.

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Key Words

• congenital heart disease
• global health
• malnutrition
• mortality
• ventricular septal defect

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MESH Headings

• Humans
• Heart Septal Defects, Ventricular/surgery
• Heart Septal Defects, Ventricular/mortality
• Heart Septal Defects, Ventricular/complications
• Male
• Female
• Infant
• Hospital Mortality
• Child, Preschool
• Length of Stay/statistics & numerical data
• Malnutrition/mortality
• Malnutrition/epidemiology
• Malnutrition/diagnosis
• Risk Factors
• Cardiac Surgical Procedures/adverse effects
• Intensive Care Units/statistics & numerical data
• Nutritional Status
• Postoperative Complications/epidemiology
• Postoperative Complications/mortality
• Retrospective Studies
• Risk Assessment
• Time Factors

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Grants

• P30 DK040561 NIDDK NIH HHS
• National Institutes of Health

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Affiliation(s)

Rachel E. Wittenberg Harvard Medical SchoolBostonMAUSA
Kimberlee Gauvreau Harvard Medical SchoolBostonMAUSA Boston Children’s HospitalBostonMAUSA
Christopher P. Duggan Harvard Medical SchoolBostonMAUSA Boston Children’s HospitalBostonMAUSA
Xinwei Du Shanghai Children’s Medical CenterShanghaiChina
Do Giang Nhi Dong 1Ho Chi Minh CityVietnam
Kishore Jayanthi Star HospitalHyderabadIndia
Nestor Sandoval Fundación Cardioinfantil y LaCardioBogotáColombia
Sivakumar Sivalingam Institut Jantung NegaraKuala LumpurMalaysia
Xiaolei Zhao TEDA International Cardiovascular HospitalTianjinChina
Kathy J. Jenkins Harvard Medical SchoolBostonMAUSA Boston Children’s HospitalBostonMAUSA

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Preventing Stunting in South African Children Under 5: Evaluating the Combined Impacts of Maternal Characteristics and Low Socioeconomic Conditions

More than 140 million children under five suffered from stunting in 2020. This highlights the ongoing challenge of addressing childhood malnutrition globally. We utilized data from a nationally representative sample of children under five years of age (n = 14,151) who participated in five cycles of the South African National Income Dynamics Study (SA-NIDS) (2008-2017). We estimated the proportion of stunted children attributed to the mothers' anthropometric characteristics and socioeconomic conditions. We also quantified the population-level burden of low-socioeconomic conditions on hunger/food insecurity among pregnant women (n = 22,814) who participated in the nine rounds of the South African General Household Surveys (GHS) (2008-2021). Results from weighted-multivariate logistic regression were incorporated into the population-level impacts of correlates of stunting and low-socioeconomic conditions. The prevalence of stunting declined from 25% in 2008 to 23% in 2017. Mothers' anthropometric measures (underweight/height < 160 cm), marital status, low education, absence of medical insurance and low-socioeconomic conditions were all identified as the most influential risk factors for stunting. Their population-level impacts on stunting increased substantially from 34% (in 2008) to 65% (in 2017). Comprehensive strategies emphasizing enhanced food security, extended breastfeeding, appropriate nutrition, and access to adequate healthcare and education are urgently needed to reduce the burden of food insecurity low-socioeconomic, malnutrition, and its long-term consequences.

Influence of maternal and neonatal continuum of care on the risk of intergenerational cycle of stunting: a cross-sectional study

OBJECTIVES

This study aimed to analyse the influence of the continuum of care during pregnancy and neonatal periods on the risk of intergenerational cycle of stunting.

DESIGN

This study was a cross-sectional study, with data analysed from the 2018 Basic Health Research in Indonesia.

SETTINGS

Basic Health Research 2018 was conducted throughout 513 cities/regencies in 34 provinces in Indonesia. The households were selected through two-stage sampling methods. First, census blocks (CB) were selected using probability proportional to size methods in each urban/rural stratum from each city/regency. Ten households were then selected from each CB using systematic sampling methods. All family members of the selected households were measured and interviewed.

PARTICIPANTS

This study analyses 31 603 children aged 0-24 months.

OUTCOMES MEASURES

The dependent variable was the risk of the intergenerational cycle of stunting. Mothers who had a height less than 150.1 cm (short stature mothers) and had children (≤ 24 months of age) with length-for-age Z-score less than -2 Standard Deviation (SD) of the WHO Child Growth Standard (stunted children) were defined as at risk of the intergenerational cycle of stunting.

RESULTS

Mothers with incomplete maternal and neonatal care visits were 30% more likely to be at risk on the intergenerational cycle of stunting (OR (95% CI): 1.3 (1.00 to 1.63)) after adjusting for economic status.

CONCLUSION

The continuum of maternal and neonatal healthcare visits could potentially break the intergenerational cycle of stunting, especially in populations where stunted mothers are prevalent.

Colonization during a key developmental window reveals microbiota-dependent shifts in growth and immunity during undernutrition

BACKGROUND

Childhood undernutrition is a major global health challenge with devastating lifelong consequences. Linear growth stunting due to undernutrition has been linked to poor health outcomes, and mothers who experience growth stunting in childhood are more likely to give birth to stunted children later in life. Based on these findings, we hypothesized that intergenerational colonization of mice with microbiota from human donors with undernutrition may recapitulate certain immune and growth changes observed in this disorder.

RESULTS

To test this hypothesis, we developed a gnotobiotic murine model of undernutrition using microbiota from human infants with healthy or stunted growth trajectories. Intergenerational colonization with microbiota derived from children with growth stunting lead to less linear growth and the development of immune features of undernutrition and enteropathy, including intestinal villus blunting, lower liver IGF-1 and accumulation of intraepithelial lymphocytes and plasma cells in the small intestine. In contrast, colonization after weaning lead to fewer host phenotypic changes between these distinct microbial communities.

CONCLUSIONS

These results are broadly consistent with previous findings demonstrating that exposure of the immune system to microbial products during the weaning phase is a critical determinant of later life immune function. Overall, our results suggest intergenerational colonization with human microbiota samples is a useful approach with which to investigate microbiota-dependent changes in growth and immunity in early life. Murine models that capture the intergenerational and multifactorial nature of undernutrition are critical to understanding the underlying biology of this disorder. Video Abstract.

Evidence that highly canalized fetal traits are sensitive to intergenerational effects of maternal developmental nutrition

OBJECTIVES

Maternal experiences before pregnancy predict birth outcomes, a key indicator of health trajectories, but the timing and pathways for these effects are poorly understood. Here we test the hypothesis that maternal pre-adult growth patterns predict pregnancy glucose and offspring fetal growth in Cebu, Philippines.

METHODS

Using multiple regression and path analysis, gestational age-adjusted birthweight and variables reflecting infancy, childhood, and post-childhood/adolescent weight gain (conditional weights) were used to predict pregnancy HbA1c and offspring birth outcomes among participants in the Cebu Longitudinal Health and Nutrition Survey.

RESULTS

Maternal early/mid-childhood weight gain predicted birth weight, length, and head circumference in female offspring. Late-childhood/adolescent weight gain predicted birth length, birth weight, skinfold thickness, and head circumference in female offspring, and head circumference in male offspring. Pregnancy HbA1c did not mediate relationships between maternal growth and birth size parameters.

DISCUSSION

In Cebu, maternal growth patterns throughout infancy, childhood, and adolescence predict fetal growth via a pathway independent of circulating glucose, with stronger impacts on female than male offspring, consistent with a role of developmental nutrition on offspring fetal growth. Notably, the strength of relationships followed a pattern opposite to what occurs in response to acute pregnancy stress, with strongest effects on head circumference and birth length and weakest on skinfolds. We speculate that developmental sensitivities are reversed for stable, long-term nutritional cues that reflect average local environments. These findings are relevant to public health and life-history theory as further evidence of developmental influences on health and resource allocation across the life course.

Global relevance of MGRS growth standards: the case of India

The most common measures of childhood undernutrition are based on anthropometric measures such as height-for-age (stunting/chronic undernutrition) and weight-for-height (wasting/acute undernutrition). It is well recognised that the determinants of undernutrition are multiple, including food intake, dietary diversity, health, sanitation and women's status. Currently, most countries across the world including India use the globally accepted WHO-Multicentre Growth Reference Study (MGRS) growth standards (2006) for the purposes of measurement as well as for evaluating progress on these metrics. However, there is some discussion on the universal relevance of these standards, and in the Indian context, whether these standards overestimate the prevalence of stunting, considering differences in genetic potential for growth. This is especially relevant in the context of increasing burden of obesity and non-communicable diseases in India. Based on a detailed review of literature, policy documents and expert inputs, this review paper discusses the relevance of the WHO growth standards for height/stunting, in the context of India. Issues discussed related to the MGRS methodology include pooling of data and intersite and intrasite variability, opting for standards as opposed to references, and external validity. Other issues related to plasticity of stunting and the influence of maternal heights are also discussed, in the context of analysing the appropriateness of using universal growth standards. Based on the review, it is recommended that the current standards may continue to be used until a newer global standard is established through a similar study.

Undernutrition in children under five associated with wealth-related inequality in 24 low- and middle-income countries from 2017 to 2022

Undernourishment is a persistent public health problem contributing to increased mortality in children under five in low-income countries, likely exacerbated by socio-economic disparities within communities. This paper aimed to examine the effect of wealth-related inequality on undernutrition in children under five in low, lower-middle, and upper-middle-income countries (LMICs). We analyzed cross-sectional data from the demographic and health survey program collected between 2017 and 2022 from 24 LMICs. Children born within 5 years preceding the survey were included in the analysis. Child undernutrition was the dependent variable (measured by stunting, wasting, and underweight) and country-level wealth-based inequality was the independent variable assessed by concentration index values stratified by the World Bank's income categories. Within country inequality of child undernutrition was determined by concentration index (C) values with 95% confidence intervals (95% CI) and sub-group analysis by place of residence and sex of the child. We then fit bootstrapped meta-regression to check the variation in inequality of child undernutrition across different income category countries. The analysis was controlled by potential confounding variables. From the total sample size of 334,502 children included in the study, 35% were undernourished. Wealth-related inequality in child undernutrition was observed in 11 countries, consistently across income categories. Child undernutrition was highly concentrated among the poor households of Türkiye [C: - 0.26, 95% CI - 0.31 to - 0.20], and Cameroon [C: - 0.19, 95% CI - 0.22 to - 0.17], and relatively it was less concentrated among the poor in Liberia [C: - 0.07, 95% CI - 0.11 to - 0.04], and Gambia [C: - 0.07, 95% CI - 0.11 to - 0.04]. There is no difference in undernutrition associated with inequality between the three broad LMIC categories. The wealth-related inequality in child undernutrition within many of the included countries is still very significant. However, the economic category of countries made no difference in explaining wealth-related inequality in child undernutrition. Inter-sectoral collaboration to fight poverty and render special attention to the disadvantaged population segments would potentially help to address the observed inequity.

An overview of the nutritional status of childbearing age women, children and adolescents living in a rural area of Madagascar: preliminary results of the Tany Vao project

OBJECTIVE

To describe the food consumption, nutrition knowledge and nutritional assessment of childbearing age women and their children, living in rural villages in Madagascar. The results presented are related to the Tany Vao research study.

DESIGN

A cross-sectional pilot study.

SETTING

The study was carried out in Ampanitosoha village on Nosy Mitsio island in Madagascar.

PARTICIPANTS

32 women (14-49 years) and 36 children and adolescents (2-17 years).

RESULTS

70 % of the women lacked nutrition knowledge and did not reach the Minimum Dietary Diversity Index for Women cut-off. The median BMI was 21·1 kg/m2 but 55·2 % of the women exceeded the cut-off for waist-to-hip ratio, 51·7 % for waist-to-height ratio and 81·2 % for mid-upper arm circumference (MUAC). Almost all had adequate intake of energy, protein and carbohydrates, while 27·6 % had excessive fat intake and 75·9 % of added sugars. Over half of the women did not meet the micronutrients Reference Daily Intake (RDI). For children, the MUAC z-score was lower for boys than for girls (P-value = 0·041).

CONCLUSIONS

These results underline the importance of increasing women's nutritional knowledge to promote healthy pregnancy and lactation. Moreover, it is fundamental to provide people living in rural areas with sustainable tools to improve dietary diversity and support long-term health.

The interlink between chrono-nutrition and stunting: current insights and future perspectives

Stunting is the one factor that is responsible for the irretrievable damage to children's mental and physical health. Stunting imitates chronic undernutrition throughout the most extreme critical stages of growth and development of a child in their early life, and due to that stunted child does not completely develop and are too short for their age. Stunting is mainly linked with brain underdevelopment, along with lifelong damaging consequences, comprising weakened mental and learning capacity, deprived performance in school during childhood, and enhanced risks of nutrition linked to chronic long-lasting ailments, such as diabetes, hypertension, diabesity, and obesity in the future. In this review, the authors mainly summarize the latest studies related to chronic nutrition and how it is related to stunting. Optimal nutrition, particularly during pregnancy and the first 24 months of a child's life, is crucial in preventing stunting. Circadian rhythms play a significant role in maternal and fetal health, affecting outcomes such as premature birth and stunting. Maintaining a balanced diet, avoiding late-night carbohydrate-heavy meals during pregnancy, and promoting breastfeeding align with the body's biological clock, which can benefit newborns in various ways. Providing dedicated spaces for breastfeeding in public places is important to support infant health.

Sociodemographic inequalities in cardiovascular risk factors among adolescents from indigenous areas in Chiapas, Mexico

This study was aimed to determine the prevalence of cardiovascular risk factors among different sociodemographic groups of adolescents from indigenous communities in Chiapas, Mexico. A cross-sectional prevalence study was performed in urban and rural communities in the Tzotzil-Tzeltal and Selva regions of Chiapas. A sample of 253 adolescents was studied, of whom 48% were girls and 52% were boys. A descriptive analysis of quantitative variables was performed using measures of central tendency and dispersion. The prevalence of cardiovascular risk factors stratified by sex, geographical area, years of schooling, and ethnicity of the mothers was estimated. The prevalence of cardiovascular risk factors was analyzed in relation to the sociodemographic characteristics of the study population. Low HDL-c (51%) was the predominant cardiovascular risk factor. Girls had a higher prevalence of abdominal obesity, hypertriglyceridemia, and borderline total cholesterol than boys. High diastolic blood pressure was more prevalent in boys. Adolescents from urban areas had a higher prevalence of overweight/obesity and insulin resistance than adolescents from rural areas. The prevalence of overweight/obesity and abdominal obesity was higher in adolescents whose mothers had ≥ 7 years of schooling compared with adolescents with less educated mothers. Differences by maternal ethnicity also influenced the prevalence of insulin resistance. Among the main findings, this study associated sociodemographic and geographical inequalities with cardiovascular risk factors. Promoting a healthy lifestyle for this young population is absolutely necessary to prevent cardiovascular diseases in adulthood.

Gender-specific disaggregated analysis of childhood undernutrition in Ethiopia: evidence from 2000-2016 nationwide survey

INTRODUCTION

Childhood undernutrition has been investigated extensively in previous literature but gender inequality detailing the burden of undernutrition has not been adequately addressed in scientific papers, especially in Ethiopia, where undernutrition is known to be a public health problem of high significance, necessitating increased efforts to address it and reduce this inequality. This study was carried out to: (1) explore gender differences in the prevalence of stunting, wasting, and underweight, and (2) compare the factors associated with childhood undernutrition between boys and girls in Ethiopia.

METHODS

The study used a dataset of more than 33,564 children aged under 5 years (boys: 17,078 and girls: 16,486) who were included in the nationally representative Ethiopia Demographic and Health Survey (EDHS) from 2000 to 2016. The outcome variables were anthropometric indices: stunting (height-for-age < -2 standard deviations), wasting (weight-for-height < -2 standard deviations), and underweight (weight-for-age < -2 standard deviations). Gender-specific multilevel analyses were used to examine and compare the factors associated with child undernutrition.

RESULTS

The overall prevalence of stunting (49.1% for boys vs 45.3% for girls, p < 0.001), wasting (11.9% for boys vs 9.9% for girls, p < 0.001), and underweight (33.1% for boys vs 29.8% for girls, p < 0.001) higher among boys compared to girls. Boys significantly had higher odds of stunting (aOR: 1.31, 95%CI: 1.21-1.42), wasting (aOR: 1.35, 1.23-1.48), and underweight (aOR: 1.38, 95%CI: 1.26-1.50) than girls. The common factors associated with childhood undernutrition for male and female children were the child's age, perceived size of the child at birth, breastfeeding status, maternal stature, maternal education, toilet facility, wealth index, and place of residence. Boys who were perceived by their mothers to be average sized at birth and were born to uneducated mothers had a higher likelihood of experiencing wasting, in contrast to girls. Among boys, birth order (firstborn), household size (1-4), and place of residence (urban) were associated with lower odds of being underweight. Boys living in cities had lower odds of being stunted. While girls born to mothers with no education and worked in agriculture were at a higher odd of being stunted.

CONCLUSION

Our study revealed that boys were more likely to be malnourished than girls, regardless of their age category, and there were variations in the factors determining undernutrition among boys and girls. The differences in the burden of undernutrition were significant and alarming, positioning Ethiopia to be questioned whether it will meet the set Sustainable Development Goals (SDGs), including SDG 2 of zero hunger by 2030. These findings call for more effort to address malnutrition as a significant public health issue in Ethiopia, and to urgently recognise the need for enhanced interventions that address the gender gap in childhood undernutrition.

Nutritional status of young children born with low birthweight in a low resource setting: an observational study

OBJECTIVE

Every year, an estimated 20 million babies are born with low birthweight and this number is increasing globally. Survivors are at risk of lifelong morbidities like undernutrition. We assessed the growth and nutritional status for children born with low birthweight at Mulago Hospital, Uganda.

METHODS

We conducted a cross sectional study to describe the nutritional status of children aged between 22 and 38 months and born weighing ≤ 2000 g. Anthropometric measurements; weight for height, height for age and weight for age z-scores were generated based on the World Health Organization standards to define wasting, stunting and underweight respectively. Data was collected using a structured questionnaire and analysis was done using STATA version 14.

RESULTS

Of the 251 children, 129 (51.4%) were male, mean age was 29.7 months SD 4.5) and maternal mean age was 29.9 (SD 5.3). A total of 101(40.2%) had normal nutritional status. The prevalence of wasting, underweight and stunting were: 8 (3.2%), 36 (14.4%) and 106 (42.2%) respectively.

CONCLUSION

Six of ten children born with low birthweight were at risk of undernutrition in early childhood: underweight and stunting were higher than the national prevalence. Targeted interventions are needed for children with very low birth weight.

Attitudes, beliefs and social norms regarding infant and young child feeding among Nigerian mothers, fathers and grandmothers across time

Infant and young child feeding (IYCF) interventions in low-resource countries mainly target pregnant women and mothers of young children; however, fathers and grandmothers also influence IYCF practices. We conducted focus group discussions with mothers, fathers and grandmothers of young children across three time points in areas where an IYCF social and behaviour change intervention was implemented in Nigeria to explore differences by participant type and shifts over time in attitudes, beliefs and social norms related to breastfeeding and dietary diversity (DD). Overall, across time points, we found more discrepancies in attitudes, beliefs and social norms for early initiation of breastfeeding (EIBF) and exclusive breastfeeding (EBF) among different participant types than for DD. Although most participants agreed EIBF and EBF are good practices, mothers believed this more strongly than fathers and grandmothers; however, at endline, a shift towards acceptance of EIBF and EBF appeared among fathers and grandmothers. Across time points, all participant types acknowledged the nutritional and health benefits of green leafy vegetables and animal-source foods but described various barriers to feeding them to children. Across time points, all participant types also highlighted the importance of health workers and antenatal visits as important sources of IYCF knowledge and facilitators to following recommended practices. Insights from this study highlight the importance of including key influencers of IYCF practices in qualitative research.

Dietary Patterns of Children from the Amazon Region of Ecuador: A Descriptive, Qualitative Investigation

Many young children in Ecuador suffer from high rates of malnutrition and stunting that affect their long-term growth and development. Little is known about the dietary patterns of children from the Amazon region who experience some of the highest rates of stunting (height-for-age) within Ecuador. Semi-structured interviews were conducted with 50 mothers of young children living in the Ecuadorian Amazon. In addition to descriptions of overall dietary patterns, three themes emerged from the interviews relating to strengths mothers have in feeding their children healthy diets: knowledge, autonomous and independent children, and supportive and responsive parenting. Five themes were found relating to barriers mothers have in feeding their children healthy diets. The first four themes concerned barriers (lack of knowledge of healthy foods, lack of access to healthy foods, not enough money, and child's health) related to multidimensional poverty. All these influenced the last theme found, namely, how difficult of an eater the child was. The implications of intervention efforts to reduce undernutrition and promote children's development by building on specific family and community strengths and identified barriers are also discussed in this paper.

When did the substantial loss of child linear growth occur?

BACKGROUND

Epidemiological studies show that the height-for-age Z-scores (HAZ) falter dramatically shortly after birth until the end of the first two years. Understanding these changes in linear growth in the first two years can help us understand the critical period of child linear growth and propose interventions.

OBJECTIVES

This study objectives were to describe the pattern of linear growth faltering and analyze the changes in length-for-age Z-scores (LAZs) throughout the first two years based on birthweight and length status.

METHODS

This study analyzed 408 children, participants in Longitudinal Study on Child Growth and Development in Bogor, Indonesia. The linear growth pattern was described based on birthweight and length status. Birthweight and length status was categorized into normal and Small for Gestational Age (SGA). Changes in LAZs (Δ LAZs) in 0-6 months, 6-12 months, and 12-23 months were calculated. General Linear Model Univariate analysis was conducted to analyze the difference of Δ LAZ between SGA and normal children.

RESULTS

Though full-term SGA children have significantly higher linear growth velocity during the first 6 months of the infancy period, full-term SGA children could not catch up with the attained growth/height of normal children throughout the first two years. Thus, full-term SGA children ended up with a higher prevalence of stunted. Both in SGA and normal children, the substantial loss of LAZ occurred between 0-6 months.

CONCLUSION

The finding in this study showed that the first 1000 days of life is still the best period in stunting prevention; however, the stunting prevention program should start earlier, focusing on the first 500 days of life, and potentially the prenatal period.

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.

Globally elevated levels of histone H3 lysine 9 trimethylation in early infancy are associated with poor growth trajectory in Bangladeshi children

BACKGROUND

Stunting is a global health problem affecting hundreds of millions of children worldwide and contributing to 45% of deaths in children under the age of five. Current therapeutic interventions have limited efficacy. Understanding the epigenetic changes underlying stunting will elucidate molecular mechanisms and likely lead to new therapies.

RESULTS

We profiled the repressive mark histone H3 lysine 9 trimethylation (H3K9me3) genome-wide in peripheral blood mononuclear cells (PBMCs) from 18-week-old infants (n = 15) and mothers (n = 14) enrolled in the PROVIDE study established in an urban slum in Bangladesh. We associated H3K9me3 levels within individual loci as well as genome-wide with anthropometric measurements and other biomarkers of stunting and performed functional annotation of differentially affected regions. Despite the relatively small number of samples from this vulnerable population, we observed globally elevated H3K9me3 levels were associated with poor linear growth between birth and one year of age. A large proportion of the differentially methylated genes code for proteins targeting viral mRNA and highly significant regions were enriched in transposon elements with potential regulatory roles in immune system activation and cytokine production. Maternal data show a similar trend with child's anthropometry; however, these trends lack statistical significance to infer an intergenerational relationship.

CONCLUSIONS

We speculate that high H3K9me3 levels may result in poor linear growth by repressing genes involved in immune system activation. Importantly, changes to H3K9me3 were detectable before the overt manifestation of stunting and therefore may be valuable as new biomarkers of stunting.

Child Nutrition Outcomes and Maternal Nutrition-Related Knowledge in Rural Localities of Mbombela, South Africa

Poor nutrition outcomes among children have become one of the major public health concerns in South Africa, attributed to poor feeding practices and maternal nutrition-related knowledge with conflicting data. In view of this, a cross-sectional study was conducted to determine the association of nutrition outcomes of children aged under two years with feeding practices and maternal nutrition-related knowledge in Mbombela, South Africa. Mothers' nutrition-related knowledge was estimated using an adapted structured questionnaire on colostrum, continued breastfeeding, diarrhea prevention and treatment using oral rehydration solution, immunization, and family planning, and scored as excellent (80-100), good (60-79), average (40-59), and fair (0-39). This was along with questions on socio-demographic factors and obstetric history, as well as anthropometric measurements. Child nutrition outcomes were estimated by WHO classification using z-scores for stunting (length-for-age (LAZ)), underweight (weight-for-age (WAZ)), and thinness (body mass index-for-age (BAZ)). Using STATA 17, 400 pairs of children (8 ± 6 months) and their mothers (29 ± 6 years) participated in the study and were living in a poor socio-economic status environment. Half of children were stunted (50%) and over half (54%) were obese, while mothers were underweight (39%) and overweight (34%). In addition to one third of mothers reporting obstetric complications, two thirds, initiated breastfeeding within one hour of delivery, 30% exclusively breastfed, 48% introduced early complementary feeding, and 70% practiced mixed feeding. Twenty-eight percent (28%) of mothers had fair nutrition-related knowledge, while 66% had average knowledge, 6% good knowledge, and none of the mothers had excellent knowledge. A chi-square test showed that mothers' nutrition-related knowledge was significantly associated with child stunting. The final hierarchical logistic regression showed significant associations of stunting with mothers' nutrition-related knowledge (average: AOR = 1.92, 95%CI: 1.12-3.29), child's age (6-11 months: AOR = 2.63, 95%CI: 1.53-4.53 and 12-23 months: AOR = 3.19, 95%CI: 1.41-7.25), and education (completing Grade 12: AOR = 0.36, 95%CI: 0.15-0.86). Contextual and intensified interventions on continued education for mothers to gain accurate information on nutrition-related knowledge and feeding practices could ultimately enhance child nutrition outcomes in poorer settings. Efforts should therefore be made to ensure that nutrition knowledge is appropriately provided based on the phases of child growth from 0 to 2 years, even beyond infancy into school age.

Coming to the Caribbean-acclimation of Rhesus macaques (Macaca mulatta) at Cayo Santiago

OBJECTIVES

To investigate whether the Cayo Santiago, Puerto Rico (Latitude: 18.1564°N; temperature range 19°C to 32°C) rhesus macaque population has acclimated to their tropical island conditions since arriving from Lucknow, India (Latitude: 26.8470°N; temperature range 8°C to 41°C) in 1938.

MATERIALS AND METHODS

Using the derived skeletal collection, measurements were taken of long bone lengths, diaphyseal circumference, and body weight using 635 (237 males and 398 females) skeletally mature individuals. Measurements sampled colony members born over a 51-year time span at Cayo Santiago, from 1951 to 2002.

RESULTS

Results demonstrated that body weights and diaphyseal circumferences significantly declined in both males and females. Long bone lengths relative to body weight and diaphyseal circumference also increased in females. Whereas body weight, long bone length and diaphyseal circumference declined at near parallel rates in males.

DISCUSSION

The population has acclimated to homogenous, tropical, conditions of the Caribbean island since their arrival over 80 years ago. Trends in both sexes aligned with Bergmann's rule, though females displayed a greater decline in body weight, as well as greater affinity with Allen's rule, than did males. Buffering effects related to male competition may be responsible for this discrepancy. Overall, the Cayo Santiago populations, as shown over a significant period (1951-2002) of their history, have acclimated to their island conditions by decreasing in size and altering body proportions.

The association between maternal stature and adverse birth outcomes and the modifying effect of race and ethnicity: a population-based retrospective cohort study

BACKGROUND

There are known differences in the risk of perinatal and maternal birth outcomes because of maternal factors, such as body mass index and maternal race. However, the association of maternal height with adverse birth outcomes and the potential differences in this relationship by race and ethnicity have been understudied.

OBJECTIVE

This study aimed to examine the association between maternal stature and adverse perinatal outcomes and the potential modification of the association by race and ethnicity.

STUDY DESIGN

This retrospective cohort study was conducted using data on all singleton births in the United States in 2016 and 2017 (N=7,361,713) obtained from the National Center for Health Statistics. Short and tall stature were defined as <10th and >90th percentiles of the maternal height distribution (<154.9 and >172.7 cm, respectively). Race and ethnicity categories included non-Hispanic White, non-Hispanic Black, American Indian or Alaskan Native Asian or Pacific Islander, and Hispanic. The primary outcomes were preterm birth (<37 weeks of gestation), perinatal death, and composite perinatal death or severe neonatal morbidity. Logistic regression was used to obtain adjusted odds ratios and 95% confidence intervals with adjustment for confounding by maternal age, body mass index, and other factors. Multiplicative and additive effect modifications by race and ethnicity were assessed.

RESULTS

The study population included 7,361,713 women with a singleton stillbirth or live birth. Short women had an increased risk of adverse outcomes, whereas tall women had a decreased risk relative to average-stature women. Short women had an increased risk of perinatal death and composite perinatal death or severe neonatal morbidity (adjusted odds ratios, 1.14 [95% confidence interval, 1.10-1.17] and 1.21 [95% confidence interval, 1.19-1.23], respectively). The association between short stature and perinatal death was attenuated in non-Hispanic Black women compared with non-Hispanic White women (adjusted odds ratio, 1.10 [95% confidence interval, 1.03-1.17] vs 1.26 [95% confidence interval, 1.19-1.33]). Compared with average-stature women, tall non-Hispanic White women had lower rates of preterm birth, perinatal death, and composite perinatal death or severe neonatal morbidity (adjusted odds ratios, 0.82 [95% confidence interval, 0.81-0.83], 0.95 [95% confidence interval, 0.91-1.00], and 0.90 [95% confidence interval, 0.88-0.93], respectively). The association between tall and average stature with perinatal death was reversed in Hispanic women (adjusted odds ratio, 1.27; 95% confidence interval, 1.12-1.44). Compared with average-stature women, all tall women had lower rates of preterm birth, particularly among non-Hispanic Black and Hispanic women.

CONCLUSION

Relative to average-stature women, short women have an increased risk of adverse perinatal outcomes across all race and ethnicity groups; these associations were attenuated in Hispanic women and for some adverse outcomes in non-Hispanic Black and Asian women. Tall mothers have a lower risk of preterm birth in all racial and ethnic groups, whereas tall non-Hispanic White mothers have a lower risk of perinatal death or severe neonatal morbidity compared with average-stature women.

Children's Educational Outcomes and Persistence and Severity of Household Food Insecurity in India: Longitudinal Evidence from Young Lives

BACKGROUND

Food insecurity is a pressing global challenge with far-reaching consequences for health and well-being. However, little attention has focused specifically on the experiences of children and adolescents over the age of 5 y in food insecure households.

OBJECTIVES

We examine whether the persistence and severity of household food insecurity are negatively associated with children's educational outcomes.

METHODS

We used data for the younger cohort of the longitudinal Young Lives data from rounds 3 (2009), 4 (2013), and 5 (2016), when children were aged 8 y, 12 y, and 15 y, respectively. Drawing on the Household Food Insecurity and Access Scale, we used descriptive statistics, graphical analysis, and multilevel regressions to document how the persistence and severity of household food insecurity are associated with children's educational outcomes (years of education, maths, and vocabulary [PPVT] test scores). We controlled for potentially confounding sociodemographic characteristics, including children's own baseline grade attained and test scores in "value-added" models, to provide robust estimates of household food insecurity in predicting children's educational outcomes.

RESULTS

Household food insecurity generally declined between 2009 and 2016. Fewer than 50% of households were food secure across the 3 rounds of data we examined. Our robust, multivariate, value-added models show that the persistence and severity of food insecurity are negatively associated with all 3 children's educational outcomes we examined.

CONCLUSIONS

We add to a small but growing literature exploring how household food insecurity is associated with children's educational outcomes in the Global South. Our findings on severity of food insecurity highlight the importance of understanding food insecurity along the severity continuum rather than as a dichotomous state, as previously done in existing literature. Addressing household food insecurity in childhood and adolescence may be a key factor to improve children's educational outcomes.

Does maternal stature modify the association between infants who are small or large for gestational age and adverse perinatal outcomes? A retrospective cohort study

OBJECTIVE

To investigate the effect of maternal stature on adverse birth outcomes and quantify perinatal risks associated with small- and large-for-gestational age infants (SGA and LGA, respectively) born to mothers of short, average, and tall stature.

DESIGN

Retrospective cohort study.

SETTING

USA, 2016-2017.

POPULATION

Women with a singleton live birth (N = 7 325 741).

METHODS

Using data from the National Center for Health Statistics, short and tall stature were defined as <10th and >90th centile of the maternal height distribution. Modified Poisson regression was used to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (95% CIs).

MAIN OUTCOME MEASURES

Preterm birth (<37 weeks of gestation), neonatal intensive care unit (NICU) admission and severe neonatal morbidity/mortality (SNMM).

RESULTS

With increased maternal height, the risk of adverse outcomes increased in SGA infants and decreased in LGA infants compared with infants appropriate-for-gestational age (AGA) (p < 0.001). Infants who were SGA born to women of tall stature had the highest risk of NICU admission (aRR 1.98, 95% CI 1.91-2.05; p < 0.001), whereas LGA infants born to women of tall stature had the lowest risk (aRR 0.85, 95% CI 0.82-0.88; p < 0.001), compared with AGA infants born to women of average stature. LGA infants born to women of short stature had an increased risk of NICU admission and SNMM, compared with AGA infants born to women of average stature (aRR 1.32, 95% CI 1.27-1.38; aRR 1.21, 95% CI 1.13-1.29, respectively).

CONCLUSIONS

Maternal height modifies the association between SGA and LGA status at birth and neonatal outcomes. This quantification of risk can assist healthcare providers in monitoring fetal growth, and optimising neonatal care and follow-up.

Peri-Conceptional Folic Acid Supplementation and Children’s Physical Development: A Birth Cohort Study

Background: Maternal lack of folic acid supplementation during pregnancy may increase the risk of low birth weight and preterm delivery. However, little is known about the relationship between folic acid supplementation during pregnancy and the physical development of offspring in the later stage. Objective: This study aimed to explore the association between maternal folic acid supplementation status during pregnancy and the physical development of preschool children. Methods: A total of 3064 mother–child pairs with data on maternal folic acid supplementation status during pregnancy and children’s anthropometric measurements were recruited from the Ma’anshan-Anhui Birth Cohort (MABC) in China. Maternal folic acid supplementation status during pregnancy was the main exposure, and the primary outcomes were children’s growth development trajectories. Children’s growth development trajectories were fitted using group-based trajectory models. The association between maternal folic acid supplementation status during pregnancy and children’s growth trajectories was performed using multiple logistic regression models. Results: After adjusting for potential confounders, we found that the absence of maternal folic acid supplementation before pregnancy and in the first trimester was significantly associated with a “high level” trajectory (trajectory 3) and a “high rising level” trajectory (trajectory 4) of BMI-Z scores in children 0 to 6 years of age (OR = 1.423, 95%CI:1.022–1.982; OR = 1.654, 95%CI: 1.024–2.671). In children aged 4 to 6 years old, a “high level” trajectory (trajectory 3) of body fat ratio was substantially related to maternal no folic acid supplementation before pregnancy and in the first trimester (OR = 1.833, 95%CI:1.037–3.240). No significant additional benefits associated with physical developmental indicators in preschool children have been observed with continued folic acid supplementation after the first trimester of gestation. Conclusions: Maternal non-supplementation with folic acid during pregnancy is associated with a “high level” BMI trajectory and a “high level” body fat ratio trajectory in preschool-aged children.

Associations of Diet Quality, Socioeconomic Factors, and Nutritional Status with Gestational Weight Gain among Pregnant Women in Dar es Salaam, Tanzania

Background

Gestational weight gain (GWG) is a modifiable factor associated with maternal and child health outcomes, but the relationship between diet quality and GWG has not been evaluated using metrics validated for low-income and middle-income countries (LMICs).

Objective

This study aimed to investigate relationships between diet quality, socioeconomic characteristics, and GWG adequacy using the novel Global Diet Quality Score (GDQS), the first diet quality indicator validated for use across LMIC.

Methods

Weights of pregnant women enrolled between 12 and 27 wk of gestation (N = 7577) were recorded in Dar es Salaam, Tanzania, from 2001 to 2005 during a prenatal micronutrient supplementation trial. GWG adequacy was the ratio of measured GWG to Institute of Medicine-recommended GWG, categorized into severely inadequate (<70%), inadequate (70 to <90%), adequate (90 to <125%), or excessive (≥125%). Dietary data were collected using 24-h recalls. Multinomial logit models were used to estimate relationships between GDQS tercile, macronutrient intake, nutritional status, and socioeconomic characteristics and GWG.

Results

GDQS scores in the second [relative risk (RR): 0.82; 95% confidence interval (CI): 0.70, 0.97] tercile were associated with lower risk of inadequate weight gain than those in the first tercile. Increased protein intake was associated with higher risk of severely inadequate GWG (RR: 1.06; 95% CI: 1.02, 1.09). Nutritional status and socioeconomic factors were associated with GWG: underweight prepregnancy BMI (in kg/m2) with a higher risk of severely inadequate GWG (RR: 1.49; 95% CI: 1.12, 1.99), overweight or obese BMI with a higher risk of excessive GWG (RR: 6.80; 95% CI: 5.34, 8.66), and a higher education (RR: 0.61; 95% CI: 0.42, 0.89), wealth (RR: 0.68; 95% CI: 0.48, 0.80), and height (RR: 0.96; 95% CI: 0.95, 0.98) with a lower risk of severely inadequate GWG.

Conclusions

Dietary indicators showed few associations with GWG. However, stronger relationships were revealed between GWG, nutritional status, and several socioeconomic factors.This trial was registered at clinicaltrials.gov as NCT00197548.

From growth charts to growth status: how concepts of optimal growth and tempo influence the interpretation of growth measurements

Growth measurements are largely uninterpretable without comparison to a growth chart. Consequently, the characteristics of a growth chart become an integral component of the interpretation of growth measurements. The concepts of optimal growth and tempo are well recognised by auxologists, yet their implications for interpretation of growth measurements remain problematic. This narrative review discusses the concept of optimal growth and how it serves as a guiding principle in the development and use of growth charts. The challenges of operationalising tempo for growth assessment are also discussed. Illustrative examples highlight the importance of these two central concepts in the use and interpretation of growth measurements.

Development and validation of a new set of indicators to assess the quality of maternal and child nutritional care at the primary care

Introduction

Maternal and child malnutrition is a worldwide public health problem with short, medium, and long-term adverse consequences for both mother and child. In Mexico, maternal and child malnutrition represents a serious public health problem that must be urgently addressed. In this context, Primary Health Care (PHC) plays an important role in the prevention, detection, monitoring, and treatment of the different forms of maternal and child malnutrition. Assessing the quality of nutritional care offered at this level of care is necessary in order to improve it; however, there are no indicators for the evaluation of this quality. Therefore, this study aimed at developing a set of indicators to assess the quality of maternal and child nutritional care at PHC.

Methods

We developed indicators for different stages of life: preconception, pregnancy, infancy, and preschool age. A systematic review of the literature on clinical guidelines for the prevention, diagnosis, and treatment of the different forms of malnutrition was carried out; the recommendations of the guidelines evaluated with good quality were extracted.

Results

Based on these recommendations, 22 indicators were constructed. A pilot study was carried out to validate the indicators and 16 indicators were selected to assess the maternal and child nutritional care at PHC.

Short stature and language development in the United Kingdom: a longitudinal analysis of children from the Millennium Cohort Study

BACKGROUND

In low- and middle-income countries, poverty and impaired growth prevent children from meeting their cognitive developmental potential. There are few studies investigating these relationships in high-income settings.

METHODS

Participants were 12,536 children born between 2000 and 2002 in the UK and participating in the Millennium Cohort Study (MCS). Short stature was defined as having a height-for-age 2 or more standard deviations below the median (≤ - 2 SDS) at age 3 years. Standardized British Abilities Scales II (BAS II) language measures, used to assess language development at ages 3, 5, 7 and 11 years, were the main outcome assessed.

RESULTS

Children with short stature at age 3 years (4.1%) had language development scores that were consistently lower from ages 3 to 11 years (- 0.26 standard deviations (SD) (95% CI - 0.37, - 0.15)). This effect was attenuated but remained significant after adjustment for covariates. Trajectory analysis produced four distinct patterns of language development scores (low-declining, low-improving, average and high). Multinomial logistic regression models showed that children with short stature had a higher risk of being in the low-declining group, relative to the average group (relative risk ratio (RRR) = 2.11 (95% CI 1.51, 2.95)). They were also less likely to be in the high-scoring group (RRR = 0.65 (0.52, 0.82)). Children with short stature at age 3 years who had 'caught up' by age 5 years (height-for-age ≥ 2 SDS) did not have significantly different scores from children with persistent short stature, but had a higher probability of being in the high-performing group than children without catch-up growth (RRR = 1.84 (1.11, 3.07)).

CONCLUSIONS

Short stature at age 3 years was associated with lower language development scores at ages 3 to 11 years in UK children. These associations remained significant after adjustment for socioeconomic, child and parental factors.

Maternal height and child health and schooling in sub-Saharan Africa: Decomposition and heterogeneity

Maternal height is associated with mortality and anthropometry in low-and-middle-income countries. This paper explored residual associations and potential underlying mechanisms linking maternal height to several child outcomes using regression models with neighborhood and half-sibling fixed effects and Gelbach decomposition on 108 Demographic and Health Surveys from 37 sub-Saharan African countries. When adjusting for time of birth, twinning, sex, and survey, a single z-score (6.5 cm) increase in mother's height was associated with a 22% reduction in the average deficit in height-for-age among children under five (according to the WHO 2006 growth standard), 16% lower neonatal mortality (age <1 month) , 10% lower postneonatal mortality (age 1-11 months), 11% lower child mortality (age 12-59 months) , and 2% increase in school attendance among 7-16-year-olds. Adjusting further for maternal education, household living standards, maternal fertility and birth related factors, and neighborhood reduced the coefficients for maternal height by 22% for child height-for-age, 26% for neonatal mortality, 46% for postneonatal mortality, 56% for child mortality, and 90% for school attendance. The decomposition showed that adjusting for neighborhood had a substantial impact on the association of maternal height with all outcomes, especially child mortality. Adjusting for unobserved father and household factors also had a particularly large impact on the association with child mortality. The robustness of the relationship with neonatal mortality suggests that pregnancy and perinatal factors are an important link between maternal height and child outcomes. Adult living standards and socioeconomic and related behavioral factors likely play a small role. Genetics may also play a large role in linking maternal height and child height-for-age, especially for educated mothers, whose height was presumably impacted less by early life adversity.

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.

School water, sanitation, and hygiene (WaSH) intervention to improve malnutrition, dehydration, health literacy, and handwashing: a cluster-randomised controlled trial in Metro Manila, Philippines

BACKGROUND

The impacts of multicomponent school water, sanitation, and hygiene (WaSH) interventions on children's health are unclear. We conducted a cluster-randomized controlled trial to test the effects of a school WaSH intervention on children's malnutrition, dehydration, health literacy (HL), and handwashing (HW) in Metro Manila, Philippines.

METHODS

The trial lasted from June 2017 to March 2018 and included children, in grades 5, 6, 7, and 10, from 15 schools. At baseline 756 children were enrolled. Seventy-eight children in two clusters were purposively assigned to the control group (CG); 13 clusters were randomly assigned to one of three intervention groups: low-intensity health education (LIHE; two schools, n = 116 children), medium-intensity health education (MIHE; seven schools, n = 356 children), and high-intensity health education (HIHE; four schools, n = 206 children). The intervention consisted of health education (HE), WaSH policy workshops, provision of hygiene supplies, and WaSH facilities repairs. Outcomes were: height-for-age and body mass index-for-age Z scores (HAZ, BAZ); stunting, undernutrition, overnutrition, dehydration prevalence; HL and HW scores. We used anthropometry to measure children's physical growth, urine test strips to measure dehydration, questionnaires to measure HL, and observation to measure HW practice. The same measurements were used during baseline and endline. We used multilevel mixed-effects logistic and linear regression models to assess intervention effects.

RESULTS

None of the interventions reduced undernutrition prevalence or improved HAZ, BAZ, or overall HL scores. Low-intensity HE reduced stunting (adjusted odds ratio [aOR] 0.95; 95% CI 0.93 to 0.96), while low- (aOR 0.57; 95% CI 0.34 to 0.96) and high-intensity HE (aOR 0.63; 95% CI 0.42 to 0.93) reduced overnutrition. Medium- (adjusted incidence rate ratio [aIRR] 0.02; 95% CI 0.01 to 0.04) and high-intensity HE (aIRR 0.01; 95% CI 0.00 to 0.16) reduced severe dehydration. Medium- (aOR 3.18; 95% CI 1.34 to 7.55) and high-intensity HE (aOR 3.89; 95% CI 3.74 to 4.05) increased observed HW after using the toilet/urinal.

CONCLUSION

Increasing the intensity of HE reduced prevalence of stunting, overnutrition, and severe dehydration and increased prevalence of observed HW. Data may be relevant for school WaSH interventions in the Global South. Interventions may have been more effective if adherence was higher, exposure to interventions longer, parents/caregivers were more involved, or household WaSH was addressed.

TRIAL REGISTRATION NUMBER

DRKS00021623.

Association between prenatal provision of lipid‐based nutrient supplements and caesarean delivery: Findings from a randomised controlled trial in Malawi

In populations with a high prevalence of childhood and adolescent undernutrition, supplementation during pregnancy aiming at improving maternal nutritional status and preventing fetal growth restriction might theoretically lead to cephalopelvic disproportion and delivery complications. We investigated whether the prenatal provision of small‐quantity lipid‐based nutrient supplements (SQ‐LNS) was associated with an increased risk of caesarean section (CS) or other delivery complications. Pregnant Malawian women were randomised to receive daily i) iron–folic acid (IFA) capsule (control), ii) multiple micronutrient (MMN) capsule of 18 micronutrients (second control), or iii) SQ‐LNS with similar micronutrients as MMN, plus four minerals and macronutrients contributing 118 kcal. We analysed the associations of SQ‐LNS, CS, and other delivery complications using log‐binomial regressions. Among 1391 women enrolled, 1255 had delivery information available. The incidence of CS and delivery complications was 6.3% and 8.2%, respectively. The incidence of CS was 4.0%, 6.0%, and 8.9% (p = 0.017) in the IFA, MMN, and LNS groups, respectively. Compared to the IFA group, the relative risk (95% confidence interval) of CS was 2.2 (1.3–3.8) (p = 0.006) in the LNS group and 1.5 (0.8–2.7) (p = 0.200) in the MMN group. We found no significant differences for other delivery complications. Provision of SQ‐LNS to pregnant women may have increased the incidence of CS. The baseline rate was, however, lower than recommended. It is unclear if the higher CS incidence in the SQ‐LNS group resulted from increased obstetric needs or more active health seeking and a better supply of services. Trial registered at clinicaltrials.gov, NCT01239693.

Provision of lipid‐based nutrient supplements (LNS) to pregnant Malawian women was associated with a higher incidence of caesarean delivery compared with iron–folic acid, which is the standard of care.

The overall rate of caesarean section in this study was lower than recommended, and it remains unclear if the increased incidence in the LNS group resulted from increased obstetric needs or more active health seeking and a better supply of services.

The association of LNS with higher caesarean delivery risk is a possible phenomenon in some settings and calls for monitoring obstetric complications in future prenatal nutritional supplementation studies and programs.

A Study of Maternal Anemia and Utilization of Antenatal and Postnatal Care Services in Devbhumi Dwarka, Gujarat

Background and objective Despite significant gains and achieving progress in the last decade, maternal anemia remains a major public health concern in India. Both antenatal (AN) and postnatal (PN) women are populations adversely affected by anemia. Reducing anemia among AN and PN women is one of the national priorities of Anemia Mukt Bharat. The present study aimed at assessing the prevalence of anemia, utilization of AN and PN care (ANC and PNC) services, and drivers of anemia among pregnant and lactating women (PLWs) in Devbhumi Dwarka district, Gujarat. Methods A descriptive cross-sectional study was conducted in four blocks of Devbhumi Dwarka district, Gujarat. A total of 1,185 PLWs were interviewed. Anemia was determined based on the last Hb test record on the Mamta Card (Mother and Child Protection Card). Results The mean age of the study population was 25.19 ±3.91 years: 24.95 ±3.94 years for pregnant women and 25.45 ±4.01 years for lactating women. The prevalence of anemia among pregnant women (Hb: <11 g/dL) was 72.92%; 33.91% had moderate and 0.83% had severe anemia. The prevalence of anemia among lactating women (Hb: <12 g/dL) was 26%; 63.93% had moderate and 1.29% had severe anemia. The utilization of nutrition and health services was found to be limited. Of the other sociodemographic factors, age (p=0.045), birth spacing (p=0.014), and education (p=0.017) were significant determinants of anemia among pregnant women, whereas parity (p=0.002), birth spacing (p=0.003), religion (p=0.041), and receipt of take-home ration (THR) (p=0.018) were significantly associated with anemia among lactating women. Conclusion The study revealed a high prevalence of anemia among PLWs and sub-optimal utilization of nutritional and healthcare services in Devbhumi Dwarka. Implementing interventions such as comprehensive nutrition education and counseling can contribute toward improving maternal and child health outcomes.

Nutritional inequalities among under-five children: a geospatial analysis of hotspots and cold spots in 73 low- and middle-income countries

BACKGROUND

Child undernutrition is a severe health problem in the developing world, which affects children's development in the long term. This study analyses the extent and patterns of under-five child undernutrition using Demographic and Health Surveys (DHS) for 73 low- and middle-income countries (LMICs).

METHODS

First, we mapped the prevalence of undernutrition in the developing world. Second, using the LISA (a local indicator of spatial association) technique, we analyzed the geographical patterns in undernutrition to highlight the localized hotspots (regions with high undernutrition prevalence surrounded by similar other regions), cold spots (regions with low undernutrition prevalence surrounded by similar other regions), and outliers (regions with high undernutrition surrounded by low undernutrition and vice versa). Third, we used Moran's I to find global patterns in child undernutrition.

RESULTS

We find that South Asia has the highest under-five child undernutrition rates. The intra-country nutritional inequalities are highest in Burundi (stunting), Kenya (wasting), and Madagascar (underweight). The local indicator of spatial association (LISA) analysis suggests that South Asia, Middle East and North Africa (MENA) region, and Sub-Saharan Africa are undernutrition hotspots and Europe and Central Asia and Latin America, and the Caribbean are undernutrition cold spots (regions with low undernutrition surrounded by similar other regions). Getis Ord-Gi* estimates generally support LISA analysis. Moran's I and Geary's C gave similar results about the global patterns of undernutrition. Geographically weighted regressions suggest that several socioeconomic indicators significantly explain child undernutrition.

CONCLUSIONS

We found a significant within and across country variation in stunting, wasting and underweight rates among the under-five children's population. The geospatial analysis also suggested that stunting, wasting, and underweight patterns exhibit clear regional patterns, underscoring the need for coordinated interventions at the regional level.

Dietary practices and nutritional status of young children in the former ensete monoculture dominated Sidama region, southern Ethiopia: A community based cross-sectional study

Background

Child undernutrition is a challenge in Ethiopia, where morbidity and mortality among children are attributed to it. This study aimed to describe the dietary practices, household food insecurity, and nutritional status of young children in Dale district, Sidama region, southern Ethiopia. We discuss our findings in light of research from the same area 3 to 5 decades ago, and we analyze factors associated with linear growth of young children.

Method

A community-based cross-sectional study design was employed. Children less than two years old and their primary caretakers (n = 903) were included in this study. Among whom 791 children were aged above six months and 742 children out of 791 provided a 24-hour dietary recall. Interviews capturing other dietary practices, food insecurity, socio-demographic characteristics, anthropometric measurements, and haemoglobin assessments were performed for all. The WHO Child Growth Standards were used to calculate anthropometric indices and to describe stunting (length-for-age z-score <-2). Haemoglobin measures below 11g/dl were defined as low haemoglobin levels (anaemia). Multilevel linear regression was used to identify factors associated with length-for-age z-scores.

Result

The prevalence of stunting, wasting, and anaemia was 39.5%, 3.9%, and 61.7%, respectively. The majority of children (97%) ate cereals (maize) during the past 24 hours, and 79.6% of households use maize as the main food. Three fourth (75%) of the total households were food insecure ranging from mild to severe food insecurity. Boys were at higher risk of having lower length-for-age z-score than girls (β -0.53; 95% Confidence Interval (CI): -0.78, -0.27). For each month the children grew older, length-for-age z-score decreased slightly (β -0.06; -0.07, -0.04). Household food insecurity scores (β -0.05; -0.08, -0.01) and children haemoglobin levels, (β 0.21; 0.06, 0.35) were also associated with length-for-age z-score among young children.

Conclusion

Linear growth failure (stunting) was prevalent among young children in the rural Sidama region and the majority of them were also anaemic. Older age, male sex, a lower haemoglobin level in children, and household food insecurity were risk factors of linear growth failure in young children. Maize seems to be the dominant food in this previously ensete dominated area; however, there have been minimal improvements in length-for-age z-score over decades. Strategies to ensure household’s food access and improve the quality of child diets need to be implemented.

Head circumference as an epigenetic risk factor for maternal nutrition

Nutrition indicators for malnutrition can be screened by many signs such as stunting, underweight or obesity, muscle wasting, and low caloric and nutrients intake. Those deficiencies are also associated with low socioeconomic status. Anthropometry can assess nutritional status by maternal weight measurements during pregnancy. However, most studies have focused primarily on identifying changes in weight or Body Mass Index (BMI), and their effects on neonatal measures at present time. Whereas head circumference (HC) has been associated with nutrition in the past. When the mother was exposed to poor nutrition and unfavorable social conditions during fetal life, it was hypothesized that the intergenerational cycle was potentially mediated by epigenetic mechanisms. To investigate this theory, maternal head circumference (MHC) was associated with neonatal head circumference (NHC) in pregnant women without preexisting chronic conditions, differentiated by sociodemographic characteristics. A multiple linear regression model showed that each 1 cm-increase in MHC correlated with a 0.11 cm increase in NHC (β95% CI 0.07 to 0.15). Notwithstanding, associations between maternal and neonatal anthropometrics according to gestational age at birth have been extensively explained. Path analysis showed the influence of social status and the latent variable was socioeconomic status. A model of maternal height and head circumference was tested with effects on neonatal HC. The social variable lacked significance to predict neonatal HC in the total sample (p = 0.212) and in the South/Southeast (p = 0.095), in contrast to the Northeast (p = 0.047). This study highlights the potential intergenerational influence of maternal nutrition on HC, suggesting that maternal nutrition may be more relevant in families with major social vulnerability.

The Indirect Impact of Smallholder Vegetable Production on Children's Nutrition Outcomes in Rural Vietnam

Childhood undernutrition, particularly stunting, wasting, and micronutrient deficiencies, remains a major health concern in rural Vietnam. While literature suggests leveraging agriculture to improve child nutrition via agricultural diversification, market engagement, and women's empowerment, very few studies have empirically explored how smallholder vegetable production can influence household nutrition. This paper examines the association of household-level vegetable diversity, market access, and market participation with nutrition outcome measures of children in smallholder households. We use a cross-sectional household dataset, collected in 2016 in northwest Vietnam, covering 234 children aged 6–60 months. We estimate and compare the results of regression models using three-stage least squares (3SLS), ordinary least squares (OLS), logistic regression, and seemingly unrelated regression (SUR), to explore variations in six nutrition outcome measures: height-for-age z-score (HAZ), weight-for-height z-score (WHZ), weight-for-age z-score (WAZ), stunting, wasting, and underweight. Our results suggest smallholder vegetable production has a significant indirect association with children's nutrition status via market participation. Market participation is an important factor in improving girls' HAZ and WHZ, and in reducing the probability of boys being stunted and underweight. The additional income from selling vegetables allows households to purchase nutritious food, which is likely to have a positive impact on children's nutrition outcomes.

Birth length is the strongest predictor of linear growth status and stunting in the first 2 years of life after a preconception maternal nutrition intervention: the children of the Women First trial

BACKGROUND

The multicountry Women First trial demonstrated that nutritional supplementation initiated prior to conception (arm 1) or early pregnancy (arm 2) and continued until delivery resulted in significantly greater length at birth and 6 mo compared with infants in the control arm (arm 3).

OBJECTIVES

We evaluated intervention effects on infants' longitudinal growth trajectory from birth through 24 mo and identified predictors of length status and stunting at 24 mo.

METHODS

Infants' anthropometry was obtained at 6, 12, 18, and 24 mo after the Women First trial (registered at clinicaltrials.gov as NCT01883193), which was conducted in low-resource settings: Democratic Republic of Congo, Guatemala, India, and Pakistan. Longitudinal models evaluated intervention effects on infants' growth trajectory from birth to 24 mo, with additional modeling used to identify adjusted predictors for growth trajectories and outcomes at 24 mo.

RESULTS

Data for 2337 (95% of original live births) infants were evaluated. At 24 mo, stunting rates were 62.8%, 64.8%, and 66.3% for arms 1, 2, and 3, respectively (NS). For the length-for-age z-score (LAZ) trajectory, treatment arm was a significant predictor, with adjusted mean differences of 0.19 SD (95% CI: 0.08, 0.30; P < 0.001) and 0.17 SD (95% CI: 0.07, 0.27; P < 0.001) for arms 1 and 2, respectively. The strongest predictors of LAZ at 24 mo were birth LAZ <-2 and <-1 to ≥-2, with adjusted mean differences of -0.76 SD (95% CI: -0.93, -0.58; P < 0.001) and -0.47 SD (95% CI: -0.56, -0.38; P < 0.001), respectively. For infants with ultrasound-determined gestational age (n = 1329), the strongest predictors of stunting were birth LAZ <-2 and <-1 to ≥- 2: adjusted relative risk of 1.62 (95% CI: 1.39, 1.88; P < 0.001) and 1.46 (95% CI: 1.31, 1.62; P < 0.001), respectively.

CONCLUSIONS

Substantial improvements in postnatal growth are likely to depend on improved intrauterine growth, especially during early pregnancy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Effect of Pumpkin Seed Biscuits and Moringa Capsules on (Malondialdehyde) Levels and Birth Outcomes of Pregnant Women

BACKGROUND: Maternal and infant mortality is a global health problem, the direct cause of which is malnutrition. Dietary supplements and vegetables are mandatory to support the nutritional needs of pregnant women. Moringa oleifera and pumpkin seeds contain many nutrients, and the price is relatively cheap; therefore, they are very good for consumption by pregnant women. The aim of the study was to find literature on the effect of pumpkin seed biscuits and moringa capsules on the effects of malondialdehyde (MDA) levels and birth outcomes of pregnant women. AIM: The objective of the study was to review journals related to the effect of pumpkin seed biscuits and moringa capsules on (MDA) levels and birth outcomes of pregnant women. METHODS: Study literature by collecting relevant journal data based on PubMed, ScienceDirect, and ProQuest. RESULTS: supplementary food that is cheap and easily available to pregnant women by giving pumpkin seeds and moringa leaf extract has an impact on improving nutritional status and preventing such as low birth weight (LBW). Moreover, the result found that food ingredients from pumpkin seeds and moringa have high nutritional value and are very beneficial for pregnant and lactating women. CONCLUSION: The screened articles with inclusion and exclusion criteria support and recommend additional nutrients such as Moringa oleifera and pumpkin seeds to pregnant women. These two foods directly contribute to the prevention of MDA which causes stress, preeclampsia, LBW babies, severe anemia, babies growth and development, as well as maternal and babies mortality.

The "Cinderella sector": The challenges of promoting food and nutrition for young children in early years' settings in England

The quality of food that children eat in early childhood has profound impacts on their future wellbeing. In England, many children eat the majority of meals in early years' settings including nurseries and childminders. We conducted 16 interviews with 18 stakeholders exploring food provision, the use of voluntary nutrition guidelines, and the effects of government support on the early years' sector. Key themes emerging from our thematic analysis included feeling insufficiently consulted, undervalued, support being unequally distributed, needing to fill multiple support roles for families, disagreement about the role and effect of voluntary nutrition standards, and being chronically underfunded.

A review of the prevalence, trends, and determinants of coexisting forms of malnutrition in neonates, infants, and children

OBJECTIVE

Coexisting Forms of Malnutrition (CFM) refers to the presence of more than one type of nutritional disorder in an individual. Worldwide, CFM affects more than half of all malnourished children, and compared to standalone forms of malnutrition, CFM is associated with a higher risk of illness and death. This review examined published literature for assessing the prevalence, trends, and determinants of CFM in neonates, infants, and children.

METHODS

A review of community-based observational studies was conducted. Seven databases, (CINAHL, Cochrane Library, EMBASE, Medline, PubMed, Scopus, and Web of Science) were used in December-2021 to retrieve literature. Google, Google Scholar and TROVE were used to search for grey literature. Key stakeholders were also contacted for unpublished documents. Studies measuring the prevalence, and/or trends, and/or determinants of CFM presenting in individuals were included. The quality of included studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools for prevalence and longitudinal studies.

RESULTS

The search retrieved 14,207 articles, of which 24 were included in this review. The prevalence of CFM varied by geographical area and specific types. In children under 5 years, the coexistence of stunting with overweight/obesity ranged from 0.8% in the United States to over 10% in Ukraine and Syria, while the prevalence of coexisting wasting with stunting ranged from 0.1% in most of the South American countries to 9.2% in Niger. A decrease in CFM prevalence was observed in all countries, except Indonesia. Studies in China and Indonesia showed a positive association between rurality of residence and coexisting stunting with overweight/obesity. Evidence for other risk and protective factors for CFM is too minimal or conflicting to be conclusive.

CONCLUSION

Evidence regarding the prevalence, determinants and trends for CFM is scarce. Apart from the coexistence of stunting with overweight/obesity, the determinants of other types of CFM are unclear. CFM in any form results in an increased risk of health adversities which can be different from comparable standalone forms, thus, there is an urgent need to explore the determinants and distribution of different types of CFM.

Undernutrition and its associated factors among pregnant women at the public hospitals of Bench-Sheko and Kaffa zone, southwest Ethiopia

Background

Undernutrition in pregnant women, expressed as low mid-upper arm circumference, is responsible for maternal mortality and morbidity, adverse birth outcomes, subsequent childhood malnutrition, and mortality. As a result, the purpose of this study was to determine the prevalence of maternal undernutrition and associated factors during pregnancy in public hospitals in the Bench-Sheko and Kaffa zones of southwest Ethiopia.

Methods

A facility-based cross-sectional study design was employed among 566 women who received antenatal care from March-May 2021 at the public hospitals of the Bench-Sheko and Kaffa zones, Southwest Ethiopia. A systematic random sampling technique was used to select the research unit. Undernutrition was measured by mid-upper arm circumference. The data were entered into Epi- Data version 3.1 and then exported to Statistical Package for Social Science (SPSS) version 21 software for analysis. Multivariate logistic regression models were constructed using variables with a P-value <0.25 in bivariate logistic regression analysis. Finally, in multivariate logistic regression analysis, the variable with a (P-value < 0.05) is considered statistically significant.

Results

A total of 566 pregnant women participated in our study with a response rate of 98.3%. The overall prevalence of undernutrition among pregnant women was 42.4% (95% CI: 38.3, 46.5). In multivariate logistic regression, the age of mothers between 16-24 years old (AOR = 3.9, 95% CI: 1.60, 9.70), household food insecurity (AOR = 1.81, 95% CI: 1.04, 3.15), and poor dietary knowledge (AOR = 3.25, 95% CI: 1.94, 5.47) were the factors significantly associated with undernutrition among pregnant women.

Conclusion

According to this study finding, the prevalence of undernutrition was very much high in the study area, which was significantly associated with the age groups of 16-24 years older women, poor dietary knowledge, and household food insecurity. Therefore, the strategies and programs targeted towards reducing and preventing undernutrition among pregnant mothers should be made at all levels to improve their nutritional status, and also health information, nutrition counseling, and food assistant should be provided.

Energy Intake and Food Restriction as Determinant Factors of Chronic Energy Deficiency among Pregnant Women in Rural Area of Sungai Sembilan, Riau, Indonesia

BACKGROUND OF THE STUDY: Maternal malnutrition is a major public health problem in Indonesia which is shown by high prevalence of chronic energy deficiency (CED) among pregnant women. CED was expressed by the measurement of Mid Upper Arm Circumference (MUAC) showing value less than 23.5 cm. AIM OF THE STUDY: This study aimed to identify the factors associated with chronic energy deficiency among pregnant women in rural area, Riau Province. METHODOLOGY: A community- based cross sectional study was conducted among 130 samples of pregnant women in Sungai Sembilan Community Health Center in June 2020. Data was collected using structured and field-study questionnaires. Mid Upper Arm Circumference (MUAC) was measured by MUAC tape. Energy and protein intake were assessed using 24-hour food recall. Multiple logistic regression was employed to analyse factors associated with CED by using SPSS version 20. RESULTS: The prevalence of CED among pregnant women was 64.9%. Age of mothers, food restriction, infection disease status, protein and energy intake were associated significantly with CED. Furthermore, energy intake and food restriction in pregnancy were risk factors of CED (AOR = 3.04, 95% CI: 1.1 – 8.3 and AOR = 6.73, 95% CI: 1.33 – 33.9, respectively). We found that proportion of energy intake below 80% RDA and mothers with food restriction were higher among CED group. CONCLUSION: High prevalence of chronic energy deficiency (CED) was found among pregnant women. Hence, innovative intervention was required to overcome this problem.

A qualitative inquiry of food insecurity in Belize

OBJECTIVE

To explore and provide contextual meaning around issues surrounding food insecurity, namely factors influencing food access, as one domain of food security.

DESIGN

A community-based, qualitative inquiry using semi-structured face-to-face interviews was conducted as part of a larger sequential mixed-methods study.

SETTING

Cayo District, Belize, May 2019-August 2019.

PARTICIPANTS

Thirty English-speaking individuals (eight males, twenty-two females) between the ages of 18-70, with varying family composition residing within the Cayo District.

RESULTS

Participants describe a complex interconnectedness between family- and individual-level barriers to food access. Specifically, family composition, income, education and employment influence individuals' ability to afford and access food for themselves or their families. Participants also cite challenges with transportation and distance to food sources and educational opportunities as barriers to accessing food.

CONCLUSION

These findings provide insight around food security and food access barriers in a middle-income country and provide avenues for further study and potential interventions. Increased and sustained investment in primary and secondary education, including programmes to support enrollment, should be a priority to decreasing food insecurity. Attention to building public infrastructure may also ease burdens around accessing foods.

An exploration of cultural influencing factors on dietary diversity in Malagasy children aged 6-59 months

Background

More than 1.7 million children in Madagascar are stunted, with low dietary diversity being a determinant. Although diverse crops are produced in the Vakinankaratra region, it registers the highest stunting prevalence rate nationally. While children’s diets may be influenced by region-specific cultural factors, little is known about this link so far. The aim of this study was to determine the influence of cultural habits on dietary diversity in children between 6 to 59 months in the Vakinankaratra region.

Methods

A mixed method design with a qualitative lead approach was used, including three transect walks, six focus group discussions and 51 semi-structured interviews with caregivers. The interviews contained a quantitative part to assess the four feeding indicators: ‘minimum meal frequency’, ‘minimum dietary diversity’, ‘minimum acceptable diet’ and the consumption of iron-rich foods. Participants were selected by convenience sampling. Data was collected in November 2019 in three communities displaying maximal possible variation.

Results

Subsistence farming with diverse crops and livestock was found to be a common practice. Minimum meal frequency was achieved by 78% of the sixty included children. In total, 45% attained minimum dietary diversity and 40% consumed a minimum acceptable diet. Across the three communities, the range of children attaining a minimum acceptable diet was 25–60%. Older, no longer breastfed children were prone to not achieving a minimum acceptable diet. Although caregivers had a basic idea of important foods for child development, these were often not available to or affordable for them. An effect of cultural events on diet, especially diversity, was found. Whilst for annual events this effect was short-term, the region-specific ceremony of reburying the dead (Famadihana) was found to have a long-term influence on the diet of certain families.

Conclusions

The dietary diversity of children under five in the Vakinankaratra region is influenced by cultural factors like agricultural practices, caregivers’ knowledge of child nutrition, food taboos and a region-specific cultural event. Cultural determinants, especially important traditions that result in significant expenditures, may thus influence the quality of children’s diet and should therefore be considered in future nutrition programmes and research on child malnutrition and stunting.

Differences in maternal and early child nutritional status by offspring sex in lowland Nepal

OBJECTIVE

On average, boys grow faster than girls in early life but appear more susceptible to undernutrition. We investigated sex differences in early child growth, and whether maternal nutritional status and diet differed by offspring sex during and after pregnancy in an undernourished population.

METHODS

We analyzed longitudinal data from a cluster-randomized trial from plains Nepal, stratifying results by child or gestational age. Children's outcomes (0-20 months) were weight, length, and head circumference and their z-scores relative to WHO reference data in 2-monthly intervals (n range: 24837 to 25 946). Maternal outcomes were mid-upper arm circumference (MUAC), and body mass index (BMI) during pregnancy (12-40 weeks) (n = 5550 and n = 5519) and postpartum (n = 15 710 and n = 15 356), and diet in pregnancy. We fitted unadjusted and adjusted mixed-effects linear and logistic regression models comparing boys with girls.

RESULTS

Boys were larger than girls, however relative to their sex-specific reference they had lower length and head circumference z-scores from birth to 12 months, but higher weight-for-length z-scores from 0 to 6 months. Mothers of sons had higher MUAC and BMI around 36 weeks gestation but no other differences in pregnancy diets or pregnancy/postpartum maternal anthropometry were detected. Larger sex differences in children's size in the food supplementation study arm suggest that food restriction in pregnancy may limit fetal growth of boys more than girls.

CONCLUSIONS

Generally, mothers' anthropometry and dietary intake do not differ according to offspring sex. As boys are consistently larger, we expect that poor maternal nutritional status may compromise their growth more than girls. Copyright © 2021 John Wiley & Sons, Ltd.

Community-level environmental characteristics predictive of childhood stunting in Bangladesh - a study based on the repeated cross-sectional surveys

Coastal morphology makes Bangladesh vulnerable to environmental hazards and climate change. Therefore, environmental characteristics may shape population health, including child health. The prevalence of stunting among under-five aged (U5) children is high in Bangladesh. However, there is a lack of research on environmental predictors of stunting. This study aimed to assess the association between community-level environmental characteristics and stunting using pooled data from the three latest Bangladesh demographic and health surveys (BDHS). According to the multilevel model, rainfall, distance to protected areas, and vegetation index showed a nonlinear association with stunting. The temperature was inversely, and distance to water bodies was positively related to stunting. Overall, results evidence the environmental characteristics are predictive of stunting, and these characteristics should be taken into account during intervention design to minimise the negative effects of environmental change on child health. Further research is also necessary to comprehend the causal pathways between environmental characteristics and stunting in Bangladesh.