Undernutrition among infants less than 6 months of age: an underestimated public health problem in India

Routine antibiotics for infants less than 6 months of age with growth failure/faltering: a systematic review

OBJECTIVE

This systematic review commissioned by WHO aimed to synthesise evidence from current literature on the effects of systematically given, routine use of antibiotics for infants under 6 months of age with growth failure/faltering.

SETTINGS

Low-income and middle-income countries.

PARTICIPANTS

The study population was infants less than 6 months of age with growth failure/faltering.

INTERVENTION

The intervention group was infants who received no antibiotics or antibiotics other than those recommended in 2013 guidelines by WHO to treat childhood severe acute malnutrition. The comparison group was infants who received antibiotics according to the aforementioned guidelines.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was all-cause mortality, and secondary outcomes: clinical deterioration, antimicrobial resistance, recovery from comorbidity, adverse events, markers of intestinal inflammation, markers of systemic inflammation, hospital-acquired infections and non-response. The Grading of Recommendations Assessment, Development and Evaluation approach was considered to report the overall evidence quality for an outcome.

RESULTS

We screened 5137 titles and abstracts and reviewed the full text of 157 studies. None of the studies from the literature search qualified to answer the question for this systematic review.

CONCLUSIONS

There is a paucity of evidence on the routine use of antibiotics for the treatment of malnutrition in infants less than 6 months of age. Future studies with adequate sample sizes are needed to assess the potential risks and benefits of antibiotics in malnourished infants under 6 months of age.

PROSPERO REGISTRATION NUMBER

CRD42021277073.

Drivers of Stunting Reduction in Yogyakarta, Indonesia: A Case Study

BACKGROUND

Chronic malnutrition in children is a severe global health concern. In Yogyakarta, the number of children who are too short for their age has dropped dramatically over the past few decades.

OBJECTIVE

To perform an analysis of trends, policies, and programs; and an assessment of government, community, household, and individual drivers of the stunting reduction in Yogyakarta, Indonesia.

METHOD

Using a mixed-methods approach, there were three types of research: (1) analysis of quantitative data, (2) evaluation of stunting policy, and (3) focus group discussions and in-depth interviews to collect qualitative data.

RESULTS

The prevalence of stunting has decreased from year to year. Mean height-for-age z-scores (HAZ) improved by 0.22 SDs from 2013 to 2021. Male and female toddlers aged <20 months have relatively the same body length as the WHO median, but it is lower for children >20 months old. The COVID-19 pandemic has contributed to an increase in stunting-concurrent wasting. Nutrition-specific and -sensitive interventions have been carried out with coverage that continues to increase from year to year, although in 2020, or at the beginning of the COVID-19 pandemic, the coverage of specific interventions decreased. The government has committed to tackling stunting by implementing the five pillars of stunting prevention and the eight convergent stunting actions. As the drivers of stunting reduction, national and community stakeholders and mothers, at the village level, cited a combination of poverty reduction, years of formal education, prevention of early marriage, access to food, enhanced knowledge and perception, and increased access to sanitation and hygiene.

CONCLUSIONS

Nutrition-specific and -sensitive sector improvements have been crucial for decreasing stunting in Yogyakarta, particularly in the areas of poverty reduction, food access, preventing child marriage, sanitation, education, and increasing knowledge and perception.

Is Infant and Young Child-feeding (IYCF) a potential double-duty strategy to prevent the double burden of malnutrition among children at the critical age? Evidence of association from urban slums in Pune, Maharashtra, India

BACKGROUND

This study characterized undernutrition among children (0-24 months) by age groups specified for Infant and Young Child-feeding (IYCF) and determined the association between child malnutrition and IYCF.

METHODS

This cross-sectional survey recruited mother-children dyads (N = 1443). WHO standards were used to assess nutritional status and IYCF indicators. Multivariate analyses were performed to assess the association between IYCF and nutritional indicators.

RESULTS

Stunting, underweight, wasting, overweight, and obesity were prevalent in 33.1%, 26%, 20.2%, 4.6%, and 2.9% of the children, respectively. Age-wise distribution of undernutrition identified severity of stunting and underweight at 10-24 months (median < -1.6 SD; < -1.2 SD; 25th percentile at -2.6 & -2.2 SD respectively) and wasting highest at 0-6 months (25th percentile close to -2SD). Boys manifested higher stunting (lower value -5.2 SD) and were more wasted (lower value -4.7 SD). IYCF prevalence recorded early initiation at 45.2%, exclusive breastfeeding at 23.1%, and prelacteal and bottle-feeding at 37.5 and 22.5% respectively. Child minimum diet diversity (MDD) ≥4 was not achieved by 84%. Minimum meal frequency and minimum acceptable diet were achieved by 75% and 14% respectively. Bottle-feeding increased the odds of wasting [AOR: 1.501 (95% CI: 1.062-2.121)], severe stunting [AOR: 1.595 (95% CI: 1.079-2.358)] and underweight [AOR: 1.519 (95% CI 1.102-2.094)]. Wasting according to BAZ scores was associated with delayed initiation of breastfeeding [AOR: 1.387 (95% CI: 1.018-1.889)] and bottle feeding [AOR: 1.538 (95% CI: 1.087-2.175)]. Delayed introduction of complementary feeding increased the odds of severe stunting [AOR: 2.189 (95% CI: 1.090-4.399)]. Formula feeding increased the odds of underweight [AOR: 1.738 (95% CI: 1.046-2.888)] and obesity [AOR: 4.664 (95% CI: 1.351-16.10)]. Prelacteal feeding increased the odds of severe forms of stunting and underweight by 56% and 79% respectively, and overweight by 96%.

CONCLUSION

Setting and age-specific interventions to improve age-appropriate child-feeding practices are vital to address the double burden of malnutrition in the critical age group.

Protocol for a systematic review on routine use of antibiotics for infants less than 6 months of age with growth failure/faltering

INTRODUCTION

Antibiotics have been used as an adjunct in treating children with severe acute malnutrition 6-59 months of age; however, the data for infants less than 6 months are scarce. The WHO recently started guideline development for preventing and treating wasting, including growth failure/faltering in infants less than 6 months. This systematic review commissioned by WHO aims to synthesise evidence from current literature on the effectiveness of antibiotics for infants less than 6 months of age with growth failure/faltering.

METHODS AND ANALYSIS

We will conduct a systematic review and meta-analysis for studies that assessed the effect of antibiotics in the treatment of infants with growth faltering. We will search multiple electronic databases. We will include randomised control trials and non-randomised studies with a control arm. The study population is infants less than 6 months of age with growth failure. The intervention group will be infants who received no antibiotics or antibiotics other than recommended in 2013 guidelines by WHO to treat severe acute malnutrition in children. The comparison group will be infants who received antibiotics according to the 2013 guideline by WHO. We will consider the following outcomes: mortality, clinical deterioration, antimicrobial resistance, recovery from comorbidity, adverse events, markers of intestinal inflammation, markers of systemic inflammation, hospital-acquired infections, non-response. We will use the meta-analysis to pool the studies where applicable. We will use the Grading of Recommendations Assessment, Development, and Evaluation approach to reporting the overall evidence quality for an outcome.

ETHICS AND DISSEMINATION

This is a systematic review and will not involve contact with a human subject. The findings of this review will be published in a peer-review journal and will guide the WHO's recommendation for the use of antibiotics in infants less than 6 months of age with growth failure.

PROSPERO REGISTRATION NUMBER

CRD42021277073.

Healthy Family Index of Families with Children Experiencing Stunting

Stunting is a global problem that has a long-term impact on the quality of human resources. Stunting prevention can be achieved throughout supervision during the first 1000 days of life. The study aimed to examine whether health-conscious families can reduce and prevent stunting. The study location was in the operational area of Mifa Bersaudara Ltd. from March to September 2019. The research method used in this study was a quantitative observational study using a cross-sectional design. The instrument assessing the family health indicators issued by the Ministry of Health of Indonesia was used. The data were analysed using the health-conscious family index formula and Z-score for the infant nutritional status. The study participants were 293 families with toddlers. The study results show that the families living surrounding the operational area of the Mifa Bersaudara Ltd. are mostly pre-healthy families (51.5%) with more than 30% (n=88) of stunted children. There is a relationship between a healthy family index and stunting (p-value<0.05). The logistic regression test shows a significant relationship between the incidence of stunting and the families following the family planning program, exclusive breastfeeding, toddlers receiving monitoring, and no family members who smoke. Stunting is associated with health-conscious families. The incidence of stunting in infants and toddlers is associated with families that plan the pregnancy spacing (family planning), babies getting exclusive breastfeeding, toddlers getting growth monitoring, and no smoking family members.

Eco-geographic patterns of child malnutrition in India and its association with cereal cultivation: An analysis using demographic health survey and agriculture datasets

Background: High prevalence of maternal malnutrition, low birth-weight and child malnutrition in India contribute substantially to the global malnutrition burden. Rural India has disproportionately higher levels of child malnutrition. Stunting and wasting are the primary determinants of child malnutrition and their district-level distribution shows clustering in different geographies and regions. Cereals, particularly millets, constitute the bulk of protein intake among the poor, especially in rural areas in India where high prevalence of wasting persists.

Methods: The previous round of National Family Health Survey (NFHS4) has disaggregated data by district, enabling a more fine-scale characterisation of the prevalence of markers of malnutrition. We used data from NFHS4 and agricultural statistics datasets to analyse relationship of prevalence of malnutrition at the district level and area under cereal cultivation. We analysed malnutrition through data on under-5 stunting and wasting by district. 

Results: Stunting and wasting patterns across districts show a distinct geographical and age distribution; districts with higher wasting showed relatively higher prevalence at six months of age. Wasting prevalence at district level was associated with higher cultivation of millets, with a stronger association seen for jowar and other millets (Kodo millet, little millet, proso millet, barnyard millet and foxtail millet). District level stunting was associated with higher district level cultivation of wheat. In multivariable analysis, wasting was positively associated with women’s body mass index and stunting with women’s short stature.

Conclusions: Well-designed intervention studies will be required to confirm causal pathways contributing to ecogeographic patterns of child malnutrition. The cultivation of other millets has a strong association with prevalence of wasting. State-of-the-art studies that improve our understanding of bio-availability of amino acids and other nutrients from the prevalent dietary matrices of rural poor communities will be needed to confirm causal pathways contributing to potential eco-geographic patterns.

Health and nutritional status of children hospitalized during the COVID-19 pandemic, Bangladesh

Objective

To compare the health and nutrition of children younger than 5 years admitted to hospital during and before the coronavirus disease 2019 (COVID-19) pandemic in Bangladesh.

Methods

We collected data from hospital records of children 0–59 months admitted to the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh in March 2020–February 2021 (COVID-19 period; n = 2552) and March 2019–February 2020 (pre-COVID-19 period; n = 6738). Data collected included sociodemographic, anthropometric, clinical and biochemical characteristics. We compared these data for child admissions in the COVID-19 and pre-COVID-19 periods, including infants 0–11 months born during and before the pandemic and admitted to hospital.

Findings

Admissions of children as a percentage of total admissions were lower in March 2020 (2.47%; 63/2552) than March 2019 (8.30%; 559/6738), but increased to 20.61% (526/2552) in February 2021, three times greater than in the pre-COVID-19 period (6.69%; 451/6738). Children admitted during the COVID-19 period were significantly more likely to have dehydration, severe sepsis or septic shock, convulsions, hypernatraemia and raised creatinine than children admitted before the pandemic (P < 0.05). In infants < 6 months and those born during the pandemic, stunting and wasting were significantly higher than in infants in the pre-COVID-19 period (P < 0.05). The risk of death was higher in infants < 6 months during the pandemic (odds ratio: 1.66; 95% confidence interval: 0.95–2.92).

Conclusion

During the pandemic, children presented with more severe illness and poorer nutrition. Efforts are needed to reduce the adverse effects of the pandemic on the health and well-being of children.

Reducing Stunting Prevalence: Causes, Impacts, and Strategies

The prevalence of stunting in Indonesia was still high at 24.4% based on the 2021 Indonesian Nutritional Status Study, while at 20.9% in Central Java. Policymakers need to make quick and practical decisions to support the creation of an environment that empowers communities in stunting prevention. This current study aimed to describe the cause and effect of stunting and various applicable models of community empowerment in various regions of Indonesia to prevent stunting cases. This study used a qualitative method and focus group discussions (FDG) for data collection. It was conducted in mid-2022. The participants were the technical officers of the provincial government, National Population and Family Planning Board (BKKBN), non-government organizations, nutritionists, child health experts and academicians, as many as 2 participants from each organization selected by the purposive sampling method. The FGD results showed several good practices in some regions. One initiative to replicate is providing stunting prevention training for cadres and mothers of childbearing age and health promotion programs for prospective brides at least three months before marriage. Besides, forming a team for collecting data on prospective brides, and improving the existing recording system is required to reduce stunting prevalence.

The effect of convergent action on reducing stunting prevalence in under-five children in Banggai District, Central Sulawesi, Indonesia

OBJECTIVE

This study aimed to assess the amount of changes in prevalence of stunting after one-year convergence intervention.

METHODS

This was an evaluation study of national program that implemented in Banggai District beginning 2018. There were ten villages (n=532) that included in the program based on severity of stunting prevalence. Data were analyzed using chi-square and independent t-test using SPSS.

RESULT

After a year program, stunting reduced to 38.91% or 2.18% from the baseline (41.09%). The highest reduction was in at 0-5 mo (8.59%) and 6-11 mo (8.46%). There was no difference using height for age z-score in all ages (-1.64±1.19 to -1.59±1.38, p=0.506). However, the reduction was significant at 0-11 months (-1.20±1.23 to 0.78±1.58, p=0.020) but no in other age categories (p>0.05).

CONCLUSION

The convergence action for one year intervention reduced significantly stunting in 0-11 months of children but not in other age categories of under five children.

Assessing the role of mid upper arm circumference in identification of low birthweight and wasting in early infancy in India

AIM

We conducted this study to examine the mid upper-arm circumference (MUAC) of full-term infants from birth to 6 months; construct gender-specific MUAC graphs; and assess the role of MUAC as a surrogate marker for low birthweight and wasting in infants younger than 6 months.

METHODS

This is a prospective longitudinal study of 268 (133 female and 135 male) new-borns in a tertiary care centre in Navi Mumbai, India. We measured weight, length, head circumference and MUAC. We drew the MUAC curves for the first 6 months using the mean MUAC and standard deviation (SD) values and assessed the diagnostic test properties of MUAC at birth as a marker of low birthweight.

RESULTS

The mean (SD) birthweight of the male and female new-borns was 2756.2 g (368.1) and 2803.8 g (326.2), respectively (P = 0.25). The mean (SD) MUAC at birth was 8.7 (0.3) cm in males and 8.8 (0.2) cm in females, respectively (P = 0.14). The plotted mean MUAC curve in infants who were classified with wasting was between the -1SD and -2SD in both genders. The sensitivity and NPV for detecting low birthweight were 100% at cut-off of 8.6 cm in females and 8.7 cm in males, respectively (area under the curve: 0.92 (females) and 0.96 (males)).

CONCLUSION

MUAC may be a good proxy for low birthweight at birth and the curves from our study show that it may also help in the diagnosis of wasting in infants below 6 months of age in the community, particularly in resource-constrained settings.

100 days outcome of severe wasting in hospitalised infants <6 months of age

OBJECTIVE

To assess the outcome of severe wasting in infants below 6 months of age.

DESIGN

A prospective observational study conducted between January 2017 and October 2018.

SETTING

A medical college-affiliated hospital in Eastern Delhi, catering mainly to the urban poor population.

PARTICIPANTS

All children with severe wasting (weight-for-length Z-score (WLZ) < -3 sd) between 1 and 6 months of age, requiring hospitalisation.

RESULTS

Out of fifty children enrolled, during hospitalisation, forty-two (84 %) recovered (WLZ > -3 sd) and discharged; the median (interquartile range (IQR)) duration of stay was 9·5 (6·5, 13·0) d. After 100 d of enrolment, sustained cure (WLZ > -2 SD) could be achieved in only fifteen (30 %) infants, while another fourteen (28 %) recovered from severe wasting, but remained in moderately wasted state (WLZ between -2 and -3 sd). Overall, there were three (6 %) deaths (all during first week of hospitalisation); three (6 %) relapses and fifteen (30 %) defaulters (5, 5, 2, 1 and 2 defaulted during hospitalisation at day 15, day 60, day 75 and day 90, respectively).

CONCLUSIONS

The overall recovery rate from severe wasting in infants below 6 months of age was below the acceptable levels. In order to achieve better long-term outcome, community linkage services after discharge from hospital are required for supervised feeding, close monitoring and supportive care.

Towards identifying malnutrition among infants under 6 months: a mixed-methods study of South-Sudanese refugees in Ethiopia

OBJECTIVES

To determine (i) whether distinct groups of infants under 6 months old (U6M) were identifiable as malnourished based on anthropometric measures and if so to determine the probability of admittance to GOAL Ethiopia's Management of At Risk Mothers and Infants (MAMI) programme based on group membership; (ii) whether there were discrepancies in admission using recognised anthropometric criteria, compared with group membership and (iii) the barriers and potential solutions to identifying malnutrition within U6M.

DESIGN

Mixed-methods approaches were used, whereby data collected by GOAL Ethiopia underwent: factor mixture modelling, χ2 analysis and logistic regression analysis. Qualitative analysis was performed through coding of key informant interviews.

SETTING

Data were collected in two refugee camps in Ethiopia. Key informant interviews were conducted remotely with international MAMI programmers and nutrition experts.

PARTICIPANTS

Participants were 3444 South-Sudanese U6M and eleven key informants experienced in MAMI programming.

RESULTS

Well-nourished and malnourished groups were identified, with notable discrepancies between group membership and MAMI programme admittance. Despite weight for age z-scores (WAZ) emerging as the most discriminant measure to identify malnutrition, admittance was most strongly associated with mid-upper arm circumference (MUAC). Misconceptions surrounding malnutrition, a dearth of evidence and issues with the current identification protocol emerged as barriers to identifying malnutrition among U6M.

CONCLUSIONS

Our model suggests that WAZ is the most discriminating anthropometric measure for malnutrition in this population. However, the challenges of using WAZ should be weighed up against the more scalable, but potentially overly sensitive and less accurate use of MUAC among U6M.

Determinants of Breastfeeding Practices and Its Association With Infant Anthropometry: Results From a Prospective Cohort Study in South India

Introduction

Despite national efforts for promoting exclusive breastfeeding (EBF) during the first 6 months of the infants' life, breastfeeding rates are low in India. Evidence on the interference of supplementary food on optimal nourishment and growth of the infant has also been well-established. Our study was undertaken to assess the effect of breastfeeding practices on infant anthropometry and determine the various factors affecting breastfeeding practices.

Methods

A prospective cohort study - Maternal antecedents of adiposity and studying the transgenerational role of hyperglycemia and insulin (MAASTHI) was conducted at a tertiary care public hospital in Bengaluru, South India. From the consenting women, data such as obstetric history, infant feeding practices, anthropometry of mother and child, the psychosocial status of the women using the Edinburgh Postnatal Depression Scale (EPDS), was collected at baseline and subsequent follow-up: post-delivery and 14 weeks after birth. In this study, we analyzed data collected from April 2016 to April 2018, with descriptive statistics presented in mean and standard deviation, and logistic regression adjusting for confounders.

Results

Among the 240 women enrolled in the study, 33% (n= 80) were using supplementary food for their infants at 14 weeks of infants age. Infants who received supplementary feeding at age 14 weeks had nearly 2.5 times higher odds of being wasted (OR: 2.449, p-value: 0.002) as compared to exclusively breastfed infants.

Conclusion

Infants between 14 to 16 weeks of age who received supplementary feeding were at risk of wasting as compared to exclusively breastfed infants. Despite strong evidence in support of the benefits of exclusive breastfeeding, awareness in urban women in India is low. Increased focus on promoting exclusive breastfeeding is necessary to ensure proper nutritional intake and healthy growth of infants.

Criteria for undernutrition screening in hospitalised infants under 6 months: a diagnostic accuracy study in a resource-poor setting

PURPOSE

We aimed to describe the prevalence of undernutrition in hospitalised infants aged under 6 months and test the utility of simple index measures to detect undernutrition.

DESIGN

Diagnostic accuracy study: weight, length, mid-upper arm circumference (MUAC), triceps and subscapular skinfolds were measured in infants aged 2 weeks to 6 months admitted to a Teaching Hospital in Enugu, Nigeria. Index criteria : low (<-2SD) weight-for-age Z-scores (WAZ), weight-for-length Z-scores (WLZ); MUAC <11 cm. Reference definition: weight faltering (conditional weight gain below fifth percentile for healthy Nigerian infants) or sum of skinfolds (SSF) <10 mm.

RESULTS

Of 125 hospitalised infants, only 5% (6) were admitted specifically for undernutrition, but low SSF were found in 33% (41) and, 24% (25) with known birth weight had weight faltering, giving an undernutrition prevalence of 36%. Low WAZ was the most discriminating predictor of undernutrition (sensitivity 69%, positive predictive value 86%, likelihood ratio 5.5; area under receiver operator curves 0.90) followed by MUAC (73%, 73%, 4.9; 0.86), while WLZ performed least well (49%, 67%, 2.9; 0.84). Where both MUAC and WAZ were low, there was sensitivity 90%, positive predictive value 82% and likelihood ratio 8.7.

CONCLUSIONS

Infants aged under 6 months admitted to hospital in Nigeria had a high prevalence of undernutrition. In young, high-risk population, a low WAZ alone was a valuable screening criterion, while combining weight with MUAC gave even higher discrimination. Measurement of length to calculate WLZ was a less useful predictor in this population.

Prevalence and Risk Factors of Undernutrition among Children Less than 2 Years in Urban Slums of Pune, Maharashtra, India

Undernutrition and its risk factors among children aged 0-23 months in urban slums of Pune was studied. Maternal and child characteristics, household food security and anthropometric measurements of 400 children were recorded. Results identified prevalence of stunting to be 34%, wasting 15.3% and underweight 21.8%. Odds of stunting was higher among children 7 to 12 months of age (AOR=7.064, 95% CI: 1.908-26.150). Odds of wasting was higher among children 7 to 12 months (AOR=3.144, 95% CI: 1.631-6.060), age < 6 months (AOR=2.546, 95% CI: 1.259-5.149) and not feeding colostrum (AOR=2.806, 95% CI=1.059 -7.478). Birth weight < 2500gm increased the risk of all three manifests of undernutrition. Children who were not immunised or received partial immunization had 1.5 times greater risk of being underweight (AOR=1.933, 95% CI: 1.118-3.342). Age specific interventions to address specific risk factors is a priority to address this public health issue.

Effective nutrition education and communication for sustainable maternal and child health

Maternal and child health (MCH) consists of an interdependent reproductive system that collectively determines the survival of the mother during childbirth, and determines the health and survival of the child. This interdependency underscores the importance of appropriate and timely interventions during pregnancy through the first 1000 d at the minimum. The Millennium Development Goals (MDG) recommended the use of the continuum of care for the development of interventions by addressing all the stages of MCH. The purpose of the present paper is to review the factors that contributed to the attainment of the MDG 4 and MDG 5 by analysing the interventions conducted by the countries that achieved at least 5·0 and 5·5 %, respectively, and determine the level of their intervention based on the MCH conceptual framework. Out of the eighteen selected countries discussed, fifteen countries achieved their target for either MDG 4 or MDG 5 or both, while three countries did not achieve their target. The countries that were more likely to achieve their targets addressed the societal, underlying and direct causes, and implemented country wide policies. In contrast, the countries that did not succeed were more likely to address the direct causes with poor policy implementation. Understanding the motivation and limitations of the target population, including nutrition education and targeting behaviour change has the potential to result in sustainable MCH. This information has the potential to enlighten the policymakers as we progress to the sustainable development goals, specifically goals 2 and 3.

Determinants of age-specific undernutrition in children aged less than 2 years-the Bangladesh context

Globally, undernutrition affects nearly half of all children aged less than 5 years. It is more prominent in low- and middle-income countries. This study aimed to identify the age-specific risk factors for different categories of undernutrition among Bangladeshi children aged less than 2 years. Data of 10,291 children aged less than 2 years were collected between October 2011 to November 2013 through the Food Security Nutritional Surveillance Project in Bangladesh. Simple logistic regression established bivariate relationships between the categories of undernutrition and the relevant risk factors. Multiple logistic regression constructed the age-specific regression models depicting the independent association and effect size of the risk factors contributing to the various categories of undernutrition among study population. Stunting was prevalent among 30.9% of the study children, whereas 9.7% were wasted and 24.9% were underweight. Being a male child, increase in age, maternal body mass index and education, and household food insecurity were the strongest predictors for all categories of undernutrition in terms of effect size. Our study shows that the different categories of childhood undernutrition have different age-specific risk factors. Maternal body mass index and household food insecurity were the common age-specific risk factors for all categories of undernutrition. We expect our findings to enhance the existing evidence base for the risk factors of undernutrition among children aged less than 2 years.

Admission profile and discharge outcomes for infants aged less than 6 months admitted to inpatient therapeutic care in 10 countries. A secondary data analysis

Evidence on the management of acute malnutrition in infants aged less than 6 months (infants <6mo) is scarce. To understand outcomes using current protocols, we analysed a sample of 24 045 children aged 0-60 months from 21 datasets of inpatient therapeutic care programmes in 10 countries. We compared the proportion of admissions, the anthropometric profile at admission and the discharge outcomes between infants <6mo and children aged 6-60 months (older children). Infants <6mo accounted for 12% of admissions. The quality of anthropometric data at admission was more problematic in infants <6mo than in older children with a greater proportion of missing data (a 6.9 percentage point difference for length values, 95% CI: 6.0; 7.9, P < 0.01), anthropometric measures that could not be converted to indices (a 15.6 percentage point difference for weight-for-length z-score values, 95% CI: 14.3; 16.9, P < 0.01) and anthropometric indices that were flagged as outliers (a 2.7 percentage point difference for any anthropometric index being flagged as an outlier, 95% CI: 1.7; 3.8, P < 0.01). A high proportion of both infants <6mo and older children were discharged as recovered. Infants <6mo showed a greater risk of death during treatment (risk ratio 1.30, 95% CI: 1.09; 1.56, P < 0.01). Infants <6mo represent an important proportion of admissions to therapeutic feeding programmes, and there are crucial challenges associated with their care. Systematic compilation and analysis of routine data for infants <6mo is necessary for monitoring programme performance and should be promoted as a tool to monitor the impact of new guidelines on care.

Risk factors for severe acute malnutrition in children below 5 y of age in India: a case-control study

OBJECTIVE

To determine the possible risk factors for severe acute malnutrition (SAM) in children below 5 y admitted in a hospital in north India.

METHODS

This case-control study was conducted in a medical college hospital in children below 5 y of age. All cases of SAM (diagnosed as per WHO definition) between 6 and 59 mo of age were compared with age-matched controls with weight for height above -2SD of WHO 2006 growth standards. Data regarding socio-demographic parameters, feeding practices and immunization were compared between the groups by univariable and multivariable logistic regression models.

RESULTS

A total of 76 cases and 115 controls were enrolled. Among the 14 factors compared, maternal illiteracy, daily family income less than Rs. 200, large family size, lack of exclusive breast feeding in first 6 mo, bottle feeding, administration of pre-lacteals, deprivation of colostrum and incomplete immunization were significant risk factors for SAM. Regarding complementary feeding, it was the consistency, rather than the age of initiation, frequency and variety which showed a significant influence on occurrence of SAM. Multivariate analysis revealed that the risk of SAM was independently associated with 6 factors, namely, illiteracy among mothers, incomplete immunization, practice of bottle feeding, consistency of complementary feeding, deprivation of colostrum and receipt of pre-lacteals at birth.

CONCLUSIONS

The present study identifies certain risk factors which need to be focused on during health planning and policy making related to children with SAM in India.

The stunting syndrome in developing countries

Linear growth failure is the most common form of undernutrition globally. With an estimated 165 million children below 5 years of age affected, stunting has been identified as a major public health priority, and there are ambitious targets to reduce the prevalence of stunting by 40% between 2010 and 2025. We view this condition as a 'stunting syndrome' in which multiple pathological changes marked by linear growth retardation in early life are associated with increased morbidity and mortality, reduced physical, neurodevelopmental and economic capacity and an elevated risk of metabolic disease into adulthood. Stunting is a cyclical process because women who were themselves stunted in childhood tend to have stunted offspring, creating an intergenerational cycle of poverty and reduced human capital that is difficult to break. In this review, the mechanisms underlying linear growth failure at different ages are described, the short-, medium- and long-term consequences of stunting are discussed, and the evidence for windows of opportunity during the life cycle to target interventions at the stunting syndrome are evaluated.

Eliciting a policy response for the rising epidemic of overweight-obesity in India

India is experiencing multiple transitions with respect to nutrition patterns, epidemiology and demography. Along with staggering childhood undernutrition, a rapid rise in chronic diseases and their risk factors including overweight-obesity (O-O), among all sections of society, is compounding India's health challenges. We present an overview of the O-O scenario (prevalence, determinants) and profile existing initiatives to address this modifiable risk factor in India. Urgent attention from all sectors, committed resources, policy support and targeted actions are warranted to combat the dual burden of malnutrition. The health systems should be reoriented and strengthened, in addition to enabling actions in other sectors, to address prevention and control of non-communicable diseases and associated risk factors like O-O.