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

Addressing Stunting in Children Under Five: Insights and Opportunities from Nepal, Bangladesh, and Vietnam-A Review of Literature

Background: Stunting remains a significant global health issue, particularly in low- and middle-income countries (LMICs). Globally, around 22% of children under five are affected, with high rates persisting in South and Southeast Asia. This review examines government-led programs in high-performing LMICs (Nepal, Bangladesh, and Vietnam) to identify key strategies and opportunities for effective intervention. Methods: A literature search was conducted on PubMed using keywords and Medical Subject Heading terms, including "stunting", "child undernutrition", "malnutrition" and the names of the three specified countries. Articles were evaluated for relevance based on their focus on stunting prevalence, risk factors, and interventions in these countries, without restrictions on publication date or language. Results: Stunting prevalence among children under five has significantly declined in Nepal, Bangladesh, and Vietnam over the past two decades, reflecting the impact of sustained nutrition and health interventions. Nepal reduced stunting from 55.8% in 2000 to 26.7% in 2022, Bangladesh from 54.7% to 26.4%, and Vietnam from 41.5% to 19.3%. Successful strategies included multisectoral approaches integrating nutrition-specific and nutrition-sensitive interventions, enhanced policy frameworks, and strong governance. Despite progress, challenges remain, such as high wasting prevalence in Nepal and disparities among marginalized communities in Vietnam, emphasizing the need for targeted, context-specific interventions. Conclusions: Effective stunting reduction requires multisectoral strategies addressing underlying, intermediate, and immediate determinants. Insights from Nepal, Bangladesh, and Vietnam highlight the importance of sustained government commitment, robust policies, and coordinated interventions. Adapting these successful strategies to local contexts can support stunting prevention and management, promoting healthier and more resilient communities.

The accuracy of a novel stunting risk detection application based on nutrition and sanitation indicators in children aged under five years

BACKGROUND

Adaptive and innovative technologies to prevent stunting are being developed continuously in various countries. This study aimed to develop and evaluate the accuracy of a stunting risk detection application based on nutrition and sanitation indicators in children aged under five years.

METHODS

This cross-sectional study was conducted between June and September 2023 and involved 316 mother-child pairs selected by simple random sampling from urban (n = 244) and rural (n = 72) areas in Bogor, West Java Province, Indonesia. An application was developed to detect stunting risk based on 25 indicators: eight indicators of maternal and child characteristics, eight nutrition indicators, and nine indicators of personal hygiene and sanitation. The nutrition and sanitation indicators were determined according to the World Health Organization conceptual framework for stunting. The accuracy of the stunting prediction model was analyzed using the Area Under Curve (AUC) and the Receiver Operating Characteristics (ROC) Curve method.

RESULTS

Of the 316 included children, 29.5% were stunting. The developed stunting risk detection application exhibited good sensitivity (88.3%) and specificity (83.3%). It accurately detected children at risk of stunting with an AUC of 89.6%. In urban areas, eight indicators were significantly predictive of stunting: mother's height, child's age, exclusive breastfeeding, frequency of protein consumption, balanced diet, washing hands with soap, availability of complete room functions in the house, and good household waste management. In rural areas, eight indicators were significantly predictive of stunting: mother's height, history of infectious disease, early initiation of breastfeeding, frequency of protein consumption, complementary feeding, washing hands with soap, availability of safe food storage, and availability of clean water sources for drinking. Mother's height was the dominant factor in predicting stunting in urban (adjusted odds ratio [aOR] = 3.321, 95% confidence interval [CI] = 1.202-3.051, p = 0.006) and rural (aOR = 3.927, 95% CI = 1.132-4.281, p = 0.001).

CONCLUSION

The developed application exhibited good accuracy and quickly assessed the risk of stunting in children, enabling it to provide appropriate recommendations to prevent stunting. However, it must be improved by simplifying the number of included indicators and re-testing on a broader scale.

Professionalisation of Community Health Workers: Time for a Formal Contract

Community health workers (CHWs) are the backbone of strong primary healthcare systems. If properly supported, they can add significant value to access to healthcare service delivery. Yet, despite their proven effectiveness globally, systemwide support for CHWs remains sub-optimal. This study explores the concept of 'proCHW' programs - where CHWs are skilled, supplied, supervised and salaried. We suggest a fifth component is added to this framework-security (defined as formal contracts). Currently, many CHWs work voluntarily without any formal contract, rendering them vulnerable to sudden replacements. Therefore, institutionalising formal contracts will provide legal safeguards for CHWs, ensuring fair and safe employment conditions, including a minimum wage and opportunities for career advancement. To enable funding for establishing formal contracts for CHWs, strong political commitment, public-private partnerships, and tailored funding strategies based on local administrative systems are needed. By addressing these challenges, sustainable funding can be achieved, maximising the impact of CHW-led programs and improving primary health care globally.

Priority Health Conditions and Global Life Expectancy Disparities

Importance

Life expectancy is a composite health measure reflecting acute and life-course exposures. Identifying conditions behind disparities in life expectancy can guide policy, planning, and financing to battle the most urgent health problems.

Objective

To examine the contribution of 33 causes of death to life expectancy disparities, highlighting 2 sets of priority conditions-8 infectious and maternal and child health conditions (I-8) and 7 noncommunicable diseases and injuries (NCD-7).

Design, Setting, and Participants

This cross-sectional study examined life expectancy disparities in 7 global regions and 165 countries from 2000 to 2021. Western Europe and Canada (hereafter referred to as the North Atlantic) in 2019 were used as a benchmark for life expectancy achievable with advanced health care and living standards. Life expectancy gaps in locations with life expectancy lower than the benchmark were decomposed by cause of death using the Pollard decomposition on the Global Health Estimates from the World Health Organization. Data were analyzed from February to March 2025.

Exposure

Geographic location (countries and regions).

Main Outcome and Measure

Life expectancy at birth.

Results

In the median country in 2019, the I-8 and NCD-7 together accounted for 80% (IQR, 71%-88%) of the life expectancy gap compared with the North Atlantic. Outside sub-Saharan Africa, the NCD-7 accounted for the largest share of the gap; for example, more than the total life expectancy gap in China, or 5.5 (95% uncertainty bounds [UB], 5.0-6.0) years of a 4.3-year life expectancy gap; and 6.4 (95% UB, 5.9-6.8) years of a 11.5-year gap in India. However, reduced mortality from the I-8 contributed to enormous improvements in sub-Saharan Africa, accounting for 21.4 (95% UB, 20.6-22.2) years of a 31-year gap in 2000 and 11.4 (95% UB, 10.9-11.8) years of a 22-year gap in 2019. India transitioned from having most of the gap accounted for by the I-8 in 2000, or 11.9 (95% UB, 11.0-13.0) years of a 19.6-year life expectancy gap, to having a larger share accounted for by the NCD-7 in 2019.

Conclusions and Relevance

This cross-sectional study suggests that a limited number of causes account for most life expectancy disparities. Together with current information on risk factors, interventions, and morbidity not yet reflected in life expectancy, the varying contributions of these causes to gaps in life expectancy can help focus health policy and guide interventions to reduce risk factors and treat conditions.

Protein supplementation delivered alone or in combination with presumptive azithromycin treatment for enteric pathogens did not improve linear growth in Bangladeshi infants: results of a cluster-randomized controlled trial

BACKGROUND

Protein requirements established for healthy populations may be insufficient to support healthy growth in infants consuming largely cereal-based complementary foods and frequently exposed to enteric pathogens.

OBJECTIVES

This study aimed to assess independent and combined effects of protein supplementation and antibiotic treatment on linear growth of infants aged 6-12 mo.

METHODS

We conducted a 2 × 4 factorial cluster-randomized trial in northwestern Bangladesh, allocating 566 clusters to masked azithromycin (10 mg/kg × 3 d) or placebo at 6 and 9 mo of age and unmasked delivery of an egg white protein-rich blended food supplement (250 kcal; 10 g added protein), a rice-based isocaloric supplement, egg, or nutrition education from 6 to 12 mo. We measured length at 6 and 12 mo. For this cluster-level intention-to-treat analysis of the 2 × 2 antibiotic and protein interventions, we used multiple linear or log-binomial regression with generalized estimating equations to assess changes in length-for-age z (LAZ) score and stunting (LAZ < -2), respectively.

RESULTS

We enrolled 2055 infants (283 clusters) and included 1821 infants (281 clusters) with complete anthropometry data at 6 and 12 mo in our analysis. There were no significant interactions between the protein and antibiotic interventions for any outcomes. Independently, protein supplement did not improve LAZ (β: 0.05; 95% CI: 0.00, 0.11; P = 0.07) or reduce stunting (prevalence ratio: 1.12; 95% CI: 0.85, 1.49; P = 0.41) compared with the isocaloric supplement. The antibiotic intervention had no effect on LAZ (β: -0.05; 95% CI: -0.11, 0.01; P = 0.09) or stunting (prevalence ratio: 0.99; 95% CI: 0.75, 1.31; P = 0.96), relative to the placebo.

CONCLUSIONS

Supplementation to increase intakes of high-quality protein, provided with or without presumptive treatment for enteric pathogens, did not improve linear growth from 6 to 12 mo of age. This trial was registered at clinicaltrials.gov as NCT03683667.

Undernutrition and antibody response to measles, tetanus and Haemophilus Influenzae type b (Hib) vaccination in pre-school south African children: The VHEMBE birth cohort study

BACKGROUND

Under-vaccination is undoubtedly driving recent worldwide measles outbreaks, but undernutrition may also be playing a role in low- and middle-income countries. Studies have shown reduced immune response to vaccines in undernourished children but few have followed children beyond infancy, when they are more likely to be exposed to infectious diseases.

METHODS

In the Venda Health Examination of Mothers, Babies and the Environment (VHEMBE) South African birth cohort study, we examined the relationship between undernutrition, as measured by stunting and other growth measures, and vaccine-specific serum antibody level to three different vaccine types: measles, tetanus and Haemophilus influenzae type b (Hib). We included 621 fully-vaccinated children with anthropometric measurements at ages 1, 2, and 3.5 years and antibody levels at 3.5 and 5 years.

RESULTS

At 5 years of age, 90.4% of fully-vaccinated children were protected against measles, 66.7% against tetanus, and 56.1% against Hib. Children who were stunted or had any indicator of diminished growth at 3.5 years averaged a 24.1% (95% CI = -44.2, 0.6) or a 27.2% (95% CI = -45.1, -1.3) lower antibody titer for measles, respectively, relative to those with normal growth. In addition, girls, but not boys, with any indicator of diminished growth at 3.5 years averaged a 36.8% (-59.3, -7.0) lower antibody titer for tetanus. We found no association between undernutrition and Hib antibody titers.

CONCLUSIONS

Early life undernutrition may be associated with lower induction or persistence of antibody responses to certain vaccines. Addressing child undernutrition may improve vaccine efficacy and reduce the burden of vaccine-preventable diseases.

Exploring the determinants of malnutrition in 2-5 year Iranian children using structural equation modeling: national food and nutrition surveillance

BACKGROUND

Childhood malnutrition remains a critical public health challenge in low- and middle-income countries, contributing significantly to morbidity and mortality among children aged 2-5 years. This study was undertaken to assess the nutritional status of 2-5 y children and to explore the main determinants of child malnutrition in eight food insecure provinces of Iran.

METHODS

In each province, participants were invited to attend the health house/center to complete the questionnaire on the pre-appointed day. In this study, an android application comprising electronic questionnaires was employed for data collection. Anthropometric, dietary, food security and socioeconomic status (SES) assessments were performed. Structural equation modeling (SEM) was done to assess the structural relationship of malnutrition indicators (z-score of height to age (HAZ), z-score of weight to age (WAZ) and z-score of weight to height (WHZ)) with other variables.

RESULTS

Overall, 2247 children aged 42.2 ± 0.3 months were enrolled in the study, of whom 1048 (46.6%) were female and 1438 (64%) were urban residents. Based on Z score criteria, 216 (10.1%) of the studied children had less than - 2SD HAZ, 193 (8.4%) had lower than - 2SD WHZ and 188 (8.1%) had lower than - 2SD WAZ. The prevalence rates of stunting, wasting and underweight were not significantly different between boys and girls. Nevertheless, the occurrence of stunting was significantly higher in children residing in rural than in urban areas (p = 0.025). SEM analysis revealed that higher SES had a positive relationship with HAZ (0.089), WAZ (0.163) and WHZ (0.109). The effect of SES was greatest on WAZ, indicated by the highest absolute value of a path coefficient. There were specific indirect effects of father's education on HAZ (0.032, p = 0.001), WHZ (0.045, < 0.001) and WAZ (0.061, < 0.001) through effect on SES and DDS. SES had a direct effect on DDS (0.202).

CONCLUSIONS

Our findings using SEM approach provided more concrete evidence for the effect of the household's SES on child's nutritional status. Nevertheless, we still need to monitor the studied population in the context of our surveillance program to document more conclusive causal associations.

Sibling gender dynamics and childhood stunting in Ghana

BACKGROUND

Stunting remains a public health concern in sub-Saharan Africa. Despite the evolving awareness of the effect of family composition on child health outcomes, the influence of sibling gender on stunting has seldom been consistent. The current study investigated the association between sibling composition and stunting among children under five years in Ghana.

METHODS

This cross-sectional study utilized data from the most recent Ghana Demographic and Health Survey (GDHS 2022), focusing on 5416 mother-child dyads. Stunting prevalence was assessed through descriptive analysis, while logistic regression analysis was employed to examine the association between sibling composition and identify other risk factors associated with stunting.

RESULTS

The prevalence of stunting among children under five years of age was 18%. It was observed from the male sex-stratified model that having male siblings and having a combination of male and female siblings increased male children's odds of being stunted. In contrast, having siblings of either gender or having a combination of male and female siblings may not pose any stunting threats to female children as observed in the female sex-stratified model. Furthermore, being a male child (OR: 1.54; 95% CI: 1.25, 1.90) and never being breastfed (OR: 2.07; 95% CI: 1.31, 3.21) increased children's likelihood of stunting.

CONCLUSION

This study concludes that the extra nutrients boys require for healthy growth and development may increase their competition for nutrients, especially in households with limited resource. Parents and guardians are advised to be consciously aware of the subtle and apparent competition between male children and take appropriate measures to prevent children's deprivation of nutrition by their male siblings.

Suboptimal nutritional status of school-age children in Addis Ababa: evidence from the analysis of socioeconomic, environmental, and behavioral factors

Background

School-aged children (6-14 years old) are susceptible to malnutrition and micronutrient deficiencies. Environmental and behavioral factors greatly influence their nutritional status. This study aimed to examine the association between dietary factors and the nutritional status of school-aged children attending public and private schools in Addis Ababa.

Methods

A community-based cross-sectional study design was employed from March to August 2023. A total of 309 study participants were randomly selected from 10 schools. Data were entered into Epidata version 3.1 and exported to SPSS version 23.0 for analysis. WHO Anthro Plus 1.0.4 was used to assess the measurements of weight-for-age (WAZ), height-for-age (HAZ), and BMI-for-age (BAZ) for overweight, stunting, and underweight, while wasting was assessed using MUAC. A Poisson regression model was used to determine the association between predictor variables and stunting, wasting, underweight, and overweight, with adjusted prevalence ratios (APR). APR and 95% CI were used to identify statistically significant variables.

Results

Findings revealed the prevalence of wasting (15%), stunting (24%), underweight (36%), and overweight (19%) among school-aged children. Factors influencing stunting include marital status, house ownership, education level of parents/caregivers, child sex, and meal skipping. Wasting was linked to wealth index, child age, dietary diversity, dietary habits, water access, and toilet facilities. Underweight predictors include parent/caregiver age, marital status, and meal frequency. Moreover, school type appeared as a significant factor for overweight.

Conclusions

The overall nutritional status of school-aged children is suboptimal, influenced by sociodemographic, environmental, and behavioral factors. Addressing these factors through targeted interventions is crucial, particularly for the most vulnerable groups.

Determination of appropriate policy targets to reduce the prevalence of stunting in children under five years of age in urban-poor communities in Indonesia: a secondary data analysis of the 2022 Indonesian national nutritional status survey

OBJECTIVE

Based on previous studies, urban-poor societies are very vulnerable to stunted children under five. The study aims to determine the appropriate policy targets to reduce the prevalence of stunted under-five children in urban-poor communities in Indonesia.

DESIGN

A study was conducted using a secondary data analysis. The study analysed existing data from the 2022 Indonesian National Nutritional Status Survey.

SETTING AND PARTICIPANTS

At the national level, Indonesia encompassed 43 284 toddlers.

INTERVENTIONS

Non-intervention study.

PRIMARY AND SECONDARY OUTCOMES

The study's eight independent factors were the mother's age, education, marital status, employment, wealth, antenatal care (ANC), children's age and sex, with nutritional status as the dependent variable. We employed a binary logistic regression test for the most recent exam.

RESULTS

Maternal age was related to stunted toddlers in communities of urban poor in Indonesia. The lower the education, the higher the possibility of having stunted kids. Unemployed mothers were 1.153 times more likely than employed mothers to have stunted under-five children (95% CI 1.145 to 1.160). The poorest were 1.235 times more likely to get stunted under-five than the poorer (95% CI 1.227 to 1.242). Mothers without ANC during pregnancy were 1.212 times more likely to get stunted kids than those with ANC during pregnancy (95% CI 1.186 to 1.240). All kids' ages were more probable than 0-11 to be stunted. Boys were 1.099 times more likely to be stunted than girls (AOR 1.099; 95% CI 1.093 to 1.105).

CONCLUSION

The appropriate policy targets to reduce the prevalence of stunted under-five children in urban-poor communities in Indonesia were younger mothers, those with poor education, those unemployed, the most impoverished, those without ANC, those with older under-five and those with boy kids.

Exploring the return-on-investment for scaling screening and psychosocial treatment for women with common perinatal mental health problems in Malawi: Developing a cost-benefit-calculator tool

This study sought to develop a user-friendly decision-making tool to explore country-specific estimates for costs and economic consequences of different options for scaling screening and psychosocial interventions for women with common perinatal mental health problems in Malawi. We developed a simple simulation model using a structure and parameter estimates that were established iteratively with experts, based on published trials, international databases and resources, statistical data, best practice guidance and intervention manuals. The model projects annual costs and returns to investment from 2022 to 2026. The study perspective is societal, including health expenditure and productivity losses. Outcomes in the form of health-related quality of life are measured in Disability Adjusted Life Years, which were converted into monetary values. Economic consequences include those that occur in the year in which the intervention takes place. Results suggest that the net benefit is relatively small at the beginning but increases over time as learning effects lead to a higher number of women being identified and receiving (cost‑)effective treatment. For a scenario in which screening is first provided by health professionals (such as midwives) and a second screening and the intervention are provided by trained and supervised volunteers to equal proportions in group and individual sessions, as well as in clinic versus community setting, total costs in 2022 amount to US$ 0.66 million and health benefits to US$ 0.36 million. Costs increase to US$ 1.03 million and health benefits to US$ 0.93 million in 2026. Net benefits increase from US$ 35,000 in 2022 to US$ 0.52 million in 2026, and return-on-investment ratios from 1.05 to 1.45. Results from sensitivity analysis suggest that positive net benefit results are highly sensitive to an increase in staff salaries. This study demonstrates the feasibility of developing an economic decision-making tool that can be used by local policy makers and influencers to inform investments in maternal mental health.

The Egg Hub Model: A Sustainable and Replicable Approach to Address Food Security and Improve Livelihoods

Background

Despite progress in improving living standards and reduced poverty, food insecurity and malnutrition remain a significant issue worldwide. Childhood is a critical time for the intake of protein to support physical and cognitive growth, including animal-source foods like eggs which can effectively mitigate stunting in low- and middle-income countries. In Malawi, high malnutrition rates among women and children represent a significant public health challenge, but high-quality sources such as eggs remain costly, scarce, and rarely consumed by children in Malawi. The Egg Hub model, identified and piloted by local agri-food entrepreneurs and the Sight and Life Foundation in Malawi, tackles the obstacles faced by smallholder farmers, working to increase egg production, enhance availability, and improve consumption within rural communities by supporting small-scale farmers transition from unsustainable and unproductive backyard rearing to small-scale farm through access to high-quality inputs, training, loans, and a guaranteed market for their eggs.

Objectives

This paper provides a detailed account of the implementation of the pilot of the Egg Hub Model in Malawi including the demand creation process, the impact of the model on producers, consumers, and operators, and the social, economic, and environmental sustainability aspects of the model.

Methods

Qualitative and quantitative surveys (n = 217 consumers) were used for demand creation and qualitative surveys were used with 15 retailers to determine egg sales. With 16 farmers and the egg hub operator, business metrics, including profits and loss records, were analyzed.

Results

The pilot of the Egg Hub model in Malawi supported 85 farmers to triple their egg production, allowing their communities to purchase eggs at prices reduced by 40%, benefiting an estimated number of 180,000 rural poor. Egg consumption among the target population increased from an average of 2 to 9 eggs/month and led to reduced egg wastage and better biosecurity, reducing the risk of children's exposure to chicken feces and infections. The achievements of this Egg Hub in Malawi allowed the model to be replicated in Ethiopia, Peru, and Brazil, producing 40 million eggs annually and benefiting more than half a million consumers.

Conclusion

The Egg Hub model is a comprehensive and scalable solution to increase egg supply, address malnutrition and food insecurity, and improve livelihoods. The advantages include centralizing key activities through a community-centered approach, empowering female farmers, increasing access to a highly nutritious food, and economic benefits for farmers and their communities.

Effects of short birth interval on child malnutrition in the Asia-Pacific region: Evidence from a systematic review and meta-analysis

Child malnutrition remains a significant concern in the Asia-Pacific region, with short birth intervals recognised as a potential risk factor. However, evidence of this association is inconclusive. This study aimed to systematically review the existing evidence and assess the summary effects of short birth interval on child malnutrition in the Asia-Pacific region. Five electronic databases were searched in May 2023 to identify relevant studies reporting the association between short birth interval and child malnutrition, including stunting, wasting, underweight, anaemia and overall malnutrition, in Asia-Pacific region between September 2000 and May 2023. Fixed-effects or random-effects meta-analysis was performed to estimate the summary effects of short birth interval on child malnutrition. Out of 56 studies meeting the inclusion criteria, 48 were included in quantitative synthesis through meta-analysis. We found a slightly higher likelihood of stunting (n = 25, odds ratio [OR] = 1.13; 95% confidence interval [CI]: 0.97-1.32) and overall malnutrition (n = 3, OR = 2.42; 95% CI: 0.88-6.65) among children born in short birth intervals compared to those with nonshort intervals, although the effect was not statistically significant. However, caution is warranted due to identified heterogeneity across studies. Subgroup analysis demonstrated significant effects of short birth intervals on child malnutrition in national-level studies and studies with larger sample sizes. These findings underscore short birth intervals as a significant contributor to child malnutrition in the Asia-Pacific region. Implementing effective policies and programs is vital to alleviate this burden, ultimately reducing child malnutrition and associated adverse outcomes, including child mortality.

Perspective: Connecting the dots between domestic livestock ownership and child linear growth in low- and middle-income countries

Child stunting due to linear growth faltering remains a pervasive issue in low- and middle-income countries. Two schools of thought have existed pertaining to the role of domestic livestock ownership (DLO) in child linear growth. On one hand, it is argued that DLO leads to greater income and financial security, resulting in better child-raising conditions, including greater animal-source food (ASF) consumption, having protective effects towards child stunting. On the other hand, researchers argue that DLO contributes to faecal contamination and transmission of zoonotic enteric infections from animals to children, thus having destructive effects on child growth. Reviews of this association have revealed ambiguous findings. In this perspective, we argue that measuring the association between exposures to domesticated animals and child stunting is difficult and the ambiguous associations revealed are a result of confounding and differences in the management of DLO. We also argue that the increasingly prominent area of research of environmental enteric dysfunction, a sub-clinical condition of the small intestine thought to be due to frequent faecal pathogen exposure and associated with stunting, will be a useful tool to measure the potential destructive effects of DLO on child growth. We present our argument and identify challenges and considerations and directions for future research.

Less stunted? The impact of Chinese health aid on child nutrition

Despite the increasing recognition of China's role as a global health donor, particularly in Africa, few studies have explored its effectiveness. We geographically matched project-level aid data from AidData with household survey data from Demographic and Health Surveys across eight African countries to examine the effect of Chinese health aid on the nutritional status of children in recipient countries. In addition to adopting a spatiotemporal identification strategy, we also included mother fixed-effects to examine variations among siblings who were exposed to Chinese health aid projects at different times. The empirical results consistently indicated that children living adjacent to Chinese health aid projects had a better nutritional status. The treatment effect of Chinese health aid projects is heterogeneous across household characteristics, types, and sectors of aid projects. Finally, vaccination may serve as a mechanism linking Chinese health aid and child nutrition in the treatment areas of recipient countries.

Effects of Cooking with Liquefied Petroleum Gas or Biomass on Stunting in Infants

BACKGROUND

Household air pollution is associated with stunted growth in infants. Whether the replacement of biomass fuel (e.g., wood, dung, or agricultural crop waste) with liquefied petroleum gas (LPG) for cooking can reduce the risk of stunting is unknown.

METHODS

We conducted a randomized trial involving 3200 pregnant women 18 to 34 years of age in four low- and middle-income countries. Women at 9 to less than 20 weeks' gestation were randomly assigned to use a free LPG cookstove with continuous free fuel delivery for 18 months (intervention group) or to continue using a biomass cookstove (control group). The length of each infant was measured at 12 months of age, and personal exposures to fine particulate matter (particles with an aerodynamic diameter of ≤2.5 μm) were monitored starting at pregnancy and continuing until the infants were 1 year of age. The primary outcome for which data are presented in the current report - stunting (defined as a length-for-age z score that was more than two standard deviations below the median of a growth standard) at 12 months of age - was one of four primary outcomes of the trial. Intention-to-treat analyses were performed to estimate the relative risk of stunting.

RESULTS

Adherence to the intervention was high, and the intervention resulted in lower prenatal and postnatal 24-hour personal exposures to fine particulate matter than the control (mean prenatal exposure, 35.0 μg per cubic meter vs. 103.3 μg per cubic meter; mean postnatal exposure, 37.9 μg per cubic meter vs. 109.2 μg per cubic meter). Among 3061 live births, 1171 (76.2%) of the 1536 infants born to women in the intervention group and 1186 (77.8%) of the 1525 infants born to women in the control group had a valid length measurement at 12 months of age. Stunting occurred in 321 of the 1171 infants included in the analysis (27.4%) of the infants born to women in the intervention group and in 299 of the 1186 infants included in the analysis (25.2%) of those born to women in the control group (relative risk, 1.10; 98.75% confidence interval, 0.94 to 1.29; P = 0.12).

CONCLUSIONS

An intervention strategy starting in pregnancy and aimed at mitigating household air pollution by replacing biomass fuel with LPG for cooking did not reduce the risk of stunting in infants. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).

Factors associated with children's cognitive, language, and motor development in deprived urban settings in Bangladesh

BACKGROUND

Children's development is multifactorial. Although there have been several studies exploring the association of children's development with maternal, child, and environmental factors, we are unaware of any study that assessed those factors in children whose mothers were enrolled in a social safety net programme in low- and middle-income countries. This study aimed to identify the factors associated with disadvantaged children's cognitive, language, and motor development at age 6-16 months in deprived settings of urban Bangladesh and to identify relative importance of these factors of children's development. We also explored if there were any gender differences in child development.

METHODS

This cross-sectional study was conducted in a deprived setting of urban Bangladesh. Bayley III was used for assessing children's cognitive, language, and motor development. Multivariable linear regression model was used to find the factors associated with children's development, and dominance analysis was used to explore the relative importance of the factors.

RESULTS

Out of the total 599 mother-child dyads, 303 (50.58%) were girls. The factors associated with children's development were length-for-age Z-score (cognitive: B = 1.21 [95% CI = 0.31, 2.11], P = 0.008; language: 1.67 [0.79, 2.55] P < 0.001; motor: 2.15 [1.01, 3.29] P < 0.001) and home environment (cognitive: 0.58 [0.27, 0.89] P < 0.001; language: 0.59 [0.27, 0.92], P < 0.001; motor: 0.44 [0.09, 0.79] P = 0.013). Girls had higher cognitive (1.90 [0.17, 3.6], P = 0.031) and language (2.53 [0.55, 4.51], P = 0.013) development compared with boys. Families with a higher number of under five children within the households had lower language (-1.57 [-2.78, -0.36], P = 0.011) development. Violence against the mother and the families' food security status were not associated with the children's development. Children's length-for-age Z-score (27%) and home stimulation environment (23%) were the most important factors of cognitive development.

CONCLUSION

Children's nutritional status and home environment are important factors for disadvantaged children's development in deprived urban settings of Bangladesh. Both early child development-focussed parenting and nutrition interventions should be considered when designing child development programmes in urban settings in low- and middle-income countries.

Costs and cost-effectiveness of treatment setting for children with wasting, oedema and growth failure/faltering: A systematic review

This systematic review aimed to address the existing evidence gaps, and guide policy decisions on the settings within which to treat infants <12 months of age with growth faltering/failure, and infants and children aged <60 months with moderate wasting or severe wasting and/or bilateral pitting oedema. Twelve electronic databases were searched for studies published before 10 December 2021. The searches yielded 16,709 records from which 31 studies were eligible and included in the review. Three studies were judged as low quality, whilst 14 were moderate and the remaining 14 were high quality. We identified very few cost and cost-effectiveness analyses for most of the models of care with the certainty of evidence being judged at very low or low. However, there were 17 cost and 6 cost-effectiveness analyses for the initiation of treatment in outpatient settings for severe wasting and/or bilateral pitting oedema in infants and children <60 months of age. From this evidence, the costs appear lowest for initiating treatment in community settings, followed by initiating treatment in community and transferring to outpatient settings, initiating treatment in outpatients then transferring to community settings, initiating treatment in outpatient settings, and lastly initiating treatment in inpatient settings. In addition, the evidence suggested that initiation of treatment in outpatient settings is highly cost-effective when compared to doing nothing or no programme implementation scenarios, using country-specific WHO GDP per capita thresholds. The incremental cost-effectiveness ratios ranged from $20 to $145 per DALY averted from a provider perspective, and $68 to $161 per DALY averted from a societal perspective. However, the certainty of the evidence was judged as moderate because of comparisons to do nothing/ no programme scenarios which potentially limits the applicability of the evidence in real-world settings. There is therefore a need for evidence that compare the different available alternatives.

Innovative financing for nutrition

Given the constraints of both overseas development aid and domestic financing for nutrition, innovative financing is critical-yet nutrition lags behind other sectors in catalysing it. Here, we argue that the framing for nutrition must evolve and critical actions must be taken to generate more money for nutrition and more nutrition for money. Food systems hold some of the most powerful opportunities to improve human and planetary health while increasing productivity-and the private sector has a key role to play in this.

A systematic review and meta-analysis of the prevalence of childhood undernutrition in North Africa

Undernutrition (stunting, wasting and underweight) among children remains a public health concern in North Africa, especially following recent conflicts in the region. Therefore, this paper systematically reviews and meta-analyses the prevalence of undernutrition among children under five in North Africa to determine whether efforts to reduce undernutrition are on track to achieving the Sustainable Development Goals (SDGs) by 2030. Eligible studies published between 1st January 2006 and 10th April 2022 were searched for, using five electronic bibliographic databases (Ovid MEDLINE, Web of Science, Embase (Ovid), ProQuest and CINAHL). The JBI critical appraisal tool was used, and a meta-analysis was conducted using the 'metaprop' command in STATA, to estimate the prevalence of each undernutrition indicator in the seven North African countries (Egypt, Sudan, Libya, Algeria, Tunisia, Morocco, and Western Sahara). Due to the significant heterogeneity among studies (I2 >50%), a random effect model and sensitivity analysis were conducted to examine the effect of outliers. Out of 1592 initially identified, 27 met the selection criteria. The prevalence of stunting, wasting and being underweight were 23.5%, 7.9% and 12.9%, respectively. Significant variations between the countries with the highest rates of stunting and wasting were reported in Sudan (36%, 14.1%), Egypt (23.7%, 7.5%), Libya (23.1%, 5.9%), and Morocco (19.9%, 5.1%). Sudan also had the highest prevalence of underweight (24.6%), followed by Egypt (7%), Morocco (6.1%), and Libya (4.3%) with more than one in ten children in Algeria and Tunisia having stunted growth. In conclusion, undernutrition is widespread in the North African region, particularly in Sudan, Egypt, Libya, and Morocco, making it challenging to meet the SDGs by 2030. Nutrition monitoring and evaluation in these countries is highly recommended.

Malnutrition and gender disparities in the Eastern Mediterranean Region: The need for action

Malnutrition takes a heavy toll on the populations of the Eastern Mediterranean Region (EMR), with gender related socioeconomic risk factors impacting undernutrition and obesity in both women and men. This perspective article, a derivative of a report by the World Health Organization, reviews the scientific literature on the effect of gender on malnutrition related outcomes in the EMR. Results revealed that biological and gender-related socioeconomic risk factors play a role for undernutrition and obesity in both women and men. Malnutrition can be negatively influenced by gender-biased cultural standards, habits, structural determinants, differential exposures, and health system gaps. This can result, for example, in women tending to focus on familial and household related needs, at the expense of their own health and physical mobility and on suffering more food insecurity, undernutrition, micronutrient deficiencies and obesity compared to men in the EMR. Conflict and crisis situations negatively affect both genders, but generally put women at a higher risk of adverse. Women's socially limited autonomy in mobility is also an obstacle to access to health services in the EMR, including those related to nutrition. Multi-level approaches are needed to address gender issues to enable a more equitable distribution of resources and reduce the impact of malnutrition in the EMR.

Risk Factors for Stunting among Children under Five Years in the Province of East Nusa Tenggara (NTT), Indonesia

In East Nusa Tenggara Province, Indonesia, 42.6% of children under five had stunted growth in 2018, which affects both individual and communal levels. The first step in creating effective interventions is identifying the risk factors for stunting. This study aims to pinpoint the stunting risk factors in East Nusa Tenggara Province, Indonesia, by incorporating secondary data from the 2018 Indonesia Basic Health Research (RISKESDAS). This study implemented a cross-sectional design by utilizing the data of individuals who were successfully visited during the survey. Initial data screening in East Nusa Tenggara Province based on the criteria for children aged 0−59 months and stunting showed as many as 1643. Multivariate logistic regression analysis was performed to evaluate the relationship between children’s characteristics and stunting. There was a significant relationship between age group variables for younger children (aged 12−23, 24−35, and 36−47 months), mothers with low education, and children living in rural areas with the incidence of stunting in children (p-value < 0.05). The dominant factors that caused stunting in this study were the children’s age of 24−35 months (OR = 2.08, 95% CI: 1.12−3.86), mothers with low education (OR = 1.57, 95% CI: 1.18−2.08), and children living in rural areas (OR = 1.39, 95% CI: 1.01−1.91). The highest prevalence of stunting was in the group of children aged 12−23 months (45.2%). To prevent child stunting, the government must intervene for mothers with low education and those living in rural areas. Intervention includes intensive socialization about improving nutritional status during pregnancy and practicing complementary feeding and breastfeeding habits until the child is 24 months old.

Ukraine's triple emergency: Food crisis amid conflicts and COVID-19 pandemic

Globally, both Russia and Ukraine play a key role in food production. Both countries are known for their meticulous positions in producing and exporting wheat, maize, sunflower seed oil, and cotton seed oil. Although the conflict between Russia and Ukraine has been going on for more than 5 years, the recent invasion of Russia in Ukraine has endangered food security in Ukraine during the COVID-19 pandemic. As COVID-19 cripples the healthcare infrastructure of Ukraine, food insecurity challenges the civilian population to migration. As the conflict intensitifes, damages to properties, loss of lives, rise of infectious diseases, incremental rise in energy prices, and fuel consumption are some of the possible consequences. This commentary aims to highlight the different ways in which access to food has been endangered, the implications that food crisis has on the world, and thus provide key recommendations on what needs to be addressed to mitigate the rising risks of the food crisis in the world.