Critical windows for nutritional interventions against stunting

Undernutrition and associated factors among pregnant women in Ethiopia. A systematic review and meta-analysis

Background

Maternal undernutrition is a major public health concern due to its association with mortality and overall disease burden for mothers and their children. Maternal nutrition determines pregnancy outcomes since reduced intake of nutrients influences gestational age length, placental function, and fetal growth during pregnancy. The complexity of the intergenerational aspects of maternal nutrition may also confound the design of interventions. Therefore, this research aimed to assess the prevalence of undernutrition and associated factors among pregnant women in Ethiopia.

Methods

We identified the literature from PubMed, EMBASE, Scopus, and CINAHL databases. Data were entered into Microsoft Excel and then exported to Stata version 17 statistical software for analysis. The I2 and Q-statistic values detect the level of heterogeneity, and meta regression was performed to investigate between-study heterogeneity using more than one moderator. JBI quality assessment tools were used to include relevant articles. Evidence of publication bias was indicated using the funnel plot and Egger's linear regression test. The effect size was expressed in the form of point estimates and an odds ratio of 95% CI in the fixed-effect model.

Result

In total, 19 studies fulfill the inclusion criteria. The pooled prevalence of undernutrition among pregnant women was 32% (95% CI 31.3-33.2 I2 = 97.5%, P < 0.0). Illiteracy (AOR = 3.6 95% CI; 2.3-5.6), rural residence (AOR = 2.6 95% CI; 1.2-3.5), a lack of prenatal dietary advice (AOR = 2.6 95% CI; 1.8-3.7), household food insecurity (AOR = 2.5 95% CI; 1.9-3.2), and low dietary diversity score (AOR = 3.7 95% CI; 2.2-5.9) appear to be significantly associated with undernutrition among pregnant women.

Conclusion

The review showed that the prevalence of undernutrition is still high among pregnant women. Illiteracy, rural residence, a lack of prenatal dietary advice, household food insecurity, and low dietary diversity score were significantly associated with undernutrition during pregnancy. Interventions should focus on educating the public and helping families access food or supplements they need through local markets, health systems, and community-based support, as undernutrition is caused by numerous interconnected causes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/#myprospero, identifier: CRD42023417028.

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

Background

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

Method

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

Results

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

Conclusion

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

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.

Meals, Education, and Gardens for In-School Adolescents: A Cluster Randomized Trial of an Adolescent Nutrition Intervention Package in Tanzania

PURPOSE

This study aimed to implement and evaluate integrated, school-based nutrition intervention packages for adolescents in Dodoma, Tanzania.

METHODS

A cluster randomized controlled trial was conducted among six secondary schools in Dodoma, Tanzania. Two schools received the full-intervention package of school meals, nutrition education, school gardens, and community workshops. Two schools received the partial-intervention package without the school meals component. Two schools served as the controls and did not receive any intervention. The intervention was implemented over one academic year. The analytical sample included 534 adolescents aged 14 to 17 at baseline and 286 parents. Outcomes included nutrition knowledge, food preferences, diet quality, food insecurity, physical activity, growth, and anemia. Linear models were used to estimate mean differences, and logistic regression models were used to estimate odds ratios (ORs).

RESULTS

Compared to the control, both the partial (OR: 0.59; 95% confidence interval [CI]: 0.35, 1.00) and full (OR: 0.49; 95% CI: 0.40, 0.59) interventions were associated with lower odds of poor diet quality among adolescents. Among the parents, both the partial (OR: 0.28; 95% CI: 0.20, 0.40) and full (OR: 0.28; 95% CI: 0.13, 0.58) interventions were associated with lower odds of poor diet quality. The partial (OR: 0.29; 95% CI: 0.18, 0.47) and full (OR: 0.47; 95% CI: 0.30, 0.72) interventions were associated with lower odds of adolescent overweight or obesity.

DISCUSSION

School-based nutritional intervention packages incorporating multiple actions may improve the diet quality of adolescents and their household members and reduce the double burden of adolescent malnutrition.

8-Year Follow-up of a Maternal Education Trial in a Low-Resource Setting

OBJECTIVES

Nutrition and stimulation interventions promote early childhood development, but little is known about their long-term benefits in low- and middle-income countries. We conducted a follow-up study of a cluster-randomized maternal education trial performed in children aged 6 to 8 months to assess the sustainability of developmental benefits after 8 years.

METHODS

The education intervention lasted 6 months and consisted of nutrition, hygiene, sanitation, and child stimulation aspects. We assessed child processing and cognitive abilities using the Kaufman Assessment Battery for Children Second Edition (KABC-II) and attention and inhibitory control using the Test of Variables of Attention after 8 years. The original trial included 511 mother-child pairs (intervention, n = 263; control, n = 248), whereas in the current study, 361 (71%; intervention, n = 185; control, n = 176) pairs were available for analyses.

RESULTS

The intervention group scored higher than the controls (all P < .001) on all 5 KABC-II subscales and on the KABC-II global score (mean difference: 14; 95% confidence interval, 12-16; P < .001). For all 5 Test of Variables of Attention variables, the intervention group scored higher than the controls on both the visual and auditory tasks (all P < .05). Because the intervention was delivered as a package, a limitation is that we cannot pinpoint the individual contribution of each component (nutrition, hygiene, and stimulation) to the developmental benefits.

CONCLUSIONS

The intervention group consistently scored markedly higher on both neuropsychological tests. Thus, even 8 years after the original maternal education intervention, the developmental benefits that we observed at child age of 1, 2, and 3 years, were sustained.

Food and nutrition knowledge, attitudes and practices among children in public primary school with canteens in southern Benin: a case study

BACKGROUND

Food and nutrition notion among schoolchildren in Benin is still less documented. Few studies have examined the determinants of food and nutrition among schoolchildren while others have attempted to link knowledge, attitudes and practices to diet. The present study aims to evaluate food and nutrition knowledge, attitudes and practices among schoolchildren enrolled in public primary schools canteens in Cotonou and its surroundings.

METHODS

A diagnostic study was conducted in twelve public primary schools with canteens. A structured interview questionnaire was used to collect data from 861 schoolchildren aged 7 to 14 years. Three scores were used to assess the level of knowledge, attitude and practice. The overall score was the total of correct responses. The maximum score for all the three parameters was 15, 6 and 4 respectively for knowledge, attitude and practices. Data were analyzed using STATA 16. Logistic regression was performed to identify the relationship between food and nutrition practices and knowledge and attitude. Pearson goodness of fit test was performed to verify the adequacy of the model. A P-value of less than 0.05 (P < 0.05) was considered significant at 95% confidence interval.

RESULTS

schoolchildren's nutrition knowledge was low (mean score 2.52 ± 1.33) while attitude and practices were acceptable (mean score 4.08 ± 1.39 and 2.84 ± 0.77). Only 18.2% of schoolchildren knew the different food groups and 3.4% knew that they should eat at least five fruits and vegetables a day. Most of the schoolchildren (93.6%) were favorable to eat at least five fruits and vegetables and 86.8% were willing to eat more than 3 times a day. Among all practices, snacking between meals and eating breakfast were poorly observed by the schoolchildren. Nutrition knowledge was associated with practices observed among schoolchildren but not with attitudes. However, a significant positive association was observed (p < 0.05) between attitudes and practices.

CONCLUSION

Knowledge on food and nutrition among schoolchildren from public primary schools with canteen was low. This study suggests implementation of nutritional education to improve schoolchildren's knowledge and attitudes towards healthy diets and nutrition.

Pearl Memorial Lecture. Humans at the extremes: Exploring human adaptation to ecological and social stressors

The field of human biology has long explored how human populations have adapted to extreme environmental circumstances. Yet, it has become increasingly clear that conditions of social stress, poverty, and lifestyle change play equally important roles in shaping human biological variation and health. In this paper, I provide a brief background on the foundational human adaptability research of the International Biological Programme (IBP) from the 1960s, highlighting how its successes and critiques have shaped current research directions in the field. I then discuss and reflect on my own field research that has examined the influence of both environmental and social stresses on human populations living in different ecosystems: the Peruvian Andes, the Siberian arctic, and the Bolivian rainforest. Finally, I consider how the papers in this special issue advance our understanding of human adaptability to extreme conditions and offer directions for future research. Drawing on our field's distinctive evolutionary and biocultural perspectives, human biologists are uniquely positioned to examine how the interplay between social and ecological domains influences the human condition.

Quantity and quality of physical activity during adolescence: Evidence from a mixed-method study in rural Telangana, India

Adolescence is a unique transitional stage of physical and psychological development. As preferences and behavioural choices adopted in adolescence influence lifelong physical activity habits and health outcomes in adulthood, rural transformation in low- and middle-income countries has the potential to significantly change traditional roles and shape the next generation. By using a mixed-method approach that integrates energy expenditure estimates from accelerometer devices with 24-hour recall time-use data from adolescent boys and girls and qualitative interviews with adolescents and their caregivers, this study sheds light on the patterns of quantity and quality of physical activity of 395 adolescents in Khammam and Mahbubnagar districts of rural Telangana, India. The study shows that energy expenditure and time use are highest for educational-related activities followed by leisure in both adolescent boys and girls. However, notwithstanding the process of rural transformation and the educational infrastructure and economic opportunities provided to adolescent boys and girls, social and cultural norms allow boys, especially in late adolescence to spend more time and energy in activities outside the home such as pursuing economic work, sports and socialising, while girls spend more time and energy at home doing domestic work. The quantitative and qualitative exploration of physical activity and time use among adolescents, as expounded in this study cutting across age groups and gender, highlights the need for changes in gendered norms and renewed government strategies and investments in that direction.

Ten2Twenty-Ghana: a randomised controlled trial on the efficacy of multiple micronutrient-fortified biscuits on the micronutrient status of adolescent girls

Adolescent girls are an important target group for micronutrient interventions particularly in Sub-Saharan Africa where adolescent pregnancy and micronutrient deficiencies are common. When consumed in sufficient amounts and at levels appropriate for the population, fortified foods may be a useful strategy for this group, but little is known about their effectiveness and timing (regarding menarche), particularly in resource-poor environments. We evaluated the effect of consuming multiple micronutrient-fortified biscuits (MMB), sold in the Ghanaian market, 5 d/week for 26 weeks compared with unfortified biscuits (UB) on the micronutrient status of female adolescents. We also explored to what extent the intervention effect varied before or after menarche. Ten2Twenty-Ghana was a 26-week double-blind, randomised controlled trial among adolescent girls aged 10-17 years (n 621) in the Mion District, Ghana. Biomarkers of micronutrient status included concentrations of Hb, plasma ferritin (PF), soluble transferrin receptor (TfR) and retinol-binding protein (RBP), including body-iron stores. Intention-to-treat analysis was supplemented by protocol-specific analysis. We found no effect of the intervention on PF, TfR and RBP. MMB consumption did not affect anaemia and micronutrient deficiencies at the population level. MMB consumption increased the prevalence of vitamin A deficiency by 6·2 % (95 % CI (0·7, 11·6)) among pre-menarche girls when adjusted for baseline micronutrient status, age and height-for-age Z-score, but it decreased the prevalence of deficient/low vitamin A status by -9·6 % (95 % CI (-18·9, -0·3)) among post-menarche girls. Consuming MMB available in the market did not increase iron status in our study, but reduced the prevalence of deficient/low vitamin A status in post-menarcheal girls.

Metabolic Alterations in Mothers Living with HIV and Their HIV-Exposed, Uninfected Infants

HIV-exposed, uninfected (HEU) children present with suboptimal growth and a greater susceptibility to infection in early life when compared to HIV-unexposed, uninfected (HUU) children. The reasons for these findings are poorly understood. We used a metabolomics approach to investigate the metabolic differences between pregnant women living with HIV (PWLWH) and their HEU infants compared to the uninfected and unexposed controls. Untargeted metabolomic profiling was performed using 1H-NMR spectroscopy on maternal plasma at 28 weeks' gestation and infant plasma at birth, 6/10 weeks, and 6 months. PWLWH were older but, apart from a larger 28 week mid-upper-arm circumference, anthropometrically similar to the controls. At all the time points, HEU infants had a significantly reduced growth compared to HUU infants. PWLWH had lower plasma 3-hydroxybutyric acid, acetoacetic acid, and acetic acid levels. In infants at birth, threonine and myo-inositol levels were lower in the HEU group while formic acid levels were higher. At 6/10 weeks, betaine and tyrosine levels were lower in the HEU group. Finally, at six months, 3-hydroxyisobutyric acid levels were lower while glycine levels were higher in the HEU infants. The NMR analysis has provided preliminary information indicating differences between HEU and HUU infants' plasma metabolites involved in energy utilization, growth, and protection from infection.

Reconsidering the developmental origins of adult disease paradigm: The 'metabolic coordination of childbirth' hypothesis

In uncomplicated pregnancies, birthweight is inversely associated with adult non-communicable disease (NCD) risk. One proposed mechanism is maternal malnutrition during pregnancy. Another explanation is that shared genes link birthweight with NCDs. Both hypotheses are supported, but evolutionary perspectives address only the environmental pathway. We propose that genetic and environmental associations of birthweight with NCD risk reflect coordinated regulatory systems between mother and foetus, that evolved to reduce risks of obstructed labour. First, the foetus must tailor its growth to maternal metabolic signals, as it cannot predict the size of the birth canal from its own genome. Second, we predict that maternal alleles that promote placental nutrient supply have been selected to constrain foetal growth and gestation length when fetally expressed. Conversely, maternal alleles that increase birth canal size have been selected to promote foetal growth and gestation when fetally expressed. Evidence supports these hypotheses. These regulatory mechanisms may have undergone powerful selection as hominin neonates evolved larger size and encephalisation, since every mother is at risk of gestating a baby excessively for her pelvis. Our perspective can explain the inverse association of birthweight with NCD risk across most of the birthweight range: any constraint of birthweight, through plastic or genetic mechanisms, may reduce the capacity for homeostasis and increase NCD susceptibility. However, maternal obesity and diabetes can overwhelm this coordination system, challenging vaginal delivery while increasing offspring NCD risk. We argue that selection on viable vaginal delivery played an over-arching role in shaping the association of birthweight with NCD risk.

Developing and demonstrating an atomistic and holistic model of anthropometric failure among children under five years of age using the National Family Health Survey (NFHS)-5 data from India

Introduction

Composite Index of Anthropometric Failure (CIAF) and its further modifications have not incorporated all the combinations of malnutrition. We propose a new model incorporating all the forms of malnutrition among children under five years of age. However, the current models might misclassify a growing child as malnourished. Our objective is to develop a comprehensive scoring system using the three anthropometric Z-scores [height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height (WHZ) Z-scores] and demonstrate the proposed CIAF model using the National Family Health Survey-5 (NFHS-5) data from India.

Methods

A new scoring system was developed using the WAZ, HAZ, and WHZ scores to determine the child's nutritional status. We also proposed a new CIAF model by including all possible categories of malnutrition and practically demonstrated it using the NFHS-5 dataset after applying the new scoring system. Under-five children with heights, weights, and ages available were included in the analysis. The groups of malnutrition are presented as weighted proportions before and after applying the new score to the proposed model.

Results

Our final analysis included individual-level data of 198,802 children under five years of age (weighted N = 195,197). After applying the new scoring system to the proposed model, the prevalence of stunting has reduced to 11.8% (95% CI 11.66-11.94) from 13.2% (95% CI 13.09-13.39) and wasting prevalence has reduced to 4.9% (95% CI 4.85-5.04) from 6.4% (95% CI 6.29-6.51). The most common forms of anthropometric failures among Indian children by using the newly developed CIAF model are: "Stunting and underweight" (30,127; 15.4%), Stunting only (23,035; 11.8%), and "wasting and underweight" (14,698; 7.5%). We found a new category called "Stunting, underweight, and overweight" (stunting = HAZ < -2SD, underweight = WAZ < -2SD, overweight = WHZ > +2SD). It constituted 0.1% (220 children) of the total sample.

Conclusion

When the new scoring system is applied to the proposed CIAF model, it captures all forms and combinations of malnutrition among under-five children without overlap and prevents misclassifying a growing child as malnourished. The newly identified category shows that stunting (HAZ < -2SD), overweight (WHZ > +2SD) and underweight (WAZ < -2SD) can co-exist in the same child.

Growth Profiles of Children and Adolescents Living with and without Perinatal HIV Infection in Southern Africa: A Secondary Analysis of Cohort Data

Impaired linear growth and slower pubertal growth can be associated with perinatal HIV infection. We characterised growth relative to population norms, among the full adolescent period in southern Africa to better understand processes leading to morbidity in adulthood. We conducted a secondary analysis of 945 adolescents aged 8-20 years from urban Malawi and Zimbabwe; we included children with HIV (CWH), an uninfected comparison group from a cohort study, and CWH with co-morbid chronic lung disease (CLD) from a randomised controlled trial. We used latent class analysis of anthropometric Z-scores generated from British 1990 reference equations at two annual time-points, to identify growth trajectory profiles and used multinomial logistic regression to identify factors associated with growth profiles. Growth faltering (one or more of weight-for-age, height-for-age, or BMI-for-age Z-scores < -2) occurred in 38% (116/303) of CWH from the cohort study, 62% (209/336) of CWH with CLD, and 14% (44/306) of HIV-uninfected participants. We identified seven different growth profiles, defined, relatively, as (1) average growth, (2) tall not thin, (3) short not thin, (4) stunted not thin, (5) thin not stunted, (6) thin and stunted and (7) very thin and stunted. Females in profile 3 exhibited the highest body fat percentage, which increased over 1 year. Males at older age and CWH especially those with CLD were more likely to fall into growth profiles 4-7. Improvements in height-for-age Z-scores were observed in profiles 6-7 over 1 year. Interventions to target those with the worst growth faltering and longer-term follow-up to assess the impact on adult health are warranted.

Patterns in child stunting by age: A cross-sectional study of 94 low- and middle-income countries

Child stunting prevalence is primarily used as an indicator of impeded physical growth due to undernutrition and infections, which also increases the risk of mortality, morbidity and cognitive problems, particularly when occurring during the 1000 days from conception to age 2 years. This paper estimated the relationship between stunting prevalence and age for children 0-59 months old in 94 low- and middle-income countries. The overall stunting prevalence was 32%. We found higher stunting prevalence among older children until around 28 months of age-presumably from longer exposure times and accumulation of adverse exposures to undernutrition and infections. In most countries, the stunting prevalence was lower for older children after around 28 months-presumably mostly due to further adverse exposures being less detrimental for older children, and catch-up growth. The age for which stunting prevalence was the highest was fairly consistent across countries. Stunting prevalence and gradient of the rise in stunting prevalence by age varied across world regions, countries, living standards and sex. Poorer countries and households had a higher prevalence at all ages and a sharper positive age gradient before age 2. Boys had higher stunting prevalence but had peak stunting prevalence at lower ages than girls. Stunting prevalence was similar for boys and girls after around age 45 months. These results suggest that programmes to prevent undernutrition and infections should focus on younger children to optimise impact in reducing stunting prevalence. Importantly, however, since some catch-up growth may be achieved after age 2, screening around this time can be beneficial.

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.

Early-childhood linear growth faltering in low- and middle-income countries

Globally, 149 million children under 5 years of age are estimated to be stunted (length more than 2 standard deviations below international growth standards)1,2. Stunting, a form of linear growth faltering, increases the risk of illness, impaired cognitive development and mortality. Global stunting estimates rely on cross-sectional surveys, which cannot provide direct information about the timing of onset or persistence of growth faltering-a key consideration for defining critical windows to deliver preventive interventions. Here we completed a pooled analysis of longitudinal studies in low- and middle-income countries (n = 32 cohorts, 52,640 children, ages 0-24 months), allowing us to identify the typical age of onset of linear growth faltering and to investigate recurrent faltering in early life. The highest incidence of stunting onset occurred from birth to the age of 3 months, with substantially higher stunting at birth in South Asia. From 0 to 15 months, stunting reversal was rare; children who reversed their stunting status frequently relapsed, and relapse rates were substantially higher among children born stunted. Early onset and low reversal rates suggest that improving children's linear growth will require life course interventions for women of childbearing age and a greater emphasis on interventions for children under 6 months of age.

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.

Concurrent wasting and stunting among marginalised children in Sana'a city, Yemen: a cross-sectional study

Concurrent wasting and stunting (WaSt) is a serious form of malnutrition among young children, particularly vulnerable groups affected by the conflict. Understanding the prevalence and risk factors of WaSt among vulnerable children is important to develop effective intervention measures to reduce the burden of WaSt. The present study aimed to identify the prevalence of and risk factors for WaSt among marginalised children aged 6-59 months in Sana'a city, Yemen. A community-based cross-sectional design was conducted on a total sample size of 450 marginalised children aged 6-59 months who lived at home with their mothers. Multivariable logistic regression analysis was performed and the prevalence of WaSt was found to be 10⋅7 %. Children aged 24-59 months were protected from WaSt (adjusted odds ratio (AOR) 0⋅40, 95 % confidence interval (CI) 0⋅21, 0⋅75). A higher prevalence of WaSt was associated with male sex (AOR 2⋅31, 95 % CI 1⋅13, 4⋅71), no history of being breastfed (AOR 3⋅57, 95 % CI 1⋅23, 10⋅39), acute diarrhoea (AOR 2⋅12, 95 % CI 1⋅12, 4⋅02) and family income sources of assistance from others (AOR 2⋅74, 95 % CI 1⋅08, 6⋅93) or salary work (AOR 2⋅22, 95 % CI 1⋅10, 4⋅47). Continued breast- and bottle-feeding were not associated with WaSt in children aged 6-23 months. Mothers' age, education and work status, family size and drinking water source were not associated with WaSt. Overall, we found that the prevalence of WaSt among marginalised children remained high. Interventions to improve household income, hygienic conditions and child feeding practices are necessary to promote child growth.

Global variations in pubertal growth spurts in adolescents living with perinatal HIV

OBJECTIVE

To describe pubertal growth spurts among adolescents living with perinatally acquired HIV (ALWPHIV) on antiretroviral therapy (ART).

DESIGN

Observational data collected from 1994 to 2015 in the CIPHER global cohort collaboration.

METHODS

ALWPHIV who initiated ART age less than 10 years with at least four height measurements age at least 8 years were included. Super Imposition by Translation And Rotation (SITAR) models, with parameters representing timing and intensity of the growth spurt, were used to describe growth, separately by sex. Associations between region, ART regimen, age, height-for-age (HAZ), and BMI-for-age z -scores (BMIz) at ART initiation (baseline) and age 10 years, and SITAR parameters were explored.

RESULTS

Four thousand seven hundred and twenty-three ALWPHIV were included: 51% from East and Southern Africa (excluding Botswana and South Africa), 17% Botswana and South Africa, 6% West and Central Africa, 11% Europe and North America, 11% Asia-Pacific, and 4% Central, South America, and Caribbean. Growth spurts were later and least intense in sub-Saharan regions. In females, older baseline age and lower BMIz at baseline were associated with later and more intense growth spurts; lower HAZ was associated with later growth spurts. In males, older baseline age and lower HAZ were associated with later and less intense growth spurts; however, associations between baseline HAZ and timing varied by age. Lower HAZ and BMIz at 10 years were associated with later and less intense growth spurts in both sexes.

CONCLUSION

ALWPHIV who started ART at older ages or already stunted were more likely to have delayed pubertal growth spurts. Longer-term follow-up is important to understand the impact of delayed growth.

The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial: Protocol for school-age follow-up

Background: There is a need for follow-up of early-life stunting intervention trials into childhood to determine their long-term impact. A holistic school-age assessment of health, growth, physical and cognitive function will help to comprehensively characterise the sustained effects of early-life interventions. Methods: The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe assessed the effects of improved infant and young child feeding (IYCF) and/or improved water, sanitation and hygiene (WASH) on stunting and anaemia at 18 months. Among children enrolled to SHINE, 1,275 have been followed up at 7-8 years of age (1,000 children who have not been exposed to HIV, 268 exposed to HIV antenatally who remain HIV negative and 7 HIV positive children). Children were assessed using the School-Age Health, Activity, Resilience, Anthropometry and Neurocognitive (SAHARAN) toolbox, to measure their growth, body composition, cognitive and physical function. In parallel, a caregiver questionnaire assessed household demographics, socioeconomic status, adversity, nurturing, caregiver support, food and water insecurity. A monthly morbidity questionnaire is currently being administered by community health workers to evaluate school-age rates of infection and healthcare-seeking. The impact of the SHINE IYCF and WASH interventions, the early-life 'exposome', maternal HIV, and contemporary exposures on each school-age outcome will be assessed. We will also undertake an exploratory factor analysis to generate new, simpler metrics for assessment of cognition (COG-SAHARAN), growth (GROW-SAHARAN) and combined growth, cognitive and physical function (SUB-SAHARAN). The SUB-SAHARAN toolbox will be used to conduct annual assessments within the SHINE cohort from ages 8-12 years. Ethics and dissemination: Approval was obtained from Medical Research Council of Zimbabwe (08/02/21) and registered with Pan-African Clinical Trials Registry (PACTR202201828512110, 24/01/22). Primary caregivers provided written informed consent and children written assent. Findings will be disseminated through community sensitisation, peer-reviewed journals and stakeholders including the Zimbabwean Ministry of Health and Child Care.

Tools for assessing child and adolescent stunting: Lookup tables, growth charts and a novel appropriate-technology "MEIRU" wallchart - a diagnostic accuracy study

Stunting affects 149 million children worldwide and is a form of chronic malnutrition defined by low height-for-age. Surveys and intervention programmes depend on effective assessment and identification of affected individuals. Gold standard assessment is based on height-for-age Z-score (HAZ): HAZ <-2 defines stunting; HAZ <-3 defines severe stunting. However, a major problem for field-based programmes is that Z-scores can be time-intensive and challenging to calculate. We thus developed a novel wallchart that we have coined 'MEIRU wallchart' to easily and accurately identify stunted children and adolescents. Our study aim was to evaluate its performance and acceptability against other methods used in current clinical/field practice. We undertook a non-interventional diagnostic accuracy study in Malawi. We recruited 244 participants aged 8-19 years and determined each individual's stunting status using, in varying order: the MEIRU wallchart, traditional lookup tables, and traditional growth charts. All were compared against 'gold standard' HAZ, calculated using AnthroPlus WHO software. Local community healthcare workers performed all the assessments. The wallchart method was strongly preferred by both participants and staff. It had an overall accuracy of 95.5%(kappa = 0.91) and was faster than lookup tables by an average of 62.5%(41.4sec; p<0.001) per measurement. Lookup tables and growth charts had overall agreements of 59.4%(kappa = 0.36) and 61.9%(kappa = 0.31) respectively. At the HAZ-2 cut-off, the wallchart had a sensitivity of 97.6%(95%CI: 91.5-99.7) and specificity of 96.3%(95%CI: 92.1-98.6). We conclude that the MEIRU wallchart performs well and is acceptable for screening and identification of stunted children/adolescents by community-level health workers. It fulfils key criteria that justify a role in future screening programmes: easy to perform and interpret; acceptable; accurate; sensitive and specific. Potential future uses include: conducting rapid stunting prevalence surveys; identifying affected individuals for interventions. Current field methods, lookup tables and growth charts performed poorly and should be used with caution.

Undernutrition among rural school-age children: a major public health challenge for an aspirational district in Karnataka, India

Background

For school-age children, a healthy transition from childhood to adolescence and adulthood depends on proper nutrition. Globally, most nutritional surveys focus on preschool and adolescents, neglecting school-age children. Recent studies have shown the prevalence of thinness among adolescents to be 26.5% in Karnataka. Similarly, among children aged < 5 years in the Raichur district, the prevalence of stunting, wasting, and being underweight was 39.8, 23.2, and 40.7%, respectively. The present study aimed to bridge the data gap between < 5 years of children and adolescents through a nutritional survey of school-going children in Raichur, one of the aspirational districts of India.

Materials and methods

A cross-sectional survey was conducted from January to March 2020 among rural school-age children (n = 2700) in 30 villages of the Raichur district of Karnataka, India. The school children were selected through a multi-stage cluster sampling technique. The WHO Anthro-plus software was used for calculating the age and sex-specific Z-scores for weight-for-age (WAZ), height-for-age (HAZ), and BMI-for-age (BAZ).

Results

Of the 2,700 school-age children surveyed, the mean weight and height were 22.2 kg (+5.8) and 124.9 cm (+11.6), respectively. The prevalence of children having weight-for-age Z-scores < -2 SD (Underweight) was 45.3% (95% CI: 42.7%-47.8%). The magnitude of stunting and severe stunting was 19.5% (95% CI: 18.0%-21.0%) and 7.6% (95% CI: 6.6%-8.6%), respectively. The proportion of children with BMI for age Z-scores < -2SD (thinness) was 43% (95% CI: 41.1%-44.9%), with sub-district Sindhanur having a dual burden of malnutrition.

Conclusion

Despite many flagship programs, the prevalence of undernutrition in school-age children remains a considerable public health problem in the aspirational district of Raichur, India. Furthermore, exploratory studies are recommended to identify the factors associated with undernutrition among school-age children and strategize evidence-based intervention.

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

Childhood undernutrition is a major global health challenge with devastating lifelong consequences. Linear growth stunting due to undernutrition has been linked to poor outcomes, and mothers who experience stunting are more likely to give birth to stunted children. Murine models that capture the intergenerational and multifactorial nature of undernutrition are critical to understanding the underlying biology of this disorder. Here we report a gnotobiotic mouse model of undernutrition using microbiota from human infants with healthy or stunted growth trajectories. Intergenerational transmission of microbiota from parents to offspring leads to the development of growth and immune features of undernutrition and enteropathy, including reduced linear growth, intestinal villus blunting and accumulation of intraepithelial lymphocytes. In contrast, colonization after weaning reduces sensitivity to detect changes driven by distinct microbial communities. Overall, these results suggest intergenerational colonization is a useful approach with which to investigate microbiota-dependent growth and immunity in early life.

Factors associated with recovery from stunting at 24 months of age among infants and young children enrolled in the Pediatric Development Clinic (PDC): A retrospective cohort study in rural Rwanda

INTRODUCTION

Stunting (low height/length-for-age) in early life is associated with poor long-term health and developmental outcomes. Nutrition interventions provided during the first 1,000 days of life can result in improved catch-up growth and development outcomes. We assessed factors associated with stunting recovery at 24 months of age among infants and young Children enrolled in Pediatric Development Clinics (PDC) who were stunted at 11 months of age.

METHODS

This retrospective cohort study included infants and young children who enrolled in PDCs in two rural districts in Rwanda between April 2014 and December 2018. Children were included in the study if their PDC enrollment happened within 2 months after birth, were stunted at 11 months of age (considered as baseline) and had a stunting status measured and analyzed at 24 months of age. We defined moderate stunting as length-for-age z-score (LAZ) < -2 and ≥-3 and severe stunting as LAZ <-3 based on the 2006 WHO child growth standards. Stunting recovery at 24 months of age was defined as the child's LAZ changing from <-2 to > -2. We used logistic regression analysis to investigate factors associated with stunting recovery. The factors analyzed included child and mother's socio-demographic and clinical characteristics.

RESULTS

Of the 179 children who were eligible for this study, 100 (55.9%) were severely stunted at age 11 months. At 24 months of age, 37 (20.7%) children recovered from stunting, while 21 (21.0%) severely stunted children improved to moderate stunting and 20 (25.3%) moderately-stunted children worsened to severe stunting. Early stunting at 6 months of age was associated with lower odds of stunting recovery, with the odds of stunting recovery being reduced by 80% (aOR: 0.2; 95%CI: 0.07-0.81) for severely stunted children and by 60% (aOR: 0.4; 95% CI: 0.16-0.97) for moderately stunted children (p = 0.035). Lower odds of stunting recovery were also observed among children who were severely stunted at 11 months of age (aOR: 0.3; 95% CI: 0.1-0.6, p = 0.004). No other maternal or child factors were statistically significantly associated with recovery from stunting at 24 months in our final adjusted model.

CONCLUSION

A substantial proportion of children who were enrolled in PDC within 2 months after birth and were stunted at 11 months of age recovered from stunting at 24 months of age. Children who were severely stunted at 11 months of age (baseline) and those who were stunted at 6 months of age were less likely to recover from stunting at 24 months of age compared to those with moderate stunting at 11 months and no stunting at 6 months of age, respectively. More focus on prevention and early identification of stunting during pregnancy and early life is important to the healthy growth of a child.

Factors associated with fathers' involvement in infant and young child feeding and nurturing care in the urban slums of Bangladesh: A cross-sectional study

Optimal infant and young child feeding (IYCF) and nurturing care during the first years of children's lives are crucial for ensuring their growth and development. The IYCF and nurturing practices are associated with a multifaceted interplay of context-specific factors where fathers' involvement is necessary. The aim of this study is to explore the current scenario of fathers' involvement in IYCF practices in the urban slums of Bangladesh. A cross-sectional survey among the residents of the Sat Tola slum in Dhaka, the capital of Bangladesh was conducted. To avoid social desirability bias, 361 mothers of children aged <24 months were interviewed regarding fathers' involvement. An operational definition of father's involvement was developed based on 11 criteria and then scoring was applied to classify 'Good Involvement' and associated factors were identified using multivariable logistic regression. Fathers' mean age was around 31 (SD ± 6.09) years and the majority of them (44.32%) completed primary education. Fathers had diversified occupations such as day laborer (32.41%), garment worker (22.71%), and business (14.96%). Factors that were significantly associated with the father's involvement in IYCF practices include educational status (aOR = 3.98, 95% CI = 1.91, 8.26, p < .00) and theiroccupational status (aOR = 0.34, 95% CI = 0.16, 0.70, p = .00). Fathers were more active for their first child (aOR: 1.99, 95% CI = 1.04, 3.79, p = .03). Having child in the age group of 14-20 months (aOR = 2.73, 95% CI = 1.32, 5.64, p = <.01) and wife in the age group of 21-30 years (aOR = 2.34, 95% CI = 1.20, 4.58, p = .01) were significantly associated. The study finding explored that fathers' education and occupation as well as mothers' age and education were significantly associated factors for fathers' involvement in the IYCF practices. Further longitudinal studies are recommended to establish the causal relationship between fathers' involvement with IYCF and their impact on child growth and development.

Utilization of growth monitoring and promotion services and undernutrition of children less than two years of age in Northern Ghana

BACKGROUND

Child undernutrition is a major public health problem and an important indicator of child's health. Adequate nutrition is critical for a child's growth and development. Growth monitoring and promotion (GMP) services is a nutrition intervention aimed at improving the nutritional status of children. We assessed the utilization of growth monitoring and promotion services and nutritional status of children less than two years of age in northern Ghana.

METHODS

This was a descriptive cross-sectional study that involved face-to-face interviews among 266 mothers with children < 2 years of age attending child welfare clinics (CWC). We also collected anthropometric measurements. Descriptive statistic was performed and data presented as percentage. The nutritional status of children was classified as underweight (weight-for-age z score < -2 standard deviations), stunted (length-for-age Z score < - 2) and wasted (weight-for-length z score < -2) while utilization of GMP services was based on attendance to CWC and ability to interpret different growth curves. Chi square test was used to determine the relationship between utilization of GMP services and nutritional status of children at an alpha of 0.05.

RESULTS

The prevalence of undernutrition shows that, 18.6% of the children were underweight, 14.7% were stunted and 7.9% were wasted. About 60% of the mothers accessed GMP services regularly. Less than half of the mothers were able to interpret the children's growth curve correctly: falling growth curve (36.8%), flattening growth curve (35.7%) and rising growth curve (27.4%). In combining children < 6 and 6-23 months of age, only one-third (33.1%) of mothers practiced appropriate infant and young child feeding. Regular GMP services was found to have a statistically significant relationship with underweight (P < 0.001), stunting (P = 0.006) and wasting (P = 0.042).

CONCLUSION

The level of undernutrition remains high and child feeding practices is poor. Maternal utilization of GMP services is also low in the study area. Similarly, ability to interpret the child's growth curve appropriately persist as a challenge among women. Thus, attention is needed to improve utilization of GMP services to address child undernutrition challenges.

Comparison between the World Health Organization and Bahraini children growth standards

OBJECTIVE

The aim of this study was to investigate the growth patterns of Bahraini female and male infants/young children aged 0-24 months in the Kingdom of Bahrain.

METHODS

A cross-sectional approach was employed to track the growth parameters among healthy Bahraini female and male infants/children aged 0-24 months. A multistage probability sampling criteria was used to collect information from official records. Anthropometric measurements (weight and length) and demographic characteristics on feeding practices were gathered. Generalized Additive Models for Location Scale and Shape (GAMLSS)/Lambda-Mu-Sigma methodology was implemented to select distribution type, optimize smoothing parameters, perform regression of growth models, and construct percentiles and Z-score charts and tables for weight for age, length for age, length for weight, and body mass index (BMI) for age.

RESULTS

Findings were compared with WHO Multicentre Growth Reference Study (MGRS) data. A total of 403 healthy infants/children (210 males and 193 females) were recruited. At birth, the mean weight, length, and BMI were 3.2±0.4 kg, 3.1±0.4 kg, 49.7±2.3 cm, 48.8±2.1 cm, 13.2±1.6 kg/m2, and 12.8±1.5 kg/m2 for males and females, respectively. Anthropometrics of males were all statistically significantly higher than those of females at all age levels. The length and weight of the Bahraini infants/children were slightly higher than those of the WHO-MGRS.

CONCLUSION

The outcomes of this study, presented as charts and tables, showed significant differences in comparison with the WHO-MGRS reference charts. Specifically, Bahraini children aged between 0 and 24 months of both sexes were taller and heavier than their cohorts in the MGRS reference charts. Further longitudinal studies are needed for monitoring the growth pattern of children using body composition methods, adiposity markers, and determinant factors of growth to investigate this deviation from the WHO-MGRS.

Dynamics and consequences of nutrition-related microbial dysbiosis in early life: study protocol of the VITERBI GUT project

Introduction

Early life under- and overnutrition (jointly termed malnutrition) is increasingly recognized as an important risk factor for adult obesity and metabolic syndrome, a diet-related cluster of conditions including high blood sugar, fat and cholesterol. Nevertheless, the exact factors linking early life malnutrition with metabolic syndrome remain poorly characterized. We hypothesize that the microbiota plays a crucial role in this trajectory and that the pathophysiological mechanisms underlying under- and overnutrition are, to some extent, shared. We further hypothesize that a "dysbiotic seed microbiota" is transmitted to children during the birth process, altering the children's microbiota composition and metabolic health. The overall objective of this project is to understand the precise causes and biological mechanisms linking prenatal or early life under- or overnutrition with the predisposition to develop overnutrition and/or metabolic disease in later life, as well as to investigate the possibility of a dysbiotic seed microbiota inheritance in the context of maternal malnutrition.

Methods/design

VITERBI GUT is a prospective birth cohort allowing to study the link between early life malnutrition, the microbiota and metabolic health. VITERBI GUT will include 100 undernourished, 100 normally nourished and 100 overnourished pregnant women living in Vientiane, Lao People's Democratic Republic (PDR). Women will be recruited during their third trimester of pregnancy and followed with their child until its second birthday. Anthropometric, clinical, metabolic and nutritional data are collected from both the mother and the child. The microbiota composition of maternal and child's fecal and oral samples as well as maternal vaginal and breast milk samples will be determined using amplicon and shotgun metagenomic sequencing. Epigenetic modifications and lipid profiles will be assessed in the child's blood at 2 years of age. We will investigate for possible associations between metabolic health, epigenetics, and microbial changes.

Discussion

We expect the VITERBI GUT project to contribute to the emerging literature linking the early life microbiota, epigenetic changes and growth/metabolic health. We also expect this project to give new (molecular) insights into the mechanisms linking malnutrition-induced early life dysbiosis and metabolic health in later life, opening new avenues for microbiota-engineering using microbiota-targeted interventions.

Characterising school-age health and function in rural Zimbabwe using the SAHARAN toolbox

INTRODUCTION

We developed the School-Age Health, Activity, Resilience, Anthropometry and Neurocognitive (SAHARAN) toolbox to address the shortage of school-age assessment tools that combine growth, physical and cognitive function. Here we present i) development, acceptability and feasibility of the SAHARAN toolbox; ii) characteristics of a pilot cohort; and iii) associations between the domains measured in the cohort.

METHODS

Growth was measured with anthropometry, knee-heel length and skinfold thicknesses. Bioimpedance analysis measured lean mass index and phase angle. Cognition was assessed using the mental processing index, derived from the Kaufman Assessment Battery for Children version 2, a fine motor finger-tapping task, and School Achievement Test (SAT). Physical function combined grip strength, broad jump and the 20m shuttle-run test to produce a total physical score. A caregiver questionnaire was performed in parallel.

RESULTS

The SAHARAN toolbox was feasible to implement in rural Zimbabwe, and highly acceptable to children and caregivers following some minor modifications. Eighty children with mean (SD) age 7.6 (0.2) years had mean height-for-age (HAZ) and weight-for-age Z-scores (WAZ) of -0.63 (0.81) and -0.55 (0.85), respectively. Lean mass index and total skinfold thicknesses were related to WAZ and BMI Z-score, but not to HAZ. Total physical score was associated with unit rises in HAZ (1.29, 95% CI 0.75, 1.82, p<0.001), and lean mass index (0.50, 95% CI 0.16, 0.83, p = 0.004), but not skinfold thicknesses. The SAT was associated with unit increases in the mental processing index and child socioemotional score. The caregiver questionnaire identified high levels of adversity and food insecurity.

CONCLUSIONS

The SAHARAN toolbox provided a feasible and acceptable holistic assessment of child growth and function in mid-childhood. We found clear associations between growth, height-adjusted lean mass and physical function, but not cognitive function. The SAHARAN toolbox could be deployed to characterise school-age growth, development and function elsewhere in sub-Saharan Africa.

Effect of milk protein and whey permeate in large quantity lipid-based nutrient supplement on linear growth and body composition among stunted children: A randomized 2 × 2 factorial trial in Uganda

BACKGROUND

Despite possible benefits for growth, milk is costly to include in foods for undernourished children. Furthermore, the relative effects of different milk components, milk protein (MP), and whey permeate (WP) are unclear. We aimed to assess the effects of MP and WP in lipid-based nutrient supplement (LNS), and of LNS itself, on linear growth and body composition among stunted children.

METHODS AND FINDINGS

We performed a randomized, double-blind, 2 × 2 factorial trial among 12 to 59 months old stunted children in Uganda. Children were randomized to 4 formulations of LNS with MP or soy protein isolate and WP or maltodextrin (100 g/day for 12 weeks) or no supplementation. Investigators and outcome assessors were blinded; however, participants were only blinded to the ingredients in LNS. Data were analyzed based on intention-to-treat (ITT) using linear mixed-effects models adjusted for age, sex, season, and site. Primary outcomes were change in height and knee-heel length, and secondary outcomes included body composition by bioimpedance analysis (ISRCTN13093195). Between February and September 2020, we enrolled 750 children with a median age of 30 (interquartile range 23 to 41) months, with mean (± standard deviation) height-for-age z-score (HAZ) -3.02 ± 0.74 and 12.7% (95) were breastfed. The 750 children were randomized to LNS (n = 600) with or without MP (n = 299 versus n = 301) and WP (n = 301 versus n = 299), or no supplementation (n = 150); 736 (98.1%), evenly distributed between groups, completed 12-week follow-up. Eleven serious adverse events occurred in 10 (1.3%) children, mainly hospitalization with malaria and anemia, all deemed unrelated to the intervention. Unsupplemented children had 0.06 (95% confidence interval, CI [0.02, 0.10]; p = 0.015) decline in HAZ, accompanied by 0.29 (95% CI [0.20, 0.39]; p < 0.001) kg/m2 increase in fat mass index (FMI), but 0.06 (95% CI [-0.002; 0.12]; p = 0.057) kg/m2 decline in fat-free mass index (FFMI). There were no interactions between MP and WP. The main effects of MP were 0.03 (95% CI [-0.10, 0.16]; p = 0.662) cm in height and 0.2 (95% CI [-0.3, 0.7]; p = 0.389) mm in knee-heel length. The main effects of WP were -0.08 (95% CI [-0.21, 0.05]; p = 220) cm and -0.2 (95% CI [-0.7; 0.3]; p = 403) mm, respectively. Interactions were found between WP and breastfeeding with respect to linear growth (p < 0.02), due to positive effects among breastfed and negative effects among non-breastfed children. Overall, LNS resulted in 0.56 (95% CI [0.42, 0.70]; p < 0.001) cm height increase, corresponding to 0.17 (95% CI [0.13, 0.21]; p < 0.001) HAZ increase, and 0.21 (95% CI [0.14, 0.28]; p < 0.001) kg weight increase, of which 76.5% (95% CI [61.9; 91.1]) was fat-free mass. Using height-adjusted indicators, LNS increased FFMI (0.07 kg/m2, 95% CI [0.0001; 0.13]; p = 0.049), but not FMI (0.01 kg/m2, 95% CI [-0.10, 0.12]; p = 0.800). Main limitations were lack of blinding of caregivers and short study duration.

CONCLUSIONS

Adding dairy to LNS has no additional effects on linear growth or body composition in stunted children aged 12 to 59 months. However, supplementation with LNS, irrespective of milk, supports linear catch-up growth and accretion of fat-free mass, but not fat mass. If left untreated, children already on a stunting trajectory gain fat at the expense of fat-free mass, thus nutrition programs to treat such children should be considered.

TRIAL REGISTRATION

ISRCTN13093195.

Environmental enteric dysfunction: gut and microbiota adaptation in pregnancy and infancy

Environmental enteric dysfunction (EED) is a subclinical syndrome of intestinal inflammation, malabsorption and barrier disruption that is highly prevalent in low- and middle-income countries in which poverty, food insecurity and frequent exposure to enteric pathogens impair growth, immunity and neurodevelopment in children. In this Review, we discuss advances in our understanding of EED, intestinal adaptation and the gut microbiome over the 'first 1,000 days' of life, spanning pregnancy and early childhood. Data on maternal EED are emerging, and they mirror earlier findings of increased risks for preterm birth and fetal growth restriction in mothers with either active inflammatory bowel disease or coeliac disease. The intense metabolic demands of pregnancy and lactation drive gut adaptation, including dramatic changes in the composition, function and mother-to-child transmission of the gut microbiota. We urgently need to elucidate the mechanisms by which EED undermines these critical processes so that we can improve global strategies to prevent and reverse intergenerational cycles of undernutrition.

Food environment around schools and adolescent consumption of unhealthy foods in Addis Ababa, Ethiopia

Adolescent diets may be influenced by the retail food environment around schools. However, international research to examine associations between the proximity of retail food outlets to schools and diet provides equivocal support for an association. This study aims to understand the school food environment and drivers for adolescents' consumption of unhealthy foods in Addis Ababa, Ethiopia. Mixed-methods research was conducted, 1200 adolescents (10-14 years) from randomly selected government schools were surveyed, along with vendors within 5-min' walk of the schools and focus group discussions (FGDs) with adolescent groups. Mixed-effect logistic regression investigated the relationship between the number of vendors around the schools and the consumption of selected unhealthy foods. Thematic analysis was used to summarize findings from the FGDs. Consumption of sweets and sugar-sweetened beverages (S-SSB) and deep-fried foods (DFF) at least once a week was reported by 78.6% and 54.3% of the adolescents, respectively. Although all schools were surrounded by food vendors selling DFF and S-SSB, consumption was not associated with the number of vendors available around the school. However, adolescents' awareness and perception of healthy food, and their concerns about the safety of foods in the market, influenced their dietary choices and behaviours. Lack of financial resources to purchase food as desired also played a role in their selection of food and eating habits. Reported unhealthy food consumption is high among adolescents in Addis Ababa. Thus, further research is warranted to come up with school-based interventions that promote access and healthy food choices among adolescents.

Diminishing benefits of urban living for children and adolescents' growth and development

Optimal growth and development in childhood and adolescence is crucial for lifelong health and well-being1-6. Here we used data from 2,325 population-based studies, with measurements of height and weight from 71 million participants, to report the height and body-mass index (BMI) of children and adolescents aged 5-19 years on the basis of rural and urban place of residence in 200 countries and territories from 1990 to 2020. In 1990, children and adolescents residing in cities were taller than their rural counterparts in all but a few high-income countries. By 2020, the urban height advantage became smaller in most countries, and in many high-income western countries it reversed into a small urban-based disadvantage. The exception was for boys in most countries in sub-Saharan Africa and in some countries in Oceania, south Asia and the region of central Asia, Middle East and north Africa. In these countries, successive cohorts of boys from rural places either did not gain height or possibly became shorter, and hence fell further behind their urban peers. The difference between the age-standardized mean BMI of children in urban and rural areas was <1.1 kg m-2 in the vast majority of countries. Within this small range, BMI increased slightly more in cities than in rural areas, except in south Asia, sub-Saharan Africa and some countries in central and eastern Europe. Our results show that in much of the world, the growth and developmental advantages of living in cities have diminished in the twenty-first century, whereas in much of sub-Saharan Africa they have amplified.

Validation of AND/ASPEN pediatric malnutrition diagnosis in children admitted to medical wards in two tertiary hospitals in Malaysia

BACKGROUND

Identification and management of malnutrition among pediatric hospitalized patients is critical for improved clinical outcomes and recovery. This study investigated the use of the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition (AND/ASPEN) pediatric malnutrition diagnosis in comparison with the Subjective Global Nutritional Assessment (SGNA) tool and single anthropometric indicators (weight, height, body mass index, and mid-upper arm circumference) among hospitalized children.

METHODS

A cross-sectional study was conducted among 260 children admitted to general medical wards. SGNA and anthropometric measurements were used as references. Kappa agreement, diagnostic values, and area under the curve (AUC) were analyzed to evaluate the diagnostic ability of the AND/ASPEN malnutrition diagnosis tool. Logistic binary regression was performed to determine the predictive ability of each malnutrition diagnosis tool on the length of hospital stay.

RESULTS

The AND/ASPEN diagnosis tool detected the highest malnutrition rate (41%) among the hospitalized children in comparison with the reference methods. This tool demonstrated fair specificity of 74% and sensitivity of 70% compared with the SGNA. It obtained a weak agreement in determining the presence of malnutrition by kappa (0.06-0.42) and receiver operating characteristic curve analysis (AUC = 0.54-0.72). The use of the AND/ASPEN tool obtained an odds ratio of 0.84 (95% CI, 0.44-1.61; P = 0.59) in predicting the length of hospital stay.

CONCLUSIONS

The AND/ASPEN malnutrition tool is an acceptable nutrition assessment tool for hospitalized children in general medical wards.

Home environment and nutritional status mitigate the wealth gap in child development: a longitudinal study in Vietnam

BACKGROUND

Inequity in child development is found at early age, but limited evidence exists on whether these gaps change over time and what are the mediators.

OBJECTIVE

We aim to (1) quantify wealth related gaps in cognitive and socio-emotional development in early and middle childhood; (2) examine how these gaps were mitigated by maternal, child factors and home environment.

METHODS

We assessed the offspring of women who participated in a randomized controlled trial of preconception micronutrient supplementation in Vietnam (n = 1599). Child development was measured by the Bayley Scales of Infant Development-III (at 1-2y) and the Wechsler Intelligence Scale for Children®-IV (at 6-7y). We used multivariable regression to estimate the changes in wealth gaps for child development over time, adjusting for potential factors that potentially influence cognitive development.

RESULTS

We found significant wealth gaps in cognitive development during early childhood (gaps between top and bottom quintiles: 0.5 SD); these gaps increased substantially in middle childhood (0.9 SD). Wealth disparity in social emotion did not change over time (0.26-0.28 SD). Maternal factors, quality of home environment, and child nutritional status mitigated the wealth gap in cognitive development (7-42%) in early childhood. The contribution of these mitigating factors was smaller in middle childhood (2- 15%). Wealth gap in social emotion reduced by 13% and 43% among children with better nutritional status at 2y and higher quality of home environment at 6-7y, respectively.

CONCLUSION

Interventions focusing on improving quality of home environment, maternal education, wellbeing, and child nutrition status may help reduce developmental deficits associated with poverty.

Nutritional status of school-age children and adolescents in low- and middle-income countries across seven global regions: a synthesis of scoping reviews

OBJECTIVE

To summarise available evidence on the nutritional status of school-age children and adolescents (5-19 years) from seven global regions and on interventions implemented to improve malnutrition in this population.

SETTING

Global.

DESIGN

Findings were compiled from seven scoping literature reviews, including data from low- and middle-income countries within the following UNICEF-defined global regions: East Asia and Pacific; Europe and Central Asia; South Asia; West and Central Africa; Eastern and Southern Africa; Middle East and North Africa and Latin America and the Caribbean.

RESULTS

A double burden of malnutrition was evident across the world regions reviewed: stunting, thinness, anaemia and other micronutrient deficiencies persisted, alongside rising overweight and obesity prevalence. Transitions towards diets increasingly high in energy-dense, processed and micronutrient-poor foods were observed. Evidence from intervention studies was limited, but suggested that providing multiple micronutrient-fortified foods or beverages at school may effectively target micronutrient deficiencies and facilitate weight gain in undernourished populations. Interventions to prevent or manage overweight and obesity were even more limited. There was minimal evidence of using novel technological approaches to engage school-age children and adolescents, or of involving them in designing interventions.

CONCLUSION

The limited data available on nutrition of school-age children and adolescents are neither standardised nor comparable. Consensus on methods for assessing nutritional status and its determinants for this age group is urgently needed to set targets and monitor progress. Additionally, strategies are required to ensure that nutritious, safe and sustainable diets are available, affordable and appealing.

The Impact of Iron Supplementation During Pregnancy and Change of Consumption among Stunting Children Aged 6-24 Months During the COVID-19 Pandemic in Indonesia

Background

During the COVID-19 pandemic, stunting is estimated to increase 2.4 times higher (It seems that some information is missing here because the usage of the word 'higher' hints at a comparison with some other statistic. Or please consider making the following changes in the statement: "…stunting is estimated to be 2.4 times higher than the normal trend." which can increase mortality, morbidity, and cause economic losses in the future. This study aims to identify the risk factors for stunting during the COVID-19 pandemic.

Methods

An unmatched case-control study was conducted to compare the exposure of stunted (cases) and non-stunted (controls) children. There were 127 children aged 6-24 months, 43 cases, and 84 controls.

Results

The probability of stunting was two times greater in children who experienced good changes in the consumption of tofu/tempeh (p: 0.047; AdjustedOR (aOR): 2.296; 95% CI 1.013-5.205) and fourtimes greater in children who have a mother that did not receive iron supplementation during pregnancy (p: 0.030; aOR: 4.344; 95% CI: 1.154-16.355).

Conclusions

Based on the above results, increasing access to nutritious food, and the delivery of services and information related to maternal and child health services during the pandemic needs to be intensified by using innovative low-risk platforms.

Nutrition in school-age children: a rationale for revisiting priorities

Middle childhood and early adolescence have received disproportionately low levels of scientific attention relative to other life stages, especially as related to nutrition and health. This is partly due to the justified emphasis on the first 1000 days of life, and the idea that early deficits and consequences may not be fully reversible. In addition, these stages of life may superficially appear less "eventful" than infancy or late adolescence. Finally, there has been historical ambiguity and inconsistency in terminology, depending on whether viewing "childhood" through physiologic, social, legal, or other lenses. Nevertheless, this age bracket, which encompasses most of the primary education and basic schooling years for most individuals, is marked by significant changes, inflection points, and sexually driven divergence in somatic and brain growth and development trajectories. These constitute transformative changes, and thus middle childhood and early adolescence represents a major and last opportunity to influence long-term health and productivity. This review highlights the specificities of growth and development in school age, with a focus on middle childhood and early adolescence (5 years-15 years of age, for the purposes of this review), the role of nutrition, the short- and long-term consequences of inadequate nutrition, and the current global status of nutrition in this age group. Adequate attention and emphasis on nutrition in the school-age years is critical: (a) for maintaining an adequate course of somatic and cognitive development, (b) for taking advantage of this last major opportunity to correct deficits of undernutrition and "catch-up" to normal life course development, and (c) for addressing the nutritional inadequacies and mitigating the longer-term consequences of overnutrition. This review summarizes and provides a rationale for prioritizing nutrition in school-age children, and for the need to revisit priorities and focus on this part of the life cycle to maximize individuals' potential and their contribution to society.

Childhood stunting and subsequent educational outcomes: a marginal structural model analysis from a South African longitudinal study

OBJECTIVE

To examine the association between childhood stunting and grade completion (as educational outcome) in South Africa.

DESIGN

Longitudinal study. Data were obtained using the National Income Dynamics Study over five waves (2008 to 2017). Children were tracked at wave 1 in 2008 until wave 5 in 2017 to determine their total years of schooling. We controlled for time-variant and time-varying confounding with a marginal structural model to estimate the associations between childhood stunting and subsequent grade completion.

SETTING

Nationally representative study of South African households.

PARTICIPANTS

A total of 2629 children aged 2 and 3 years in 2008.

RESULTS

We observed a substantial decrease in the prevalence of stunting between wave 1 (28·2 %) and wave 4 (8·6 %). Our marginal structural model results suggest that childhood stunting was significantly associated with decreased odds (22 % less likely) of grade completion (OR = 0·78; 95 % CI: 0·40, 0·86; P = 0·015), while those who were only stunted during early childhood had a 29 % reduction in the odds of grade completion (OR = 0·71; 95 % CI: 0·51, 0·82; P = 0·020).

CONCLUSION

These findings underscore the fact that stunting is a significant predictor of academic achievement, whose effects might be long-lasting.

The effect of preschool attendance on Children's health: Evidence from a lower middle-income country

In this study, we find that children in Vietnam who were born in December of a given year have better health outcomes than those born in January of the following year. Children born in December are taller, heavier, and less likely to be underweight and suffer from stunted growth than those born in January of the following year, though these two groups of children differ in age by only 1 month. We argue that the effect of being born in December compared to January on children's health is translated through early preschool attendance. In Vietnam, children born in December are more likely to start preschool as well as primary school 1 year earlier than those born in January of the following year. Thus, the health benefit for a child born in December would come from earlier and longer exposure to preschool. Importantly, we find that the positive effect of preschool persists over time as children grow. A possible major reason why preschool attendance improves health is the nutrition provided for children in preschools.

Growth improvement following antiretroviral therapy initiation in children with perinatally-acquired HIV diagnosed in older childhood in Zimbabwe: a prospective cohort study

BACKGROUND

Children who initiate antiretroviral therapy (ART) before age 5 years can recover height and weight compared to uninfected peers, but growth outcomes are unknown for children initiating ART at older ages. We investigated factors associated with growth failure at ART initiation and modelled growth by age on ART.

METHODS

We conducted secondary analysis of cohort of children aged 6-15 years late-diagnosed with HIV in Harare, Zimbabwe, with entry at ART initiation in 2013-2015. Factors associated with height-for-age (HAZ), weight-for-age (WAZ) and BMI-for-age (BAZ) z-scores <- 2 (stunting, underweight and wasting respectively) at ART initiation were assessed using multivariable logistic regression. These outcomes were compared at ART initiation and 12 month follow-up using paired t-tests. HAZ and BAZ were modelled using restricted cubic splines.

RESULTS

Participants (N = 302; 51.6% female; median age 11 years) were followed for a median of 16.6 months (IQR 11.0-19.8). At ART initiation 34.8% were stunted, 34.5% underweight and 15.1% wasted. Stunting was associated with age ≥ 12 years, CD4 count < 200 cells/μl, tuberculosis (TB) history and history of hospitalisation. Underweight was associated with older age, male sex and TB history, and wasting was associated with older age, TB history and hospitalisation. One year post-initiation, t-tests showed increased WAZ (p = 0.007) and BAZ (p = 0.004), but no evidence of changed HAZ (p = 0.85). Modelling showed that HAZ and BAZ decreased in early adolescence for boys on ART, but not girls.

CONCLUSION

Stunting and underweight were prevalent at ART initiation among late-diagnosed children, and HAZ did not improve after 1 year. Adolescent boys with perinatally acquired HIV and late diagnosis are particularly at risk of growth failure in puberty.

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.

A cross-sectional study design to assess the sexual experiences and contraceptive use of adolescents and youths attending high school and college in Jimma town

BACKGROUND

Adolescents and youths in Ethiopia have limited access to reproductive health services designed to address their needs. Therefore, the study aims to assess adolescents' and youth's sexual practice, contraceptive use, and behavioral patterns towards safe sexual exercise.

METHODS

A quantitative cross-sectional study design was used on 374 students selected from high school and vocational colleges to assess their sexual experience and contraceptive use and related perceptions using pre-tested self-administered semi-structured questionnaires. We used descriptive analyses to report their sexual and reproductive health status and logistic regression to examine the association between contraceptive use and other variables.

RESULTS

The results show that 52.7% of the respondents (students) migrated or moved from rural to urban to continue their high school and college education at urban. 41.7% of the respondents were with less than 18 years, of which 75.9% of them already initiated sexual intercourse. Of all the students who started sexual intercourse (51.1%), only 30.9% used contraceptives, but condom use accounts for 49.2%. Overall, 84.8% of those who practiced sexual intercourse were at risk of acquiring sexually transmitted diseases due to not using a condom. About 3% of the respondents reported unwanted pregnancy experiences, of which 64% of these pregnancies were reported to be aborted.

CONCLUSION

Adolescents and youths attending high schools and College are at increased risk of acquiring HIV and unwanted pregnancy due to low levels of contraceptive use. Specifically, a designed youths-friendly reproductive health service is needed to avert related problems and contribute to sustainable development goals.

Predictive Utility of Composite Child Feeding Indices (CCFIs) for Child Nutritional Status: Comparative Analyses for the Most Suitable Formula for Constructing an Optimum CCFI

Composite child feeding indices (CCFIs) developed from various relevant measures of dietary intake by infants and young children have several potential applications in nutritional epidemiological studies for the development and deployment of precise public health nutrition interventions against child undernutrition. The predictive utility of some CCFIs (computed from varying formulation components) for child nutritional status (stunting, wasting, and underweight) were compared. The purpose of the study was to identify the most suitable among them for possible standardization, validation, and adoption by nutritional health researchers. Using cluster sampling, data from 581 mother–child pairs were collected. Multivariable regression analyses were applied to the data obtained through a community-based analytical cross-sectional survey design. Three of the CCFIs were found to be significantly associated with only wasting (WHZ) from the linear regression models after adjusting for potential confounders and/or correlates. None of the CCFIs (whether in the continuous nor categorical form) was consistently predictive of all three measures of child nutritional status, after controlling for potential confounders and/or correlates, irrespective of the choice of regression method. CCFI 5 was constructed using a dimension reduction technique—namely principal component analysis (PCA)—as the most optimal summary index in terms of predictiveness for child wasting status, validity, and reliability (Cronbach’s α = 0.80) that captured relevant dimensions of optimal child food intake. The dimension reduction approach that was used in constructing CCFI 5 is recommended for standardization, validation, and possible adoption for wider applicability across heterogeneous population settings as an optimum CCFI usable for nutritional epidemiological studies among children under five years.

Women's health: optimal nutrition throughout the lifecycle

Sex differences are an important consideration when researching and establishing policies for nutrition and optimal health. For women's health, there are important physiologic, neurologic, and hormonal distinctions throughout the lifecycle that impact nutritional needs. Distinct from those for men, these nutritional needs must be translated into appropriate nutrition policy that aims to not only avoid overt nutritional deficiency, but also to promote health and minimize risk for chronic disease. Through a series of webinars, scientific experts discussed the advances in the understanding of the unique nutritional needs, challenges and opportunities of the various life stages for women across the life course and identified emerging nutritional interventions that may be beneficial for women. Nevertheless, there is concern that existing nutrition policy intended for women's health is falling short with examples of programs that are focused more on delivering calories than achieving optimal nutrition. To be locally effective, targeted nutrition needs to offer different proposals for different cultural, socio-economic, and geographic communities, and needs to be applicable at all stages of growth and development. There must be adequate access to nutritious foods, and the information to understand and implement proven nutritional opportunities. Experts provided recommendations for improvement of current entitlement programs that will address accessibility and other social and environmental issues to support women properly throughout the lifecycle.

Home-Grown School Feeding: Implementation Lessons From a Pilot in a Poor Ethnic Minority Community in Vietnam

Background:

Undernutrition threatens the health and future of preschool children in disadvantaged remote communities. Home-grown school feeding (HGSF) in nursery schools could positively impact children’s nutrition while creating multiple benefits for the whole community. However, evidence is lacking on implementation of HGSF within multi-sectoral programs in remote areas.

Objective:

This study assessed an HGSF pilot intervention, part of a nutrition-sensitive agriculture (NSA) program, in a mountain ethnic minority community in Vietnam. It aimed to identify the changes brought about by the intervention, in particular diversity of children’s food, food sources, barriers and facilitators to change, and future challenges and strategies.

Methods:

Mixed-methods assessment covered school meal diversity, cost, and food sources but the key focus was on observed changes resulting from the HGSF intervention and perceived barriers and facilitators to its implementation. Data were collected mainly through semi-structured interviews (n = 30) and seven focus group discussions (n = 76).

Results:

School meals contributed to increasing diversity of food consumed by children. Above 30% of foods used were home-grown. Respondents reported increased school attendance; children’s food preferences and hygiene practices improved as did parents’ caring and feeding practices. Local food systems became less cash-crop-oriented and more self-reliant, contributing to household food security and income generation. Social capital increased. Positive changes were attributed to HGSF and synergy among NSA program components. Poverty and limited resilience to external shocks threatened sustainability.

Conclusions:

Implementing HGSF within an NSA program in a mountainous ethnic minority area with a high prevalence of undernutrition benefitted children and their communities.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Synergy from Village, Integrated Healthcare Center, and Early Childhood Education in Stunting Prevention (Case Study)

BACKGROUND: Stunting is a growth faltering condition due to the accumulation of insufficient nutrition that lasts a long time, especially in the first 1000 days of life Basic health research (Riskedas) in 2013 stated that in Indonesia, there has been an increase in the prevalence of stunting in children from 36.8% in 2010 to 37.2% in 2013. Although the stunting rate based on Riskesdas 2018 fell to 30.8%, the challenge of accelerating stunting reduction still quite big. One of the causes is the problem of multisector convergence of planning, budgeting, actuation-implementation, monitoring, and control of programs that have not synergized with each other. AIM: This research is intended to see the picture of the synergy between village, Integrated Health Center (IHC), and early childhood education (PAUD) in preventing stunting. METHODS: This research is a case study took place s in Klaten and Boyolali areas. Research respondents are the officers of village, IHC, and PAUD. The research instrument used was questionnaire aimed at assessing the synergy between stunting prevention activities that had been carried out. This synergy includes knowledge, planning, budgeting, mobilization-implementation, monitoring, and evaluation carried out by the village, IHC and PAUD officials. Data were analyzed using one-way analysis of variance and Duncan test for further analysis (post hoc). The test was carried out with a significance level of 5%. RESULTS: Analysis of stunting prevention activities which include knowledge, planning, budgeting, actuation-implementation, monitoring, and evaluation has a relatively low average score in general. These results indicate that the synergy between village, IHC, and PAUD officials in preventing stunting is still not optimal. The achievement of the best efforts and synergies in the two areas can be seen in the implementation aspect. On the other hand, the less visible aspect is the funding aspect. The knowledge score of IHC officers is known to be lower than that of village officials and PAUD officers. Therefore, this multisector convergence problem requires a solution that is appropriate to the geographical conditions and local context. CONCLUSION: Based on the results of research conducted in the two areas that were used as research locations, the synergy between the village apparatus, IHC, and PAUD in stunting prevention activities still needs to be optimized, especially in terms of the role of each agency and the coordination of the three.

Risk factors for early childhood growth faltering in rural Cambodia: a cross-sectional study

OBJECTIVE

This study aimed to determine risk factors of growth faltering by assessing childhood nutrition and household water, sanitation, and hygiene (WASH) variables and their association with nutritional status of children under 24 months in rural Cambodia.

DESIGN

We conducted surveys in 491 villages (clusters) randomised across 55 rural communes in Cambodia in September 2016 to measure associations between child, household and community-level risk factors for stunting and length-for-age z-score (LAZ). We measured 4036 children under 24 months of age from 3877 households (491 clusters). We analysed associations between nutrition/WASH practices and child growth (LAZ, stunting) using generalised estimating equations (GEEs) to fit linear regression models with robust SEs in a pooled analysis and in age-stratified analyses; child-level and household-level variables were modelled separately from community-level variables.

RESULTS

After adjustment for potential confounding, we found household-level and community-level water, sanitation and hygiene factors to be associated with child growth among children under 24 months: presence of water and soap at a household's handwashing station was positively associated with child growth (adjusted mean difference in LAZ +0.10, 95% CI 0.03 to 0.16); household-level use of an improved drinking water source and adequate child stool disposal practices were protective against stunting (adjusted prevalence ratio (aPR) 0.80, 95% CI 0.67 to 0.97; aPR 0.82, 95% CI 0.64 to 1.03). In our age-stratified analysis, we found associations between child growth and community-level factors among children 1-6 months of age: shared sanitation was negatively associated with growth (-0.47 LAZ, 95% CI -0.90 to -0.05 compared with children in communities with no shared facilities); improved sanitation facilities were protective against stunting (aPR 0.43, 95% CI 0.21 to 0.88 compared with children in communities with no improved sanitation facilities); and open defecation was associated with more stunting (aPR 2.13, 95% CI 1.10 to 4.11 compared with children in communities with no open defecation). These sanitation risk factors were only measured in the youngest age strata (1-6 months). Presence of water and soap at the household level were associated with taller children in the 1-6 month and 6-12 month age strata (+0.10 LAZ, 95% CI -0.02 to 0.22 among children 1-6 months of age; +0.11 LAZ, 95% CI -0.02 to 0.25 among children 6-12 months of age compared with children in households with no water and soap). Household use of improved drinking water source was positively associated with growth among older children (+0.13 LAZ, 95% CI -0.01 to 0.28 among children 12-24 months of age).

CONCLUSION

In rural Cambodia, water, sanitation and hygiene behaviours were associated with growth faltering among children under 24 months of age. Community-level sanitation factors were positively associated with growth, particularly for infants under 6 months of age. We should continue to make effort to: investigate the relationships between water, sanitation, hygiene and human health and expand WASH access for young children.

Nourishing Hope? Changes in Malnutrition and Changes in Girls' Aspirations-Evidence From the Suaahara II Adolescent Girls Panel in Nepal

PURPOSE

Malnutrition is a pressing public health challenge in South Asia with adverse consequences for adolescent girls' well-being and, potentially, aspirations as drivers of developmental progress. This study aimed to investigate associations between changes in malnutrition and changes in girls' aspirations in key life domains.

METHODS

We analyzed two-period panel data from the Suaahara II Adolescent Girls Panel (10-19 years) in Nepal (2018-2019, n = 613). Height, weight, blood samples, 24-hour dietary recalls, and indicators of girls' educational, occupational, marital, and fertility aspirations were collected. Height-for-age z-scores, body mass index-for-age z-scores, hemoglobin concentration (Hb g/dL), and dietary diversity scores for women were calculated. Through cluster-robust fixed-effects regressions, we examined whether changes in thinness (body mass index-for-age z-scores < -2 standard deviation), anemia (Hb <115 g/L nonpregnant <11 years; Hb <120 g/L nonpregnant >12 years; Hb <110 g/L pregnant), and reaching minimum dietary diversity for women were associated with changes in educational, marital, or fertility aspirations.

RESULTS

A change from thinness to no thinness increased girls' aspired ages of having a first child by 2.77 years (standard error [SE] 1.22, p = .025). A change from anemia to no anemia increased girls' aspired years of education by .54 (SE .27, p = .044). This association was stronger for postmenarche girls (b -.62, SE .29, p = .035). No associations were found between changes in minimum dietary diversity for women and any of the aspirations.

CONCLUSIONS

Thinness and anemia were negatively associated with adolescent girls' aspirations in domains of fertility and education. Multisectoral integrated policies and programs that improve adolescent nutritional status and diets have the potential to foster adolescent girls' aspirations and thereby increase their future potential.