Revisiting the relationship of weight and height in early childhood

Height and weight trajectories are associated with submaximal and maximal exercise capacity in children with congenital heart defects

Children with congenital heart defects (CHD) are often short/lightweight relative to peers. Limited growth, particularly height, may reflect energy deficits impacting physical activity. Latent class analyses of growth from birth and Bruce treadmill exercise data retrospectively identified for height, weight, and body mass index z-scores growth trajectories. Linear regression models examined exercise parameters by growth trajectory, adjusting for age/sex/CHD severity. A total of 213 children with CHD (39% female, 12.1 ± 2.9 years) achieved 85.8 ± 10.1% of the predicted peak heart rate. Peak heart rate among children whose height was consistently below average (class 1) was 15.2 ± 4.9 beats/min lower than children with other height trajectories. These children also attained a lower percentage of predicted peak heart rate. Children whose weight (p = 0.03) or body mass index (p < 0.001) z-score increased throughout childhood had significantly lower exercise duration (mean difference 1-2 min) than children whose growth trajectories were stable or declined. Children with above-average weight or an increasing body mass index also used a higher percentage of their heart rate reserve at each submaximal exercise stage. A very low height z-score trajectory is associated with decreased exercise capacity that may increase the risk for morbidities associated with a sedentary lifestyle. Future studies should examine potential mechanisms for the observed height deficits, such as an inadequate energy supply that could impact physical activity participation, congestive heart failure, cyanosis, pubertal stage, supplemental feeding history, or familial growth patterns. Prospective studies examining growth in relation to objective measures of daily physical activity are required.

Diagnostic interval of inflammatory bowel disease in Chinese children and its relationship with growth parameters: a retrospective study

Background

Delayed diagnosis of inflammatory bowel disease (IBD) is common in Europe and North America, with limited research in Asia. We aimed to investigate factors influencing delayed diagnosis of IBD in Chinese children and the impact of delayed diagnosis on growth.

Methods

This was a retrospective study. Clinical data on children with IBD were collected through electronic medical records. The diagnostic interval includes the time from symptom onset to hospital admission and admission to diagnosis. Diagnostic delay was defined as the upper quartile of the time interval from the first symptom to the diagnosis of IBD. For the effect on growth indicators, the length of follow-up was at least 3 months from diagnosis.

Results

This study included 222 children with IBD, predominantly with Crohn's disease (86.0%). Approximately one-quarter of children require more than 366 days to be diagnosed with IBD, primarily due to the extended interval between the onset of initial symptoms and hospital admission. Multivariate logistic regression models showed that fever was associated with a prolonged time interval from first symptom onset to admission and the odds ratio (OR) was 0.45 [95% confidence interval (CI) 0.22-0.94]. Age and bloody stools were associated with prolonged intervals from admission to diagnosis, with ORs of 0.84 (95% CI 0.77-0.92) and 0.36 (95% CI 0.14-0.94), respectively. Delayed diagnosis was associated with height at first admission and follow-up. Children with a delayed diagnosis had a 5.87-fold higher chance of growth retardation upon initial admission compared to children without a delayed diagnosis (95% CI 1.59-24.05). After 15.7 months of follow-up, this elevated risk remained (OR 3.28, 95% CI 1.00-10.50).

Conclusion

Delayed diagnosis is common in Chinese children with IBD and is associated with persistent height impairment.

Examining the burden and relationship between stunting and wasting among Timor-Leste under five rural children

Globally and in Timor-Leste, wasting and stunting remain major public health problems among 'under five years children, but the interrelationship between the two has been poorly investigated. A better understanding of this interrelationship is a prerequisite to improving wasting and stunting programming. In our study, we assessed the influence of age on the prevalence of wasting and stunting, the overlap between the two conditions, and the effect of wasting parameters on linear growth catch-up using the data of 401 children recruited at 0 to 54 months of age [median (IQR) of 17 (7-32) months] with repeated anthropometric assessments [median (IQR) follow-up time was 25 (16-39) months]. At recruitment, prevalences of stunting, wasting and concurrence of the two conditions were 54.6%, 9.5% and 4.6%, respectively. These prevalences were already high and above the thresholds for public health importance among children below months of age and remained high throughouttheir childhood. Over the follow-up period, the change (95%CI) in Height-for-Age Z-score (HAZ) was -0.01 (-0.13; 0.11) (p = 0.850), and that of the Height-for-Age Difference (HAD) was -3.74 (-4.28; -3.21) cm (p<0.001). Stunting reversal was observed in 25.6% of those stunted at recruitment, while a positive change in HAD was observed in only 19.6% of assessed children. Path analysis by structural equation modelling showed no significant direct effect of WHZ at recruitment on the likelihood of positive change in HAD, with its influence being fully mediated by its change over the follow-up period. This change had an inverse relationship with the occurrence of a positive change in HAD. On the contrary, Mid-Upper Arm Circumference at recruitment had a significant positive direct effect on the likelihood of a positive HAD change. These results show that interventions to combat wasting and stunting need to be integrated.

The epidemiology and impact of persistent Campylobacter infections on childhood growth among children 0-24 months of age in resource-limited settings

Background

Campylobacter is the leading cause of bacterial gastroenteritis worldwide. It is generally associated with an acute gastrointestinal infection causing a self-limiting diarrheal episode. However, there is evidence that persistent/recurrent carriage of Campylobacter also occurs. In hyperendemic settings the epidemiology and consequences of persistent Campylobacter enteric infections is poorly studied.

Methods

Risk factors for and growth consequences of persistent Campylobacter infections detected by polymerase chain reaction (qPCR) were evaluated with data from the MAL-ED birth cohort study in children 0-24 months of age between November 2009 and February 2012. A persistent Campylobacter infection was defined as three or more consecutive Campylobacter positive monthly stools.

Findings

Across all study sites, 45.5% (781/1715) of children experienced at least one persistent Campylobacter episode. The average cumulative duration of days in which children with persistent Campylobacter were positive for Campylobacter spp. was 150 days (inter-quartile range: 28-236 days). Children who experienced a persistent Campylobacter episode had an attained 24-month length-for-age (LAZ) score that was 0.23 (95% (CI): -0.31, -0.15) less than children without a persistent Campylobacter episode. Among children who had at least one episode of Campylobacter over a 3-month or 9-month window, persistent episodes were not significantly associated with poorer 3-month weight gain (-28.7 g, 95% CI: -63.4 g, 6.0 g) but were associated with poorer 9-month linear growth (-0.134 cm 95% CI: -0.246, -0.022) compared to children with an episode that resolved within 31 days.

Interpretation

Persistent/recurrent Campylobacter infection is common among children and has a measurable negative impact on linear growth in early childhood.

Funding

Funding for this study was provided by the Bill and Melinda Gates Foundation (OPP1066146 and OPP1152146), the National Institutes of Health United States (R01AI158576 and R21AI163801 to MNK and CTP; K43TW012298 to FS; K01AI168493 to JMC; GOL was supported by K01AI145080. This research was also supported in part by USDA-ARS CRIS project 2030-42000-055-00D. The funders had no role in study design, study implementation, data analysis, or interpretation of the results.

The Double Burden of Malnutrition is Associated with Continued Breastfeeding and Early Consumption of Ultra-Processed Drinks in Socially Vulnerable Brazilian Children

This study aimed to assess the association between the double burden of malnutrition (DBM) with continued breastfeeding and the early introduction of ultra-processed drinks in children living in situations of social vulnerability. This cross-sectional population-based study was carried out in a capital city in the Northeast of Brazil, which included 561 children. It was observed that introducing soft drinks into the child's diet during the first year of life was directly associated with DBM but indirectly with continuous breastfeeding for 12 or more months. These results indicate paths that can be followed to reverse the current scenario.

Effect of a Center-Based Early Childhood Care and Education Program on Child Nutritional Status: A Secondary Analysis of a Stepped-Wedge Cluster Randomized Controlled Trial in Rural Sindh, Pakistan

BACKGROUND

High-quality early childhood care and education (ECCE) programs can positively impact children's development. However, as an unintended consequence, ECCE attendance may also affect children's nutritional status.

OBJECTIVE

We evaluated the effect of a center-based ECCE intervention on child nutritional outcomes in rural Pakistan.

METHODS

This study utilized data from a stepped-wedge cluster randomized controlled trial of a center-based ECCE program that trained female youth to run high-quality preschools for children aged 3.5-5.5 y (Youth Leaders for Early Childhood Assuring Children are Prepared for School (LEAPS) program) in rural Sindh, Pakistan. The program did not include any school meals. A total of 99 village clusters were randomized to receive the LEAPS intervention in 3 steps, and repeated cross-sectional surveys were conducted to assess the impact on children (age: 4.5-5.5 y) at 4- time points. ITT analyses with multilevel mixed-effect models were used to estimate the effect of the intervention on child anthropometric outcomes.

RESULTS

The analysis included 3858 children with anthropometric data from 4 cross-sectional survey rounds. The LEAPS intervention was found to have a positive effect on child height-for-age z score (mean difference: 0.13 z-scores; 95% confidence interval [CI]: 0.02, 0.24). However, there was a negative effect on weight-based anthropometric indicators, -0.29 weight-for-height z score (WHZ) (95% CI: -0.42, -0.15), -0.13 BMI z score (BMIZ) (95% CI: -0.23, -0.03), and -0.16 mid-upper arm circumference-for-age z score MUACZ (95% CI: -0.25, -0.05). An exploratory analysis suggested that the magnitude of the negative effect of LEAPS on WHZ, BMIZ, and weight-for-age z score (WAZ) was greater in the survey round during the COVID-19 lockdown.

DISCUSSION

The LEAPS intervention positively affected child linear growth but had negative effects on multiple weight-based anthropometric measures. ECCE programs in low- and middle-income country settings should evaluate the integration of nutrition-specific interventions (eg school lunch, counseling on healthy diets) and infection control strategies to promote children's healthy growth and development.

CLINICAL TRIAL REGISTRY

clinicaltrials.gov, NCT03764436, https://clinicaltrials.gov/ct2/show/NCT03764436.

Safety and Efficacy of Hizentra® Following Pediatric Hematopoietic Cell Transplant for Treatment of Primary Immunodeficiencies

Primary immunodeficiency disease (PIDD) comprises a group of disorders of immune function. Some of the most severe PIDD can be treated with hematopoietic cell transplant (HCT). Hizentra® is a 20% liquid IgG product approved for subcutaneous administration in adults and children greater than 2 years of age with PIDD-associated antibody deficiency. Limited information is available on the use of Hizentra® in children following HCT for PIDD. A multicenter retrospective chart review demonstrated 37 infants and children (median age 70.1 [range 12.0 to 176.4] months) with PIDD treated by HCT who received Hizentra® infusions over a median duration of 31 (range 4-96) months post-transplant. The most common indication for HCT was IL2RG SCID (n = 16). Thirty-two patients switched from IVIG to SCIG administration, due to one or more of the following reasons: patient/caregiver (n = 17) or physician (n = 12) preference, discontinuation of central venous catheter (n = 16), desire for home infusion (n = 12), improved IgG serum levels following lower levels on IVIG (n = 10), and loss of venous access (n = 8). Serious bacterial infections occurred at a rate of 0.041 per patient-year while on therapy. Weight percentile increased by a mean of 16% during the observation period, with females demonstrating the largest gains. Mild local reactions were observed in 24%; 76% had no local reactions. One serious adverse event (death from sepsis) was reported. Hizentra® was discontinued in 15 (41%) patients, most commonly due to recovery of B cell function (n = 11). These data demonstrate that Hizentra® is a safe and effective option in children who have received HCT for PIDD.

Anesthesia characteristic of an algorithm of bupivacaine dose based on height in caesarean section under spinal anesthesia: a retrospective cohort study

BACKGROUND

An algorithm of bupivacaine dose based on height is applied to reduce maternal hypotension in caesarean section under spinal anesthesia. This study is designed to further verify whether the algorithm of bupivacaine dose based on height is suitable.

METHODS

The parturients were grouped according to height. The comparison of anesthesia characteristic among subgroups was carried out. The univariate and multivariate binary logistic regressions were executed to reanalyze the interference factor for the anesthesia characteristic.

RESULTS

When the dose of bupivacaine was adjusted by using the height based dosing algorithm, except for weight (P < 0.05), other general data did not present statistical changes with height (P > 0.05); the incidences of complications, characteristics of sensory or motor block, quality of anesthesia and neonatal outcome were of no statistical difference among parturients with different heights (P > 0.05); the height, weight and body mass index were not related with maternal hypotension (P > 0.05). When the dose of bupivacaine is constant, except for weight and body mass index (P > 0.05), the height was the independent risk factor for maternal hypotension (P < 0.05).

CONCLUSIONS

Except for weight and body mass index, the height has an influence on the bupivacaine dose. It is reasonable that the bupivacaine dose is adjusted by using this dosing algorithm based on height.

TRIAL REGISTRATION

This study was registered at http://clinicaltrials.gov (13/04/2018, NCT03497364).

The relationship between wasting and stunting in young children: A systematic review

In 2014, the Emergency Nutrition Network published a report on the relationship between wasting and stunting. We aim to review evidence generated since that review to better understand the implications for improving child nutrition, health and survival. We conducted a systematic review following PRISMA guidelines, registered with PROSPERO. We identified search terms that describe wasting and stunting and the relationship between the two. We included studies related to children under five from low- and middle-income countries that assessed both ponderal growth/wasting and linear growth/stunting and the association between the two. We included 45 studies. The review found the peak incidence of both wasting and stunting is between birth and 3 months. There is a strong association between the two conditions whereby episodes of wasting contribute to stunting and, to a lesser extent, stunting leads to wasting. Children with multiple anthropometric deficits, including concurrent stunting and wasting, have the highest risk of near-term mortality when compared with children with any one deficit alone. Furthermore, evidence suggests that the use of mid-upper-arm circumference combined with weight-for-age Z score might effectively identify children at most risk of near-term mortality. Wasting and stunting, driven by common factors, frequently occur in the same child, either simultaneously or at different moments through their life course. Evidence of a process of accumulation of nutritional deficits and increased risk of mortality over a child's life demonstrates the pressing need for integrated policy, financing and programmatic approaches to the prevention and treatment of child malnutrition.

Time trends and social inequalities in child malnutrition: nationwide estimates from Brazil's food and nutrition surveillance system, 2009-2017

OBJECTIVE

In Brazil, national estimates of childhood malnutrition have not been updated since 2006. The use of health information systems is an important complementary data source for analysing time trends on health and nutrition. This study aimed to examine temporal trends and socio-demographic inequalities in the prevalence of malnutrition in children attending primary health care services between 2009 and 2017.

DESIGN

Time trends study based on data from Brazil's Food and Nutrition Surveillance System. Malnutrition prevalence (stunting, wasting, overweight and double burden) was annually estimated by socio-demographic variables. Prais-Winsten regression models were used to analyse time trends. Annual percent change (APC) and 95 % CI were calculated.

SETTING

Primary health care services, Brazil.

PARTICIPANTS

Children under 5 years old.

RESULTS

In total, 15,239,753 children were included. An increase in the prevalence of overweight (APC = 3·4 %; P = 0·015) and a decline in the prevalence of wasting (-6·2 %; P = 0·002) were observed. The prevalence of stunting (-3·2 %, P = 0·359) and double burden (-1·4 %, P = 0·630) had discrete and non-significant reductions. Despite the significant reduction in the prevalence of undernutrition among children in the most vulnerable subgroups (black, conditional cash transfer's recipients and residents of poorest and less developed areas), high prevalence of stunting and wasting persist alongside a disproportionate increase in the prevalence of overweight in these groups.

CONCLUSIONS

The observed pattern in stunting (high and persistent prevalence) and increase in overweight elucidate setbacks in advances already observed in previous periods and stresses the need for social and political strategies to address multiple forms of malnutrition.

The Roles of Nutrition Education and Food Vouchers in Improving Child Nutrition: Evidence from a Field Experiment in Ethiopia

Mothers' lack of knowledge about child nutrition and limited resources lead to poor diets among children in developing countries, increasing their risk of chronic undernutrition. We implemented a cluster randomized control trial that randomly provides four-month-long Behavior Change Communication (BCC) and food vouchers in Ethiopia. We find improvements in child-feeding practices and a reduction in chronic child undernutrition only when BCC and vouchers are provided together. BCC or voucher alone had limited impacts. Our results highlight the importance of adding an effective educational component to existing transfer programs.

Gut Microbiota-Targeted Nutritional Interventions Improving Child Growth in Low- and Middle-Income Countries: A Systematic Review

The objective of this systematic literature review was to evaluate the efficacy of probiotic, prebiotic, and synbiotic interventions compared with control on improving growth outcomes of children living in low- and middle-income countries (LMICs). Probiotics had a beneficial effect on ≥1 of the growth outcomes in 5 out of the 11 included studies. Of these, 3 studies were conducted in undernourished children, 1 in healthy children, and 1 in children without a described health status. No effect of prebiotics on growth outcomes was seen in the 4 included studies. Synbiotics had a beneficial effect on growth outcomes in 3 out of 4 studies. Although a limited number of studies with high heterogeneity indicate that probiotics and synbiotics may have the potential to improve the growth of both undernourished and healthy children living in LMICs, more research is needed to confirm the observed effects. This review was registered at www.crd.york.ac.uk/prospero/ as CRD42020212998.

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

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

Child Undernutrition following the Introduction of a Large-Scale Toilet Construction Campaign in India

BACKGROUND

Lack of toilets and the widespread practice of open defecation may contribute to India's large burden of child undernutrition.

OBJECTIVES

We examine whether a large national sanitation campaign launched in 2014, the Swachh Bharat Mission (SBM), precedes a reduction in stunting and wasting among under 5-y-old (u5) children in India.

METHODS

In this observational study, we used district-level data from before (2013-2014) and after (2015-2016) SBM from 3 national surveys to derive, as our outcomes, the percentage of u5 children per district who are stunted and wasted. We defined our exposures as 1) binary indicator of SBM and 2) percentage of households with toilets per district. Our analytic sample comprised nearly all 640 Indian districts (with ∼1200 rural/urban divisions per district per time point). Linear regression analyses controlled for baseline differences in districts, linear time trends by state, and relevant covariates.

RESULTS

Relative to pre-SBM, u5 stunting declines by 0.06% (95% CI: -0.10, -0.01; P = 0.009) with every percentage increase in households with toilets post-SBM. Rural regions and districts with higher pre-SBM toilet availability show greater decline in u5 stunting post-SBM.

CONCLUSIONS

An increase in toilet availability on a national scale, precipitated by the SBM sanitation campaign, is associated with a reduction in undernutrition among u5 children in India over the early phase of the campaign.

Early childhood growth trajectory and later cognitive ability: evidence from a large prospective birth cohort of healthy term-born children

BACKGROUND

Most studies of associations between child growth and cognitive ability were based on size at one or two ages and a single measure of cognition. We aimed to characterize different aspects of early growth and their associations with cognitive outcomes in childhood through adolescence.

METHODS

In a sample of 12 368 Belarusian children born at term, we examined associations of length/height and weight trajectories over the first 6.5 years of life with cognitive ability at 6.5 and 16 years and its change over time. We estimated growth trajectories using two random-effects models-the SuperImposition by Translation and Rotation to model overall patterns of growth and the Jenss-Bayley to distinguish growth in infancy from post infancy. Cognitive ability was measured using the Wechsler Abbreviated Scales of Intelligence at 6.5 years and the computerized NeuroTrax test at 16 years.

RESULTS

Higher length/height between birth and 6.5 years was associated with higher cognitive scores at 6.5 and 16 years {2.7 points [95% confidence interval (CI): 2.1, 3.2] and 2.5 points [95% CI: 1.9, 3.0], respectively, per standard deviation [SD] increase}. A 1-SD delay in the childhood height-growth spurt was negatively associated with cognitive scores [-2.4 (95% CI: -3.0, -1.8) at age 6.5; -2.2 (95% CI: -2.7, -1.6) at 16 years]. Birth size and post-infancy growth velocity were positively associated with cognitive scores at both ages. Height trajectories were not associated with the change in cognitive score. Similar results were observed for weight trajectories.

CONCLUSIONS

Among term infants, the overall size, timing of the childhood growth spurt, size at birth and post-infancy growth velocity were all associated with cognitive ability at early-school age and adolescence.

A comparison of subadult skeletal and dental development based on living and deceased samples

OBJECTIVES

A fundamental assumption in biological anthropology is that living individuals will present with different growth than non-survivors of the same population. The aim is to address the question of whether growth and development data of non-survivors are reflective of the biological consequences of selective mortality and/or stress.

MATERIALS AND METHODS

The study compares dental development and skeletal growth collected from radiographic images of contemporary samples of living and deceased individuals from the United States (birth to 20 years) and South Africa (birth to 12 years). Further evaluation of deceased individuals is used to explore differential patterns among manners of death (MOD).

RESULTS

Results do not show any significant differences in skeletal growth or dental development between living and deceased individuals. However, in the South African deceased sample the youngest individuals exhibited substantially smaller diaphyseal lengths than the living sample, but by 2 years of age the differences were negligible. In the US sample, neither significant nor substantial differences were found in dental development or diaphyseal length according to MOD and age (>2 years of age), though some long bones in individuals <2 years of age did show significant differences. No significant differences were noted in diaphyseal length according to MOD and age in the SA sample.

DISCUSSION

The current findings refute the idea that contemporary deceased and living individuals would present with differential growth and development patterns through all of ontogeny as well as the assumptions linking short stature, poor environments, and MOD.

Characterizing the contribution of high temperatures to child undernourishment in Sub-Saharan Africa

Despite improvements to global economic conditions, child undernourishment has increased in recent years, with approximately 7.5% of children suffering from wasting. Climate change is expected to worsen food insecurity and increase potential threats to nutrition, particularly in low-income and lower-middle income countries where the majority of undernourished children live. We combine anthropometric data for 192,000 children from 30 countries in Sub-Saharan Africa with historical climate data to directly estimate the effect of temperature on key malnutrition outcomes. We first document a strong negative relationship between child weight and average temperature across regions. We then exploit variation in weather conditions to statistically identify the effects of increased temperatures over multiple time scales on child nutrition. Increased temperatures in the month of survey, year leading up to survey and child lifetime lead to meaningful declines in acute measures of child nutrition. We find that the lifetime-scale effects explain most of the region-level negative relationship between weight and temperature, indicating that high temperatures may be a constraint on child nutrition. We use CMIP5 local temperature projections to project the impact of future warming, and find substantial increases in malnutrition depending on location: western Africa would see a 37% increase in the prevalence of wasting by 2100, and central and eastern Africa 25%.

Prevalence and Correlates of Undernutrition in Young Children Living in Urban Slums of Mumbai, India: A Cross Sectional Study

Background: Young children living in urban slums are vulnerable to malnutrition and subsequently poor health outcomes, but data on the correlates of stunting, underweight, wasting, and anemia specifically among 10-18 month-old children in India remain limited. Objective: In this analysis, we sought to describe the prevalence of and examine correlates for different markers of undernutrition, including stunting, underweight, and anemia among 10-18 month-old children living in urban slums, an understudied vulnerable group. Methods: Children and their mothers (n = 323) were screened for anthropometry, demographics, and complete blood counts for hemoglobin concentration between March and November 2017 (Clinicaltrials.gov ID: NCT02233764). Correlates included child and mother's age, sex, birth order, birth weight, illness episodes, hemoglobin concentration, family income, maternal height, and maternal education level. Risk ratios (RR, 95% CI) for binary outcomes (stunting, underweight, wasting and anemia) and mean differences (β, 95% CI) for continuous outcomes (anthropometric Z-scores, hemoglobin concentration) were calculated using multivariate binomial and linear regression (SAS 9.4). Results: The prevalence of stunting was 31.2%, underweight 25.1%, wasting (9.0%), and anemia (76%) among all children. Male children had a higher prevalence of poor growth indices and lower anthropometric Z-scores than females. Male sex, low birthweight, shorter maternal height, report of ≥1 episodes of illness within the past month, older maternal age, and birth order ≥2 were also associated with poor growth and anemia in multivariate models. Correlates of undernutrition were different among females and males. Female children had a 40% (20, 60%) higher risk of anemia associated with diarrhea, and male children who were firstborn had a 20% (0, 70%) lower risk of anemia. Conclusions: These results show that poor growth and anemia among young children is prevalent in urban slums of Mumbai, and that sex of the child may play an important role in informing interventions to address undernutrition.

Linear growth faltering and the role of weight attainment: Prospective analysis of young children recovering from severe wasting in Niger

Efforts to reduce the impact of stunting have been largely independent of interventions to reduce the impact of wasting, despite the observation that the conditions can coexist in the same child and increase risk of death. To optimize the management of malnourished children—who can be wasted, stunted, or both—the relationship between stunting and wasting should be elaborated. We aimed to describe the relationship between concurrent weight and height gain during and after rehabilitation from severe wasting. We conducted a secondary analysis of a randomized trial for the outpatient treatment of severe wasting, including 1,542 children who recovered and were followed for 12 weeks. We described the overlap of stunting and severe wasting and the change in stunting over time. We showed the relationship between concurrent weight and height gain using adjusted generalized estimating equations and calculated the mean rate of change in weight‐for‐height z score (WHZ) and height‐for‐age z score (HAZ) during and after rehabilitation. At baseline, 79% (n = 1,223/1,542) and 49% (n = 757/1,542) of children were stunted and severely stunted, respectively. Prevalence increased over time among children <24 months. During rehabilitation when weight was not yet fully recovered, we found rapid WHZ gain but limited HAZ gain. Following successful rehabilitation, WHZ gain slowed. The rate of HAZ gain was negative after rehabilitation but increased relative to the period during treatment. The potential relationship between weight and height gain calls for increased coverage of wasting treatment to not only prevent child mortality but also reduce linear growth faltering.

Energy, Macronutrient Intake, and Anthropometrics of Vegetarian, Vegan, and Omnivorous Children (1⁻3 Years) in Germany (VeChi Diet Study)

Due to the lack of current, large-scale studies examining their dietary intake and health, there are concerns about vegetarian (VG) and vegan (VN) diets in childhood. Therefore, the Vegetarian and Vegan Children Study (VeChi Diet Study) examined the energy and macronutrient intake as well as the anthropometrics of 430 VG, VN, and omnivorous (OM) children (1⁻3 years) in Germany. A 3-day weighed dietary record assessed dietary intake, and an online questionnaire assessed lifestyle, body weight (BW), and height. Average dietary intakes and anthropometrics were compared between groups using ANCOVA. There were no significant differences in energy intake or density and anthropometrics between the study groups. OM children had the highest adjusted median intakes of protein (OM: 2.7, VG: 2.3, VN: 2.4 g/kg BW, p < 0.0001), fat (OM: 36.0, VG: 33.5, VN: 31.2%E, p < 0.0001), and added sugars (OM: 5.3, VG: 4.5, VN: 3.8%E, p = 0.002), whereas VN children had the highest adjusted intakes of carbohydrates (OM: 50.1, VG: 54.1, VN: 56.2%E, p < 0.0001) and fiber (OM: 12.2, VG: 16.5, VN: 21.8 g/1,000 kcal, p < 0.0001). Therefore, a VG and VN diet in early childhood can provide the same amount of energy and macronutrients, leading to a normal growth in comparison to OM children.

Poverty and a child's height development during early childhood: A double disadvantage? A study of the 2006-2009 birth cohorts in Flanders

Introduction

Poverty is a well-known risk factor for a child’s health and development. This paper aimed to establish whether poverty negatively affected both intra-uterine growth and early childhood growth, i.e., whether children facing poverty were at a double disadvantage.

Methods

For this study, we made use of routinely collected data on child development throughout early childhood from the 2006–2009 birth cohorts in Kind & Gezin’s Ikaros database collected during 2,605,975 consultations with 273,935 children from birth to 730 days old. Indicators for child development at birth were gestational age and height-at-birth. A standardized height-for-age indicator captured height development throughout early childhood. A multidimensional indicator measured the risk of poverty. For the analysis of development at birth, we used linear and logistic regression; for the analysis of height development during early childhood, we estimated linear and logistic growth curve models.

Results

The risk of poverty negatively affected both gestational age and height-at-birth. Throughout early childhood, we observed a negative relation between the risk of poverty and height-for-age indicators. However, the effect varied throughout childhood. Children at risk of poverty (over)compensated for their smaller stature at birth, and between ages 6 and 18 months, approximately, the negative effects of risk of poverty decreased substantially or disappeared. However, towards the end of the period studied, children born in households at risk of poverty started to lag again in height development.

Conclusion

This study found that the risk of poverty indeed negatively affected a child’s growth, both in utero and in early childhood. However, the results suggest that developmental lags later in childhood were not merely an extension of such lags at birth.

The association between acute malnutrition and water, sanitation, and hygiene among children aged 6-59 months in rural Ethiopia

The causes of acute malnutrition-or "wasting"-are complex, and a better understanding of the underlying drivers is necessary in order to design effective interventions. Water, sanitation, and hygiene (WASH) practices may play a fundamental role in acute malnutrition, but more research is needed to confirm this relationship. We investigated the association between WASH practices and acute malnutrition among children 6 to 59 months of age in rural Ethiopia, making use of the Ethiopian Demographic and Health Survey. Descriptive statistics were used to assess the WASH status of all rural children. Bivariate logistic regression analyses were performed to assess associations between nutritional status and WASH. Multivariate logistic regression analyses were used to adjust for confounders. A total of 7,209 children were included in the analysis, of which 867 (12.0%) were acutely malnourished. Proper toilet facilities (AOR = 0.63, 95% CI [0.46, 0.86]) and a water source close to home (AOR = 0.71, 95% CI [0.61, 0.83]) were associated with a lower prevalence of wasting. A safe water source for drinking (COR = 1.03, 95% CI [0.89, 1.19]) and a safe disposal of the child's stool (AOR = 0.97, 95% CI [0.84, 1.13]) were not significantly associated with acute malnutrition. These results suggest that WASH practices are related to acute malnutrition. Future studies-in particular intervention studies-should investigate whether improving WASH practices is effective in reducing malnutrition in infants and young children.

Using structural equation modelling to assess factors influencing children's growth and nutrition in rural China

OBJECTIVE

Children's poor growth and nutrition status has serious consequences and therefore it is important to understand its contributing factors.

DESIGN

A community-based interventional study focusing on child feeding was conducted in a rural community in China. Data from the intervention group at baseline (1-4 months of age) and follow-up visits (12 and 18 months of age) were used in the present study (n 236). A structural equation model was generated to explore the effects of family wealth, household food safety, dietary intake, diseases and other factors on the growth and nutrition of young children.

RESULTS

Mother's knowledge and behaviours on household food safety had positive effects on children's weight-for-age Z-score (WAZ; β direct=0·03 and 0·15, respectively, at 12 months of age; β direct=0·02 and 0·08, respectively, at 18 months; P<0·05) and weight-for-length Z-score (WLZ; β direct=0·04 and 0·21, respectively, at 12 months of age; β direct=0·01 and 0·06, respectively, at 18 months; P<0·05). While mothers' feeding behaviours and children's dietary intake at 12 months of age were positively associated with WAZ and/or WLZ at current and later ages, children's diseases were negatively associated with WAZ and WLZ cross-sectionally.

CONCLUSIONS

Caregiver's knowledge and feeding behaviours, and children's dietary intake and diseases, are factors influencing the WAZ and WLZ of children. Promoting feeding and health knowledge and behaviours at early stages of childhood can improve children's physical growth at later ages.

Child Nutritional Status in the Changing Socioeconomic Region of the Northern Amazon, Brazil

The living conditions (i.e., socioeconomic, healthcare-related, nutritional, and environmental) to which children are exposed may influence their ability to reach their optimal growth potential. This review focuses on the relationship between the nutritional status of children under five years of age and social and environmental factors in Northern Brazil. Children living in this region have limited access to healthcare and face precarious socioeconomic and environmental conditions. This analysis was based on data from national health surveys, the consolidated food, nutrition surveillance system (SISVAN), and indicators of the DPSEEA (driving force, pressure, state, exposures, health effects, and actions) framework. The northern region has the worst living conditions in the country, and children under five years of age have significant height-for-age, weight-for-age, and weight-for-height deficits. Concomitantly, the prevalence of children who are overweight has increased significantly, although it remains lower than that in more developed Brazilian regions. Insufficient and/or inadequate dietary practices and early exposure to unfavorable living conditions are risk factors for nutritional deviations. Further advances in public health policies that consider regional characteristics, particularly in the north, where progress has been slower, are needed.

Milk with and without lactoferrin can influence intestinal damage in a pig model of malnutrition

Malnutrition remains a leading contributor to the morbidity and mortality of children under the age of five worldwide. However, the underlying mechanisms are not well understood necessitating an appropriate animal model to answer fundamental questions and conduct translational research into optimal interventions. One potential intervention is milk from livestock that more closely mimics human milk by increased levels of bioactive components that can promote a healthy intestinal epithelium. We tested the ability of cow milk and milk from transgenic cows expressing human lactoferrin at levels found in human milk (hLF milk) to mitigate the effects of malnutrition at the level of the intestine in a pig model of malnutrition. Weaned pigs (3 weeks old) were fed a protein and calorie restricted diet for five weeks, receiving cow, hLF or no milk supplementation daily from weeks 3-5. After three weeks, the restricted diet induced changes in growth, blood chemistry and intestinal structure including villous atrophy, increased ex vivo permeability and decreased expression of tight junction proteins. Addition of both cow and hLF milk to the diet increased growth rate and calcium and glucose levels while promoting growth of the intestinal epithelium. In the jejunum hLF milk restored intestinal morphology, reduced permeability and increased expression of anti-inflammatory IL-10. Overall, this pig model of malnutrition mimics salient aspects of the human condition and demonstrates that cow milk can stimulate the repair of damage to the intestinal epithelium caused by protein and calorie restriction with hLF milk improving this recovery to a greater extent.

Programmatic response to malnutrition in India, room for more than one elephant

Programming platforms need to recognize the diversity of malnutrition epidemiology in India and choose appropriate implementation designs. With severe chronic malnutrition as the dominant epidemiologic entity, the net needs to be cast wide, focusing on food security, health care, agriculture, water and sanitation, livelihoods and womens empowerment. Community-based malnutrition treatment and prevention programs need to collaborate to complement treatment with socioeconomic and preventive interventions. Expansion of nutrition rehabilitation centers should be limited to areas/districts with high wasting. Pediatric services with nested nutrition services (including counseling) requires urgent strengthening. Continuum of Care is a weak link and requires strengthening to make both hospital and community-based models meaningful.

Successive 1-Month Weight Increments in Infancy Can Be Used to Screen for Faltering Linear Growth

BACKGROUND

Linear growth faltering in the first 2 y contributes greatly to a high stunting burden, and prevention is hampered by the limited capacity in primary health care for timely screening and intervention.

OBJECTIVE

This study aimed to determine an approach to predicting long-term stunting from consecutive 1-mo weight increments in the first year of life.

METHODS

By using the reference sample of the WHO velocity standards, the analysis explored patterns of consecutive monthly weight increments among healthy infants. Four candidate screening thresholds of successive increments that could predict stunting were considered, and one was selected for further testing. The selected threshold was applied in a cohort of Bangladeshi infants to assess its predictive value for stunting at ages 12 and 24 mo.

RESULTS

Between birth and age 12 mo, 72.6% of infants in the WHO sample tracked within 1 SD of their weight and length. The selected screening criterion ("event") was 2 consecutive monthly increments below the 15th percentile. Bangladeshi infants were born relatively small and, on average, tracked downward from approximately age 6 to <24 mo (51% stunted). The population-attributable risk of stunting associated with the event was 14% at 12 mo and 9% at 24 mo. Assuming the screening strategy is effective, the estimated preventable proportion in the group who experienced the event would be 34% at 12 mo and 24% at 24 mo.

CONCLUSIONS

This analysis offers an approach for frontline workers to identify children at risk of stunting, allowing for timely initiation of preventive measures. It opens avenues for further investigation into evidence-informed application of the WHO growth velocity standards.

Subcutaneous Immunoglobulin Replacement Therapy with Hizentra® is Safe and Effective in Children Less Than 5 Years of Age

BACKGROUND

Hizentra® (IGSC 20%) is a 20% liquid IgG product approved for subcutaneous administration in adults and children 2 years of age and older who have primary immunodeficiency disease (PIDD). There is limited information about the use of IGSC 20 % in very young children including those less than 5 years of age.

METHODS

A retrospective chart review involved 88 PIDD infants and children less than 5 years of age who received Hizentra®.

RESULTS

The mean age at the start of Hizentra® was 34 months (range 2 to 59 months). IGSC 20 % was administered weekly to 86 infants (two additional infants received twice weekly and three times weekly infusions, respectively) and included an average of 63 infusions (range 6-182) for an observation period up to 45.5 months. Infusion by manual delivery occurred in 15 patients. The mean dose was 674 mg/kg/4 weeks. The mean IgG level was 942 mg/dL while on IGSC 20 %, compared to a mean trough IgG level of 794 mg/dL (p < 0.0001) during intravenous or subcutaneous IgG administration prior to IGSC 20 %. Average infusion time was 47 (range 5-120) minutes, and the median number of infusion sites was 2 (range 1-4). Local reactions were mostly mild and observed in 36/88 (41%) children. No serious adverse events were reported. A significant increase in weight percentile (7 % ± 19.2, p = 0.0012) among subjects was observed during IGSC 20% administration. The rate of serious bacterial infections was 0.067 per patient-year while receiving IGSC 20%, similar to previously reported efficacy studies.

CONCLUSIONS

Hizentra® is effective in preventing infections, and is well tolerated in children less than age 5 years.

On the Mathematical Relationship Between Latent Change Score and Autoregressive Cross-Lagged Factor Approaches: Cautions for Inferring Causal Relationship Between Variables

The present paper focuses on the relationship between latent change score (LCS) and autoregressive cross-lagged (ARCL) factor models in longitudinal designs. These models originated from different theoretical traditions for different analytic purposes, yet they share similar mathematical forms. In this paper, we elucidate the mathematical relationship between these models and show that the LCS model is reduced to the ARCL model when fixed effects are assumed in the slope factor scores. Additionally, we provide an applied example using height and weight data from a gerontological study. Throughout the example, we emphasize caution in choosing which model (ARCL or LCS) to apply due to the risk of obtaining misleading results concerning the presence and direction of causal precedence between two variables. We suggest approaching model specification not only by comparing estimates and fit indices between the LCS and ARCL models (as well as other models) but also by giving appropriate weight to substantive and theoretical considerations, such as assessing the justifiability of the assumption of random effects in the slope factor scores.

Determinants of stunting and severe stunting among under-fives: evidence from the 2011 Nepal Demographic and Health Survey

Background

Stunting remains a major public health concern in Nepal as it increases the risk of illness, irreversible body damage and mortality in children. Public health planners can reshape and redesign new interventions to reduce stunting and severe stunting among children aged less than 5 years in this country by examining their determinants. Hence, this study identifies factors associated with stunting and severe stunting among children aged less than five years in Nepal.

Methods

The sample is made up of 2380 children aged 0 to 59 months with complete anthropometric measurements from the 2011 Nepal Demographic and Health Survey (NDHS). Simple and multiple logistic regression analyses were used to examine stunting and severe stunting against a set of variables.

Results

The prevalences of stunting and severe stunting were 26.3% [95% confidence Interval (CI): 22.8, 30.1] and 10.2% (95%CI: 7.9, 13.1) for children aged 0–23 months, respectively, and 40.6 (95%CI: 37.3, 43.2) and 15.9% (95%CI: 13.9, 18.3) for those aged 0–59 months, respectively. After adjusting for potential confounding factors, multivariable analyses showed that the most consistent significant risk factors for stunted and severely stunted children aged 0–23 and 0–59 months were household wealth index (poorest household), perceived size of baby (small babies) and breastfeeding for more than 12 months (adjusted odds ratio (AOR) for stunted children aged 0–23 months = 2.60 [95% CI: (1.87, 4.02)]; AOR for severely stunted children aged 0–23 months = 2.87 [95% CI: (1.54, 5.34)]; AOR for stunted children aged 0–59 months = 3.54 [95% CI: (2.41, 5.19)] and AOR for severely stunted children aged 0–59 months = 4.15 [95% CI: (2.45, 6.93)].

Conclusions

This study suggests that poorest households and prolonged breastfeeding (more than 12 months) led to increased risk of stunting and severe stunting among Nepalese children. However, community-based education intervention are needed to reduce preventable deaths triggered by malnutrition in Nepal and should target children born to mothers of low socioeconomic status.

Catch-up growth occurs after diarrhea in early childhood

Diarrhea and linear growth faltering continue to burden low-income countries and are among the most important contributors to poor health during early childhood. Diarrhea is thought to adversely affect linear growth, but catch-up growth can occur if no additional insults are experienced. We sought to characterize catch-up growth in relation to diarrhea burden in a multisite dataset of 1007 children. Using longitudinal anthropometry and diarrheal surveillance data from 7 cohort studies in 4 countries, we examined the relation between diarrhea prevalence and growth in 3- to 6-mo periods using linear mixed-effect models. Growth during each period was calculated as a function of age using linear splines. We incorporated the longitudinal prevalence of diarrhea in both current and previous periods into the model. Diarrhea during the current period was associated with slower linear and ponderal growth. Faster (catch-up) growth in length was observed in children with no diarrhea in age groups immediately after an age group in which diarrhea was experienced [age group >6-12 mo: 0.03 mm/mo for each percentage diarrhea prevalence in the previous period (95% CI: 0.007, 0.06) relative to 11.3 mm/mo mean growth rate; age group >12-18 mo: 0.04 mm/mo (95% CI: 0.02, 0.06) relative to 8.9 mm/mo mean growth rate; age group >18-24 mo: 0.04 mm/mo (95% CI: 0.003, 0.09) relative to 7.9 mm/mo mean growth rate]. The associations were stronger in boys than in girls when separate models were run. Similar results were observed when weight was the outcome variable. When diarrheal episodes are followed by diarrhea-free periods in the first 2 y of life, catch-up growth is observed that may allow children to regain their original trajectories. The finding of a greater effect of diarrhea on linear growth in boys than in girls was unexpected and requires additional study. Diarrhea burdens are high throughout the first 2 y of life in these study sites, therefore reducing the likelihood of catch-up growth. Extending diarrhea-free periods may increase the likelihood of catch-up growth and decrease the prevalence of stunting.

The stunting syndrome in developing countries

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

Ready-to-use food-allocation policy to reduce the effects of childhood undernutrition in developing countries

Several aid groups have proposed strategies for allocating ready-to-use (therapeutic and supplementary) foods to children in developing countries. Analysis is needed to investigate whether there are better alternatives. We use a longitudinal dataset of 5,657 children from Bwamanda to construct a bivariate time-series model that tracks each child's height-for-age z score (HAZ) and weight-for-height z score (WHZ) throughout the first 5 y of life. Our optimization model chooses which individual children should receive ready-to-use therapeutic or supplementary food based on a child's sex, age, HAZ, and WHZ, to minimize the mean number of disability-adjusted life years (DALYs) per child during 6-60 mo of age [which includes childhood mortality calculated from a logistic regression and the lifelong effects of stunting (i.e., low HAZ)] subject to a budget constraint. Compared with the strategies proposed by the aid groups, which do not use HAZ information, the simple strategy arising from our analysis [which prioritizes children according to low values of a linear combination of HAZ, WHZ, and age and allocates the entire budget to therapeutic (i.e., 500 kcal/d) food for the prioritized children] reduces the number of DALYs by 9% (for the same budget) or alternatively incurs the same number of DALYs with a 61% reduction in cost. Whereas our qualitative conclusions appear to be robust, the quantitative results derived from our analysis should be treated with caution because of the lack of reliable data on the impact of supplementary food on HAZ and WHZ, the application of our model to a single cohort of children and the inclusion and exclusion errors related to imperfect food targeting.

Building convergence in science, programs, and policy actions on child undernutrition: symposium rationale and overview

Childhood stunting and wasting are often portrayed as relatively distinct manifestations of undernutrition. Little is known about how children progress from one manifestation of undernutrition to another as they grow older, nor how intervention strategies need to consider the potential overlap of these manifestations of undernutrition. While much is known about the causes of growth faltering in general, much less is known about which pre-disposing contextual and biological factors cause children to become stunted as opposed to wasted or both. Increasingly, nutrition researchers have tended to focus on one form of malnutrition or the other, lacking an integrated framework for understanding both phenomena. Similarly, some practitioner communities focus on prevention of stunting while others focus on recuperative treatment of wasting. The fragmentation of interests and perspectives on childhood undernutrition has negative consequences for advocacy efforts that aim to bring attention and resources to child nutrition across the globe. It also has serious implications for how children worldwide receive nutrition interventions and services. The symposium aimed to bring together a set of speakers from academic, practice and policy communities to discuss and debate these issues.

Promoting healthy growth: what are the priorities for research and action?

Healthy growth from conception through the first 2 y of life is the foundation for adequate organ formation and function, a strong immune system, physical health, and neurological and cognitive development. Recent studies identified several low-cost interventions to address undernutrition during this age period and noted the lower returns on investment of intervening after this critical period. Although these interventions should be implemented widely, it is recognized that existing nutrition solutions, even if universally applied, would only avert a minority fraction of the estimated death and disability due to undernutrition. This paper reviews some of the knowledge and learning needed to close this "impact gap." Five areas are prioritized for future research: 1) study healthy growth from a lifecycle perspective, because maternal, fetal, and newborn outcomes are connected; 2) understand why growth faltering begins so early in breast-fed infants in the developing world; 3) apply new tools and technologies to study long-recognized problems such as the interaction between nutrition and infection; 4) explore new hypotheses for understanding nutrient assimilation and use to discover and develop intervention leads; and 5) understand the role of the environment in healthy growth and the potential synergistic benefits of multi-sectoral interventions. Policymakers are urged to invest in nutrition-specific and -sensitive interventions to promote healthy growth from conception through the first 2 y of life because of their immediate and long-term health and development benefits.

Program responses to acute and chronic malnutrition: divergences and convergences

Program approaches for addressing acute malnutrition and those for addressing chronic malnutrition have grown in different directions. Their specialization has led to productive advances in the efficacy of specific interventions but has also created divergences in implementation. Greater convergence and integration between the 2 sets of approaches would help programs respond to the diversity of conditions faced in the field and enable a more comprehensive continuum of care from prevention to treatment. After reviewing the causes of the differences in approach, this paper examines programmatic and scientific challenges to greater convergence and suggests steps to promote effective integration of acute and chronic malnutrition services. Steps include strengthening community linkages between program platforms, assessing the degree and type of integration needed in various situations, identifying cost efficiencies, and developing joint tools where possible.