OBJECTIVES: Length-for-age z-scores (LAZ) and stunting prevalence (%LAZ <-2) are commonly used to quantify linear growth faltering in young children in low- and middle-income countries (LMICs). The Healthy Birth, Growth and Development knowledge integration (HBGDki) consortium described postnatal linear growth faltering using LAZ-by-age trajectory modelling and child-level LAZ threshold-crossing events, including incident stunting onset (first occurrence of LAZ <-2) and stunting reversal (LAZ rising from <-2 to ≥-2). Using simulations, we assessed the suitability of these LAZ threshold-crossing metrics for characterising linear growth faltering in LMICs. METHODS: We simulated a synthetic cohort with a harmonically downward-shifting LAZ trajectory from birth to 24 months of age, with mean LAZs similar to the HBGDki pooled South Asian cohorts, and without any input parameters intended to differentially affect individuals' growth across the height distribution or at different ages. We compared HBGDki empirical estimates of age interval-specific frequencies of incident stunting onset and stunting reversal with those from the synthetic cohort. Using synthetic cohorts, we examined how estimates of incident onset and reversal were affected by missing data, magnitude of the whole-population shift in the LAZ distribution and strength of the between-time-point correlation. We also compared the 3-24 month pattern of linear growth faltering expressed as age-related trajectories of average growth delay (chronological age minus height-age), mean LAZ or stunting prevalence. RESULTS: Empirical estimates of age interval-specific incident stunting onset and stunting reversal in the HBGDki cohorts were similar to those observed in a synthetic cohort. Variability in LAZ threshold-crossing event rates is explained by starting LAZ, between-time-point correlation and the magnitude of the whole-population shift in the LAZ distribution. Incident stunting onset is also affected by missing data in preceding intervals. Stunting reversal occurs due to within-child variability (ie, imperfect between-time-point correlation) in the absence of any other phenomena that cause stunted children to become non-stunted at a later age. The linear growth faltering pattern based on growth delay differed from corresponding age-related trajectories of mean LAZ or stunting prevalence. CONCLUSIONS: In longitudinal studies of linear growth faltering in LMICs, LAZ threshold-crossing indicators are byproducts of whole-population shifts in LAZ and within-child variability and should be interpreted accordingly. Reporting incident stunting onset and reversal rates, or analyses in which children are grouped by the timing of LAZ threshold-crossing events, may detract from efforts to understand when and why nearly all children in LMICs grow more slowly than expected for their age. Since mean LAZ and stunting prevalence are unsuitable for quantifying the rate and timing of population-average postnatal linear growth faltering, growth delay is recommended for consideration as a preferred metric.
BACKGROUND: Pneumonia is still a burden in children hospitalized with severe acute malnutrition (SAM). However, there is limited published information on the magnitude and characteristics of those who present with or develop pneumonia during hospitalization. We determined the prevalence and incidence of pneumonia, and associated factors among children aged 6-59 months hospitalized with SAM. METHODS: This study employed 2 study designs; cross sectional for prevalence of pneumonia and single arm retrospective cohort design for incidence of pneumonia. We used secondary data collected as part of the ProbiSAM trial that assessed the effect of Probiotics on diarrhea in children with severe acute malnutrition conducted at Mwanamugimu Nutrition Unit Mulago Hospital. Children aged 6-59 months hospitalized with SAM were assessed for prevalence and incidence of pneumonia. Prevalence of pneumonia was the proportion of pneumonia cases at the time of enrolment or within the first 48 hours of admission. 2)Incidence of pneumonia was the proportion who developed clinical signs of pneumonia for the first time during hospitalization among those who did not have pneumonia at enrolment or within 48 hours after admission. RESULTS: 400 children were included in the study and of these, 58% were males. Most (87%) of the children were aged 24 months and below. The prevalence of pneumonia was 28% (95% CI: 24-33). In multivariable analysis, factors associated with prevalence of pneumonia include: female sex (Adjusted PR: 1.72, 95% CI: 1.20-2.45), stunting (Adjusted PR: 1.60, 95% CI: 1.12-2.30) and presumptive TB (Adjusted PR: 1.95, 95% CI: 1.34-2.82). Incident pneumonia was estimated at 356 (95% CI: 305-416) per 1000 hospital admissions of children with SAM. In multivariable analysis, children at risk of pneumonia were: young age 6 to 12 months (Adjusted RR: 1.89, 95% CI: 1.10-3.29), stunting (Adjusted RR: 1.59, 95% CI: 1.15-2.20), HIV infection (Adjusted RR: 1.59, 95% CI: 1.08-2.33), presumptive TB (Adjusted RR: 1.73, 95% CI: 1.23-2.43), used a nasogastric tube for feeding (RR: 1.38, 95% CI: 1.00-1.89) and prolonged hospitalization of 15 days or more (Adjusted RR: 2.16, 95% CI: 1.39-3.35). CONCLUSION AND SIGNIFICANCE: This study identified that prevalence of pneumonia among children hospitalized with SAM is still high and similar to previous studies done in different settings in Uganda. In addition, this study showed that the risk of incident pneumonia among children hospitalized with SAM is high. These findings point out the need to develop guidelines to monitor, detect and treat incident pneumonia among children hospitalized with SAM. Stunting as factor associated with both prevalence and incidence of pneumonia underscores the importance of further research to evaluate how stunting relates to pneumonia.
Peer-reviewed article·PubMed (US National Library of Medicine)·
BACKGROUND: Improvements in child nutrition outcomes have lagged behind India’s recent rapid economic growth, a phenomenon known as the ‘Indian enigma.’ Between 2015–16 and 2019–21, stunting and wasting rates declined only slightly, with some Indian states even experiencing worsening malnutrition. This study investigates the factors driving these trends, focusing on the impact of the COVID-19 pandemic, children’s dietary quality, access to water, sanitation, and hygiene (WASH), and the role of government nutrition programmes. METHODS: The study employs a mixed-methods approach, combining a quantitative analysis of data from India’s National Family Health Surveys (NFHS) IV (2015–16) and V (2019–21) with a qualitative comparative case study of Rajasthan and Himachal Pradesh—two states with contrasting malnutrition trends. Individual- and district-level regression models were used to assess the effects of dietary diversity, WASH access, and government programmes, whilst interviews with policy makers in Rajasthan and Himachal have provided insights into programme implementation and local responses during the pandemic. RESULTS: Our findings confirm that dietary diversity, particularly consumption of animal-sourced foods, and improved WASH access are key drivers of better nutrition outcomes in India. However, contrary to expectations, we do not find a consistently negative relationship between the COVID-19 pandemic and child malnutrition. Instead, flexible expansion of some of the welfare programmes during the pandemic along with reductions in children’s disease rates and improvement in some sanitation practices may have mitigated the expected deterioration. Findings from the comparative study of Rajasthan and Himachal further highlight the importance of tailoring welfare programmes to specific local conditions, such as the large proportion of migrant labourers in Himachal. CONCLUSIONS: Our study challenges assumptions about the pandemic’s uniformly negative effects on child nutrition and highlights the importance of resilient, locally tailored safety nets. The findings underscore the need for policy interventions that enhance dietary diversity, sustain WASH improvements, and strengthen the adaptability of food and nutrition programmes to crises.
Peer-reviewed article·PubMed (US National Library of Medicine)·
Background: Undernutrition and overnutrition are considered a rising challenge among adolescents in low- and middle-income countries, including Lebanon, where overlapping economic, political, and public health crises have worsened food insecurity. Food and nutrition literacy in adolescents may serve as protective factors against food insecurity and its nutritional consequences. This study aims to evaluate the associations between adolescent and parental food and nutrition literacy with household and adolescent food insecurity, and explores their relationship with stunting and overweight/obesity. Methodology: A cross-sectional survey was conducted between March and July 2022 among 442 Lebanese adolescents (10-18 years) and one parent/caregiver per household, recruited via snowball sampling from all eight governorates. Validated tools assessed adolescent food and nutrition literacy, parental food literacy, household/adolescent food insecurity, and anthropometric status. Chi-square, t-tests, and multivariable logistic regressions identified factors associated with food insecurity, stunting, and overweight/obesity. Results: Higher adolescent food and nutrition literacy was significantly associated with lower odds of severe food insecurity (aOR = 0.43, 95% CI: 0.26-0.70). Higher parental food literacy scores were linked to reduced odds of severe household food insecurity (aOR = 0.94, 95% CI: 0.90-0.98). Severe food insecurity was more likely in households in Akkar and among adolescents not attending school or with poor food and nutrition literacy. Overweight/obesity was positively associated with attending private school and higher parental body mass index, but inversely associated with higher child food security and household crowding index. No significant association was found between food insecurity and stunting. Conclusions: Both adolescent and parental food and nutrition literacy are protective against severe food insecurity, highlighting the value of literacy-focused interventions alongside economic support measures. Addressing both educational and structural determinants may help break the cycle of malnutrition in crisis-affected Lebanese youth.
Peer-reviewed article·PubMed (US National Library of Medicine)·
A cluster-randomised controlled trial was conducted in 60 communities in southern Mali to evaluate the impact of micronutrient powders (MNP) combined with seasonal malaria chemoprevention (SMC) on anaemia (primary endpoint), Plasmodium infection, stunting and cognitive function in children < 5 years. The 60 communities were randomly allocated to the intervention or control arm, and cross-sectional biomedical and cognitive surveys were conducted after 1 and 3 years in a random sample of 3 and 5 years olds (1052 and 1081 children, respectively). All children aged 3-59 m in intervention and control communities received two rounds of SMC each year during the peak malaria season, and in intervention communities, all children aged 6-59 m additionally received 4 months of daily MNP after the peak malaria season. Despite a high baseline prevalence of anaemia and good fidelity to intervention, this trial found no evidence of impact on study outcomes. The prevalence of anaemia was similar in both arms for both age groups after 1 and 3 years of intervention-after 3 years, the prevalence of anaemia amongst 3-year olds was 57.6% in the intervention arm versus 60.1% in the control group (p = 0.352). For 5-year olds, it was 51.3% and 53.0%, respectively (p = 0.607). No effect was observed on stunting or cognitive function either.
Niélé H Diarra, Yahia Dicko, Natalie Roschnik et al.
SurvivalDevelopment
Peer-reviewed article·PubMed (US National Library of Medicine)·
BACKGROUND/OBJECTIVES: Increasing the energy density of porridges could help meet the needs of moderately malnourished, stunted children. However, it is not clear whether stunted toddlers can adequately digest and obtain energy from energy-dense porridges with thick texture. A clinical study was conducted in Bamako, Mali, using 13C-labeled substrates and serial breath sampling to determine whether stunted toddlers differed from healthy toddlers in their capacity to digest thick and thin sorghum porridges. SUBJECTS/METHODS: Experimental porridges, including a traditional porridge (control), a starch-enriched calorie-dense thick porridge, and an α-amylase-thinned calorie-dense porridge, were fed to stunted (n = 24) and healthy (n = 24) 18-30-month toddlers. Breath test results were expressed as Percent Dose Recovery and curve fit using the Weibull function to determine the kinetics of starch digestion. RESULTS: The stunted and healthy toddlers were able to digest and oxidize the starch from traditional porridge equally well, with no statistically significant differences between the kinetic parameters of the two groups. After consumption of thickened porridge, healthy toddlers had slightly faster starch digestion kinetics with PDR curves rising more rapidly (p < 0.05) and peaking earlier in the postprandial period (p < 0.01) for healthy individuals than for stunted individuals, yet these groups did not have differences in the overall extent of starch digestion, as their final CPDR values were not significantly different. Gastric emptying rate did not differ significantly between the healthy and stunted groups. CONCLUSION: Overall, we found that thick porridge supplied digestible carbohydrates to stunted and healthy toddlers, as well as thinned calorie-dense porridge.
Fatimata Cisse, Clay Swackhamer, Hawa G Diall et al.
Survival
Peer-reviewed article·PubMed (US National Library of Medicine)·
AIM: To identify the correlates of stunting and investigate their population-level impacts among children under 5 years in sub-Saharan Africa. METHODS: Data from 179 572 children under five were included from nationally representative surveys conducted across 24 sub-Saharan African countries (2015-2022). Multivariable logistic regression models and population-level impacts of risk factors were estimated to highlight their contributions to stunting prevalence across the study regions. RESULTS: Stunting prevalence ranged from 18% to 54%, with rates exceeding 50% in Burundi. Lack of basic household amenities was consistently associated with stunting, accounting for 24%-57% of cases across regions. Limited access to mass media further contributed to stunting rates, highlighting the role of education and awareness in preventing malnutrition. Maternal characteristics, such as lack of education and health insurance, were also significant risk factors, with adjusted odds ratios (aORs) ranging from 1.44 to 2.24. CONCLUSION: Socio-economic disparities are key risk factors for stunting in sub-Saharan Africa. These factors were statistically associated with a substantial proportion of stunting cases in high-prevalence regions. Targeted interventions to reduce inequalities, improve maternal education and expand essential services access are vital to achieving global nutrition targets, including the Sustainable Development Goal of reducing child stunting by 40% by 2025.
Handan Wand, Jayajothi Moodley, Sarita Naidoo et al.
SurvivalBI
Peer-reviewed article·PubMed (US National Library of Medicine)·
OBJECTIVES: Malnutrition is a global health issue affecting growth and systemic health in children, yet its impact on the choroid-a vascular layer essential for retinal nourishment-remains underexplored. This study evaluates the choroidal vascular index (CVI) and choroidal thickness in malnourished children compared to healthy controls using optical coherence tomography (OCT). It also examines the relationship between these parameters and nutritional markers, including serum ferritin, vitamin B12, vitamin D, and hemoglobin levels. METHODS: This cross-sectional study involved 52 malnourished and 40 healthy children aged 6-16 years. Malnutrition severity was categorized as mild, moderate, or severe based on WHO BMI criteria. Choroidal parameters were measured using spectral-domain optical coherence tomography (SD-OCT). Statistical analysis compared CVI and thickness between groups and assessed correlations with malnutrition severity and nutritional markers. RESULTS: CVI was significantly lower in malnourished children compared to controls (P < 0.05), while choroidal thickness showed no significant difference (P > 0.05). CVI negatively correlated with malnutrition severity (r = -0.45, P < 0.01). Ferritin and vitamin D levels were positively associated with CVI (P < 0.001), whereas vitamin B12 showed no significant relationship. Lower hemoglobin levels were linked to vascular compromise. CONCLUSIONS: Malnutrition adversely affects CVI, even in early stages, suggesting it as a marker of choroidal vascular compromise. Micronutrients, particularly ferritin and vitamin D, appear protective. Monitoring choroidal parameters and addressing nutritional deficiencies may help prevent ocular complications in malnourished children.
Elmas Yüksel Şükün, Fuat Yavrum, Begüm Yavrum
Survival
Peer-reviewed article·PubMed (US National Library of Medicine)·
BACKGROUND: Nutritional rickets remains a global health burden. The optimal management of coronal knee deformities in children/adolescents with healed nutritional rickets as to the indications of conservative treatment versus guided growth surgery remains unsettled. The objective was to report the natural history of disease regarding the remodeling potential of coronal knee deformities and isolate potential patient- and deformity-related factors that are predictors of favorable deformity remodeling. METHODS: We prospectively assessed 109 knees in 57 patients-mean age, 6.1 years (range, 2 to 12)-for spontaneous correction of their coronal knee deformities over a period of 1 year. Male/female:33/24, valgum/varum:34/23, bilateral/unilateral:52/5 patients. Outcome variables were, radiologic tibiofemoral angle and a questionnaire to assess parent satisfaction. They were correlated to independent patient- and deformity-related variables, including age, sex, deformity direction/severity, and laterality. RESULTS: The mean age of patients that achieved complete knee remodeling (4.9 y) was significantly lower compared with patients who experienced complete failure of remodeling (8.4 y), P =0.000, (95% CI, 4.3-5.4). In 109 knees, there was a highly significant negative Spearman correlation coefficient between age and degrees of coronal correction, patient satisfaction, and complete failure of remodeling R=-0.660, R=-0.475, R=-0.434, respectively, P <0.001. The knees of patients >8 years of age that failed to remodel (87.5%) was significantly higher compared with patients ≤8 years (29.9%), P =0.000, OR=16.4, (95% CI, 5.2-52.2). There were statistically significant correlations between deformity severity/tibiofemoral angle and the remodeling potential, with a cutoff angle of 16.5 degrees/13 degrees for valgum/varum above which deformities were less likely to remodel spontaneously, P =0.03, P =0.007. Complete knee remodeling in unilateral deformities was statistically but not clinically significant. Correlations of sex and deformity direction with remodeling outcomes were insignificant. The inter- and intrarater agreements were excellent for the radiologic tibiofemoral angle measurements (ICC=0.993, CI, 0.982-0.997, P <0.01) and (ICC=0.994, CI, 0.987-0.998, P <0.01), respectively. CONCLUSION: Children with coronal knee deformities of healed nutritional rickets under the age of 8 years should be given the full opportunity to remodel spontaneously for at least 1 year, particularly children with moderate deformities ≤16 degrees. This is irrespective of sex, deformity direction, and laterality. Most deformities remodel spontaneously. This suggests that these deformities may be overtreated. This could reduce unnecessary surgeries and potentiate cost-effectiveness of treatment and risk-benefit profile. LEVEL OF EVIDENCE: Level IV prognostic studies-investigating the effect of a patient characteristic on the outcome of disease.
Peer-reviewed article·PubMed (US National Library of Medicine)·
In India, poor child health is a pertinacious issue. This article investigates the impact of water and sanitation, maternal health care service utilization (MHCSU) and breastfeeding practices on under-five child health outcomes (CHOs) in India using the two rounds of the Indian Demographic and Health Survey (DHS), 2015-2016 and 2019-2021. In 2019-2021, unprotected sources of drinking water were associated with an increased prevalence of under-five wasting. Unimproved sanitation facilities were likely to increase the prevalence of under-five stunting; however, unlike in DHS 2015-2016, it had no statistically significant effect on wasting and underweight (2019-2021). Mothers who had not received at least four antenatal care visits were more likely to have stunted and underweight children (2019-2021). The absence of early initiation of breastfeeding was associated with an increased prevalence of under-five wasting and underweight but did not influence CHOs (2015-2016). In 2019-2021, the absence of exclusive breastfeeding for the initial six months was associated with increased odds of stunting and underweight among children. To improve CHOs, policymakers must focus on providing financial, material, and human resources along with soft knowledge to provide hygiene education and promote MHCSU, breastfeeding practices, engagement with frontline health workers and women's empowerment.
Charu Tayal, Rajesh Sharma, Kusum Lata
SurvivalDevelopment
Harriet Nambuya, Ezekiel Mupere, Nicolette Nabukeera-Barungi et al.
