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.     

Trends of child undernutrition in rural Ecuadorian communities with differential access to roads, 2004–2013

Road access can influence protective and risk factors associated with nutrition by affecting various social and biological processes. In northern coastal Ecuador, the construction of new roads created a remoteness gradient among villages, providing a unique opportunity to examine the impact of roads on child nutritional outcomes 10 years after the road was built. Anthropometric and haemoglobin measurements were collected from 2,350 children <5 years in Esmeraldas, Ecuador, from 2004 to 2013 across 28 villages with differing road access. Logistic generalized estimating equation models assessed the longitudinal association between village remoteness and prevalence of stunting, wasting, underweight, overweight, obesity, and anaemia. We examined the influence of socio‐economic characteristics on the pathway between remoteness and nutrition by comparing model results with and without household‐level socio‐economic covariates. Remoteness was associated with stunting (OR = 0.43, 95% CI [0.30, 0.63]) and anaemia (OR = 0.56, 95% CI [0.44, 0.70]). Over time, the prevalence of stunting was generally decreasing but remained higher in villages closer to the road compared to those farther away. Obesity increased (0.5% to 3%) over time; wasting was high (6%) but stable during the study period. Wealth and education partially explained the better nutritional outcomes in remote vs. road villages more than a decade after some communities gained road access. Establishing the extent to which these patterns persist requires additional years of observation.     

Concurrent wasting and stunting among under‐five children in Niakhar,Senegal

The study describes the patterns of concurrent wasting and stunting (WaSt) among children age 6–59 months living in the 1980s in Niakhar, a rural area of Senegal under demographic surveillance. Wasting and stunting were defined by z scores lower than ?2 in weight for height and height for age. Both conditions were found to be highly prevalent, wasting more so before age 30 months, stunting more so after age 30 months. As a result, concurrent WaSt peaked around age 18 months and its prevalence (6.2%) was primarily the product of the two conditions, with an interaction term of 1.57 (p < 10^?6). The interaction was due to the correlation between both conditions (more stunting if wasted, more wasting if stunted). Before age 30 months, boys were more likely to be concurrently wasted and stunted than girls (RR = 1.61), but the sex difference disappeared after 30 months of age. The excess susceptibility of younger boys could not be explained by muscle mass or fat mass measured by arm or muscle circumference, triceps, or subscapular skinfold. Concurrent WaSt was a strong risk factor for child mortality, and its effect was the product of the independent effect of each component, with no significant interaction.     

How well are infant and young child World Health Organization (WHO) feeding indicators associated with growth outcomes? An example from Cambodia

We assessed eight World Health Organization (WHO) core child feeding indicators for their association with stunting and underweight in Cambodia in 2000 and 2005. We compared the feeding data from the Cambodian Demographic and Health Surveys for 2000 with 2005 for 0-24 months children using the WHO feeding indicators, with stunting and underweight as outcomes. Prevalence of stunting and underweight was significantly less in 2005 than in 2000 among children aged 0-5 and 6-11 months, but stunting among children 18-23 months remained >50%. Prevalence of compliance with seven of the eight core healthy feeding indicators was higher in 2005. Exclusive breastfeeding among 0-5 months infants increased more than fivefold; among 6-11 and 12-17 months children, prevalence of feeding diversity and meeting a minimally acceptable diet, while improved, remained ≈25%. Modelling showed compliance with breastfeeding indicators was associated with reduced risk of underweight in 0-5 months infants, no association between compliance with feeding indicators and growth outcomes in other ages, and a significant association of higher relative wealth with growth outcomes overall. Between 2000 and 2005, Cambodia stabilized and focused resources on infant feeding. Prevalence of meeting the WHO feeding indicators improved, but modelling indicated that, in general, relative wealth, not feeding practices, was associated with improved growth outcomes. Yet, over 50% of children 18-23 months were stunted in 2005. Similar to the success with breastfeeding, focus on complementary feeding of 6-23 months children may reduce the risk of stunting in Cambodia.     

Risk factors for undernutrition among children 0–59 months of age in Myanmar

The prevalence of childhood stunting in Myanmar is one of the highest among the countries of Southeast Asia. Cross‐sectional data from the Myanmar Demographic Health Survey 2015–2016 were used to examine risk factors for stunting, wasting, and underweight among children aged 0–59 months. The prevalence of stunting, wasting, and underweight was 29.0%, 7.3%, and 19.2%, respectively. Accounting for sampling design and weights, multivariable logistic regression was conducted with 35 household, maternal, and child characteristics. Current pregnancy and maternal height <145 cm, home delivery, child's small birth size recalled by mother, and older age (ref: 0–5 months) predicted both stunting and underweight. Larger than average birth size was protective for all stunting, wasting, and underweight. Maternal body mass index <18.5 kg m^?2 was a common risk factor for wasting and underweight. Lower wealth quintiles, maternal engagement in nonagricultural occupation, and male child predicted stunting only. Younger child age and not receiving vitamin A supplementation in the previous 6 months were risk factors for wasting only. Regional variation was also seen, with a higher odds of stunting in the West‐South Region, North‐East States, and West States, compared with the Central Regions. In Myanmar, socio‐economic and demographic factors, poor maternal nutritional status, and living in certain geographical locations are affecting children's undernutrition. It is recommended that interventions for growth faltering focus on the first 1,000 days of life; optimum maternal nutrition be ensured during and before pregnancy and at adolescence; societal support be provided for mothers in poverty or engaged in nonagriculture; and region‐specific undernutrition pathways be understood.     

A review of child stunting determinants in Indonesia

Child stunting reduction is the first of 6 goals in the Global Nutrition Targets for 2025 and a key indicator in the second Sustainable Development Goal of Zero Hunger. The prevalence of child stunting in Indonesia has remained high over the past decade, and at the national level is approximately 37%. It is unclear whether current approaches to reduce child stunting align with the scientific evidence in Indonesia. We use the World Health Organization conceptual framework on child stunting to review the available literature and identify what has been studied and can be concluded about the determinants of child stunting in Indonesia and where data gaps remain. Consistent evidence suggests nonexclusive breastfeeding for the first 6 months, low household socio‐economic status, premature birth, short birth length, and low maternal height and education are particularly important child stunting determinants in Indonesia. Children from households with both unimproved latrines and untreated drinking water are also at increased risk. Community and societal factors—particularly, poor access to health care and living in rural areas—have been repeatedly associated with child stunting. Published studies are lacking on how education; society and culture; agriculture and food systems; and water, sanitation, and the environment contribute to child stunting. This comprehensive synthesis of the available evidence on child stunting determinants in Indonesia outlines who are the most vulnerable to stunting, which interventions have been most successful, and what new research is needed to fill knowledge gaps.     

Trends and geographic variability in gender inequalities in child mortality and stunting in India, 2006–2016

Gender disparities in child undernutrition and mortality in India have been a topic of interest for a long time, but little is known on trends or geographic variability in recent periods. We examined the degree to which historic patterns in gender disparities in child undernutrition and mortality in India have persisted given recent progress in health and nutrition. Using two nationally representative datasets from India between 2006 and 2016, we estimated mortality rates and stunting by gender and by birth order among children under 5 years old. We then tested for differences between boys and girls within each survey round for both national and state levels using bootstrapped standard errors, controlling for cluster and sampling weights. We found striking progress in child mortality and stunting in India between 2006 and 2016 for both boys and girls. Boys were more likely to die than girls during the first year of life. Girls had a higher risk of mortality between age 1 and 5 years than boys in 2006, but the improvements in survival eliminated this gender gap in 2016. For stunting, we found no gender difference in 2006, but girls had higher height‐for‐age Z‐scores (HAZ) and lower stunting than boys in 2016. Trends in gender gaps in mortality and stunting vary substantially by birth order and between states. Our findings indicate that improvements in mortality and nutritional status among girls have started to close gender disparities. Policy efforts to close gaps must stay the course in states that have made progress and be accelerated in states where disparities are still prominent.     

Exploring the impact of water,sanitation and hygiene (WASH), early adequate feeding and access to health care on urban–rural disparities of child malnutrition in China

To explore the effects of UNICEF-suggested modifiable factors, that is, water, sanitation and hygiene (WASH), early adequate feeding and health care on child malnutrition, and to examine the extent to which each factor contributes to urban–rural disparities of child malnutrition in China. Pooling two waves of regionally representative survey data from Jilin, China, in 2013 and 2018, we report on urban–rural relative risks (RRs) in the prevalence of child stunting, wasting and overweight. We employ Poisson regression to examine the effects of urban–rural setting and the three modifiable factors on the prevalence of each malnutrition outcome, that is, stunting, wasting and overweight. We perform mediation analyses to estimate the extent to which each modifiable factor could explain the urban–rural disparities in each malnutrition outcome. The prevalence of stunting, wasting and overweight were 10.9%, 6.3% and 24.7% in urban, and 27.9%, 8.2% and 35.9% in rural Jilin, respectively. The rural to urban crude RR was 2.55 (95% confidence interval [CI]: 1.92–3.39) for stunting, while the corresponding RRs for wasting and overweight were 1.31 (95% CI: 0.84–2.03) and 1.45 (95% CI: 1.20–1.76), respectively. The rural to urban RR for stunting reduced to 2.01 (95% CI: 1.44–2.79) after adjusting for WASH. The mediation analyses show that WASH could mediate 23.96% (95% CI: 4.34–43.58%) of the urban–rural disparities for stunting, while early adequate feeding and health care had no effects. To close the persistent urban–rural gap in child malnutrition, the specific context of rural China suggests that a multi-sectoral approach is warranted that focuses on the sanitation environment and other wider social determinants of health.     

Age‐appropriate infant and young child feeding practices are associated with child nutrition in India: insights from nationally representative data

Age‐appropriate infant and young child feeding (IYCF) practices are critical to child nutrition. The objective of this paper was to examine the associations between age‐appropriate IYCF practices and child nutrition outcomes in India using data from ～18 463 children of 0–23.9 months old from India's National Family Health Survey, 2005–06‐3. The outcome measures were child height‐for‐age z‐score (HAZ), weight‐for‐age z‐score (WAZ), weight‐for‐height z‐score, stunting, underweight and wasting. Linear and logistic regression analyses were used, accounting for the clustered survey data. Regression models were adjusted for child, maternal, and household characteristics, and state and urban/rural residence. The analyses indicate that in India suboptimal IYCF practices are associated with poor nutrition outcomes in children. Early initiation of breastfeeding and exclusive breastfeeding were not associated with any of the nutrition outcomes considered. Not consuming any solid or semi‐solid foods at 6–8.9 months was associated with being underweight (P < 0.05). The diet diversity score and achieving minimum diet diversity (≥4 food groups) for children 6–23 months of age were most strongly and significantly associated with HAZ, WAZ, stunting and underweight (P < 0.05). Maternal characteristics were also strongly associated with child undernutrition. In summary, poor IYCF practices, particularly poor complementary foods and feeding practices, are associated with poor child nutrition outcomes in India, particularly linear growth.     

Influences of early child nutritional status and home learning environment on child development in Vietnam

Early childhood development plays a key role in a child's future health, educational success, and economic status. However, suboptimal early development remains a global challenge. This study examines the influences of quality of the home learning environment (HOME) and child stunting in the first year of life on child development. We used data collected from a randomized controlled trial of preconceptional micronutrient supplementation in Vietnam (n = 1,458). The Bayley Scales of Infant Development‐III were used to assess cognition, language, and motor development domains at 2 years. At 1 year, 14% of children were stunted, and 15%, 58%, and 28% of children lived in poor, medium, and high HOME environments, respectively. In multivariate generalized linear regression models, living in a high HOME environment was significantly associated with higher scores (0.10 to 0.13 SD) in each of the developmental domains. Stunted children scored significantly lower for cognitive, language, and motor development (?0.11 to ?0.18), compared to nonstunted children. The negative associations between stunting on development were modified by HOME; the associations were strong among children living in homes with a poor learning environment whereas they were nonsignificant for those living in high‐quality learning environments. In conclusion, child stunting the first year of life was negatively associated with child development at 2 years among children in Vietnam, but a high‐quality HOME appeared to attenuate these associations. Early interventions aimed at improving early child growth as well as providing a stimulating home environment are critical to ensure optimal child development.     

The role of maternal education in the 15‐year trajectory of malnutrition in children under 5 years of age in Bangladesh

Malnutrition in children under 5 years of age (U5s) is a serious public health problem in low‐ and middle‐income countries including Bangladesh. Improved maternal education can contribute effectively to reduce child malnutrition. We examined the long‐term impact of maternal education on the risk of malnutrition in U5s and quantified the level of education required for the mothers to reduce the risk. We used pooled data from five nationwide demographic and health surveys conducted in 1996–1997, 1999–2000, 2004, 2007 and 2011 in Bangladesh involving 28 941 U5s. A log‐binomial regression model was used to examine the association between maternal education (no education, primary, secondary or more) and malnutrition in children, measured by stunting, underweight and wasting controlling for survey time, maternal age, maternal body mass index, maternal working status, parity, paternal education and wealth quintile. An overall improvement in maternal educational attainment was observed between 1996 and 2011. The prevalence of malnutrition although decreasing was consistently high among children of mothers with lower education compared with those of mothers with higher education. In adjusted models incorporating time effects, children of mothers with secondary or higher education were at lower risk of childhood stunting [risk ratio (RR): 0.86, 95% confidence interval (CI): 0.81, 0.89], underweight (RR: 0.83, 95% CI: 0.78, 0.88) and wasting (RR: 0.82, 95% CI: 0.74, 0.91) compared with children of mothers with no education. We demonstrated the importance of promoting women's education at least up to the secondary level as a means to tackle malnutrition in Bangladesh.     

Determinants of stunting in children under 5 years in Madagascar

Madagascar is among countries where the prevalence of stunting is dramatically high in under 5 years old children. This study investigated the determinants of child stunting based on the UNICEF framework on the causes of malnutrition. A cutoff at 24 months was used to separate the child population into two groups. By using the latest Demographic and Health Survey (2009), logistic regressions were performed to determine the variables associated with stunting. In 2009, 40.1% of the 1,863 children aged 0–23 months and 53.9% of the 2,911 children aged 24–59 months were stunted contributing to the 48.5% overall stunting prevalence in the sample. Girls were less likely to be stunted (adjusted odds ratio with confidence interval [AOR] = 0.69 [0.55–0.88] and 0.84 [0.72–0.97], p < 0.01) than boys; the risk of stunting increased with age. Regarding underlying predictors, increased maternal height was associated with lower odds of stunting in both age groups (AOR = 0.75 [0.68–0.83] and 0.69 [0.61–0.77], p < 0.001). Children living in households using iodized salt (>15 ppm) had lower risk of stunting in the younger group (AOR = 0.76 [0.61–0.94], p < 0.05). Children living in urban areas were less likely to be stunted in both age groups (AOR = 0.67 [0.51–0.88] and 0.73 [0.59–0.90] respectively, p < 0.01]. Region of residence was also a significant basic factor for stunting. This study contributes to the understanding of the determinants of child stunting in Madagascar. The results confirmed the need for specific interventions for each of the two age groups.     

Nutritional status and complementary feeding among HIV‐exposed infants: a prospective cohort study

Complementary feeding is crucial for improving child survival and promoting growth and development, particularly among HIV‐exposed children who have higher risk of morbidity and mortality than their un‐exposed peers. This prospective study employed an infant and child feeding index (ICFI) to measure complementary feeding and determine its association with nutritional status among 2092 HIV‐exposed infants followed from 6 to 24 months of age in Dar es Salaam, Tanzania. The ICFI measured both quality and quantity of complementary feeding, including current breastfeeding status, food consistency, dietary diversity scores (DDS), food group frequency score, and meal frequency. The ICFI score ranged from 0 to 9; the median score was 6 (Inter‐Quartile Range, IQR= 4–7). After adjusting for potential confounders, high ICFI scores were associated with reduced risk of stunting (high vs. low tertile hazard ratio, HR: 0.72; 95% confidence interval, CI: 0.57, 0.91; P< 0.01) and underweight (high vs. low tertile HR: 0.79; 95% CI: 0.61, 1.02; P= 0.07). Low DDS were associated with higher risk of stunting (low vs. high tertile HR: 1.59; 95% CI: 1.23, 2.07; P< 0.01) and underweight (low vs. high tertile HR: 1.48; 95% CI: 1.12, 1.96; P= 0.01). In this setting, high DDS and ICFI scores were protective of stunting and underweight. We recommend for nutrition programs in low‐income countries to emphasize educating HIV‐exposed children's caregivers on the importance of dietary diversity and optimal complementary feeding to improve nutritional status in this important subpopulation.     

Risk factors for protein–energy malnutrition in children under 5 years: Study from Luangprabang province, Laos

BACKGROUND: Laos is one of the poorest countries in which chronic malnutrition is highest. The aim of the present study was to determine the prevalence of and to identify risk factors associated with protein-energy malnutrition (PEM) in children under 5 years of age in Luangprabang province, Laos. METHODS: This cross-sectional study was undertaken from March to May 2004. Anthropometric measurements of 798 children were done and data were transformed into height-for-age, weight-for-age and weight-for-height ratios. Mothers were also interviewed with a semi-structured questionnaire. Anthropometric data were entered into Nutstat in Epi-Info 2000 and transferred to SPSS for analysis. RESULTS: There was a high prevalence of stunting, underweight and wasting, that is, 54.6%, 35%, and 6% respectively. It was also noted that children aged 12-23 months and Khmu ethnic children had a higher prevalence of stunting (65% and 66%) and underweight (45% and 40%), respectively. However, it was also found that boys were more prone to be stunted and underweight. Furthermore, restricted intake of meats, vegetables during illness, and low maternal education were main risk factors for child malnutrition in the study area. CONCLUSION: Socioeconomic-demographic factors, low maternal education, poor nutrition knowledge for mother and feeding practices for sick children are affecting children's health regarding stunting and underweight. It is recommended that an improvement in societal infrastructure, better maternal education and nutrition are needed to address the child malnutrition issue.     

Maternal autonomy is inversely related to child stunting in Andhra Pradesh, India

Child stunting, an outcome of chronic undernutrition, contributes to poor quality of life, morbidity and mortality. In South Asia, the low status of women is thought to be one of the primary determinants of undernutrition across the lifespan. Low female status can result in compromised health outcomes for women, which in turn are related to lower infant birthweight and may affect the quality of infant care and nutrition. Maternal autonomy (defined as a woman's personal power in the household and her ability to influence and change her environment) is likely an important factor influencing child care and ultimately infant and child health outcomes. To examine the relationship between maternal autonomy and child stunting in Andhra Pradesh, India, we analysed data from National Family Health Survey (NFHS)-2. We used cross-sectional demographic, health and anthropometric information for mothers and their oldest child <36 months ( n  = 821) from NFHS-2. The main explanatory variables of autonomy are presented by four dimensions – decision making, permission to travel, attitude towards domestic violence and financial autonomy – constructed using seven binary variables. Logistic regression models were used to test associations between indicators of female autonomy and the risk of having a stunted child. Women with higher autonomy {indicated by access to money [odds ratio (OR) = 0.731; 95% confidence interval (CI) 0.546, 0.981] and freedom to choose to go to the market [OR = 0.593; 95% CI 0.376, 0.933]} were significantly less likely to have a stunted child, after controlling for household socio-economic status and mother's education. In this south Indian state, two dimensions of female autonomy have an independent effect on child growth, suggesting the need for interventions that increase women's financial and physical autonomy.     

Child stunting is associated with child,maternal, and environmental factors in Vietnam

Child stunting in Vietnam has reduced substantially since the turn of the century but has remained relatively high for several years. We analysed data on children 6–59 months (n = 85,932) from the Vietnam Nutritional Surveillance System, a nationally representative cross‐sectional survey. Multivariable Poisson regression models were used to estimate relative risk (RR) of stunting, stratified by child age and ecological region. Covariates at the child, maternal, household, and environmental levels were included based on available data and the World Health Organization conceptual framework on child stunting. Among children 6–23 months, the strongest associations with child stunting were child age in years (RR: 2.49; 95% CI [2.26, 2.73]), maternal height < 145 cm compared with ≥150 cm (RR: 2.04; 95% CI [1.85, 2.26]), living in the Northeast compared with the Southeast (RR: 2.01; 95% CI [1.69, 2.39]), no maternal education compared with a graduate education (RR: 1.77; 95% CI, [1.44, 2.16]), and birthweight < 2,500 g (RR: 1.75; 95% CI [1.55, 1.98]). For children 24–59 months, the strongest associations with child stunting were no maternal education compared with a graduate education (RR: 2.07; 95% CI [1.79, 2.40]), living in the Northeast compared with the Southeast (RR: 1.94; 95% CI [1.74, 2.16]), and maternal height < 145 cm compared with ≥150 cm (RR: 1.81; 95% CI [1.69, 1.94]). Targeted approaches that address the strongest stunting determinants among vulnerable populations are needed and discussed. Multifaceted approaches outside the health sector are also needed to reduce inequalities in socioeconomic status.     

Prevalence and correlates of malnutrition among children in rural minority areas of China

BACKGROUND: Child growth retardation and malnutrition remain a matter of uttermost public concern in economically disadvantaged areas of China. The present study aimed to estimate the prevalence of protein-energy malnutrition with various anthropometric indices and examine its correlates in a large sample of poor rural minority children. METHODS: A total of 2019 children under 7 years of age belonging to the Hani, Yi, Hui, Miao ethnic minority groups and the Han major group were drawn from four poor rural minority counties in the Yunnan Province of China. Well-trained investigators completed child physical measurements and maternal interviews. Protein-energy malnutrition was defined as being underweight (weight for age), wasting (weight for height) and stunting (height for age) on the basis of reference data from the National Center of Health Statistics (NCHS)/World Health Organization (WHO). RESULTS: The respective prevalence of moderate and severe protein-energy malnutrition was 15.8 and 3.1% for underweight children, 31.8 and 19.2% for stunting and 0.9 and 0.5% for wasting. Stunting was most common in children aged 2 years. Boys were more likely to suffer from malnutrition. Logistic regression analyses showed that lower family income, lower parental height, belonging to the Miao, Yi and Hani ethnic groups compared with Han and poorer maternal child-rearing behavior significantly increased the risk for stunting of children. CONCLUSIONS: Protein-energy malnutrition is relatively high in the rural minority children of China. Chronic socioeconomic underdevelopment and genetic effects, rather than a severe or immediate lack of food, may lead to protein-energy malnutrition.     

Reconsidering childhood undernutrition: can birth spacing make a difference? An analysis of the 2002–2003 El Salvador National Family Health Survey

It is well understood that undernutrition underpins much of child morbidity and mortality in less developed countries, but the causes of undernutrition are complex and interrelated, requiring a multipronged approach for intervention. This paper uses a subsample of 3853 children under age 5 from the most recent family health survey in El Salvador to examine the relationship between birth spacing and childhood undernutrition (stunting and underweight). While recent research and guidance suggest that birth spacing of three to five years contributes to lower levels of infant and childhood mortality, little attention has been given to the possibility that short birth intervals have longer-term effects on childhood nutrition status. The analysis controls for clustering effects arising from siblings being included in the subsample, as well as variables that are associated with household resources, household structure, reproductive history and outcomes, and household social environment. The results of the multiple regression analyses find that in comparison to intervals of 36–59 months, birth intervals of less than 24 months and intervals of 24–35 months significantly increase the odds of stunting (<24 months Odds Ratio (OR) = 1.52; 95% confidence interval (CI): 1.21–1.92; 25–36 months OR = 1.30; 95% CI: 1.05–1.64). Other factors related to stunting and underweight include standard of living index quintile, child's age, mother's education, low birthweight, use of prenatal care, and region of the country where the child lives. Policy and program implications include more effective use of health services and outreach programs to counsel mothers on family planning, breastfeeding, and well child care.     

Handwashing,sanitation and family planning practices are the strongest underlying determinants of child stunting in rural indigenous communities of Jharkhand and Odisha,Eastern India: a cross‐sectional study

The World Health Organisation has called for global action to reduce child stunting by 40% by 2025. One third of the world's stunted children live in India, and children belonging to rural indigenous communities are the worst affected. We sought to identify the strongest determinants of stunting among indigenous children in rural Jharkhand and Odisha, India, to highlight key areas for intervention. We analysed data from 1227 children aged 6–23.99 months and their mothers, collected in 2010 from 18 clusters of villages with a high proportion of people from indigenous groups in three districts. We measured height and weight of mothers and children, and captured data on various basic, underlying and immediate determinants of undernutrition. We used Generalised Estimating Equations to identify individual determinants associated with children's height‐for‐age z‐score (HAZ; p < 0.10); we included these in a multivariable model to identify the strongest HAZ determinants using backwards stepwise methods. In the adjusted model, the strongest protective factors for linear growth included cooking outdoors rather than indoors (HAZ +0.66), birth spacing ≥24 months (HAZ +0.40), and handwashing with a cleansing agent (HAZ +0.32). The strongest risk factors were later birth order (HAZ ?0.38) and repeated diarrhoeal infection (HAZ ?0.23). Our results suggest multiple risk factors for linear growth faltering in indigenous communities in Jharkhand and Odisha. Interventions that could improve children's growth include reducing exposure to indoor air pollution, increasing access to family planning, reducing diarrhoeal infections, improving handwashing practices, increasing access to income and strengthening health and sanitation infrastructure.