Association of both Water, Sanitation and Hygiene (WASH) and Infant and Young Child Feeding (IYCF) practices with childhood malnutrition in Lao PDR: a cross-sectional study of the 2017 Lao Social Indicator Survey II.

OBJECTIVE: We assessed whether Water, Sanitation and Hygiene (WASH) and Infant and Young Child Feeding (IYCF), either alone or combined, were associated with malnutrition among Lao People's Democratic Republic (Lao PDR) children aged 6 to <24 months. DESIGN: This is a secondary analysis of the 2017 Lao Social Indicator Survey II (LSIS II), which used multistage probability proportional to size sampling. Logistic regression analyses were conducted with OR and its corresponding 95% CI. SETTING: The LSIS II was conducted a nationwide household-based survey covering all 18 provinces in Lao PDR. PARTICIPANTS: We had a total of 3375 children (weighted sample 3345) and 357 households with data on drinking water. OUTCOME MEASURES: The outcomes of this study were stunting and wasting. RESULTS: The prevalence of stunting and wasting was 28.9% and 10.1%, respectively. Even though households with access to a basic or improved water source were high (82.5%), over 83% of drinking water was contaminated with Escherichia coli. Access to improved sanitation, basic hygiene and adequate IYCF gave a significant lower risk of becoming stunted. The combined effect of these practices on stunting was (adjusted OR (AOR)=0.54; 95% CI=0.41 to 0.73) greater than each practice alone (improved sanitation: AOR=0.75; 95% CI=0.61 to 0.93; basic hygiene: AOR=0.69; 95% CI=0.57 to 0.83; adequate IYCF: AOR=0.79; 95% CI=0.64 to 0.98). Access to improved sanitation and adequate IYCF was associated with a significant lower risk for being wasted, and again the combined effect of these practices was (AOR=0.64; 95% CI=0.44 to 0.92) greater than each practice alone (improved sanitation: AOR=0.68; 95% CI=0.49 to 0.93 and adequate IYCF: AOR=0.66; 95% CI=0.47 to 0.92). CONCLUSION: Given the strong associations with both stunting and wasting, and the added benefits when combining WASH and IYCF, there is a need of multisectoral interventions to reduce early childhood malnutrition in Lao PDR.

The associations between stunting and wasting at 12 months of age and developmental milestones delays in a cohort of Cambodian children.

Worldwide, over 250 million children under 5 years do not reach their developmental potential due to several causes, including malnutrition. In Cambodia, the prevalence of stunting and wasting among children remains high. This prospective cohort study aimed to assess acquisition of motor and cognitive developmental milestones in early childhood and their associations with stunting and wasting. Children aged from 0 to 24 months were recruited from three provinces in Cambodia and followed up to seven times from March 2016 to June 2019, until their 5 years. Data collection included anthropometry and developmental milestones. Seven motor and seven cognitive milestones were evaluated using the Cambodian Development Milestone Assessment Tool. Associations were assessed with parametric survival models. Hazard ratios (HR) below 1 stood for lower probabilities for achieving developmental milestones. Data were available for 7394 children. At 12 months, the prevalence of stunting and wasting were 23.7% and 9.6% respectively. Both were consistently associated with delays in most motor and cognitive milestones. Stunting was strongly associated with delays in gross motor milestones (HR < 0.85; p < 0.001). Wasting was more strongly associated with delays in fine motor development and most cognitive milestones (HR < 0.75; p < 0.001). Promoting nutritional programs in the first 1000 days to prevent malnutrition is essential to further the optimal growth and motor and cognitive development of Cambodian children.

Water quality for young children in Cambodia-High contamination at collection and consumption level.

Unsafe drinking water is a leading cause of child morbidity, especially among young children in low-income settings. Safe water consumption requires high-quality water available at its source and at point of use. We examined the quality of drinking water at point of collection and point of use in 796 households in three provinces, in Cambodia. Microbiological testing for coliform and Escherichia coli contamination was conducted for samples collected. Bivariable analysis and multivariable logistic regression were used to examine associations between various factors and the deterioration in water quality (increase in the risk according coliform or E. coli concentration) between point of collection and point of use. Contamination with both coliforms and E. coli was higher at point of use than at point of collection, with contamination at point of collection to account for 76.6% (coliforms) and 46.3% (E. coli). Results suggest that child drinking water represents a considerable pathway for the ingestion of pathogens, in Cambodia. Area of residence, seasonality, type of water source, and water chlorination were associated with coliform concentration between the point of collection and point of use, whereas only seasonality was associated with E. coli contamination (OR = 1.46; 95% CI [1.05, 2.02]). Children living in rural settings were two times more likely to drink water with a deteriorating coliform concentration between the two-time points than children living in urban settings (OR = 2.00; 95% CI [1.22, 3.30]). The increase in coliform and E. coli concentrations between point of collection and point of use indicates that water contamination mostly occurs within the household. Strengthening national legislation on water quality standards and promoting safe water management at the household are needed.

Maternal mid-upper arm circumference during pregnancy and linear growth among Cambodian infants during the first months of life.

Stunting prevalence among children under 5 years remains high in Cambodia, affecting about one-third of children. In most low- and middle-income countries, linear growth faltering of young children starts in the womb. The 1,000-days window of opportunity to improve child nutritional status includes pregnancy, as maternal nutritional status is an important determinant of birthweight and child development. In Cambodia, nutritional status of pregnant women is poor, with some studies reporting >20% of pregnant women having a low mid-upper arm circumference (MUAC < 23 cm). Few studies have investigated associations between maternal nutritional status during pregnancy and neonatal growth. Using data from a Cambodian cohort study conducted from 2016 through 2018 in selected districts of Phnom Penh, Kratie, and Ratanakiri provinces, we investigated associations between maternal MUAC during pregnancy as indicator of maternal nutritional status and their offspring linear growth during early life. Multivariate regression models were used to assess the associations between maternal MUAC during the last trimester of pregnancy and infant's length-for-age z-scores during the first 3.5 months of life. Maternal MUAC was significantly associated with infant's length-for-age z-scores (regression coefficient 0.06, 95% CI [0.03, 0.09]). Infants born from mothers with a low MUAC during pregnancy had a 1.6 times higher risk (odds ratio 1.621, 95% CI [0.998, 2.636]) of being stunted during the first 3.5 months of life compared with infants born from mothers with a MUAC >23 cm. This study underlines the importance of optimum maternal MUAC during pregnancy for optimal infant growth. Interventions that aim to tackle stunting in infants should integrate improving maternal MUAC during pregnancy.

Adherence to Child Feeding Practices and Child Growth: A Retrospective Cohort Analysis in Cambodia.

Appropriate feeding in the first 1000 days of a child's life is critical for their health and growth. We determined associations between adherence to age-appropriate feeding practices and child growth in Cambodia. Children (n = 1079) were included in the first follow-up (FU) data analyses and followed for 30 months (six FUs). Data were analyzed by generalized linear mixed-effect models. Children who adhered to feeding practices on at least three FUs, with an adequate minimal dietary diversity (MDD), a minimal acceptable diet (MAD), and age-appropriate daily feeding (ADF) were less stunted (14.8%, 12.3%, and 6.4%, respectively) than children who never adhered to these indicators (25.2%, 30.1%, and 24.8%, respectively). A higher adherence to MDD and ADF was associated with a higher height-for-age Z-score (HAZ) (ß: 0.13, 95% CI: 0.01-0.25 and ß: 0.36, 95% CI: 0.22-0.50), while a higher adherence to the MDD and MAD was associated with a higher weight-for-height Z-score (WHZ) (ß: 0.19, 95% CI: 0.08-0.30; and ß: 0.16, 95% CI: 0.05-0.27). A higher adherence to a minimum meal frequency (MMF) was associated with a lower HAZ (ß: -0.99, 95% CI: -1.28--0.70). Our findings showed that to reduce wasting and stunting in Cambodia, interventions should focus on improving both the quality and quantity of food intake of children under two while targeting the whole complementary feeding period.

Identification of Acute Malnutrition in Children in Cambodia Requires Both Mid Upper Arm Circumference and Weight-For-Height to Offset Gender Bias of Each Indicator.

Malnutrition remains a serious health problem in Cambodia with over 10% of children less than five years of age suffering from acute malnutrition. In addition to the presence of nutritional edema, two indicators are recommended by the World Health Organization for the diagnosis of acute malnutrition: weight-for-height Z-scores (WHZ; with acute malnutrition defined as WHZ < −2 Z-score) and mid-upper arm circumference (MUAC, with acute malnutrition defined as MUAC < 12.5 cm). Earlier, we showed that WHZ and MUAC identified different subgroups of children with acute malnutrition. To explore factors associated with both indicators of acute malnutrition, we analyzed baseline data from a longitudinal study in three provinces in Cambodia: Phnom Penh (capital, urban environment), Kratie (rural province), and Ratanakiri (hilly, rural province). Data was available for 4381 children below 30 months of age. Malnutrition rates were higher in the two rural provinces than in the capital. Although both MUAC and WHZ showed gender bias, with MUAC identifying more girls, and WHZ identifying more boys with acute malnutrition, the gender effect was strongest for MUAC. The gender bias of MUAC diminished with older age, but remained significant up to 30 months of age. Only using both MUAC and WHZ as indicators resulted in gender neutral identification of acute malnutrition. WHZ alone always identified more children with acute malnutrition than MUAC alone. In Phnom Penh, MUAC alone identified only 11% with acute malnutrition in addition to WHZ. To conclude, both MUAC and WHZ showed gender bias in this cohort of Cambodian children. In Cambodia, implementation of a MUAC-only or a WHZ-only program for the identification of acute malnutrition would be unethical as it will lead to many children remaining undiagnosed.

Diets and Feeding Practices during the First 1000 Days Window in the Phnom Penh and North Eastern Districts of Cambodia.

Although several health and development indicators have improved significantly in Cambodia, inadequate breastfeeding and inappropriate complementary feeding practices leave many children at high risk of malnutrition during the early stages of life. In 2014, the prevalence of wasting and stunting among Cambodian children under 5 were 10% and 32%, respectively. Thus, a strong focus on improving feeding practices within the first 1000 days window to reduce child malnutrition prevalence in Cambodia is needed. This cross-sectional study assessed the current feeding practices among of women of reproductive age, pregnant women, lactating women and children less than 24 months living in six districts from Phnom Penh and two rural provinces in the North East of Cambodia. The nutritional status of pregnant women was poor, with 21.4% having a Middle Upper arm circumference below 23 cm. While breastfeeding was predominant within the first 6 months of age in every district, feeding practices of pregnant women and children were a concern, as >70% of the children were not meeting the minimum acceptable diet, and most of the women did not improve their diet during pregnancy. Inadequate nutrition during the first 1000 days is highly prevalent in Cambodia. A comprehensive national Mother, Infant and Young Child Nutrition strategy needs to be developed and operationalized to improve feeding practices of Cambodian women and children.