Impact of the COVID-19 pandemic on child malnutrition in Selangor, Malaysia: A pilot study.

BACKGROUND: Child malnutrition risk factors are globally recognized, but the specific impact of the COVID-19 pandemic on the prevalence of child malnutrition, considering socioeconomic burdens and changes in family lifestyles, remains underexplored. This study aims to identify the significance of COVID-19-related factors in relation to the prevalence of child malnutrition in Selangor, Malaysia. METHODS: Purposive sampling was employed in this pilot study to select the households with under-5 children and, a structured questionnaire was developed to gather data. Chi-squared tests, logistic regression modelling and World Health Organisation AnthroPlus software-based visualization were used for analyses. RESULTS: The present study's findings indicate that demographic and social factors, including 'Citizenship,' 'Type of House,' 'Number of Earning Members,' 'Father's Highest Educational Level,' and 'Number of Children in a Family,' have a statistically significant association with Wasting. Additionally, the mother's 'Highest Educational Level' is found to be linked to underweight prevalence. Within COVID-19 factors, "COVID-19 Impact on Employment/Business" demonstrated significance for both stunting and wasting. Multivariate analysis revealed disparities in childhood malnutrition by gender, age, and factors such as "COVID-19 impact on children's physical activity" and "COVID-19 impact on children's decrease in health over the last two weeks." CONCLUSIONS: This study identified COVID-19 factors alongside sociodemographic variables with statistically significant relationships impacting childhood malnutrition in Selangor, Malaysia. The results underscored the substantial influence of the COVID-19 pandemic on child malnutrition prevalence. Decision-makers at family and community levels can benefit by considering these factors in their actions. However, the study's limitation lay in its dataset, urging larger-scale analyses to explore further sub-categories of the examined variables.

Factors mediating the association between recurring floods and child chronic undernutrition in northern Bangladesh.

OBJECTIVES: Although there is some evidence that flood exposure in Bangladesh and other developing countries increases the risk of chronic undernutrition in children, the underlying mechanisms are, to our knowledge, unknown. The objectives of this research are to examine the association between recurrent flood exposure and the likelihood of chronic undernutrition in children and to investigate the mediators of this association. METHODS: This cross-sectional study was conducted in the Naogaon District in northern Bangladesh. Purposive sampling was used to choose 800 children between the ages of 12 and 59 mo in equal numbers in the specified flood-affected and flood-unaffected areas: 400 children from the flood-affected area and 400 from the flood-unaffected area. The nutrition indicator height for age, expressed as z scores, was used to define child chronic undernutrition. Our study focused on children who have been exposed to multiple floods in the past 5 y. RESULTS: In our sample data, children who had experienced flooding had a 1.74-times higher chance of having chronic undernutrition (95% CI, 1.53-2.28) than children who had not experienced flooding. The mediation analyses found inadequate minimum dietary diversity, history of diarrhea, not being fully vaccinated, not using clean cooking fuel, and not having a separate kitchen contributed 19.5%, 10%, 9.8%, 14.8%, and 10%, respectively, to the flood exposure-child undernutrition association. CONCLUSIONS: Flood exposure was found associated with the likelihood of child chronic undernutrition, and this relationship was mediated through lack of having a separate kitchen, history of diarrhea, insufficient vaccination, use of unclean cooking fuel, and poor minimum dietary diversity. Interventions to reduce the prevalence of these risk factors could contribute to reducing the disparities in child undernourishment brought on by exposure to flooding.

Association Between Household Food Insecurity (Access) Scores, Poverty Indicators and Child Malnutrition in Botswana.

In Botswana the Household Food Insecurity Access Scale (HFIAS) has been used in studying the urban-poor, but less in rural settings high in poverty, child malnutrition (CM), and social protection beneficiaries. This cross-sectional study compared HFIAS scores, household poverty (HP) and CM in two rural districts: Bobirwa with moderate and Mabutsane with high poverty. Households (n = 872) with children under-five years participated. Most children (87.6%) experienced food insecurity. Mean HFIAS for all households was 11.0 ± 8. HFIAS scores were higher in Mabutsane (p < .001). HFIAS scores were consistently associated with HP and CM in both districts. HFIAS can assist in targeting the rural-poor.

Maternal depression and child feeding practices: Determinants to malnutrition among young children in Malaysian rural area.

BACKGROUND: Maternal depression may affect child feeding practices and growth. OBJECTIVE: The objective of this study is to determine the relationship between child feeding practices and current maternal depression with malnutrition among young children in a rural community. METHODS: This is a case-control study consisting of 52 Malay mothers of malnourished children (case) and 50 Malay mothers of well-nourished children (control) in Kuala Langat, Selangor, Malaysia. Structured questionnaires on child feeding practices and Beck Depression Inventory: Second Edition questionnaire were distributed to mothers. RESULTS: Depressed mothers stopped exclusive breastfeeding (2.8 ± 2.1 months) earlier than non-depressed mothers (3.7 ± 2.0 months; p = 0.045). Binary logistic regression analysis showed current maternal depression was a primary contributor associated with risk of malnutrition in children (adjusted odds ratio: 2.5, 95% confidence interval: 1.08-6.09), and followed by the number of children (adjusted odds ratio: 1.3, 95% confidence interval: 1.02-1.77). CONCLUSION: Mothers who experienced depression were twice as likely to have malnourished children. Each additional child in the family will increase the risk of malnutrition by 1.3 times. Maternal depression is associated with child feeding practices and malnutrition among young children in the studied population. Preliminary screening to identify depression symptoms should be conducted to all mothers as early as the first trimester to prevent the incidence of malnutrition in children.

Interlinkages between Climate Change and Food Systems: The Impact on Child Malnutrition-Narrative Review.

The pandemics of obesity, undernutrition, and climate change represent severe threats to child health. They co-occur; interact with each other to produce sequelae at biological, psychological, or social levels; and share common underlying drivers. In this paper, we review the key issues concerning child diet and nutritional status, focusing on the interactions with climate and food systems. Inadequate infant and young child feeding practices, food insecurity, poverty, and limited access to health services are the leading causes of malnutrition across generations. Food system industrialization and globalization lead to a double burden of malnutrition, whereby undernutrition (i.e., stunting, wasting, and deficiencies in micronutrients) coexists with overweight and obesity, as well as to harmful effects on climate. Climate change and the COVID-19 pandemic are worsening child malnutrition, impacting the main underlying causes (i.e., household food security, dietary diversity, nutrient quality, and access to maternal and child health), as well as the social, economic, and political factors determining food security and nutrition (livelihoods, income, infrastructure resources, and political context). Existing interventions have the potential to be further scaled-up to concurrently address undernutrition, overnutrition, and climate change by cross-cutting education, agriculture, food systems, and social safety nets. Several stakeholders must work co-operatively to improve global sustainable nutrition.

Effects of maternal employment on child malnutrition in South Asia: An instrumental variable approach.

OBJECTIVE: Although the association between child malnutrition and maternal employment status has been widely studied in several developing countries, the causal effect of mothers' employment on their children's health remains largely unknown. The aim of this study was to examine the causal effect of maternal employment on child malnutrition in five South Asian countries. METHOD: This study used a data set of >55 200 children ages 0 to 5 y by pooling the most recent Demographic Health Surveys (DHS) from Bangladesh, India, the Maldives, Nepal, and Pakistan. An instrumental variable (IV) method was applied to measure the causal effect of the mother's employment status (working mother) on stunting and underweight among children. RESULTS: Results showed that of the children in South Asia, 37.9% and 33.6% were stunted and underweight, respectively. The IV estimates suggested that maternal employment significantly increased stunting and underweight in children. For example, the likelihood of stunting and underweight increased by about 9.5% and 6.3% points, respectively, in South Asia when mothers worked. The likelihoods in Bangladesh (39.9 and 26.6%) and Pakistan (28 and 33.4%) were high but were at moderate levels in India (5.3 and 4.2%) and Nepal (8 and 9%). CONCLUSIONS: In the present study, an adverse effect of maternal labor market participation on the nutritional status of under-five children in South Asian countries was found. These findings could be helpful for policymakers in South Asian countries to adopt suitable policies to reduce malnutrition among children, especially for the children of employed mothers.

Using traditional healers to treat child malnutrition: a qualitative study of health-seeking behaviour in eastern Ethiopia.

BACKGROUND: Malnutrition among children under five years of age is a major public health issue in many low and middle-income constrained countries. According to WHO, 5.3 million under-five children die every year and about 45% of these deaths are linked to malnutrition. While it is clear that poverty and lack of food are important factors in children's malnutrition, less is known about the ways in which local conceptions of malnutrition affect parents' treatment choices. In Ethiopia, child malnutrition is a severe public health problem and a common cause of child death, and this paper explores the local views of malnutrition and how these shape people's health-seeking behaviour. METHODS: The study was conducted in eastern Ethiopia from December 2017 to January 2019, conducting interviews and focus group discussions to explore different views and treatment options malnutrition. The study used grounded theory because it allows new and unexpected themes to arise from the data. Researchers' assumptions on local terminologies of child malnutrition are also controlled as a principle of ground theory. RESULTS: Child malnutrition was not only perceived to be related to lack of food but was understood in a wider local conceptualization of health and illness. Parents often relied on healers because they are long-standing members of the community, possess indigenous knowledge, and cost less than other options. Because health professionals and the community perceive and speak of health very differently, people often do not seek support from health services. The misalignments between how health professionals and healers diagnose and treat malnourished children have implications on the possibilities to implement change to reduce malnutrition. CONCLUSIONS: Through an exploration of people's own terminology and understandings of what a malnourished child is, as well as the underlying reasons for their illness, this paper explores how people understand malnutrition symptoms and why many tend to rely on healers rather than seeking care from health centres.

Incidence and predictors of severe acute malnutrition mortality in children aged 6-59 months admitted at Pawe general hospital, Northwest Ethiopia.

BACKGROUND: Severe acute malnutrition (SAM) is defined as a weight-for-height < -3z scores of the median WHO growth standards, or visible severe wasting or the presence of nutritional edema. SAM related mortality rates in under-five children are well documented in Ethiopia but data on their predictors are limited. We aimed to document factors associated with SAM related mortality to inform better inpatient management. METHODS: A facility-based retrospective cohort study was conducted among children admitted due to SAM at Pawe General Hospital, Northwest Ethiopia, from the 1st of January 2015 to the 31st of December 2019. Data from the records of SAM children were extracted using a standardized checklist. Epi-Data version 3.2 was used for data entry, and Stata version 14 was used for analysis. Bi-variable and multivariable Cox regression analyses were conducted to identify predictors of mortality. Variables with P<0.05 were considered significant predictors of mortality. RESULTS: Five-hundred sixty-eight SAM cases were identified of mean age was 27.4 (SD± 16.5) months. The crude death rate was 91/568 (16.02%) and the mean time to death was determined as 13 (±8) days. Independent risk factors for death were: (i) vomiting AHR = 5.1 (1.35-21.1, p = 0.026), (ii) diarrhea AHR = 2.79 (1.46-5.4, p = 0.002), (iii) needing nasogastric therapy AHR = 3.22 (1.65-6.26, p = 0.001), (iv) anemia AHR = 1.89 (1.15-3.2, p = 0.012), and (v) being readmitted with SAM AHR = 1.7 (1.12-2.8, p = 0.037). CONCLUSION: SAM mortality was high in under-five children in our setting. The identified risk factors should inform treatment and prevention strategies. Improved community health education should focus on healthy nutrition and seeking early treatment. Inpatient mortality may be reduced by stricter adherence to treatment guidelines and recognizing early the key risk factors for death.

Determinants of malnutrition among children: A systematic review.

OBJECTIVES: Child undernutrition is a major public health problem. Globally in 2020, 149 million children <5 y of age were estimated to be stunted (too short for age), 45 million to be wasted (too thin for height), and 38.9 million were overweight. The aim of this review was to examine previous studies to determine the factors associated with malnutrition and contribute to the existing body of evidence needed for the formulation of effective interventions. METHODS: This systematic review was conducted using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The Google Scholar database was used to search the studies conducted between 2012 and 2021. The included studies were searched by using some combinations of keywords and saved in Mendeley Desktop for review and referencing. RESULTS: Of 2150 articles retrieved from the Google Scholar databases, 37 met our inclusion criteria. Of the 37 studies reviewed; 13 were conducted in India, 5 in Ethiopia, 3 in Bangladesh, 2 in Ghana, 2 in Nepal, 2 in developing countries, and 1 each in Bolira, Benin, Netherland, Columbia, Pakistan, Malaysia, Africa, Egypt, Ecuadorian, and Indonesia. CONCLUSION: The most consistent factors associated with child malnutrition were maternal education, household income, maternal nutritional status, age of the child, availability of sanitation facility at home, size of family, birth order in the family, and child's birth weight. Breastfeeding and caring practices, cooking area and the fuel used, sex, and socioeconomic status of the children also contribute toward child malnutrition.

Determinants of undernutrition among private and public primary school children: A comparative cross-sectional study toward nutritional transition in northwest Ethiopia.

OBJECTIVES: Undernutrition is a major public health concern, particularly in children. The burden is higher in developing countries. Undernutrition is considered when there is one or more of the following: stunting, underweight, or wasting. Childhood undernutrition can have numerous long-term effects: a lower physical capacity for work, lower intellectual quotients, greater risk for morbidity and mortality, and cognitive impairment. Undernourished children also can have poor cognitive scores, a high absenteeism rate, and high class repetition compared with non-undernourished children. The aim of this study was to assess undernutrition and its associated factors among public and private primary school children in Gondar town, northwest Ethiopia. METHODS: A school-based, cross-sectional study was conducted from March 5 to April 9, 2019. A multistage sampling technique was applied to select study participants. A simple random (lottery) sampling method was used to select seven public schools and five private schools. Systematic random sampling was used to select 774 study participants. The data were collected through face-to-face interviews. Multivariable logistic regressions were conducted to identify factors associated with undernutrition. The World Health Organization (WHO) AnthroPlus software was used to determine the status of undernutrition. Participants with a Z-score less than -2 were considered to be undernourished. Statistical significance was declared at P < 0.05 and odds ratios (ORs) were reported with a 95% confidence interval (CI). RESULTS: The prevalence of undernutrition was higher among public school children (37.1%) than those attending private schools (28.3%). Not having family car (adjusted OR [aOR], 0.28; 95% CI, 0.09-0.84), snack frequency no more than twice a day (aOR, 5.29; 95% CI, 1.37-20.37), and vigorous intensity sports (aOR, 0.53; 95% CI, 0.32-0.91) were significantly associated with undernutrition among public primary school students. Family income below the median (aOR, 2.12; 95% CI, 1.23-3.53), no preference for sweets (aOR, 0.59; 95% CI, 0.36-0.97), and not habits while reading (aOR, 0.42; 95% CI, 0.19-0.89) were the factors significantly associated with undernutrition among private primary school students. CONCLUSION: The prevalence of undernutrition was high. Children in public schools were highly vulnerable to undernutrition compared with those in private schools. Not having a family car, snack frequency no more than twice daily, and vigorous intensity sports increase the risk for undernutrition among public school children. Family income below the median, not preferring sweets, and not having a habit of eating while reading increase the risk for undernutrition among private school children. It is better to give attention to healthy dietary habits and healthy lifestyles to reduce childhood undernutrition.

Household Food Insecurity, Dietary Diversity, and Stunting in Sub-Saharan Africa: A Systematic Review.

BACKGROUND: The significant public health problem in Sub-Saharan Africa of household food insecurity is an underlying cause of malnutrition in Sub-Saharan Africa. This study aims to systematically study the association between household food insecurity, dietary diversity, and stunting. METHODS: This review was carried out based on the recommendations of PRISMA (2015). We searched the literature in six bibliographic databases: PubMed, EMBASE, Science Direct, Web of Science, Google Scholar, and Scopus. The research was based on studies conducted in Sub-Saharan Africa about household food insecurity, dietary diversity, and stunting and was published between 2009 and 2020. RESULTS: Out of 2398 original articles identified, only 21 articles met the specific requirements of this review. Two-thirds of the articles selected showed that stunting was linked to household food insecurity and dietary diversity. CONCLUSIONS: This study found that household food insecurity and dietary diversity are significantly associated with stunting in Sub-Saharan Africa. This review recommends that in order to yield a sustainable fight against childhood malnutrition in Sub-Saharan Africa, reliable guidelines and strategies are needed to address these factors related to malnutrition.

Epidemiology of Malnutrition among Children with Cerebral Palsy in Low- and Middle-Income Countries: Findings from the Global LMIC CP Register.

BACKGROUND: This study aimed to describe the epidemiology of malnutrition among children with cerebral palsy (CP) in low- and middle-income countries (LMICs). METHODS: Data from children with confirmed CP aged <18 years registered into the Global LMIC CP Register (GLM CPR) from Bangladesh, Indonesia, Nepal, and Ghana were included. Anthropometric measurements were collected, and nutritional status was determined following the WHO guidelines. Descriptive statistics and adjusted logistic regression were used to describe the nutritional status and identify predictors of malnutrition. RESULTS: Between January 2015 and December 2020, 3619 children with CP were registered into the GLM CPR (median age at assessment: 7.0 years, 39% female). Overall, 72-98% of children from Bangladesh, Indonesia, Nepal, and Ghana had at least one form of undernutrition. The adjusted analysis showed, older age, low maternal education, spastic tri/quadriplegia, and Gross Motor Functional Classification System (GMFCS) levels III-V were significant predictors of underweight and stunting among children with CP in Bangladesh. In Nepal, female children, GMFCS III-V had higher odds of underweight and stunting. In Ghana, low maternal education was significantly associated with underweight, whereas older age and the presence of associated impairments were the significant predictors of stunting among children with CP. Having a GMFCS of III-V increased the odds of being underweight among children in Indonesia; however, no predictors were identified for stunting, as nearly all children with CP registered from Indonesia were stunted. CONCLUSION: Most children with CP in GLM CPR had undernutrition. Maternal education and moderate-to-severe motor impairment (GMFCS III-V) were significant predictors. Practical nutrition education to mothers/caregivers and management guidelines according to the motor severity using local resources could improve the nutritional outcome of children with CP in LMICs.

The relative importance of households as a source of variation in child malnutrition: a multilevel analysis in India.

BACKGROUND: Child malnutrition remains a major public health issue in India. Along with myriad upstream and social determinants of these adverse outcomes, recent studies have highlighted regional differences in mean child malnutrition rates. This research helps policy makers look between urban and rural communities and states to take a population-level approach to addressing the root causes of child malnutrition. However, one gap in this between-population approach has been the omission of households as a unit of analysis. Households could represent important sources of variation in child malnutrition within communities, districts, and states. METHODS: Using the fourth round of India's National Family Health Survey from 2015 to 2016, we analyzed four and five-level multilevel models to estimate the proportion of variation in child malnutrition attributable to states, districts, communities, households, and children. RESULTS: Overall, we found that of the four levels that children were nested in (households, communities, districts, and states), the greatest proportion of variation in child height-for-age Z score, weight-for-age Z score, weight-for-height Z score, hemoglobin, birthweight, stunting, underweight, wasting, anemia, and low birthweight was attributable to households. Furthermore, we found that when the household level is omitted from models, the variance estimates for communities and children are overestimated. CONCLUSIONS: These findings highlight the importance of households as an important source of clustering and variation in child malnutrition outcomes. As such, policies and interventions should address household-level social determinants, such as asset and social deprivations, in order to prevent poor child growth outcomes among the most vulnerable households in India.

Nutritional Status of Children with Cerebral Palsy in Gorkha, Nepal: Findings from the Nepal Cerebral Palsy Register.

BACKGROUND: The study aimed to define the burden and underlying risk factors of malnutrition among children with cerebral palsy (CP) in Gorkha district, Nepal. METHODS: The first population-based register of children with CP in Gorkha, Nepal (i.e., Nepal CP Register-NCPR) was established in 2018. Children aged <18 years with confirmed CP were registered following standard protocol. Nutritional status was determined based on anthropometric measurements (height/length, weight, mid-upper-arm-circumference) following WHO guidelines. Descriptive analyses and adjusted logistic regression were completed. RESULTS: Between June-October 2018, 182 children with CP were registered into the NCPR (mean (SD) age at assessment: 10.3 (5.0) years, 37.4% female). Overall, 51.7%, 64.1%, and 29.3% children were underweight, stunted, and thin, respectively. Furthermore, 14.3% of children with CP aged <5 years had severe wasting. Underweight and stunting were significantly higher among children with spastic CP (p = 0.02, p < 0.001) and/or Gross Motor Function Classification System (GMFCS) level (III-V) (p = 0.01, p < 0.001) and/or who were not enrolled in school (p = 0.01, p < 0.001). In adjusted analysis, GMFCS level III-V and non-attendance to school significantly increased the odds of stunting by 8.2 (95% CI 1.6, 40.8) and 4.0 (95% CI 1.2, 13.2) times, respectively. CONCLUSIONS: the high rate of different forms of undernutrition among children with CP in Gorkha, Nepal is concerning. Need-based intervention should be taken as priority to improve their nutritional outcome.

Efficacy of ready-to-use therapeutic food in malnourished children with cancer: Results of a randomized, open-label phase 3 trial.

BACKGROUND: The adverse influence of undernutrition in children with cancer may be remediated by early nutritional intervention. This study assessed the efficacy of ready-to-use therapeutic food (RUTF) in improving nutritional status and reducing treatment-related toxicities (TRTs) in such children. METHODS: In a randomized controlled phase-3 open-label trial, severely and moderately undernourished children with cancer were randomized 1:1 to receive standard nutritional therapy (SNT) or SNT+RUTF for 6 weeks. The primary outcome (weight gain >10%) and secondary outcomes (improved/maintained nutritional status, improved body composition) were assessed after 6 weeks. TRTs were assessed over 6 months. RESULTS: Between July 2015 and March 2018, 260 subjects were enrolled, 126 were analyzable in both arms at 6 weeks. More children on RUTF had weight gain (98 [77.8%] vs. 81 [64.2%], p = .025) with a greater increase in fat mass as a percentage of body mass (median 2% [IQR -0.12 to 4.9] vs. 0.5% [IQR -1.45 to 2.27, p = .005]) but a greater loss of lean mass (median -1.86% [IQR -4.4 to 0.50] vs. -0.4% [IQR -2.4 to 1.4, p = .007]) compared to the SNT arm. Fewer subjects on the RUTF arm had episodes of severe infection (10.6% vs. 31%, p < .0001), treatment delays (17.7% vs. 39%, p < .0001), and severe mucositis (11% vs. 23.8%, p = .006) compared to the SNT arm. The odds of developing TRTs on the RUTF arm were lower even after adjusting for improvement in nutritional status. CONCLUSIONS: RUTF is efficacious in improving weight gain and nutritional status in undernourished children with cancer and decreases TRTs. Incorporating RUTF into a healthy, balanced diet should be considered in undernourished children with cancer.

Inappropriate diet and fatal malnutrition in a 10-year-old child fed only infant formula throughout life: Novel pathological diagnostic criterion for starvation via lipophagy.

Fatal starvation is rarely seen in developed countries; when it occurs, it may be associated with medicolegal problems. Forensic pathologists are required to determine leading causes of death and provide opinions on the influence of starvation, especially in cases of suspected child abuse. Recently, starvation-induced steatosis was suggested to be regulated by lipophagy. Here, we report an extremely rare case of death by malnutrition of a 10-year-old boy, who was fed only infant formula throughout his life. The deceased presented with severe hepatic steatosis, probably related to prolonged malnutrition. Fatty liver changes, with deposition of small lipid droplets deposited in the peripheral lobules. High levels of P62 protein (overexpression of which indicates an autophagy impairment) were seen around the central vein region, whereas light-chain-3 (LC3) protein (an indicator of lipophagy activation) was unremarkable. Thus, in our case, impaired lipophagy influenced starvation-induced steatosis. To our knowledge, this article is the first to evaluate the application of lipophagy in forensic investigations as an objective diagnostic criterion.

The Joint Effect of Maternal Marital Status and Type of Household Cooking Fuel on Child Nutritional Status in Sub-Saharan Africa: Analysis of Cross-Sectional Surveys on Children from 31 Countries.

The current study sought to investigate the joint effect of maternal marital status and type of household cooking fuel on child nutritional status in sub-Saharan Africa. Data in the children's files of 31 sub-Saharan African countries were pooled from the Demographic and Health Surveys collected between 2010 and 2019. The outcome variables were three child anthropometrics: stunting (height-for-age z-scores); wasting (weight-for-height z-scores); and underweight (weight-for-age z-scores). The joint effect of maternal marital status and type of household cooking fuel on child nutritional status was examined using multilevel regression models. The results were presented as adjusted odds ratios (aORs) at p < 0.05. The percentages of children who were stunted, wasted and underweight in the 31 countries in sub-Saharan Africa were 31%, 8% and 17%, respectively. On the joint effect of maternal marital status and type of household cooking fuel on stunting, we found that compared to children born to married mothers who used clean household cooking fuel, children born to single mothers who use unclean household cooking fuel, children born to single women who use clean household cooking fuel, and children born to married women who used unclean household cooking were more likely to be stunted. With wasting, children born to single mothers who used unclean household cooking fuel and children born to married women who used unclean household cooking fuel were more likely to be wasted compared to children born to married mothers who used clean household cooking fuel. With underweight, we found that compared to children born to married mothers who used clean household cooking fuel, children born to single mothers who used unclean household cooking fuel, children born to single women who used clean household cooking fuel and children born to married women who used unclean household cooking were more likely to be underweight. It is imperative for the governments of the 31 sub-Saharan African countries to double their efforts to end the use of unclean household cooking fuel. This goal could be achieved by promoting clean household cooking fuel (e.g., electricity, gas, ethanol, solar, etc.) through effective health education, and promotion programmes. The attention of policymakers is drawn to the urgent need for children's nutritional status policies and programmes (e.g., dietary supplementation, increasing dietary diversity, improving agriculture and food security) to be targeted towards at-risk sub-populations (i.e., single mothered households).

Comparing costs and cost-efficiency of platforms for micronutrient powder (MNP) delivery to children in rural Uganda.

Micronutrient powder (MNP) can reduce iron deficiency in young children, which has been well established in efficacy trials. However, the cost of different delivery platforms has not been determined. We calculated the cost and cost-efficiency of distributed MNP through community-based mechanisms and in health facilities in a primarily rural district in Uganda. An endline survey (n = 1072) identified reach and adherence. During the 9-month pilot, 37,458 (community platform) and 12,390 (facility platform) packets of MNP were distributed. Each packet consisted of 30 MNP sachets. In 2016, total costs were $277,082 (community platform, $0.24/sachet) and $221,568 (facility platform, $0.59/sachet). The cost per child reached was lower in the community platform ($53.24) than the facility platform ($65.97). The cost per child adhering to a protocol was $58.08 (community platform) and $72.69 (facility platform). The estimated cost of scaling up the community platform pilot to the district level over 3 years to cover approximately 17,890 children was $1.23 million (scale-up integrated into a partner agency program) to $1.62 million (government scale-up scenario). Unlike previous estimates, these included opportunity costs. Community-based MNP delivery costs were greater, yet more cost-efficient per child reached and adhering to protocol than facility-based delivery. However, total costs for untargeted MNP delivery under program settings are potentially prohibitive.