Child Height-for-age Z-scores Research Articles

The relationships between optimal infant feeding practices and child development and attained height at age 2 years and 6-7 years.

Limited evidence exists on the long-term effects of early feeding practices on child growth and development. We examined the relationships between infant feeding practices and child height and development at ages 2 and 6-7 years. We studied 885 mother-child dyads from a randomized controlled trial of preconception supplementation in Vietnam. Early initiation of breastfeeding (EIBF), exclusive breastfeeding (EBF), breastfeeding (BF) duration and minimum dietary diversity (MDD) were assessed using World Health Organization(WHO) guidelines. Child development was assessed by the Bayley Scales of Infant Development-III at 2 years and the Wechsler Intelligence Scale for Children®-IV at 6-7years. Child height-for-age z-score (HAZ) was calculated from child height and age. Multivariable regression and structural equation models were used in analyses that controlled for confounding. EIBF and EBF at 6monthsoccurred in 52% and 62% of children, respectively. Mean breastfeeding duration was 18 monthsand 83% achieved MDD at 1year. EIBF was associated with motor (β = 0.13, 95% confidence interval [CI]: 0.00, 0.28) and cognitive development at 2years(β = 0.12, 95%CI: -0.01, 0.26), which in turn were positively associated with cognitive development at 6-7years. EBF was directly associated with development at 6-7years (β = 0.21, 95% CI:0.08, 0.34) whereas motor and cognitive development at 2years explained 41%-75% of the relationship between EIBF and development at 6-7years. HAZ at 2years also mediated 70% of the association between MDD at 1year and HAZ at 6-7years. BF duration was not associated with child development and HAZ. Early infant feeding practices, especially EIBF and EBF, have important long-term implications for optimizing child linear growth and cognition as they begin school.

An empirical study of factors associated with height-for-age z-scores of children aged 6-23 months in northwest Rwanda: the role of care practices related to child feeding and health.

We aimed to identify the factors influencing child height-for-age z-scores (HAZ) as a measure of child nutritional status in Rwanda, and to examine the role of child feeding and health practices. We conducted a cross-sectional study involving 379 children (aged 6-23 months) and their mothers in northwest Rwanda. Data were collected using a pre-tested, structured questionnaire. An infant and young child feeding practices index (ICFI) and health practices index (HPI) were developed and categorised into tertiles, and linear regression analyses were performed to assess their association with child HAZ. Overall, mothers of non-stunted children exhibited better feeding and health practices than those of stunted children. ICFI was positively associated with child HAZ. We found an adjusted mean HAZ difference of 0·14 between children whose mothers were in high ICFI tertile compared with those in low tertile. Neither HPI nor any of its components were significantly associated with child HAZ. Other factors that were positively associated with child HAZ were infant birth weight (P < 0·001) and maternal height (P < 0·001). Child age, sex (male) (P < 0·05) and altitude (P < 0·05) were negatively associated with child HAZ. Diarrhoea (P < 0·05) and respiratory infections (P < 0·05) were negatively associated with HAZ in younger children aged 6-11 months. Policies to reduce stunting in this population must focus on both pre- and postnatal factors. Appropriate child feeding practices, particularly breast-feeding promotion and improvement in children's dietary diversity combined with measures to control infections should be given priority.

An age profile perspective on two puzzles in global child health: The Indian Enigma & economic growth

We provide an age-profile perspective and two classes of regression models that make progress on differentiating between two types of determinants of child health: health endowment effects provided to the child at birth; and health investment effects determined by the post-birth stream of health inputs provided to the child and the productivity of those investments. We apply the framework to two related puzzles in the child health demography literature: the Indian Enigma, where Indian children are on average less tall than African children; and the apparent lack of strong correlation between economic growth and child height-for-age z-score (HAZ). In the context of the Indian Enigma, we find that the Indian-African child HAZ gap (between 0.3sd and 0.5sd) is present immediately after birth and maintains a similar magnitude across the first three years of life. We interpret this as evidence that causes affecting health endowments (such as maternal physiology, fertility timing or in utero nutrition) likely explain the greater part of the Indian Enigma. We also estimate a robust association between a 10% increase in (ln) GDP per capita and a 0.04sd increase in child height by age 2. However, this correlation is not present at birth and is instead driven by differences in child growth rates. We interpret these results as indicating that economic growth influences the post-birth health input stream, and/or the biological productivity of those inputs.

Drivers of stunting reduction in Senegal: a country case study

ABSTRACTBackgroundSenegal has been an exemplar country in the West African region, reducing child stunting prevalence by 17.9% from 1992 to 2017.ObjectivesIn this study, we aimed to conduct a systematic in-depth assessment of factors at the national, community, household, and individual levels to determine the key enablers of Senegal's success in reducing stunting in children <5 y old between 1992/93 and 2017.MethodsA mixed methods approach was implemented, comprising quantitative data analysis, a systematic literature review, creation of a timeline of nutrition-related programs, and qualitative interviews with national and regional stakeholders and mothers in communities. Demographic and Health Surveys and Multiple Indicator Cluster Surveys were used to explore stunting inequalities and factors related to the change in height-for-age z-score (HAZ) using difference-in-difference linear regression and the Oaxaca-Blinder decomposition method.ResultsPopulation-wide gains in average child HAZ and stunting prevalence have occurred from 1992/93 to 2017. Stunting prevalence reduction varied by geographical region and prevalence gaps were reduced slightly between wealth quintiles, maternal education groups, and urban compared with rural residence. Statistical determinants of change included improvements in maternal and newborn health (27.8%), economic improvement (19.5%), increases in parental education (14.9%), and better piped water access (8.1%). Key effective nutrition programs used a community-based approach, including the Community Nutrition Program and the Nutrition Enhancement Program. Stakeholders felt sustained political will and multisectoral collaboration along with improvements in poverty, women's education, hygiene practices, and accessibility to health services at the community level reduced the burden of stunting.ConclusionsSenegal's success in the stunting decline is largely attributed to the country's political stability, the government's prioritization of nutrition and execution of nutrition efforts using a multisectoral approach, improvements in the availability of health services and maternal education, access to piped water and sanitation facilities, and poverty reduction. Further efforts in the health, water and sanitation, and agriculture sectors will support continued success.

Links between Maternal Employment and Child Nutrition in Rural Tanzania

Improving child nutrition and empowering women are two important and closely connected development goals. Fostering female employment is often seen as an avenue to serve both these goals, especially if it helps to empower the mothers of undernourished children. However, maternal employment can influence child nutrition through different mechanisms, and the net effect may not necessarily be positive. We develop a theoretical model to show that maternal employment can affect child nutrition through changes in income, intrahousehold bargaining power, and time available for childcare. The links are analyzed empirically using panel data from farm households in rural Tanzania. We find that the links between maternal employment and child height‐for‐age Z‐scores (HAZ) are non‐linear. Off‐farm employment is negatively associated with child HAZ at low levels of labor supply. The association turns positive at higher levels of labor supply and negative again at very high levels. The associations between maternal on‐farm work and child nutrition are weaker and not statistically significant. These findings can help to better design development interventions that foster synergies and avoid potential tradeoffs between female empowerment and child nutrition goals.

The Reduction in Total Fertility Rate Predicts One Fourth of the Gain in Child Height in the Last Decade: Evidence from 44 Low- and Middle-Income Countries

Abstract Objectives Poor child growth is associated with losses in human capital and economic productivity. High fertility rates are an increasing concern in many low- and middle-income countries (LMICs). The link between population-level fertility and child height remains underexplored. Methods Data were from 88 cross-sectional Demographic and Health Surveys from 44 LMICs across three regions between 2000 and 2015. Sample sizes (number of children aged 0–59 months) were 287,032 for South Asia (SAS), 345,256 for sub-Saharan Africa (SSA), and 130,040 for South America (SAM). We explored the association between fertility and child height-for-age z-score (HAZ). Fertility was indexed using total fertility rate (TFR), the number of children born to a woman were she to survive through her childbearing years according to age-specific fertility rates. TFR was calculated at the village level using birth histories and age distributions of women aged 15–49 years. Fixed effects regression models were used to estimate the association between changes in village level TFR and changes in child HAZ. These models were adjusted for country fixed effects, survey-year fixed effects, clustering, and demographic and socioeconomic covariates for the child, mother, and household. Country-level regression decomposition analysis was used to estimate the contribution of the actual TFR reduction from World Bank data to the actual gain in child HAZ. Results On average, individual level HAZ was −1.46 (95% CI −1.47, −1.45) in SAS, −1.50 (95% CI −1.50, −1.49) in SSA and −1.19 (95% CI −1.20, −1.19) in SAM. Mean country level TFR was 2.69 (95% CI 2.36–3.01) in SAS, 5.21 (95% CI 4.96, 5.47) in SSA and 2.76 (95% CI 2.50, 3.02) in SAM. The adjusted fixed effects models showed that a 1-unit decrease in village level TFR was associated with a 0.20 (95% CI 0.18, 0.21) increase in child HAZ in SAS, 0.09 (95% CI 0.07, 0.10) in SSA and 0.15 (95% CI 0.14, 0.17) in SAM. Decomposition analysis showed that reductions in TFR explained 25.7% of the increase in mean HAZ across countries between 2000 and 2015. Conclusions These findings point to an underappreciated role of fertility in the global discourse on childhood stunting. Noncoercive policies, interventions and incentives leading to replacement level fertility have the potential to support rapid reductions in stunting required to achieve development goals. Funding Sources None.

Heterogeneous effects of factors on child nutritional status in Bangladesh using linear quantile mixed model

Earlier studies to assess the effects of risk factors on child nutritional status in Bangladesh have used conventional regression models that are inadequate to capture a complete scenario of effects. Therefore, this study aimed to evaluate the heterogeneous effects of factors at different points of conditional height-for-age Z-score (HAZ) distribution accounting for cluster-level variation using linear quantile mixed model (LQMM) and to compare them with a linear mixed model (LMM). In addition, an unconditional quantile model (UQM) was used to measure the effect of factors on the unconditional (marginal) HAZ distribution. A total of 6340 children aged 0–59 months extracted from the 2014 Bangladesh Demographic and Health Survey. Different factors – maternal characteristics (age, occupation, nutritional status, parity, birth interval), parental education, child age, breastfeeding status, and morbidity had significant heterogeneous effects on HAZ distribution. For example, secondary or higher educated parents had substantial differential impacts on the lower tail and upper tail of the child HAZ distribution, which was masked by LMM estimate. Moreover, significant cluster-level variations found across all quantiles of child HAZ. During intervention design, heterogeneous effects of factors and cluster variation ought to consider addressing the undernutrition problem in Bangladesh.

Women's empowerment and child nutrition: The role of intrinsic agency.

Women's empowerment is associated with improved child nutrition, and both underpin the achievement of multiple Sustainable Development Goals (SDGs). We examined pathways by which women's empowerment influences child nutritional status. We pooled nationally representative data from Demographic and Health Surveys (2011–2016) collected from married women with children aged 6–24 months in Ethiopia, Kenya, Rwanda, Tanzania, and Uganda (n = 13,780). We operationalized child nutritional status using anemia, height-for-age z-score (HAZ), and weight-for-age z-score (WHZ). We operationalized women's empowerment using a validated measure comprised of three latent domains: social/human assets (“assets”), intrinsic agency (attitudes about intimate partner violence), and instrumental agency (influence in household decision making). We used structural equation models with latent constructs to estimate hypothesized pathways from women's empowerment to child nutritional status with further mediation by maternal body mass index (BMI) and stratification by wealth. Women's empowerment domains were directly and positively associated with maternal BMI (estimate±SE: assets, 0.17 ± 0.03; intrinsic agency, 0.23 ± 0.03; instrumental agency, 0.03 ± 0.01). Maternal BMI was directly and positively associated with child HAZ (0.08 ± 0.04) and child WHZ (0.35 ± 0.03). Assets were indirectly associated with child HAZ and WHZ through intrinsic agency and maternal BMI. In the lowest wealth category, the direct effects from women's empowerment to child nutritional status were significant (assets and instrumental agency were associated with anemia; intrinsic agency associated with HAZ). In the highest wealth category, direct effects from women's empowerment on child nutritional status were significant (intrinsic and instrumental agency associated with WHZ). Improving women's empowerment, especially intrinsic agency, in East Africa could improve child nutrition directly and via improved maternal nutrition. These findings suggest that efforts to realize SDG 5 may have spillover effects on other SDGs. However, strategies to improve nutrition through empowerment approaches may need to also address household resource constraints.

Optimization and validation of the EconomicClusters model for facilitating global health disparities research: Examples from Cameroon and Ghana.

Health disparities research in low- and middle-income countries (LMICs) is hampered by the difficulty of measuring economic status in low-resource settings. We previously developed the EconomicClusters k-medoids clustering-based algorithm for defining population-specific economic models based on few Demographic and Health Surveys (DHS) assets. The algorithm previously defined a twenty-group economic model for Cameroon. The aims of this study are to optimize the functionality of our EconomicClusters algorithm and app based on collaborator feedback from early use of this twenty-group economic model, to test the validity of the model as a metric of economic status, and to assess the utility of the model in another LMIC context. We condense the twenty Cameroonian economic groups into fewer, ordinally-ranked, groups using agglomerative hierarchical clustering based on mean cluster child height-for-age Z-score (HAZ), women’s literacy score, and proportion of children who are deceased. We develop an EconomicClusters model for Ghana consisting of five economic groups and rank these groups based on the same three variables. The proportion of variance in women’s literacy score accounted for by the EconomicClusters model was 5–12% less than the proportion of variance accounted for by the DHS Wealth Index model. The proportion of the variance in child HAZ and proportion of children who are deceased accounted for by the EconomicClusters model was similar to (0.4–2.5% less than) the proportion of variance accounted for by the DHS Wealth Index model. The EconomicClusters model requires asking only five questions, as opposed to greater than twenty Wealth Index questions. The EconomicClusters algorithm and app could facilitate health disparities research in any country with DHS data by generating ordinally-ranked, population-specific economic models that perform nearly as well as the Wealth Index in evaluating variability in health and social outcomes based on wealth status but that are more feasible to assess in time-constrained settings.

Family networks and infant health promotion: a mixed-methods evaluation from a cluster randomised controlled trial in rural Malawi

ObjectiveParents may rely on information provided by extended family members when making decisions concerning the health of their children. We evaluate whether extended family members affected the success of an...

Assessing the effect of drought severity on height-for-age z-score in Kenyan children: a secondary analysis

BackgroundGlobally, droughts are occurring more regularly and are having negative effects on population health, particularly in countries such as Kenya, where agriculture is a primary driver of the economy and a source of subsistence for many communities. Children are particularly susceptible to weather-related shocks. Previous research has shown an association between drought and cross-sectional indicators of malnutrition, such as stunting. In this study, we explored various longitudinal and spatial analysis approaches to evaluating the effect of drought on height-for-age z-scores (HAZ) over time and space among young children in Kenya. MethodsUsing anthropometric data from three georeferenced Kenyan Demographic and Health Surveys (KDHS) and the self-calibrated Palmer Drought Severity Index, we developed multivariate linear regression and spatial lag and error models (with Moran's I calculations) to investigate the association between drought severity and HAZ in children aged 0–5 years. Initial covariates included age of the child, sex, maternal age, height and education, wealth index, urban or rural location, and size at birth. We then did multilevel and geographically weighted regression modelling using frequentist or Bayesian methods and with inclusion of household-level covariates, such as livelihood zones. To assess the effect of changes in drought severity on child HAZ over time, KDHS data from 2003, 2008–09, and 2014 were analysed with spatiotemporal modelling. FindingsPreliminary results from the multivariate linear model showed a negative, non-significant association between drought severity and HAZ among Kenyan children in 2014 (β=0·033, p=0·101); however, there was a significant interaction between drought severity and age (β=–0·002, p<0·0007). The spatial lag model gave similar results. Other variables associated with HAZ included wealth index, age, sex, maternal education, and maternal height. Global Moran's I calculations indicated that there was a slight positive spatial autocorrelation across child HAZ (I=0·047, p<0·0001). InterpretationIncreased drought severity was associated with a non-significant decrease in HAZ among Kenyan children. However, a significant interaction between age and drought severity indicates that the effect of drought on HAZ varies by age. Findings from this study will help to inform the development of methodological approaches for improving understanding of the effects of climate change on child health. Expanding these analyses to other east-African countries will also contribute to the development of national adaptation strategies and planning in anticipation of increased climate variability. FundingCanadian Institutes of Health Research (Institute of Public and Population Health).

Adolescent mothers' anthropometrics and grandmothers' schooling predict infant anthropometrics in Ethiopia, India, Peru, and Vietnam.

We investigated intergenerational associations of adolescent mothers' and grandmothers' anthropometrics and schooling with adolescent mothers' offspring's anthropometrics in Ethiopia, India, Peru, and Vietnam. We examined birthweight (n = 283), birthweight Z-score (BWZ), conditional growth in weight-for-age Z-score (cWAZ, residuals from a regression of WAZ at last survey round on BWZ, sex, and age), and height-for-age Z-score (HAZ) of children born to older cohort adolescent girls in the Young Lives study. Our key independent variables were adolescent mothers' body size: HAZ and body-mass-index-for-age Z-score (BMIZ) at age 8, conditional HAZ (cHAZ, residuals from a regression of HAZ at the end of a growth period on prior HAZ, age, and sex), conditional BMIZ growth (cBMIZ, calculated analogously), and grandmaternal BMIZ, HAZ, and schooling. We adjusted for child, maternal, and household characteristics. Adolescent mothers' cHAZ (ages 8-15) predicted birthweight (β = 130 g, 95% confidence interval (CI) 31-228), BWZ (β = 0.31, CI 0.09-0.53), and cWAZ (β = 0.28, CI 0.04-0.51). Adolescent mothers' BMIZ at age 8 predicted birthweight (β = 79 g, CI 16-43) and BWZ (β = 0.22, CI 0.08-0.36). Adolescent mothers' cBMIZ (ages 12-15) predicted child cWAZ and HAZ. Grandmothers' schooling predicted grandchild birthweight (β = 22 g, CI 1-44) and BWZ (β = 0.05, CI 0.01-0.10).

Maternal nutrition knowledge and child nutritional outcomes in urban Kenya

We examine the link between maternal nutrition knowledge and nutritional outcomes of children and adolescents (5–18 years) measured in terms of height-for-age Z-scores (HAZ). One particular focus is on the role of different types of nutrition knowledge. The analysis builds on household-level and individual-level data collected in urban Kenya in 2012 and 2015. Various regression models are developed and estimated. Results show that maternal nutrition knowledge – measured through an aggregate knowledge score – is positively associated with child HAZ, even after controlling for other influencing factors such as household living standard and general maternal education. However, disaggregation by type of knowledge reveals important differences. Maternal knowledge about food ingredients only has a weak positive association with child HAZ. For maternal knowledge about specific dietary recommendations, no significant association is detected. The strongest positive association with child HAZ is found for maternal knowledge about the health consequences of not following recommended dietary practices. These findings have direct relevance for nutrition and health policies, especially for designing the contents of educational campaigns and training programs.

Differential effects of dietary diversity and maternal characteristics on linear growth of children aged 6-59 months in sub-Saharan Africa: a multi-country analysis.

To investigate the differential effects of dietary diversity (DD) and maternal characteristics on child linear growth at different points of the conditional distribution of height-for-age Z-score (HAZ) in sub-Saharan Africa. Secondary analysis of data from nationally representative cross-sectional samples of singleton children aged 0-59 months, born to mothers aged 15-49 years. The outcome variable was child HAZ. Quantile regression was used to perform the multivariate analysis. The most recent Demographic and Health Surveys from Ghana, Nigeria, Kenya, Mozambique and Democratic Republic of Congo (DRC). The present analysis was restricted to children aged 6-59 months (n 31 604). DD was associated positively with HAZ in the first four quantiles (5th, 10th, 25th and 50th) and the highest quantile (90th) in Nigeria. The largest effect occurred at the very bottom (5th quantile) and the very top (90th quantile) of the conditional HAZ distribution. In DRC, DD was significantly and positively associated with HAZ in the two lower quantiles (5th, 10th). The largest effects of maternal education occurred at the lower end of the conditional HAZ distribution in Ghana, Nigeria and DRC. Maternal BMI and height also had positive effects on HAZ at different points of the conditional distribution of HAZ. Our analysis shows that the association between DD and maternal factors and HAZ differs along the conditional HAZ distribution. Intervention measures need to take into account the heterogeneous effect of the determinants of child nutritional status along the different percentiles of the HAZ distribution.

Nonnative Cattle Ownership, Diet, and Child Height-for-Age: Evidence from the 2011 Uganda Demographic and Health Survey.

In underresourced settings where domestic animals and children often cohabitate, there is limited evidence about the net impact of domestic animal ownership on child health. We analyzed the 2011 Uganda Demographic and Health Survey to determine whether household ownership of native cattle, goats, sheep, chickens, pigs, and nonnative cattle was associated with child height-for-age z-scores (HAZ), and to assess the influence of diet on this association in rural and urban environments. Using weighted multivariable linear regression, we found that nonnative cattle ownership was positively associated with HAZ in rural children 0 to < 2 years of age (+1.32 standard deviations [SD], 95% confidence interval [CI] = 0.2-2.5) and 2 to < 5 years of age (+0.58 SD, 95% CI = 0.003-1.2), and urban children 2 to < 5 years of age (+1.08 SD, 95% CI = 0.38-1.8). Sheep ownership was positively associated with HAZ in rural children 2 to < 5 years of age (+0.29 SD, 95% CI = 0.002-0.58) and goat ownership was positively associated with HAZ in rural children 0 to < 2 years of age (+0.27 SD, 95% CI = 0.003-0.55). We observed no other significant associations. Children who lived in households that owned nonnative cattle consumed dairy more frequently; however, the relationship between child HAZ and nonnative cattle ownership was not mediated by child dairy consumption. These findings suggest that domestic animal ownership may not be detrimental to child HAZ, and that nonnative cattle ownership is beneficial for child HAZ through pathways other than dairy consumption.

Is Exposure to Poultry Harmful to Child Nutrition? An Observational Analysis for Rural Ethiopia.

Although strategic thinking on water, sanitation and hygiene (WASH) has prioritized reducing exposure to human feces in order to limit diarrheal infections, recent research suggests that elevated exposure to livestock–particularly poultry and poultry feces–may be an important risk factor for diarrhea, environmental enteric disorder (EED) and respiratory infections, all of which may seriously retard linear growth in young children. Yet a very different literature on nutrition-sensitive agriculture suggests that livestock ownership is highly beneficial for child growth outcomes through its importance for increasing consumption of nutrient-rich animal sourced foods, such as eggs. Together, these two literatures suggest that the net nutritional benefit of poultry ownership is particularly ambiguous and potentially mediated by whether or not children are highly exposed to poultry. We test this novel hypothesis using a large agricultural survey of rural Ethiopian households that includes measures of child height-for-age Z-scores (HAZ), ownership of poultry and other types of livestock, and an indicator of whether livestock are kept within the main household dwelling overnight. We used least squares regression analysis to estimate unadjusted and adjusted models that control for a wide range of potentially confounding factors. We find that while poultry ownership is positively associated with child HAZ [β = 0.291, s.e. = 0.094], the practice of corralling poultry in the household dwelling overnight is negatively associated with HAZ [β = -0.250, s.e. = 0.118]. Moreover, we find no negative associations between HAZ and corralling other livestock species indoors. These results suggest that while poultry ownership can be beneficial to child growth, overly close exposure to poultry poses a concurrent risk factor for undernutrition, most likely because of increased risk of infection.

Drivers of nutritional change in four South Asian countries: a dynamic observational analysis.

This paper quantifies the factors explaining long‐term improvements in child height for age z‐scores in Bangladesh (1996/1997–2011), India (1992/1993–2005/2006), Nepal (1997–2011) and Pakistan (1991–2013). We apply the same statistical techniques to data from a common data source from which we have extracted a set of common explanatory variables that capture ‘nutrition‐sensitive’ factors. Three are particularly important in explaining height for age z‐score changes over these timeframes: improvements in material well‐being; increases in female education; and improvements in sanitation. These factors have comparable associations across all four countries.

Women’s Empowerment Mitigates the Negative Effects of Low Production Diversity on Maternal and Child Nutrition in Nepal

We use household survey data from Nepal to investigate relationships between women’s empowerment in agriculture and production diversity on maternal and child dietary diversity and anthropometric outcomes. Production diversity is positively associated with maternal and child dietary diversity, and weight-for-height z-scores. Women’s group membership, control over income, reduced workload, and overall empowerment are positively associated with better maternal nutrition. Control over income is positively associated with height-for-age z-scores (HAZ), and a lower gender parity gap improves children’s diets and HAZ. Women’s empowerment mitigates the negative effect of low production diversity on maternal and child dietary diversity and HAZ.

Chronic immune activation in Zimbabwean infants mediates the influence of clinical morbidity on child growth

This study aims to determine the extent to which chronic immune activation (IA) mediates the influence of clinical morbidity on child growth. We conducted a case‐control study of 202 Zimbabwean infants who were stunted (height‐for‐age Z‐score (HAZ) &lt;‐2) or non‐stunted (HAZ&gt;;‐0.5), respectively, at 18 months and for whom morbidity histories and cryopreserved plasma had been collected at 6 weeks, and 3, 6, 12, and 18 months of age. We measured biomarkers of immune activation (CRP, AGP, IL‐6) and growth hormone axis (IGF‐1) by ELISA. Using generalized estimating equations, report of recent diarrhea (P=0.09), cough (P=0.35), or fever (P=0.18) was not strongly associated with child HAZ. Diarrhea was, however, negatively associated with IGF‐1 (P&lt;0.001) and positively associated with AGP (P=0.001); IGF‐1 suppression following diarrhea did not recover at subsequent visits. Report of cough and fever were similarly negatively associated with IGF‐1 (P&lt;0.01) and positively associated with CRP, AGP and IL‐6 (all P&lt;0.001) levels. Structural equation models further indicated that IA mediates the effect of morbidity on IGF‐1 levels and child growth. The influence of morbidity on growth deficits may function primarily through episodic contributions to the chronic IA that is observed in both stunted and non‐stunted children in this population. These findings provide evidence of an important role for chronic inflammation and the growth hormone axis in the pathogenesis of stunting.

Child Feeding Practices Are Associated with Child Nutritional Status in Latin America: Innovative Uses of the Demographic and Health Surveys

Data from the Demographic and Health Surveys (DHS) for 5 Latin American countries (7 data sets) were used to explore the feasibility of creating a composite feeding index and to examine the association between feeding practices and child height-for-age Z-scores (HAZ). The variables used for the index were as follows: current breast-feeding, use of complementary foods and liquids in the past 24 h, frequency of use over the past week and feeding frequency. The index was made age specific for 6- to 9-, 9- to 12- and 12- to 36-mo-old age groups, and age-specific feeding terciles were created. Bivariate analyses showed that feeding practices were strongly and significantly associated with child HAZ in all 7 data sets, especially after 12 mo of age. Differences in HAZ between child feeding terciles remained significant after controlling for potentially confounding influences, for all countries except Bolivia. Multiple regression analyses also revealed that better feeding practices were more important for children of lower, compared with higher socioeconomic status (in Colombia 1995 and Nicaragua 1998); among children of Ladino (Spanish speaking) compared with indigenous origin (in Guatemala 1995); and among children whose mothers had primary schooling compared with mothers with no schooling, or mothers with higher than primary school level (Peru 1996). The data available in DHS data sets can thus be used effectively to create a composite child feeding index and to identify vulnerable groups that could be targeted by nutrition education and behavior change interventions.