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Background: In Mali, an estimated 73% of pregnant women are anaemic largely due to iron deficiency. National policy recommends women to take iron and folic acid supplements daily from first prenatal contact until 3 months postpartum. However, many pregnant women in Mali could benefit from multiple micronutrient supplements.Objective: To assess pregnant women's acceptability of and adherence to a daily multiple micronutrient supplementation scheme compared with the current daily iron and folic acid supplementation scheme.Design: Seventy pregnant women were allocated to either the daily multiple micronutrient or daily iron and folic acid supplementation scheme. Women started receiving supplements at the end of the first trimester of pregnancy until delivery and throughout the first 3 months postpartum.Results: No significant differences were observed between comparison groups with respect to women's perceptions about supplement size, colour, taste or flavour. Adherence to the multiple micronutrient supplementation scheme was better (257.5+/-20.9 tablets; average adherence 95.4%) than that to the iron and folic acid supplementation scheme (238.5+/-32.7 tablets; average adherence 92.2%; P=0.008) although both were very good, as were women's perceptions about the benefits of micronutrient supplements to their health and that of their newborns.Conclusion: Malian women adhere to prenatal/postpartum micronutrient supplementation - no matter what supplement is chosen - when access to supplements is guaranteed and when they are provided with minimum, consistent and easily understandable information and counselling, indicating that these are key elements to ensure effective programmes. These findings, together with those of the global research agenda on the efficacy of multiple micronutrient supplements for pregnant women, will inform policy development in Mali for the effective control of iron deficiency and iron-deficiency anaemia in pregnant women. [ABSTRACT FROM AUTHOR]

Background: Malnutrition rates in Sierra Leone are among the highest in the world. However, policy-makers do not always recognise the fight against malnutrition as a policy priority to ensure the healthy human capital needed to fight poverty and achieve sustained positive economic growth.Objective: The analysis presented here was conducted by an intersectoral and inter-agency group of Sierra Leonean senior policy advisors to quantify some of the potential human and economic benefits of improved policies and programmes to reduce malnutrition.Findings: The analysis revealed that 46% of child deaths in Sierra Leone are attributable to malnutrition, the single greatest cause of child mortality in the country. In the absence of adequate policy and programme action, malnutrition will be the underlying cause of an estimated 74000 child deaths over the next five years. The analysis also revealed that if current levels of iodine deficiency remain unchanged over the next five years, 252000 children could be born with varying degrees of mental retardation as a result of intrauterine iodine deficiency. Finally, the analysis showed that, in the absence of adequate policy and programme action to reduce the unacceptable rates of anaemia in women, the monetary value of agricultural productivity losses associated with anaemia in the female labour force over the next five years will exceed dollars 94.5 million.Conclusion: Sustained investment in nutrition in Sierra Leone could bring about enormous human and economic benefits to develop the social sector, revitalise the economy, and attain the poverty reduction goals that Sierra Leone has set forth. [ABSTRACT FROM AUTHOR]

Background: In areas where vitamin A deficiency (VAD) is prevalent, vitamin A repletion reduces child mortality by 23% on average.Objectives: To estimate the potential child survival benefits of policies and programmes aimed at controlling VAD in Mozambique, and to make policy and programme recommendations.Methods: The potential contribution of VAD to child mortality in Mozambique was estimated by combining the observed VAD prevalence in the under-5s (71.2%), the measured child mortality effects of VAD (risk of death in children with VAD=1.75 times higher than in children without VAD) and the observed under-5 mortality rate in the country (210 per 1000 live births).Results: In Mozambique, an estimated 2.3 million children below the age of 5 years are vitamin-A-deficient. In the absence of appropriate policy and programme action, VAD will be the attributable cause of over 30,000 deaths annually in the under-5s. This represents 34.8% of all-cause mortality in this age group.Discussion: Vitamin A supplementation (VAS) has been adopted as a short- to medium-term strategy to control VAD in children, and is integrated into routine child health services. However, the last VAS coverage survey showed that only 46% of children received a vitamin A supplement in the 6 months preceding the survey. If VAS coverage is to increase significantly in the foreseeable future, four areas appear to be of paramount importance: (1) reduce missed opportunities for VAS such as visits of sick children to child health services and community outreach activities; (2) take advantage of all potential opportunities for accelerating VAS coverage, such as additional vaccination campaigns and emergency response activities; (3) strengthen health workers' training, supervision and monitoring skills; and (4) increase community demand for VAS of children. Biannual VAS, as the primary component of an integrated strategy for VAD control in children, has the promise to be among the most cost-effective/high-impact child survival interventions in Mozambique. [ABSTRACT FROM AUTHOR]

South Asia has made significant progress in reducing child undernutrition. The prevalence of stunting declined by one third between 2000 and 2019; as a result, in 2019, there were 34 million fewer stunted children than in 2000, indicating that progress for child nutrition is possible and is happening at scale. However, no country in South Asia is on track for all nutrition targets of Sustainable Development Goal 2, and the region has the highest prevalence of stunting (33.2%) and wasting (14.8%) in the world. Nepal, the best performing country in the region, narrowly missed the Millennium Development Goal (MDG) target to half the prevalence of child underweight between 1990 and 2015 and achieved the fastest recorded reduction in stunting prevalence in the world between 2001 and 2011. In 2019, UNICEF Nepal completed a series of papers to examine Nepal's progress on maternal and child nutrition during the MDG era. The series explores the trends, distribution and disparities in stunting, micronutrient deficiencies and feeding practices in children under 5 years and anaemia in adolescents and women. Besides, it reviews national micronutrient programmes (vitamin A supplementation, iron and folic acid supplementation and universal salt iodization) and Nepal's first Multi-Sector Nutrition Plan, to illuminate the success factors and enduring challenges in the policy and programme landscape for nutrition. This overview paper summarizes the evidence from these analyses and examines the implications for the direction of future advocacy, policy and programme actions to improve maternal and child nutrition in Nepal and other similar contexts., (© 2021 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Competing Interests: Competing interests: None declared.

Young children in the East Asia and the Pacific region 1 are failing to thrive, in large numbers, as indicated by stagnation in the decline of stunting, wasting, and micronutrient deficiencies and the fastest growing rates of overweight in the world. Eliminating the triple burden of malnutrition is essential to ensure that, as a matter of right, all children reach their full physical growth and development potential and actively contribute to equitable prosperity and the sustainable development of their communities and nations. Ending all forms of malnutrition will only be achieved through the implementation of effective policies and programmes soundly based on an understanding of the leading contextual drivers of child malnutrition. To address the lack of data on these drivers in the region, the UNICEF regional office for East Asia and the Pacific commissioned a series of papers in 2017-2019 to fill gaps in the current body of evidence on the triple burden of maternal and child malnutrition. This series includes analyses of the determinants of child malnutrition including maternal nutrition status, dietary quality of children, inequity, and poverty. Additionally, policy and programmatic actions associated with improved coverage and quality of nutrition interventions are reviewed. This overview paper summarizes the findings of these analyses and presents recommendations for the direction of future advocacy, policy, and programmatic actions to address the triple burden of malnutrition in East Asia and the Pacific., (© 2020 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

In South Asia, an estimated 38% of preschool-age children have stunted growth. We aimed to assess the effect of WHO-recommended antenatal iron, and folic acid (IFA) supplements on smaller than average birth size and stunting in South Asian children <2 years old. The sample was 96,512 mothers with their most recent birth within two years, from nationally representative surveys between 2005 and 2016 in seven South Asian countries. Primary outcomes were stunting [length-for-age Z-score (LAZ) < -2], severe stunting [length-for-age Z-score (LAZ) < -3], length-for-age Z score, and perceived smaller than average birth size. Exposure was the use of IFA supplements. We conducted analyses with Poisson, linear and logistic multivariate regression adjusted for the cluster survey design, and 14 potential confounders covering the country of the survey, socio-demographic factors, household economic status, maternal characteristics, and duration of respondent recall. The prevalence of stunting was 33%, severe stunting was 14%, and perceived smaller than average birth size was 22%. Use of antenatal IFA was associated with a reduced adjusted risk of being stunted by 8% (aRR 0.92, 95% CI 0.89, 0.95), of being severely stunted by 9% (aRR 0.91, 95% CI 0.86, 0.96) and of being smaller than average birth size by 14% (aRR 0.86, 95% CI 0.80, 0.91). The adjusted mean LAZ was significantly higher in children whose mothers used IFA supplements. Maternal use of IFA in the first four months gestation and consuming 120 or more supplements throughout pregnancy was associated with the largest reduction in risk of child stunting. Antenatal IFA supplementation was associated with a significantly reduced risk of stunting, severe stunting, and smaller than average perceived birth size and improved LAZ in young South Asian children. The early and sustained use of antenatal IFA has the potential to improve child growth outcomes in South Asia and other low-and-middle-income countries with high levels of iron deficiency in pregnancy.

Overweight has become a global pandemic and is associated with a rise in diet-related non-communicable diseases and associated co-morbidities. Most of the world's undernourished people live in South Asia, yet the number of overweight and obese individuals in this region is growing. This study explores trends and correlates of overweight among pre-school age children, adolescent girls, and adult women in South Asia. Using pooled data from 12 national surveys in six countries, generalized linear mixed models were run to analyze relationships. Overweight children had significantly higher odds than non-overweight children of having an overweight mother (Adjusted Odds Ratio: 1.34, p < 0.01). Overweight adolescent girls were more likely to come from a wealthier household (Adjusted Prevalence Ratio (APR): 2.46, p < 0.01) in an urban area (1.74, p < 0.01), and have formal education (1.22, p < 0.01), compared to non-overweight girls. Similar relationships were seen among overweight vs. non-overweight adult women. In Bangladesh, India, and Nepal, overweight among girls and women increased over time, while differentials associated with household wealth, urban residence, and formal education attenuated over time. Overweight and obesity are becoming more prevalent across South Asia in a context of persisting undernutrition. Once a condition of the wealthier, more educated and urban, rates of overweight are increasing among poorer, less educated, and rural women. This requires immediate attention to 'multi-use' policies and programmes.

Despite improvements over the past 20 years, high burdens of child mortality and undernutrition still coexist in Afghanistan. Global evidence indicates that complementary feeding (CF) practices predict child survival and nutritional status. Our study aims to describe CF practices in Afghanistan and to discern underlying predictors of CF by analysing data from Afghanistan's 2015 Demographic and Healthy Survey. Multilevel models were constructed comprising potential predictors at individual, household, and community levels and four CF indicators: timely introduction of solid, semi-solid, or soft foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD) among breastfed children. INTRO prevalence among children aged 6-8 months was 56%, whereas the prevalence of MMF, MDD, and MAD among children aged 6-23 months was 55%, 23%, and 18%, respectively. Of the seven food groups considered, four were consumed by 20% or fewer children: eggs (20%), legumes and nuts (18%), fruits and vegetables (15%), and flesh foods (14%). Increasing child age and more antenatal care visits were significantly and positively associated with greater odds of meeting all CF indicators. Lower household wealth and lower community-level access to health care services were associated with lower odds of MDD and MAD. Disparities in achieving recommended CF practices were observed by region. CF practices in Afghanistan are poor and significant socioeconomic inequities in CF are observed across the country. Our study calls for urgent policy and programme attention to improve complementary feeding practices as an intrinsic part of the national development agenda., (© 2018 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Stunting (length-for-age z score < -2) before 2 years of age has shown associations with poor child developmental indicators, but information at the population level is scarce in South Asia, the region with the highest burden of stunting. We examined associations between z scores (i.e., height for age [HAZ], weight for age [WAZ], and weight for height [WHZ]) and undernutrition (i.e., stunting [HAZ < -2], wasting [WHZ < -2], and underweight [WAZ < -2]) with learning/cognition and social-emotional development among children 36-59 months of age. Data from Multiple Indicator Cluster Surveys in Bangladesh (n = 8,659), Bhutan (n = 2,038), Nepal (n = 2,253), and Pakistan (Punjab n = 11,369 and Sindh n = 6,718) were used. Children were considered developmentally "on-track" in learning/cognition or social-emotional domains if they met specific early child development criteria. Meta-analysis was conducted to examine regional associations, adjusting for socio-economic status, early childhood education, and quality of care. In a pooled sample, on-track learning/cognition development was positively associated with HAZ (OR = 1.17, 95% CI [1.07, 1.27]) and WAZ (OR = 1.18, 95% CI [1.07, 1.31]) and negatively associated with stunting (OR = 0.72, 95% CI [0.60, 0.86]) and underweight (OR = 0.75, 95% CI [0.66, 0.86]) but not associated with WHZ or wasting. On-track development of social-emotional domain was not associated with any z scores or undernutrition indicators. Across several countries of South Asia, stunted children were less likely to be developmentally "on track" for learning/cognition. It is likely that interventions that prevent stunting may benefit child development, leading to significant individual and societal gains given the large burden of child stunting in regions like South Asia., (© 2018 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Anaemia inhibits health and development in Bhutan. We estimated anaemia prevalence and explored risk factors in children and women using data from Bhutan's National Nutrition Survey 2015. Prevalence was calculated using life-stage-specific cut-offs adjusted for altitude and survey design. Risk factors were evaluated in modified Poisson regressions. Anaemia affected 42%, 29%, 36%, and 28% of children, adolescent girls, and non-pregnant and pregnant women, respectively. Risk of anaemia was greater in children who were younger (RR 2.0, 95% CI [1.7, 2.3] and RR 1.9, 95% CI [1.6, 2.3], respectively, for 12-23 and 6-11 vs. 24-59 months), male (1.2, 1.1-1.4, ref.: female), and stunted (1.2, 1.0-1.3, ref.: height-for-age ≥ -2z). Older (15-19 years) versus younger (10-14 years) adolescents were at higher risk (1.5, 1.2-1.8), as were adolescents living at home versus at school (1.2, 0.9-1.6) and those working versus studying (1.3, 1.0-1.7). Among adult women, anaemia risk increased with age (1.2, 1.0-1.4 and 1.3, 1.1-1.5, for 30-39 and 40-49, respectively, vs. 20-29 years) and was higher for women without schooling (1.1, 1.0-1.3, vs. primary schooling), who were unmarried or separated (1.4, 1.2-1.7 and 1.3, 1.1-1.6, respectively, vs. married), without a child <5 years (1.1, 1.0-1.3), and lacking improved sanitation (1.1, 1.0-1.3). High coverage of antennal iron and folic acid supplementation may contribute to the lower prevalence of anaemia among pregnant women and women with young children. Expansion of iron supplementation programmes, fortification, and other strategies to improve dietary iron intake may reduce the prevalence of anaemia, but causes of anaemia other than iron deficiency (e.g., thalassemias) should also be investigated., (© 2018 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Childhood malnutrition remains endemic in South Asia, although the burden varies by country. We examined the anthropometric status and risk factors for malnutrition among children aged 0-59 months through the 2015 National Nutrition Survey in Bhutan. We assessed in 1,506 children nutritional status (by z-scores of height-for-age [HAZ], weight-for-height [WHZ], and weight-for-age [WAZ]), estimating prevalence, adjusted for survey design, of stunting, wasting, underweight, and overweight (<-2 for HAZ, WHZ, and WAZ and >2 for WHZ). Children were also assessed for pedal oedema. We conducted multivariable linear/logistic regression analysis to identify child, maternal, and household risk factors for childhood undernutrition and overweight, excluding children with oedema (1.7%). Mean (SE) HAZ, WHZ, and WAZ were -0.82 (0.13), 0.10 (0.04), and -0.42 (0.05), respectively. Prevalence of stunting, wasting, underweight, and overweight were 21.2%, 2.6%, 7.4%, and 2.6%, respectively. In multivariable regressions, risk of stunting significantly increased by age: 5.3% at <6 months (reference), 16.8% at 6-23 months (OR = 3.06, 95% CI [0.63, 14.8]), and 25.0% at 24-59 months (OR = 5.07, [1.16, 22.2]). Risk of stunting also decreased in a dose-response manner with improved maternal education. None of the examined variables were significantly associated with wasting or overweight. Despite a WHZ distribution comparable with the World Health Organization reference (with ~2.6% vs. an expected 2.5% of children beyond 2 z in each tail), stunting persists in one fifth of preschool Bhutanese children, suggesting that other nutrient deficits or nonnutritional factors may be constraining linear growth for a substantial proportion of children., (© 2018 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

We analysed socio-economic inequalities in stunting in South Asia and investigated disparities associated with factors at the individual, caregiver, and household levels (poor dietary diversity, low maternal education, and household poverty). We used time-series analysis of data from 55,459 children ages 6-23 months from Demographic and Health Surveys in Bangladesh, India, Nepal, and Pakistan (1991-2014). Logistic regression models, adjusted for age, sex, birth order, and place of residency, examined associations between stunting and multiple types of socio-economic disadvantage. All countries had high stunting rates. Bangladesh and Nepal recorded the largest reductions-2.9 and 4.1 percentage points per year, respectively-compared to 1.3 and 0.6 percentage points in India and Pakistan, respectively. Socio-economic adversity was associated with increased risk of stunting, regardless of disadvantage type. Poor children with inadequate diets and with poorly educated mothers experienced greater risk of stunting. Although stunting rates declined in the most deprived groups, socio-economic differences were largely preserved over time and in some cases worsened, namely, between wealth quintiles. The disproportionate burden of stunting experienced by the most disadvantaged children and the worsening inequalities between socio-economic groups are of concern in countries with substantial stunting burdens. Closing the gap between best and worst performing countries, and between most and least disadvantaged groups within countries, would yield substantial improvements in stunting rates in South Asia. To do so, greater attention needs to be paid to addressing the social, economic, and political drivers of stunting with targeted efforts towards the populations experiencing the greatest disadvantage and child growth faltering., (© 2017 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Bangladesh has experienced steady socio-economic development. However, improvements in child growth have not kept pace. It is important to document complementary feeding (CF) practices-a key determinant of children's growth-and their trends over time. The study aims to examine trends in CF practices in children aged 6-23 months using data from Bangladesh Demographic and Health Surveys conducted in 2004, 2007, 2011, and 2014. Multilevel logistic regression models were applied to identify independent predictors of four CF practice indicators among children 6-23 months, namely, timely introduction of complementary foods, minimum meal frequency, minimum dietary diversity, and minimum acceptable diet. Introduction of complementary foods was achieved among 64-71% of children between 2004 and 2014. The proportion meeting minimum meal frequency increased from 2004 to 2007 (71-81%) and declined and held steady at 65% from 2011 to 2014. The proportion meeting minimum dietary diversity in 2011 and 2014 was low (25% and 28%), and so was minimum acceptable diet (19% and 20%). From 2007 to 2014, child dietary diversity decreased and the most decline was in the consumption of legumes and nuts (29% to 8%), vitamin A-rich fruits and vegetables (54% to 41%), and other fruits and vegetables (47% to 20%). Young child age (6-11 months), poor parental education, household poverty, and residence in the Chittagong and Sylhet independently predicted poorer feeding practices. Dietary diversity and overall diet in Bangladeshi children are strikingly poor. Stagnation or worsening of feeding practices in the past decade are concerning and call for decisive policy and programme action to address inappropriate child feeding practices., (© 2018 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

The sustainable development of nations relies on children developing to their full potential and leading healthy, productive, and prosperous lives. Poor nutrition in early life threatens the growth and development of children, especially so in South Asia, which has the highest burdens of stunting, wasting, and anaemia in the world. Targeted actions to reduce stunting and other forms of child malnutrition in South Asia should be informed by an understanding of what drives poor nutrition in children, who is most affected, and effective programme approaches. To this end, the UNICEF Regional Office for South Asia commissioned a series of papers in 2016-2017 to fill knowledge gaps in the current body of evidence on maternal and child nutrition in South Asia, including analyses of: (a) the links between anthropometric failure in children and child development; (b) the time trends, current distribution, disparities and inequities of child stunting, wasting and anaemia, and their direct and underlying causes, including maternal anaemia, low birth weight, breastfeeding, and complementary feeding; (c) policy and programme actions to increase the coverage of nutrition interventions during pregnancy, improve breastfeeding practices, and care for severely wasted children. This overview paper summarizes the evidence from these analyses and examines the implications for the direction of future advocacy, policy, and programme actions to improve maternal and child nutrition in South Asia., (© 2018 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

In South Asia, childhood undernutrition persists while overweight is increasing. Internationally recommended infant and young child feeding (IYCF) practices promote healthy nutritional status; however, little is known about IYCF in Bhutan, investigated here using 2015 National Nutrition Survey data. WHO/UNICEF IYCF indicators, anthropometry and household socio-economic status were available for 441 children <24 months. Stunting, wasting, and underweight prevalence (<-2Z length-for-age [LAZ], weight-for-age, [WAZ] and weight-for-length [WLZ], respectively) were 15%, 9%, and 5%, respectively, whereas overweight (WLZ >2) prevalence was 6%. In survey-design-adjusted analyses, 52% of mothers of 0- to 5-month olds reported exclusive breastfeeding (EBF), with EBF less common for girls than boys (OR: 0.2 [95% CI: 0.1-0.9]). Although 61% of children were breastfed at 2 years and 75% of children >6 months met a minimum daily meal frequency, only 18% of children 6-23 months met minimum dietary diversity. IYCF was unassociated with risk of stunting, wasting, or underweight, possibly due to relatively low prevalence of anthropometric failure and small sample size. However, currently-breastfed children were less often overweight [OR: ~0.1 (95% upper limit ≤1.0)]. Neither breastfeeding nor most complementary feeding practices differed by socio-economic status, but children in the highest two fifth of a wealth index had 7.8 (1.3-46.9) and 5.3 (1.1-25.2) times greater odds than children in the lowest fifth of meeting minimum dietary diversity criteria. Low rates of EBF, given possible protection of breastfeeding against overweight, and inadequate dietary diversity offer evidence to guide future program interventions to improve nutritional status of young children., (© 2017 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Although there has been a focus on preventing stunting over the past decade, wasting has received less policy and programmatic attention. Recent national surveys from six South Asian countries were pooled to generate a dataset of 62,509 children aged 0 to 59 months to explore associations between low birthweight (LBW) and suboptimal infant and young child feeding (IYCF) practices with child wasting, severe wasting, and the co-occurrence of wasting and stunting. Logistic regression models accounted for the surveys' clustered designs and adjusted for a potential confounding factors. Children with reported LBW had significantly higher odds of being wasted (adjusted odds ratio [95% CI]: 1.60 [1.45, 1.76]) or severely wasted (1.57 [1.34, 1.83]), compared with non-LBW children. Similarly, children aged 0 to 23 months who were not breastfed within the first hour post-partum, those who were provided prelacteal feeds, and those aged 0 to 5 months who were not exclusively breastfed, were more likely to be wasted (P < 0.05 for all three feeding practices). In India, not achieving minimum diet diversity and minimum adequate diet were significantly associated with the co-occurrence of stunting and wasting. In other words, many key domains of concern to development agents who seek to address stunting are also of direct concern to those focused on wasting. The co-occurrence of wasting and stunting requires more integrated interventions. That is, programmes aimed at preventing LBW and poor IYCF to avert stunting should be linked more effectively with actions aimed at the management of wasting., (© 2018 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Severe wasting is the most widespread form of severe acute malnutrition, affecting an estimated 17 million children globally. This analysis assesses the effectiveness of Pakistan's community management of acute malnutrition (CMAM) programme. We conducted a retrospective case series analysis of 32,458 children aged 6-59 months who were admitted to the programme with a mid-upper arm circumference (MUAC) < 115 mm (January 1-December 31, 2014). We found that at admission, 59.6% of the children were girls and 87.4% were in the age group 6-23 months old. While in the programme, 120 children (0.4%) died, 3,456 (10.6%) defaulted, and 28,882 (89.0%) were discharged after a mean length of stay of 69.3 ± 25.7 days. Children's mean weight gain while in the programme was 3.2 ± 2.7 g/kg body weight/day. At discharge, 28,499 children (98.7% of discharged) had recovered (MUAC ≥ 125 mm). The odds of death were significantly higher among children with weight-for-height (WHZ) < -3 and/or height-for-age (HAZ) < -2 at admission. The odds of recovery on the basis of MUAC ≥125 mm were higher among children with HAZ ≥ -2 at admission. The odds of recovery on the basis of WHZ ≥ -2 were significantly higher among children with WHZ ≥ -3 and/or HAZ < -2 at admission. Pakistan's CMAM programme is effective in achieving good survival and recovery rates. Population-level impact could be increased by giving priority to children 6-23 months old and children with multiple anthropometric failure and by scaling up CMAM in the provinces and areas where the risk, prevalence, and/or burden of severe acute malnutrition is highest., (© 2018 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Anemia remains one of the most intractable public health challenges in South Asia. This paper analyzes individual-level and household-level determinants of anemia among children and women in Nepal and Pakistan. Applying multivariate modified Poisson models to recent national survey data, we find that the prevalence of anemia was significantly higher among women from the poorest households in Pakistan (adjusted prevalence ratio [95% CI]: 1.10 [1.04-1.17]), women lacking sanitation facilities in Nepal (1.22 [1.12-1.33]), and among undernourished women (BMI < 18.5 kg/m 2 ) in both countries (Nepal: 1.10 [1.00-1.21] and Pakistan: 1.07 [1.02-1.13]). Similarly, children in both countries were more likely to be anemic if stunted (Nepal: 1.19 [1.09-1.30] and Pakistan: 1.10 [1.07-1.14]) and having an anemic mother (Nepal: 1.31 [1.20-1.42] and Pakistan: 1.21 [1.17-1.26]). Policies and programs need to target vulnerable and hard-to-reach subpopulations who continue to bear a disproportionate burden of anemia. Covariates of poverty underpin rates of anemia among children and their mothers, but income growth alone will not suffice to resolve such deeply entrenched problems. Greater understanding of the relative role of various diet, health, sanitation, and educational factors by local context should guide investments to resolve anemia in tandem with stunting and maternal underweight., (© 2017 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

There is evidence that suboptimal complementary feeding contributes to poor child growth. However, little is known about time trends and determinants of complementary feeding in Nepal, where the prevalence of child undernutrition remains unacceptably high. The objective of the study was to examine the trends and predictors of suboptimal complementary feeding in Nepali children aged 6-23 months using nationally representative data collected from 2001 to 2014. Data from the 2001, 2006, and 2011 Nepal Demographic and Health Surveys and the 2014 Multiple Indicator Cluster Survey were used to estimate the prevalence, trends and predictors of four WHO-UNICEF complementary feeding indicators: timely introduction of complementary foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD). We used multilevel logistic regression models to identify independent factors associated with these indicators at the individual, household and community levels. In 2014, the weighted proportion of children meeting INTRO, MMF, MDD, and MAD criteria were 72%, 82%, 36% and 35%, respectively, with modest average annual rate of increase ranging from 1% to 2%. Increasing child age, maternal education, antenatal visits, and community-level access to health care services independently predicted increasing odds of achieving MMF, MDD, and MAD. Practices also varied by ecological zone and sociocultural group. Complementary feeding practices in Nepal have improved slowly in the past 15 years. Inequities in the risk of inappropriate complementary feeding are evident, calling for programme design and implementation to address poor feeding and malnutrition among the most vulnerable Nepali children., (© 2017 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

South Asia continues to carry the greatest share and number of wasted children worldwide. Understanding the determinants of wasting is important as policymakers renew efforts to tackle this persistent public health and development problem. Using data from national surveys in Bangladesh, India, the Maldives, Nepal, Pakistan and Afghanistan, this analysis explores factors associated with wasting among children aged 0 to 59 months (n = 252,797). We conducted multivariate mixed logistic regression and backwards stepwise methods to identify parsimonious models for each country separately (all p values <0.05). Younger children (0 to 5 months), and those whose mothers had a low body mass index (<18.5 kg/m2) had greater odds of being wasted in all countries. Later birth order, being male, maternal illiteracy, short maternal stature, lack of improved water source, and household poverty were also associated with wasting in various countries, but not systematically in all. Seasonality was also not consistently associated with wasting in the final models. These findings suggest that pre-conception (adolescence), pregnancy and early postpartum, represent windows of opportunity for tackling child wasting, not only stunting. Our analysis suggests that the underlying determinants of wasting and stunting in South Asia are similar, but not universal across geographies. Cost-effective interventions to prevent both stunting and wasting, and to treat severe wasting, need to be scaled up urgently. Separating these two manifestations of child undernutrition in conceptual and programmatic terms may unnecessarily impair progress to reach the Sustainable Development Goals targets aimed at addressing both child stunting and wasting., Competing Interests: The authors have declared that no competing interests exist.

Background: Formal education can be a nutrition-sensitive intervention that supports the scale-up and impact of nutrition-specific actions. Maternal education has long been linked to child survival, growth, and development while adult earnings and nutrition are tied to years in school as a child. However, less is known about the relationship between maternal education and the micronutrient status of children, women and the general population., Methods: Using country-level data and an ecological study design, we explored the global associations between women's educational attainment and: a) anemia and vitamin A deficiency (VAD) in children aged 6-59 months; b) anemia in non-pregnant women; and c) zinc deficiency, urinary iodine excretion (UIE), and the proportion of infants protected against iodine deficiency in the general population Cross-sectional relationships (2005-2013) were assessed using linear regression models., Results: Percentage of women without schooling was negatively associated with all outcomes. Number of years of schooling among women was positively associated with all outcomes except for UIE and the proportion of infants protected against iodine deficiency. Income level was a significant effect modifier of the effect of years of women's schooling on child anemia as well as of the proportion of women without formal education on zinc deficiency in the population. The relationship was strongest in low-income countries for child anemia, and was not significant in upper middle-income countries. For zinc deficiency, the relationship was not significant in low or lower middle income countries, which may suggest that a minimum threshold of resources needs to be reached before education can influence zinc status., Conclusions: While relationships between maternal schooling and micronutrient outcomes vary around the globe, more schooling is generally linked to lower rates of deficiency. These findings draw policy-relevant connections between formal education and anemia and micronutrient status globally. It is necessary to examine the mechanisms through which this relationship may be working at both household and country level.

'Hidden hunger' is a term used to describe human deficiencies of key vitamins and minerals, also known as micronutrients. While global in scale, the prevalence of micronutrient deficiencies is particularly high in South Asia despite recent successes in economic growth, agricultural output and health care. The present paper reviews the most recent evidence on patterns and trends of hidden hunger across the region, with a focus on the most significant deficiencies - iodine, Fe, vitamin A and Zn - and interprets these in terms of health and economic consequences. The challenge for South Asian policy makers is to invest in actions that can cost-effectively resolve chronic nutrient gaps facing millions of households. Appropriate solutions are available today, so governments should build on evidence-based successes that combine targeted health system delivery of quality services with carefully designed multisector actions that help promote healthier diets, reduce poverty and ensure social protection simultaneously.

Stunting, caused by experiences of chronic nutritional deprivation, affects approximately 25% of children under age five globally (i.e., 156 million children). In this review, evidence of a relationship between stunting and child development in low- and middle-income countries is summarized, and issues for further research are discussed. We focus on studies that measured low height-for-age among children less than 5 years old as the exposure and gross/fine motor skills, psychosocial competencies, cognitive abilities, or schooling and learning milestones as the outcomes. This review highlights three key findings. First, the variability in child development tools and metrics used among studies and the differences in the timing and frequency of the assessments complicate comparisons across study findings. Second, considerable evidence from across many countries supports an association between stunting and poor child development despite methodological differences and heterogeneity in the magnitude of associations. Further, effect sizes differ by developmental domain with greater associations shown for cognitive/schooling outcomes. How stunting influences child development, which domains of child development are more affected, and how the various domains of child development influence one another require further experimental research to test causal pathways. Finally, there is mixed evidence of the additive effect of nutrition + stimulation interventions on child development. However, understanding best methods for improving child developmental outcomes - either through nutrition programs or through integrated nutrition + psychosocial stimulation programs (or nutrition + other program interventions) - is a key area of further inquiry. Given that nearly 40% of children under age five suffer from loss of developmental potential - for which stunting is likely one of the key risk factors - reductions in stunting could have tremendous implications for child development and human capital formation, particularly in low- and middle-income countries., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Appropriate feeding practices are crucial for survival, growth, and development in childhood. This paper analyzes Pakistan's Demographic and Health Survey 2012-2013 to fill the knowledge gap in risk factors of poor complementary feeding practices in Pakistani children. Multilevel models were applied to fit the multistage cluster sample of 2,827 children aged 6-23 months from 489 communities. Introduction of solid, semi-solid, or soft foods (intro) was achieved in 67% infants aged 6-8 months. Among children aged 6-23 months, the proportion of children meeting minimum meal frequency, dietary diversity (MDD), and acceptable diet criteria were 63%, 22% and 15%, respectively. Consumption of legumes and nuts, flesh foods, and vitamin A-rich fruits and vegetables was low in all children (6-19%), even among children who met the MDD criteria (15-55%). Younger child age, especially between 6 and 11 months and delayed maternal postnatal checkup were significant individual-level risk factors that consistently increased the odds of not meeting all four criteria examined. Fewer antenatal care visits predicted the odds of achieving intro and minimum meal frequency while younger maternal age and household poverty predicted the odds of achieving MDD and minimum acceptable diet. Community-level factors included geographic region and general access to maternal and child health care services. The overall poor quality of children's complementary diets in Pakistani calls for stronger policy and program action to promote the consumption of key nutrient-dense foods while prioritizing interventions for the most vulnerable children and populations., (© 2017 John Wiley & Sons Ltd.)

We analyse data from the 2012 Comprehensive Nutrition Survey in the State of Maharashtra, India, which surveyed 2,630 households. This is a unique dataset because in addition to nutritional status of mothers and children, it has information on diets of women and children and household food security. This rich dataset allows us to address three issues: whether household food security predicts higher diet diversity in children aged 6-23 months; whether household food security predicts lower risk of undernutrition; and whether the lower risk of undernutrition in children who live in food secure households is mediated by improved diet diversity for children. We find that children from moderately food insecure and severely food insecure households are more likely to have lower diet diversity scores. We find that the odds of a child being severely stunted, severely underweight, or severely wasted are higher in severely food insecure households. After controlling for children's diet diversity, and other child, maternal and household characteristics, we find that household food security is no longer statistically associated with stunting, wasting, or underweight. However, diet diversity of children is statistically significantly associated with whether a child is stunted or underweight. Our results although not causal provide evidence for understanding the extent to which household food insecurity affects children's diet diversity and how both these factors affect nutrition outcomes in children. Our analysis informs Government of Maharashtra's and India's National Nutrition Mission in their efforts for formulating appropriate policies and programmes to address child undernutrition., (© 2017 John Wiley & Sons Ltd.)

Some 37% (~64 million) South Asian children under 5 years are stunted. Most stunting occurs during the complementary feeding period (6-23 months). Our objective was to (a) characterize complementary feeding practices in South Asia and (b) review the effectiveness of information, education, and counselling (IEC) interventions aiming to improve complementary feeding in South Asia. We conducted a comprehensive review of (a) the latest nationally representative survey data and (b) peer-reviewed interventions (January 1990 to December 2015) that used IEC as the main strategy to improve complementary feeding. The analytical sample included 30,966 children aged 6-23 months. Foods made from grains are the main complementary food (76.8% of children). Only 33.2% of children are fed fruits and vegetables rich in vitamin A and a mere 17.1% are fed complementary foods containing meat, fish, poultry and/or eggs. Timely introduction, minimum meal frequency, minimum dietary diversity, and minimum acceptable diet were estimated at 57.4%, 47.7%, 33.0%, and 20.5%, respectively. The evidence on the effectiveness of IEC interventions is limited in quantity, quality, and scale. The 12 intervention studies that met the inclusion criteria indicate that IEC interventions delivered by many types of primary care workers/community resource persons using multiple contact opportunities improved the timeliness, frequency, diversity, and/or adequacy of complementary feeding. However, acceptability, availability, and affordability seem to constrain improvements in diet diversity, particularly foods of animal origin. The small size of most intervention studies and the training and/or supervision intensity of counsellors raise concerns about the potential for scale and/or sustainability of some of the interventions reviewed., (© 2017 John Wiley & Sons Ltd.)

Globally, only 52% of children aged 6-23 months meet the minimum meal frequency and a mere 29% meet the minimum dietary diversity, with large disparities across and within regions. With most of the stunting occurring during the first thousand days-from conception to age 2 years-improving complementary feeding in children 6-23 months old is an urgent priority. With this evidence in mind, UNICEF collaborated with the governments of India and Maharashtra to convene a global meeting in Mumbai, India, under the theme: First Foods: A Global Meeting to Accelerate Progress on Complementary Feeding in Young Children (November 17-18, 2015). The global meeting provided a platform that aimed to (a) synthesize the biological and implementation science on complementary feeding; (b) review the practice and experience in improving access to nutritious complementary foods and good complementary feeding practices; and (c) consolidate a strong evidence base that can inform the development of strategies and approaches to improve complementary feeding that are fit to context. This overview paper summarizes the rationale on why improving complementary foods and feeding for infants and young children matters and what it takes to improve them. It builds on the papers presented at the First Foods Global Meeting and those commissioned as a follow on to it., (© 2017 The Authors. Maternal and Child Nutrition Published by John Wiley & Sons, Ltd.)

Background: To understand the full impact of stunting in childhood it is important to consider the long-run effects of undernutrition on the outcomes of adults who were affected in early life. Focusing on the costs of stunting provides a means of evaluating the economic case for investing in childhood nutrition., Methods: We review the literature on the association between stunting and undernutrition in childhood and economic outcomes in adulthood. At the national level, we also evaluate the evidence linking stunting to economic growth. Throughout, we consider randomized controlled trials (RCTs), quasi-experimental approaches and observational studies., Results: Long-run evaluations of two randomized nutrition interventions indicate substantial returns to the programmes (a 25% and 46% increase in wages for those affected as children, respectively). Cost-benefit analyses of nutrition interventions using calibrated return estimates report a median return of 17.9:1 per child. Assessing the wage premium associated with adult height, we find that a 1-cm increase in stature is associated with a 4% increase in wages for men and a 6% increase in wages for women in our preferred set of studies which attempt to address unobserved confounding and measurement error. In contrast, the evidence on the association between economic growth and stunting is mixed., Conclusions: Countries with high rates of stunting, such as those in South Asia and sub-Saharan Africa, should scale up policies and programmes aiming to reduce child undernutrition as cost-beneficial investments that expand the economic opportunities of their children, better allowing them and their countries to reach their full potential. However, economic growth as a policy will only be effective at reducing the prevalence of stunting when increases in national income are directed at improving the diets of children, addressing gender inequalities and strengthening the status of women, improving sanitation and reducing poverty and inequities., (© The Author 2017. Published by Oxford University Press on behalf of the International Epidemiological Association)

Optimal growth and development in early childhood is determined by a complex interplay of child, maternal, household, environmental, and socioeconomic factors that influence nutritional intake, but interventions to reduce child undernutrition sometimes target specific risk factors in isolation. In this analysis, we assess the relative importance of 13 correlates of child stunting selected based on a collective review of existing multi-factorial frameworks: complementary feeding, breastfeeding, feeding frequency, dietary diversity, maternal height, body mass index (BMI), education, age at marriage, child vaccination, access to improved drinking source and sanitation facilities, household indoor air quality, and household wealth. The analytic sample consisted of nationally representative cross-sectional surveys from the most recent Demographic and Health Surveys for Bangladesh (2014), India (2005), Nepal (2011), and Pakistan (2013), and from the National Nutrition Survey for Afghanistan (2013). In the mutually adjusted logistic regression model for 3,159 infants aged 6-8 months, short maternal stature (OR: 2.93; 95% CI: 1.93-4.46) and lack of complementary foods (OR: 1.47; 95% CI: 1.12-1.93) were associated with significantly higher risk of stunting. For 18,586 children aged 6-23 months, the strongest correlates of child stunting were: maternal height (OR: 3.37, 95% CI: 2.82-4.03), household wealth (OR: 2.25, 95% CI: 1.72-2.94), maternal BMI (OR: 1.59, 95% CI: 1.27-2.00), minimum dietary diversity (OR: 1.48, 95% CI: 1.27-1.72), maternal education (OR: 1.36, 95% CI: 1.18-1.56), and age at marriage (OR: 1.17, 95% CI: 1.05-1.30). Full vaccination and minimum dietary frequency were also found to be important for severe stunting for children of this age group. Some differences were found in the relative ordering and statistical significance of the correlates in country-specific analyses. Our findings indicate that comprehensive strategies incorporating a broader progress on socioeconomic conditions as well as investments in nutrition specific programs are needed to improve child undernutrition in South Asia., (Copyright © 2017. Published by Elsevier Ltd.)

Objective: To characterize the epidemiology of wasting and identify the main predictors of wasting, severe wasting and poor weight-for-height in children., Design: We analysed a nationally representative sample of 2028 children (Multiple Indicator Survey, 2010)., Setting: Royal Kingdom of Bhutan., Subjects: Children aged 0-23 months., Results: Wasting prevalence was significantly higher among infants aged 0-11 months than among children aged 12-23 months (12·0 v. 6·7 %; P=0·004) and among boys than girls (11·0 v. 7·5 %; P=0·04). Children from the Western region had 63 % higher odds of being wasted than children from the Central/Eastern regions (adjusted OR (AOR)=1·63; 95 % CI 1·14, 2·34). Poor feeding practices were among the most significant predictors of wasting and severe wasting. Children who were given prelacteal feeds in the first days of life had 2·5 times higher odds of being severely wasted than those who were not (AOR=2·49; 95 % CI 1·19, 5·19); inadequate complementary feeding in children aged 0-23 months was associated with 58 % higher odds of being wasted (AOR=1·58; 95 % CI 1·02, 2·47) and 2·3 times higher odds of being severely wasted (AOR=2·28; 95 % CI 1·13, 4·58). The association of poor infant feeding practices with wasting and severe wasting was particularly significant in infants (0-11 months)., Conclusions: Programmes for the detection and treatment of severely wasted children need to prioritize very young children (0-11 months), particularly in the Western region. Programmes for the prevention of wasting need to prioritize the improvement of complementary foods and feeding practices in children aged 6-23 months.

Competing Interests: Competing interests: None declared.

The latest available data indicate that 38% of South Asia's children aged 0-59 months are stunted. Such high prevalence combined with the region's large child population explain why South Asia bears about 40% of the global burden of stunting. Recent analyses indicate that the poor diets of children in the first years of life, the poor nutrition of women before and during pregnancy and the prevailing poor sanitation practices in households and communities are important drivers of stunting, most likely because of underlying conditions of women's status, food insecurity, poverty, and social inequalities. With this evidence in mind, UNICEF Regional Office for South Asia convened the Regional Conference: Stop Stunting: Improving Child Feeding, Women's Nutrition, and Household Sanitation in South Asia (New Delhi, November 10-12, 2014). The Conference provided a knowledge-for-action platform with three objectives: (1) share state-of-the-art research findings on the causes of child stunting and its consequences for child growth and development and the sustainable growth and development of nations; (2) discuss better practices and the cost and benefits of scaling up programmes to improve child feeding, women's nutrition, and household sanitation in South Asia; and (3) identify implications for sectoral and cross-sectoral policy, programme, advocacy and research to accelerate progress in reducing child stunting in South Asia. This overview paper summarizes the rationale for the focus on improving child feeding, women's nutrition, and household sanitation as priority areas for investment to prevent child stunting in South Asia. It builds on the invited papers presented at or developed as a follow on to the Stop Stunting Conference., (© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

We use a representative sample of 2561 children 0-23 months old to identify the factors most significantly associated with child stunting in the state of Maharashtra, India. We find that 22.7% of children were stunted, with one-third (7.4%) of the stunted children severely stunted. Multivariate regression analyses indicate that children born with low birthweight had a 2.5-fold higher odds of being stunted [odds ratio (OR) 2.49; 95% confidence interval (CI) 1.96-3.27]; children 6-23 months old who were not fed a minimum number of times/day had a 63% higher odds of being stunted (OR 1.63; 95% CI 1.24-2.14); and lower consumption of eggs was associated with a two-fold increased odds of stunting in children 6-23 months old (OR 2.07; 95% CI 1.19-3.61); children whose mother's height was < 145 cm, had two-fold higher odds of being stunted (OR 2.04; 95% CI 1.46-2.81); lastly, children of households without access to improved sanitation had 88% higher odds of being severely stunted (OR 1.88; 95% CI 1.17-3.02). Attained linear growth (height-for-age z-score) was significantly lower in children from households without access to improved sanitation, children of mothers without access to electronic media, without decision making power regarding food or whose height was < 145 cm, children born with a low birthweight and children 6-23 months old who were not fed dairy products, fruits and vegetables. In Maharashtra children's birthweight and feeding practices, women's nutrition and status and household sanitation and poverty are the most significant predictors of stunting and poor linear growth in children under 2 years. Key messages One in five (22.7%) of children 0-23 months old in the state of Maharashtra were stunted, and one-third (7.4%) of the stunted children were severely stunted. Birthweight, child feeding, women's nutrition and household sanitation were the most significant predictors of stunting and poor linear growth in children under 2 years. Children born to mothers whose height was below 145 cm, had two-fold higher odds of being stunted; children born with a low birthweight had a 2.5-fold higher odds of being stunted. Low feeding frequency and low consumption of eggs, dairy products, fruits and vegetables were associated with stunting and poor linear growth in children 6-23 months old. Children of households without access to improved sanitation had 88% higher odds of being severely stunted., (© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Global evidence shows that children's growth deteriorates rapidly during/after illness if foods and feeding practices do not meet the additional nutrient requirements associated with illness/convalescence. To inform policies and programmes, we conducted a review of the literature published from 1990 to 2014 to document how children 0-23 months old are fed during/after common childhood illnesses. The review indicates that infant and young child feeding (IYCF) during common childhood illnesses is far from optimal. When sick, most children continue to be breastfed, but few are breastfed more frequently, as recommended. Restriction/withdrawal of complementary foods during illness is frequent because of children's anorexia (perceived/real), poor awareness of caregivers' about the feeding needs of sick children, traditional beliefs/behaviours and/or suboptimal counselling and support by health workers. As a result, many children are fed lower quantities of complementary foods and/or are fed less frequently when they are sick. Mothers/caregivers often turn to family/community elders and traditional/non-qualified practitioners to seek advice on how to feed their sick children. Thus, traditional beliefs and behaviours guide the use of 'special' feeding practices, foods and diets for sick children. A significant proportion of mothers/caregivers turn to the primary health care system for support but receive little or no advice. Building the knowledge, skills and capacity of community health workers and primary health care practitioners to provide mothers/caregivers with accurate and timely information, counselling and support on IYCF during and after common childhood illnesses, combined with large-scale communication programmes to address traditional beliefs and norms that may be harmful, is an urgent priority to reduce the high burden of child stunting in South Asia., (© 2016 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

The aim of the study was to investigate the effect of antenatal iron-folic acid (IFA) supplementation on child stunting in Nepalese children age <2 years. A retrospective cohort study design was used, in which a pooled cohort of 5235 most recent live births 2 years prior to interview from three Nepal Demographic and Health Surveys (2001, 2006 and 2011) was analysed. The primary outcome was stunting in children age <2 years. The main exposure variable was antenatal IFA supplementation. Multivariate Poisson regression analysis was performed. In our sample, 31% and 10% of Nepalese children age <2 years were stunted and severely stunted, respectively. The adjusted relative risk of being stunted was 14% lower in children whose mothers used IFA supplements compared to those whose mothers did not use (aRR = 0.86, 95% CI = 0.77-0.97). Additionally, the adjusted relative risk of being stunted was significantly reduced by 23% when antenatal IFA supplementation was started ≤6 months with ≥90 IFA supplements used during pregnancy (aRR = 0.77, 95% CI = 0.64-0.92). Antenatal IFA supplementation significantly reduced the risk of stunting in Nepalese children age <2 years. The greatest impact on the risk reduction of child stunting was when IFA supplements were started ≤6 months with ≥90 supplements were used.

Objective: To assess the appropriateness of current mid upper-arm circumference (MUAC) cut-offs to identify children with severe acute malnutrition in India., Design: The analysis concerned 6307 children admitted to nutrition rehabilitation centres (2009-2011) where they received therapeutic care as per guidelines by WHO and the Indian Academy of Pediatrics., Setting: States of Jharkhand, Madhya Pradesh and Uttar Pradesh, India., Subjects: Children aged 6-59 months with bilateral pitting oedema or weight-for-height Z-score (WHZ)<-3 or MUAC<115 mm at admission., Results: Children aged 6-23 months represented ~80 % of the admissions. Among them, the proportion with WHZ<-3 was similar to that with MUAC<115 mm (85·7 % v. 81·8 %); the proportion with MUAC<115 mm whose WHZ was <-3 was 82·6 %; and the proportion with WHZ<-3 whose MUAC<115 mm was 78·8 %. MUAC<115 mm was as effective as WHZ<-3 in identifying 6-59-month-old children with medical complications (32·2 % v. 31·6 %, respectively), the most important risk factor of death among oedema-free children. Furthermore, death rates in children with MUAC<115 mm were higher than in children with WHZ<-3 (0·61 % v. 0·58 %, respectively) and 91 % of the deaths among oedema-free children were deaths of children with MUAC<115 mm., Conclusions: In populations similar to those included in our analysis, MUAC<115 mm appears to be an appropriate criterion to identify children with severe acute malnutrition who are at a greater risk of medical complications and death, particularly among children 6-23 months old.

India is one of the first countries to introduce salt iodisation, but the national programme has experienced major setbacks. The purpose of this paper is to review the national efforts towards universal salt iodisation (USI) in India and highlight key challenges in programme implementation. A brief historical overview of the salt iodisation programme is provided and the current status of the household usage of iodised salt and population iodine status is described. The present status of the USI programme together with the challenges being faced towards achieving USI are classified in five categories, which represent the five guiding principles crucial to sustained USI programme success: ensuring political commitment, forming partnerships and coalition, ensuring availability of adequately iodised salt, strengthening the monitoring system and maintaining continuous advocacy, education and communication. A future agenda towards the achievement of USI is also proposed., (© 2013 John Wiley & Sons Ltd.)