# **6. Determinants of child nutrition status**

# A. _Average levels of potential determinants_

Child nutrient intake and infection are viewed as immediate (or direct) factors associated with child nutrition status, whereas food consumption, maternal and childcare practices, safe water and sanitation, and health service use are viewed as underlying (or indirect) factors that influence child nutrition status through nutrient intake and infection (UNICEF 1998). We examine recent levels of immediate and underlying factors, based on 2012–13 DHS statistics. Where possible, we compare the 2012–13 levels to past levels, specifically to 1990–91 and 2006–07 levels, based on DHS statistics for those years.

In addition, where possible, we compare the 2012–13 levels of factors in Pakistan to 2014 levels in Bangladesh, based on the latter’s 2014 DHS statistics. Bangladesh is a regional neighbor. Like Pakistan, it is classified as a lower middle-income country, although its per-capita national income is about two-thirds that of Pakistan. Bangladesh, however, has a much lower stunting rate than Pakistan (36% vs. 45%).<sup>26</sup> Table 1 reports the changes in the levels of factors for Pakistan, and recent differences in the levels of factors between Pakistan and Bangladesh.

_Nutrient intake:_ WHO advises against prelacteal feeds, which are any substances other than breastmilk given to an infant before breastfeeding is initiated.<sup>27</sup> It also advises that children under six months of age be exclusively breastfed, based on evidence that this practice reduces the risk of diarrhea and respiratory infection (Horta and Victoria 2013; WHO 2009). Children over six months of age have energy and nutrient needs that cannot be addressed solely by breastmilk. Therefore, WHO advises introducing semisolid or solid foods along with continued breastfeeding until children turn two. WHO also advises including seven food groups in a child’s diet from six to 23 months of age, with at least four food groups necessary for achieving minimum dietary diversity (PAHO and WHO 2003; WHO 2001).

In 2012–13, the share of children under six months of age who were exclusively breastfed was 38%, almost unchanged from 2006–07. The share of children who received prelacteal feeds during the first three days was 75%, an increase from 65% in 2006–07. Fifty-six percent of children under two years were age-appropriately breastfed. Among children from six to 23 months of age, 22% had minimum dietary diversity, and 15% had minimum acceptable diets.<sup>28</sup> In comparison, Bangladesh had a lower share of children who received prelacteal feeds during the first three days (27%), while registering higher rates of children who were exclusively breastfed (55%), ageappropriately breastfed (77%), fed with minimum dietary diversity (28%), and fed with minimum acceptable diets (23%).

> 26 Bangladesh’s wasting and underweight rates are somewhat higher than for Pakistan (14% versus 11% for wasting, 33% vs. 30% for underweight).

> 27 Prelacteal feeds increase the risk of illnesses such as diarrhea and other infections and allergies, particularly if they are given before the infant has had colostrum (WHO 2009).

> 28 Minimum acceptable diet is a summary indicator for the adequacy of infant and young child feeding practices. It incorporates minimum dietary diversity (children 6–23 months of age who received food from four or more food groups) and minimum meal frequency (children 6–23 months of age who were fed the minimum number of times or more, depending on their breastfeeding status, age, and the energy density of their meals) (WHO 2010).

14