Contribution of malnutrition to infant and child deaths in Sub-Saharan Africa and South Asia

Abstract

Introduction: Malnutrition contributes to 45% of all childhood deaths globally, but these modelled estimates lack direct measurements in countries with high malnutrition and under-5 mortality rates. We investigated malnutrition's role in infant and child deaths in the Child Health and Mortality Prevention Surveillance (CHAMPS) network.

Methods: We analysed CHAMPS data from seven sites (Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone and South Africa) collected between 2016 and 2023. An expert panel assessed each death to determine whether malnutrition was an underlying, antecedent or immediate cause or other significant condition. Malnutrition was further classified based on postmortem anthropometry using WHO growth standards for underweight (z-scores for weight-for-age <-2), stunting (length-for-age <-2), and wasting (weight-for-length or MUAC Z-scores <-2).

Results: Of 1601 infant and child deaths, malnutrition was considered a causal or significant condition in 632 (39.5%) cases, including 85 (13.4%) with HIV infection. Postmortem measurements indicated 90.1%, 61.2% and 94.1% of these cases were underweight, stunted and wasted, respectively. Most malnutrition-related deaths (n=632) had an infectious cause (89.1%). The adjusted odds of having malnutrition as causal or significant condition were 2.4 (95% CI 1.7 to 3.2) times higher for deaths involving infectious diseases compared with other causes. Common pathogens in the causal pathway for malnutrition-related deaths included Klebsiella pneumoniae (30.4%), Streptococcus pneumoniae (21.5%), Plasmodium falciparum (18.7%) and Escherichia coli/Shigella (17.2%).

Conclusion: Malnutrition was identified as a causal or significant factor in 39.5% of under-5 deaths in the CHAMPS network, often in combination with infectious diseases. These findings highlight the need for integrated interventions addressing both malnutrition and infectious diseases to effectively reduce under-5 mortality.

Keywords: Child health; Epidemiology; Global Health; Nutrition; Paediatrics.

Figure 1. Causes of death (A) and pathogens in the causal pathway (B) for infant and child deaths with and without malnutrition in causal chain or as other significant condition. CHAMPS, 2016–2023 (N=1601). CHAMPS, Child Health and Mortality Prevention Surveillance.

Figure 2. Unadjusted and adjusted associations between malnutrition in causal chain or as other significant condition and infectious causes of death in the causal chain among infant and child deaths. CHAMPS, 2016–2023. The x-axis is shown on a log₁₀ scale. ORs and 95% CIs are shown. Multivariable models were adjusted for age group, sex, location of death and site as a random effect. The association between each cause of death and malnutrition was from separate regression models. This analysis excluded deaths from infectious causes from the reference groups. The sample size for each analysis is shown. CHAMPS, Child Health and Mortality Prevention Surveillance.