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As shown in a review of 28 studies, anthropometric measurements of preschool-aged children are consistently related to the risk of subsequent mortality in community-based studies from Asia and Africa (Pelletier 1994). Although the results are consistent at this general level, a number of important questions remain concerning the relationship. The purpose of this study is to address two of these questions using data from a similar study conducted in rural northern Malawi. 1) In relation to screening, are the anthropometry-mortality relationships affected by the child's age and the interval between measurement and death (‘length of follow-up’) and 2) In relation to policy implications, is the anthropometry-mortality relationship due to confounding by socioeconomic factors, especially when considering mild-to-moderate malnutrition. The results reveal that mortality prediction is significantly affected by child's age and length of follow-up, but the strength and direction of this effect modification varies across the four commonly used anthropometric indicators [weight-for-age (WA), height-for-age (HA), weight-for-height (WH) and arm circumference-for-age (ACA)]. An important result for public health practice is that there are no statistically significant differences in prediction across these four indicators when applied to young children (6–23 mo) and employing a 1-y follow-up period. As regards confounding, the results indicate that the anthropometry-mortality relationship is not due to confounding by socioeconomic factors when all grades of malnutrition are considered. When only mild-to-moderate malnutrition is considered, statistically controlling for confounders reduces most of the anthropometric predictors to nonsignificance (probability values to >0.20), but the strength of the association (odds ratio) remains of the same order of magnitude. However, when effect modification by child's age and length of follow-up is taken into account, the effect of mild-to-moderate malnutrition (WA and WH) remains statistically significant for young children dying within 1 y of follow-up. [ABSTRACT FROM AUTHOR]

The prevention of child mortality is a commonly stated health goal in developing countries and the target of much international assistance in the health sector. Over the past decade the primary strategy for accelerating the reduction in child mortality has been the dissemination of simple, low-cost technologies, such as immunization, oral rehydration therapy and antibiotics, that target specific diseases (Huffmann and Steel 1994). This is done despite the knowledge that malnutrition and. disease have a synergistic relationship (Scrimshaw et al. 1968) and that the optimal strategy may involve a combination of health and nutrition interventions. In the 1970s, for instance, it was estimated that malnutrition (notably protein-energy malnutrition—PEM) was the underlying or contributing cause of death for roughly half of all deaths to children aged 1–4 years in several Latin American countries (Puffer and Serrano 1973). Apart from this early study, however, there has been little effort to quantify the contribution of malnutrition to child mortality in other regions of the in ways which are meaningful to policy. This paper reviews the results of 28 community-based, prospective studies, in 12 Asian and Sub-Saharan African countries, which examined the relationship between anthropometric indicators of malnutrition and child mortality. One purpose is to estimate the contribution of malnutrition to child mortality—distinguishing the effects of severe malnutrition from mild-to-moderate malnutrition— and to examine a number of related issues relevant to policy, programs and research in this are. The accumulated results are consistent in showing that the risk of mortality is inversely related to anthropometric indicators of nutritional status and that there is elevated risk even in the mild-to-moderate range of malnutrition. This latter result contradicts the findings from an earlier, landmark study which suggested that mild-to-moderate malnutrition was not associated with an increased risk of mortality (Chen et al. 1980). The present results indicate that somewhere between 20% and 75% of child deaths are statistically attributable to anthropometric deficits, with most estimates falling in the range 25–50%. When taking account of the relative proportions of severe versus mild-to-moderate malnutrition in the population, the results show further than 16–80% of all nutrition-related deaths are associated with mild-to-moderate malnutrition rather than severe malnutrition. In most studies 46–80% of all nutrition-related deaths are in the mild-to-moderate category. This represents the proportion of nutrition-related deaths that would be missed by policies and programs focusing primarily or exclusively on the severely malnourished, a bias that does exist in many public health programs in practice if not by design. Another important result is the confirmation that malnutrition has a potentiating (multiplicative) effect on mortality within populations, as predicted from the theory of synergism. This means that malnutrition has its biggest impacts in populations with already high mortality levels and that morbidity has its biggest impacts in the most malnourished populations. This finding has far-reaching implications for child survival policy and programs, suggesting that greater attention should be paid to nutritional improvement than at present. A potential limitation of the above conclusion is the possibility that the relationship between mortality and malnutrition may be confounded by behavioral and socioeconomic factors (e.g., caretaker knowledge and practices and access to health care).… [ABSTRACT FROM AUTHOR]

Objectives. Despite broad agreement that severe malnutrition contributes to child mortality in developing countries and that malnutrition has a psychologically synergistic relationship with morbidity, evidence of an epidemiologic synergism, has been lacking. Also, the literature provides conflicting evidence concerning the existence of elevated mortality among children with mild to moderate malnutrition. A review of published population-based studies of anthropometry-mortality relationships was undertaken to clarify these relationships. Methods. Six studies with the relevant data were reanalyzed to test for synergism and elevated mortality in mild to moderate malnutrition. Results. The results demonstrate that mortality increases exponentially with declining weight for age. This effect is consistent across studies and there is no apparent threshold effect on mortality. The primary difference across studies is in baseline levels of mortality, which determine the quantitative impact of malnutrition on mortality in a population. Conclusions. These results indicate that mild to moderate malnutrition is associated with elevated mortality and that there is an epidemiologic synergism between malnutrition and morbidity. This previously undemonstrated finding has significant implications for child survival policies and research. [ABSTRACT FROM AUTHOR]

Summarizes the conclusions from an analysis of epidemiologic studies of the relationship between malnutrition and mortality among children. Multiplicative effects of malnutrition and infection on child mortality; Implications for health policy on a global, country or local context.

According to conventional methods of classifying cause of death, approximately 70% of child deaths (0–4 y) worldwide are due to a small number of priority infectious diseases which, in turn, receive the vast majority of donor and national resources in the health sector. Despite the long-recognized synergism between malnutrition and infection in the causation of child mortality, malnutrition does not appear as a major cause of death in health statistics from developing countries. Part of the reason for this has been the difficulty of estimating the percent of deaths due to malnutrition, because the conventional methods of classifying cause of death do not recognize the potentiating effect of malnutrition on the disease. The purpose of this paper is to develop and test a simple method. ology to estimate the percent of child deaths in a given country or community that is due to malnutrition's potentiating effects on prevailing infectious diseases. The cornerstone of the methodology is knowledge of the strength of the association between malnutrition and mortality in developing countries, as measured in eight prospective studies. These studies reveal remarkable consistency in relative risk across different grades of malnutrition. The mean and SE of relative risk for severe malnutrition is 8.4 ± 2.1, for moderate malnutrition it is 4.6 ± 0.9, and for mild malnutrition it is 2.5 ± 0.3. When applied to survey data from Ethiopia, Malawi, Guatemala and India for illustrative purposes, this methodology indicates that 42–57% of all child deaths in these samples (6–59 mo) are due to malnutrition's potentiating effects on infectious disease, of which 76–89% is attributable to mild-to-moderate malnutrition. This methodology is recommended for use in a variety of policy and planning applications. [ABSTRACT FROM AUTHOR]