1. Predictors of Early Infant Stunting in El Alto, Bolivia Kaitlyn Stanhope MPH Candidate Hubert Department of Global Health Rollins School of Public Health Emory University Photo credit: Matt Reichel

2. Presenter Disclosures: Kaitlyn Stanhope The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose

3. Outline Introduction Methods Results Discussion Conclusion Acknowledgements

4. Background Globally, infant malnutrition is estimated to account for 45% of deaths in children under-5 years of age. 1 Stunting in infancy results in long- term adverse effects such as impaired cognitive function and increased risk of chronic disease Data on determinants of stunting is scarce in Andean Latin America and Bolivia

5. Background: El Alto, Bolivia High levels of poverty 15.6% of Bolivians live on less than $1.25 a day 2 High levels of infant malnutrition 9.4% of Bolivian infants (<5 months) are moderately or severely stunted (<-2 LAZ) 3 El Alto is a large, urban indigenous city outside La Paz Source: http://commons.wikimedia.org/wiki/File:El_Alto,_Bolivia_(4127372958).jpg

6. Key Definitions Low Birthweight: Weighing less than 2500 grams at birth regardless of gestational age (<2500 g ). Pre-term Birth: Birth before 37 weeks of gestation Measured using last menstrual period, <37 weeks Small for Gestational Age (SGA): Weight less than the tenth percentile for gestational age defined with Peru as a reference population 4 Proxy for intrauterine growth restriction (<10th%) Stunted: Chronic malnutrition Measured along a standard international scale Two or more standard deviations below the length mean for age is considered stunted (<-2 LAZ ). Exclusive Breastfeeding: Giving an infant no nutrient or liquid other than breast milk. Image credits, top to bottom: 1. Trei Brundrett, via Wiki Commons, License at: http://creativecommons.org/licenses/by- sa/2.0/deed.en 2. Zerbey, via Wiki Commons, License at: http://commons.wikimedia.org/wiki/Com mons:GNU_Free_Documentation_Licens e 3. Dogra et al., via Medscape: http://emedicine.medscape.com/article/40 4098-overview 4. Alejandro Amabar Mamai, via El Riqueno: http://www.elariquenio.com/2012/10/12/i quique-el-16-y-17-de-octubre-se-realizara- jornada-de-actualizacion-sobre-la- lactancia-materna/ 5. UNICEF, via: http://www.thousanddays.org/author/unic ef/

7. Goal The objective of this study was to identify infant and perinatal characteristics associated with moderate-to-severe stunting (LAZ <-2) among Bolivian children in early infancy (<4 months) Photo credit: Paulina Rebolledo

8. Outline Introduction Methods Results Discussion Conclusion Acknowledgements

9. Data Collection 274 mother-infant pairs Recruited through well-child visits June-October 2011 Convenience sample Data collected at two visits (4-6 weeks apart) Clinical & perinatal characteristics Infant weight & length Maternal weight, height Baseline socio-economic Women in waiting room of Bolivian hospital Photo credit: Paulina Rebolledo

10. Is your child less than one month old? Are you at least 18 years old? Do you have a history of acute illness? Has your baby been hospitalized in the past 7 days? Does your child have a history of congenital malformation or immunosuppression? Eligible Not eligible Inclusion and Exclusion Criteria

11. Analysis Multivariable logistic regression Tested for collinearity Exposures of interest: Breastfeeding Preterm birth Small-for-gestational age Inter-birth spacing Birth weight Confounders Male sex Infant Age

12. Conceptual Framework Distal Factors: Short stature BMI SES Intermediate Factors: Infant Birthweight SGA Pre-term Antenatal care Parity Interbirth spacing Proximate Factors: Feeding practices Outcome: Stunting Confounders: infant age, sex

13. Outline Introduction Methods Results Discussion Conclusion Acknowledgements

14. Overlaps in Populations of Stunted, Preterm and SGA Infants Stunted n=76 SGA n=37 Pre- term n=41 Pre-Term n=21 SGA n=18 Pre-Term and Stunted n=20Stunted n=41 Stunted and SGA n=19 Pre-Term, Stunted and SGA n=4

15. High Prevalence of Early Infant Stunting (N=264)

16. High Prevalence of Overweight and Obesity among Mothers(N=264)

17. Perinatal Characteristics Associated with Stunting (N=185) Bivariate AnalysisMultivariable Analysis* OR (95% CI) p- Value OR (95% CI) p- Value Perinatal Characteristics Preterm birth (<37 weeks) Small-for-gestational age (<10 th weight percentile) 5.69 (2.32-13.92) 4.22 (1.67-10.62) <0.001 0.002 4.17 (1.04-16.70) 3.95 (1.16-13.50) 0.040 0.028 Parity 1 birth 2-4 births 5 or more births Inter-birth spacing < 24 months Antenatal Care 0.68 (0.30-1.54) 1.00 0.63 (0.07-5.52) 3.52 (1.43-8.66) 0.41 (0.10-1.68) 0.36 0.68 0.006 0.21 -- 6.74 (1.76-25.77) -- -- 0.005 -- *Controlling for infant age, SGA, Inter-birth spacing, male sex, low birthweight, in multivariable analysis.

18. Infant Characteristics Associated with Stunting (N=185) Bivariate AnalysisMultivariable Analysis* OR (95% CI) p- Value OR (95% CI) p- Value Infant Characteristics Male Age in weeks at 1 st visit 1.23 (0.56-2.73) 0.96 (0.86-1.08) 0.61 0.52 1.57 (0.55-4.49) -- 0.400 -- Low Birthweight28.63 (7.17-114.31)<0.00112.74 (2.05-79.08)0.006 Exclusive Breastfeeding0.42 (0.19-0.93)0.030.22 (0.07-0.70)0.010 *Controlling for infant age, SGA, Inter-birth spacing, male sex, low birthweight, in multivariable analysis.

19. Outline Introduction Methods Results Discussion Conclusion Acknowledgements

20. Discussion Strengths: Data from early infancy Unique population Limitations: Small sample size (prevented stratification of small gestational age) Only 2 time points Convenience sample Future Directions Longitudinal study throughout first year of life Further measurement of socio-demographic factors

21. Conclusions In Bolivia, the prevalence of stunting is high in early infancy and early interventions are key Interventions to prevent SGA and pre-term birth are important to prevent infant stunting Birth spacing and exclusive breast feeding is also important to preventing stunting in Bolivian infants Photo credit: Matt Reichel

22. Acknowledgments Study participants and their families All study collaborators Dedicated study staff in El Alto, Bolivia

23. References 1.Black, R. E., L. H. Allen, et al. (2008). "Maternal and child undernutrition: global and regional exposures and health consequences." Lancet 371(9608): 243-260. 2.The World Bank Group. (2014). Poverty. Retrieved September 2014, from The World Bank​ 3.Coa, R. O., Luis H. (2009). Bolivia-- Encuesta Nacional de Demografia y Salud 2008. DHS Final Reports. M. DHS. Calverton, Maryland, USA, Macro International Inc. 4.Mikolajczyk RT, Zhang J, Betran AP, et al. A global reference for fetal-weight and birthweight percentiles. The Lancet 2011; 377: 1855-61