one of every five children aged less than 5 years in low - income , developing countries is malnourished . globally , undernutrition is associated with more than one - third of all deaths in this age group .
acute malnutrition defined by weight - for - height z - score ( whz ) < 2 ( i.e. , wasting ) in young children continues to be a major health problem in low - income countries , particularly bangladesh . despite recent advances in prevention and management of childhood malnutrition in bangladesh , 16% of children under 5 years of age are acutely malnourished ( whz <
childhood malnutrition places a heavy burden on many families in bangladesh and other developing countries .
it not only directly increases mortality but also imposes significant national health and development costs due to associated morbidities , including impaired cognitive ability and indirect deaths .
it is well documented that poverty and malnutrition , regardless of location , are highly intertwined .
although risk factors for malnutrition have been identified , individual factors potentially change in specific areas over time and a current characterisation of risk factors provides the basis for preventative intervention programmes .
the study was conducted in the dhaka hospital of the international centre for diarrhoeal disease research ( icddr , b ) situated in dhaka , bangladesh , a metropolitan area ( 1,500  sq  km ) with a total population of ~15 million .
each year , the dhaka hospital provides care and treatment for over 120,000 patients with diarrhoea , with or without other associated health problems .
the hospital also conducts research on enteric and other common infectious diseases as well as undernutrition and provides training on case management of diarrheal diseases , management of malnutrition , and research methodology . under - five children
constitute about 60% of the total patient population and most ( ~60% ) are from poor socioeconomic communities in urban and periurban areas of dhaka .
a nonmatched case - control study design was used to assess and identify potential risk factors associated with acute malnutrition / wasting among 659-month - old children .
children in this age group without any congenital anomaly or other chronic conditions causally associated with malnutrition ( e.g. , heart disease ) , who were admitted to the dhaka hospital of icddr , b from june to september 2012 , were enrolled .
using the contemporary growth standards of the world health organization ( 2006 ) and anthro software , weight - for - height z - score ( whz ) , weight - for - age z - score ( waz ) , height - for - age z - score ( haz ) , and body mass index - for - age z - score ( bmi - az ) of all studied children were calculated .
children with a whz  2 and without bilateral pedal edema were enrolled as control children .
verbal consent from the attending guardian , usually the mother of the child , was obtained .
one of the investigators and/or a research assistant interviewed the mother / caregiver using a pretested , structured questionnaire .
data recorded from the interviews included age and sex of child , birth order , number of total and under - five siblings , feeding and immunisation history , type of house hold latrine , marital status of mother , monthly family income , and parental age , education , and occupation . children 's nude weight using a frequently standardised digital scale with 10  g precision ( seca , model 345 , hamburg , germany ) and recumbent length to the nearest mm using a calibrated
the investigator(s ) supervised the interview process and anthropometry and reviewed the data forms daily .
data were entered using spss software for windows ( version 11.5 ) ( spss inc . , chicago , il , usa ) .
for normally distributed continuous variables , means were compared using unpaired t - tests . for continuous variables
differences in proportions were compared by the chi - square test or fisher 's exact test if the expected number in any cell was 5 .
the strength of association of selected associated / risk factors for acute malnutrition was determined by estimating odds ratios ( ors ) and their 95% confidence intervals ( cis ) . all independent variables , for example , birth order , number of siblings , socioeconomic status , parental characteristics , child feeding , and immunisation history , were analysed initially in univariate models and the attributes that were significantly associated with wasting ( dependent variable ) and biologically plausible were included in logistic regression models .
a total of 449 children were enrolled , of whom 178 were cases ( wasted children ) and 271 were controls .
their overall mean    sd age was 12.0    7.6 months ( cases were on an average 2 months older ) , and 38.5% were female without any group difference between case and control children .
the mean    sd whz and bmiaz of case and control children were 3.24  1.01 versus 0.74  0.95 and 3.21  1.04 versus 0.77  0.96 , respectively ( p < 0.001 ) . as dictated by the study design , the cases had significantly lower anthropometric values than the control children ( table 1 ) .
maternal nutritional status , family income , and the fathers ' educational levels were worse in the malnourished children ( cases ) .
cases had worse immunization status ( bacillus calmette - gurin ( bcg ) and measles vaccine ) , breastfeeding duration , and parental and other socioeconomic characteristics than control children ( table 2 ) . logistic regression analysis revealed that children with acute malnutrition were more likely than control to be older ( age > 1 year ) ( adjusted or ( aor ) : 3.1 , p = 0.004 ) , have an undernourished mother ( body mass index ( bmi ) < 18.5 ) , ( aor : 2.8 , p = 0.017 ) , have a father with no or a low - paying job ( aor : 5.8 , p < 0.001 ) , come from a family having a monthly income of less than 10,000 taka , ( 1  us$ = 80 taka ) ( aor : 2.9 , p = 0.008 ) , and have shorter period of predominant breastfeeding ( aor : 2.7 , p = 0.013 ) ( table 3 ) .
the aim of this study was to identify risk factors associated with acute malnutrition ( whz < 2 , which includes both moderate and severe wasting ) in our population of 659-month - old children .
our study shows that the major associated / risk factors for acute malnutrition among these children were older age of the child , undernourished mother , jobless father or father with a low - paying job , low total family income , and poorer breastfeeding practices .
some of these factors may operate in synergy to increase the risk of acute malnutrition .
older age as a risk / associated factor for acute malnutrition of children in our study might reflect a selection bias . however , jeyaseelan and lakshman from tamil nadu , india , and kikafunda et al . from uganda   also observed older age of a child to be significantly associated with malnutrition .
proper nutrition and child care are essential to begin in early childhood to prevent malnutrition and ensure maximum potential for normal psychomotor development as children grow older .
similar to other studies from bangladesh [ 811 ] and africa , the current study observed maternal malnutrition ( bmi less than 18.5 ) as an independent risk factor for children 's wasting / acute malnutrition .
undernourished mothers often deliver low - birth - weight ( lbw ) infants , which is an attributable risk factor for increased childhood malnutrition , morbidity , and mortality .
the capacity to adequately breastfeed may also be compromised [ 1416 ] in maternal malnutrition and such mothers might have less energy to appropriately nurture their children .
the fathers of most ( 84% ) of the wasted children in our study were rickshaw pullers or day laborers .
likewise , a study from south india   also found that children of fathers who were day laborers were ~3 times more likely to be severely underweight .
moreover , they often result in erratic or insecure incomes , at times yielding little or no earnings on a particular day .
income insecurity leads to food insecurity forcing family members to consume poor food quality and/or amount .
low family income as a possible risk factor of acute malnutrition , as found in this study , was also reported by ahmed et al .   in wasted children under 2 years
old , by nahar et al .   in severely underweight under-5 children in bangladesh , and by jeyaseelan and lakshman   in undernourished children in tamil nadu , india .
our finding of improper / inadequate breastfeeding as an associated factor with acute malnutrition is in accordance with the findings of several other studies [ 10 , 19 , 20 ] from bangladesh and elsewhere , in which early supplementation with infant formula or cow 's milk , early introduction of semisolid complementary foods , and inadequate breastfeeding were important risk factors for malnutrition in children . during the critical period of early infancy ,
the hygienic and nutritional risks associated with bottle - feeding and artificial milk are well known [ 2123 ] , and previous studies also found that breastfeeding had a significant and substantial impact on overall survival of undernourished children [ 24 , 25 ] .
it is also possible that the association with a shorter duration of predominant breastfeeding could be an example of reverse causality , whereby children who were ill and undernourished stopped breastfeeding or were provided with other foods .
one of the possible limitations of the present study is that the same personnel who obtained the anthropometric measurements of the children and mothers also conducted the interviews , so interviewer biases could be there .
however , most of the variables identified as risk / associated factors for acute malnutrition in our study were objective in type .
the other limitation was the cross - sectional nature of the present study , which did not allow us to state the identified associated factors as definite causally related risk factors .
it is worthwhile to mention that icddr , b has developed ready - to - use foods using locally available food ingredients .
these foods can be used to prevent and to treat moderate wasting in children living in food - insecure communities .
moreover , the associated factors identified for acute malnutrition in this study can be incorporated into the design and targeting of preventive interventions .
interventions that motivate behaviours more consistent with recommended infant and young child feeding practices would be expected to have a positive impact .
certain factors and possible causes of acute malnutrition are complex and involve societal and broad - based preventive programs .
 to assess the risk factors for acute malnutrition ( weight - for - height z - score ( whz ) < 2 ) , a case - control study was conducted during june  
 september 2012 in 449 children aged 659 months ( 178 with whz < 2 and 271 comparing children with whz  2 and no edema ) admitted to the dhaka hospital of icddr , b in bangladesh . 
 the overall mean  sd age was 12.0  7.6 months , 38.5% ( no difference between case and controls ) . 
 the mean  sd whz of cases and controls was 3.24  1.01 versus 0.74  0.95 ( p < 0.001 ) , respectively . 
 logistic regression analysis revealed that children with acute malnutrition were more likely than controls to be older ( age > 1 year ) ( adjusted or ( aor ) : 3.1 , p = 0.004 ) ; have an undernourished mother ( body mass index < 18.5 ) , ( aor : 2.8 , p = 0.017 ) ; have a father with no or a low - paying job ( aor : 5.8 , p < 0.001 ) ; come from a family having a monthly income of < 10,000 taka , ( 1 us$ = 80 taka ) ( aor : 2.9 , p = 0.008 ) ; and often have stopped predominant breastfeeding before 4 months of age ( aor : 2.7 , p = 0.013 ) . 
 improved understanding of these characteristics enables the design and targeting of preventive - intervention programs of childhood acute malnutrition . 
1. Introduction
2. Methods
3. Results
4. Discussion