Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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MD, DM (Clinical Pharmacology)
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Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : LC25 - LC32 Full Version

Comparison of Growth in Children of 6 to 59 Months of Age According to Birth Order: Insights from the National Family Health Survey-4


Published: August 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/49080.15301
Aravind Dharmaraj, Ananta Ghimire, Saravanan Chinnaiyan, Amrendra Kumar Tiwari, Rajendra Kumar Barik

1. Data Manager, Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India. 2. Senior Data Scientist, Evidencian, Research Associates, Bangalore, Karnataka, India. 3. Research Assistant, SRM School of Public Health, SRM Institute of Science and Technology, Chennai, Tamil Nadu, India. 4. Research Assistant, SRM School of Public Health, SRM Institute of Science and Technology, Chennai, Tamil Nadu, India. 5. Assistant Research Officer, The Inclen Trust International (AIIMS, Hi-Tech Medical College), New Delhi, India.

Correspondence Address :
Dr. Aravind Dharmaraj,
Data Manager, Wellcome Trust Research Laboratory, Division of Gastrointestinal
Sciences, Christian Medical College, Vellore, Tamil Nadu, India.
E-mail: aravindradtech@gmail.com

Abstract

Introduction: Undernutrition continues to be a major public health problem throughout the world. Higher birth order of the child contributes to higher chance of being undernutrition. But, the relationship between birth order and undernutrition has not been fully studied and understood, especially in India where the fertility rate was high.

Aim: To understand the prevalence and determinants of undernutrition using National Family Health Survey-4 (NFHS-4) India.

Materials and Methods: A national cross-sectional survey was conducted during January 2015 to December 2016. This study used information from a total weighted sample of 128859 children from India NFHS-4. Univariate and multivariate binary logistic regression were used to investigate the association of undernutrition with birth order, other child, maternal and socio-economic factors. Three models were constructed for the study, model 1 as univariate, model 2 adjusting with birth order and socio-economic predictors and model 3 adjusting with all the predictors included in the study.

Results: Of the 128859 children, median Inter Quartile Range (IQR) age was 26 (16-41) months with female/male ratio was 1:1.2. The prevalence of stunting, underweight and wasting was 37.93% (95% Confidence Interval (CI) 37.67-38.20), 34.02% (95% CI 33.76-34.28) and 20.70% (95% CI 20.48-20.92), respectively. Model-1, 2 and 3 showed that the child's higher birth order was found to have higher odds of being stunted and underweight compared with first born children. Children with lower wealth quintiles, male, vaginal delivery had higher odds of being stunted, wasted and underweight in the model-3 adjusted analysis.

Conclusion: This study indicates that higher birth order was a significant predictor of a child being stunted and underweight, as it is significant in all three models. However, further longitudinal studies are required to establish a cause-effect relationship between birth order and undernutrition and future interventions to prevent undernutrition should consider birth order as an important factor.

Keywords

Models, Predictors, Stunting, Undernutrition, Underweight, Wasting

Growth and infection among children under five years continue to be a major public health problem worldwide. Stunting, wasting and underweight are the major indicators that are used to measure undernutrition in children. Stunting is of low height for age; wasting is low weight for height, and underweight is low weight for age (1).

Globally, one in every three under-five years children is undernourished. In 2017, about 151 million children below five years of age were stunted, and 51 million were wasted globally. Southern Asia contributes 33.3% of stunting and 15.3% of wasting of the global undernutrition burden (2). According to NFHS-4 report (3), the prevalence of stunting, wasting and underweight among Indian children below five years was 38.4%, 21% and 35.8%, respectively.

Childhood wasting, unsafe water and unsafe sanitation were the leading risk factors for diarrhoea, responsible for 80.4%, 72.1% and 56.4% of diarrhoea deaths in children younger than five years, respectively. Prevention of wasting in 1762 children could avert one death from diarrhoea (4). Childhood wasting remains the leading risk factor for lower respiratory infection mortality among children younger than five years, responsible for 61.4% of lower respiratory infection deaths globally. Interventions to improve wasting, household air pollution, ambient particulate matter pollution, and expanded antibiotic use could avert one under-five years children death due to lower respiratory infection for every 4000 children treated in the countries with the highest lower respiratory infection burden (4).

Proportions of morbidity, stunting and wasting among Indian children were higher with higher birth order (3). A study conducted in urban slums of Mumbai and Bhubaneswar, India found that higher birth order is associated with undernutrition (5),(6),(7). Meanwhile, Andhra Pradesh and Telangana’s study found that younger children experienced height deficits (8). Parent’s preference towards the child may depend upon birth order consciously or unconsciously. Also, the available literature on birth order and its associated morbidity are limited in India. Therefore, it was necessary to estimate the association between growths of below five years children by birth order.

The present study was conducted with the objective was to understand the prevalence and determinants of stunting, wasting, and underweight in India and determine what extents it differs by birth order, child, maternal and socio-economic factors using NFHS-4 India datasets.

Material and Methods

This analysis was based on individual-level data from the fourth round of the NFHS, a nationally representative cross-sectional survey of India conducted January 2015 to December 2016. It provides reliable estimates on fertility, mortality, reproduction, child health and other demographic indicators at the national, state and district level (3). Around 628,900 households in 29 states and seven union territories in India were interviewed for NFHS-4, with a response rate of 98%. A two-stage stratified sampling design with villages in rural areas and Census Enumeration Blocks (CEBs) in urban areas, forming the Primary Sampling Units (PSU), were adopted during the first stage. Within each PSU, the households were selected using systematic random sampling in the second stage. Clinical, anthropometric and biochemical measurements for men, women and children were done. A detailed description of the sampling design and instruments used in the survey has been provided elsewhere (3).

In this study, children recode file (n=259627) was used, available from the Demography and Health Survey (DHS) program website, for this analysis (9). Ethical clearance was not needed as the analysis used secondary data available in the public domain. Approval was sought from Measure DHS and permission was granted for this use. The guidelines for data use as required by the DHS program were strictly followed.

Inclusion criteria: The children aged 6 to 59 months, children with data availability for outcome variable and those with values in co-variates and outcome variable were included in the study.

Exclusion criteria: The children aged below six months , those with missing data in outcome variable stunting, wasting and underweight children, those children who refused to participate in anthropometry measurement or are not alive and had missing data in co-variates were excluded from the study.

After following the complete inclusion and exclusion criteria, the sample of the study was 128859 (Table/Fig 1).

In the present study, information related to the birth order, stunting, wasting, underweight information of the child, and data for household and maternal characteristics of the child were included. As per the World Health Organisation (WHO) children stunting, wasting and underweight was defined as <2 standard deviation (SD) (1) and birth weight was defined as <2500 g as low birth weight and ≥2500 g as normal birth weight (10).

Sample zone division: India is a federal union that comprises 29 states and seven union territories a total of 36 jurisdictional entities. The states and union territories are aggregated into six zonal councils to facilitate better economic integration, resource allocation and inter-state cooperation (11). In the present study, authors used the six zonal regions, including North, South, East, West, Central and North-Eastern India. The Northern region (n=22612) consists of Jammu and Kashmir, Himachal Pradesh, Haryana, Delhi, Chandigarh, Punjab and Rajasthan. The Southern region (n=13415) consists of the states of Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, Telangana, Andaman and Nicobar Islands, Lakshadweep Islands and the Union Territory of Puducherry. The Eastern region (n=28015) consists of Bihar, Jharkhand, Odisha and West Bengal. The Western region (n=9490) consists of Gujarat, Maharashtra, Goa, Daman and Diu, and Dadra and Nagar Haveli. The Central region (n=37102) consists of the states of Chhattisgarh, Madhya Pradesh, Uttar Pradesh and Uttarakhand. The North-Eastern region (n=18225) consists of the states of Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura.

Statistical Analysis

RStudio (version 1.2.5019) was used for data analysis. Analysis was performed using a descriptive statistics and binary logistic regression. First, descriptive statistics were performed to see the prevalence of stunting, wasting and underweight by socio-demographic characteristics of the sample. Further, univariate and multivariate binary logistic regression were used to examine the determinants of all three indices of child nutritional status. Three models were constructed for the study. Model 1 assessed the univariate association between child nutritional status and independent study variables. Model 2 examined the influence of birth order on child nutritional status while controlling for the effects of socio-economic indicators (wealth index, state-wise region, place of residence, house type and type of family). In model 3, child-level factors (sex of the child, age of the child, anaemia status of child and birth weight of child) and maternal factors (age of mother, mother’s education, mode of delivery, Body Mass Index (BMI) and anaemia status) were added. Logistic regression was performed to calculate Odds Ratios (OR) and (95% CI) and p-value less than 0.05 were considered as statistically significant.

Results

Of the 128859 children, total males were 54.5% and females were 45.5% with median (IQR) age was 26 (16-41) months with female/male ratio was 1:1.2 with the majority were second-order birth (33.6%), anaemic (58.9%) and normal birth weight (87.2%). Mothers of most of the children were in the age group between 25 to 34 years (58.7%), 60.8% were of normal weight, 54.6% were anaemic.

The most common nutritional abnormality observed in the study sample was stunting followed by underweight and wasting (Table/Fig 2) a-d with 37.93 (48880/128859, 95% CI 37.67-38.20), 34.02 (43841/128859, 95% CI 33.76-34.28) and 20.70 (26675/128859, 95% CI 20.48-20.92), respectively (Table/Fig 3), (Table/Fig 4), (Table/Fig 5).

(Table/Fig 3), (Table/Fig 4), (Table/Fig 5) shows the results from binary logistic regression analysis for stunting, underweight and wasting respectively. Model 1, 2 and 3 showed that the child’s higher birth order was found to have higher odds of children being stunted and underweight compared with first born children. Therefore, suggesting higher birth order was a significant predictor of a child being stunted and underweight, as it is significant in all three models. Prevalence of stunting and underweight was increasing with the birth order of the child (Table/Fig 2).

From model 3, male children had higher odds of being stunted (aOR 1.12, 95% CI 1.09-1.14), wasted (aOR 1.15, 95% CI 1.12-1.18) and underweight (aOR 1.09, 95% CI 1.07-1.12) as compared to female children. Compared to children from the highest wealth quintile, those from lower wealth quintiles had higher odds of being stunted, wasted and underweight in the adjusted analysis. Children of mothers with primary and above education had lower odds of being stunted, wasted and underweight, compared to mothers with no education.

State-wise prevalence of stunting was highest in Bihar (48.97%) whereas underweight and wasting were highest in Jharkhand (48.85% and 31.10%), respectively [Supplementary Table-1] (3).

Discussion

This study was conducted to understand the association of birth order with child undernutrition in terms of stunting, underweight and wasting among under-five year Indian children using the NFHS-4 data. This study suggested that higher birth order increases the likelihood of being stunted and underweight of a child despite the influences of other child, maternal and socio-economic factors.

Total Fertility Rate (TFR) in India is 2.3 births per women (12). Over the past few decades, TFR has declined but it is still higher in states such as Uttar Pradesh and Bihar. Furthermore, India has one of the highest child undernutrition rates in the world. So, there was a need for understanding the relationship between birth order and nutritional abnormalities among children in India. This present study observed that higher birth order has a strong association with child stunting and underweight even after controlling for other relevant variables. It suggests that a mother having a fewest number of children is an important factor for child nutritional fulfilment. One of the reasons for this association could be that higher order births are more likely to be considered unwanted by the parents because of their socio-economic status resulting in less care, attention, food and other resources from them. This finding is consistent with several previous researches done in India (5),(13) and other countries (14),(15).

Apart from birth order, this study indicates several children, maternal and socio-economic factors have a strong effect on child nutritional abnormalities. In the present study, children with lower wealth index, lower maternal education level and low birth weight are strong undernutrition predictors. Similar to this result, a study from Ghana and Ethiopia DHS revealed higher odds of being undernutrition among low birth weight, higher birth order, lower wealth index and lower maternal educational level (16),(17). In the present study, children born with low birth weight had higher odds of being stunted, wasted and underweight. A systematic review conducted in low and middle income countries found that low birth weight was associated with higher odds of undernutrition (18). A study conducted in Uttar Pradesh among children 3-5 years and West Bengal among children 6-39 months of age revealed anaemic children had higher odds of undernutrition (19),(20). A similar result was found in the our present study. In the present study, authors found that male children had higher odds of nutritional abnormalities. This result is consistent with the previous studies in Pakistan and Iran (21),(22). The strength of the study should be considered before interpreting the results. The NFHS surveys collect individual, household, and community-level information by conducting face-to-face interviews. There is overwhelming evidence that the NFHS surveys have provided valuable information on key population and health issues and helped build India’s research capacity. And the data were collected by trained staff with a high response rate.

Limitation(s)

First limitation of the study was its study design, which was cross-sectional due to which causal relationships between different variables cannot be established. Another limitation of this study is that certain potentially essential variables such as dietary factors and micronutrients consumption were not included due to its unavailability.

Conclusion

There is still a high burden of child undernutrition in India. The maternal education, age, wealth index of the household, and the size of children at birth and birth order were the immediate factors associated with child undernutrition. The intermediate factors associated with child undernutrition were mainly maternal nutritional related factors and socio-economic indicators. These study findings provide an important interaction between birth order and child undernutrition status in India. However, further longitudinal studies are required to establish a cause-effect relationship between birth order and undernutrition. Furthermore, interventions such as community-based education and targeted nutritional interventions are required to decrease undernutrition among Indian children. Regardless of other factors higher birth order was associated with stunting and underweight. The present study has suggested that future intervention should consider higher birth order as an important factor.

Author Declaration

Availability of data and materials: The study was based on the 2015-2016 India NFHS-4. Approval to use these data was sought from Measure DHS/ICF International, and permission was granted for this use. The data are available to apply online at https://dhsprogram.com/data/available-datasets.cfm. Contact information- email: info@dhsprogram.com.

Acknowledgement

The authors are grateful to the Measure DHS for providing the data for the analysis.

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DOI and Others

10.7860/JCDR/2021/49080.15301

Date of Submission: Feb 19, 2021
Date of Peer Review: May 04, 2021
Date of Acceptance: Jun 24, 2021
Date of Publishing: Aug 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Feb 20, 2021
• Manual Googling: Jun 21, 2021
• iThenticate Software: Jul 26, 2021 (22%)

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