Key Findings
• Thirty-two percent of children under age 5 are stunted, 10 percent are wasted, and 24 percent are underweight.
• Breastfeeding is nearly universal in Cambodia. Ninety-six percent of children born in the last two years have been breastfed.
• The median duration of breastfeeding among children born in the three years before the survey is 18 months.
• Sixty-five percent of children less than age 6 months are exclusively breastfed, and the median duration of exclusive breastfeeding is four months.
• More than 8 in 10 (82 percent) children age 6-8 months (both breastfed and nonbreastfed) are introduced to complementary foods at an appropriate time.
• Overall, 30 percent of children age 6-23 months are fed appropriately based on recommended infant and young child feeding (IYCF) practices.
• Fourteen percent of women age 15-49 are underweight, that is, they fall below the body mass index (BMI) cutoff of 18.5. Eighteen percent of women are overweight or obese. The percentage of women who are overweight or obese has increased steadily over the last decade.
• Three-quarters (76 percent) of women age 15-49 with a birth in the last five years took iron tablets or syrup during the pregnancy of their last birth for more than 90 days, 72 percent took deworming medication during their most recent pregnancy, and 49 percent received iron
supplementation postpartum.
utritional status is the result of complex interactions between food consumption and the overall status of health and care practices. Numerous socioeconomic and cultural factors influence decisions on patterns of feeding and nutritional status. Adequate nutrition is critical to child development. The period from birth to age 2 is important to optimal growth, health, and development.
During this period, children who do not receive adequate nutrition can be susceptible to growth faltering, micronutrient deficiencies, and common childhood illnesses such as diarrhea and acute respiratory infections. Among women, malnutrition can result in reduced productivity, an increased susceptibility to infections, slow recovery from illness, and a heightened risk of adverse pregnancy outcomes. A woman who has poor nutritional status, as indicated by a low body mass index (BMI), short stature, anemia, or other micronutrient deficiency, has a greater risk of obstructed labor, of having a baby with a low birth weight, of producing lower quality breast milk, of mortality due to postpartum hemorrhage, and of morbidity for both herself and her baby.
The 2014 CDHS asked questions about early initiation of breastfeeding, exclusive breastfeeding during the first six months of life, continued breastfeeding until at least age 2, timely introduction of complementary foods at age 6 months (with increasing frequency of feeding solid and semisolid foods), and diet diversity. The height and weight of all children under age 5 and women age 15-49 were measured.
This chapter presents findings on infant feeding practices, maternal eating patterns, household testing of salt for adequate levels of iodine, and the nutritional status of women and children.
N
174 • Nutrition of Children and Women
16.1 N
UTRITIONALS
TATUS OFC
HILDRENNutritional status of children under age 5 is an important measure of children’s health. The anthropometric data on height and weight collected in the 2014 CDHS permit the evaluation of the nutritional status of young children in Cambodia.
16.1.1 Measurement of Nutritional Status among Young Children
In addition to questions about feeding practices of infants and young children, the 2014 CDHS included an anthropometric component in which children under age 5 in a subsample of two-thirds of the survey households were measured for height and weight. Weight measurements were taken using a lightweight electronic SECA scale designed and manufactured under the guidance of the United Nations Children’s Fund (UNICEF). The scale allowed for the weighing of very young children through an automatic mother-child adjustment that eliminated the mother’s weight while she was standing on the scale with her baby. Height measurements were carried out using a SECA measuring board also produced under the guidance of UNICEF. Children younger than age 24 months were measured lying down (recumbent length) on the board, whereas standing height was measured for older children. Based on these measurements, three internationally accepted indices were constructed and are used to reflect the nutritional status of children. These are:
• Height-for-age (stunting)
• Weight-for-height (wasting)
• Weight-for-age (underweight)
In the 2005 CDHS, children’s anthropometric measurements were compared with an international reference population defined by the U.S. National Center for Health Statistics (NCHS) and accepted by the U.S. Centers for Disease Control and Prevention (CDC). However, in the 2010 and 2014 CDHS surveys, as recommended by the World Health Organization (WHO), the nutritional status of children in the survey population was compared with the 2006 WHO child growth standards (WHO, 2006), which are based on an international sample (from Brazil, Ghana, India, Norway, Oman, and the United States) of ethnically, culturally, and genetically diverse healthy children living under optimum conditions conducive to achieving a child’s full genetic growth potential. The 1977 NCHS/CDC/WHO reference was replaced with the 2006 WHO child growth standards because of the prescriptive rather than descriptive nature of the WHO standards versus the NCHS reference. Also, the 2006 WHO child growth standards identify the breastfed child as the normative model for growth and development and document how children should grow under optimum conditions and infant feeding and child health practices.
The use of the 2006 WHO child growth standards is based on the finding that well-nourished children in all population groups for which data exist follow very similar growth patterns before puberty.
The internationally based standard population serves as a point of comparison, facilitating examination of differences in the anthropometric status of subgroups in a population and of changes in nutritional status over time.
The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) from the mean of the reference population are considered short for their age (stunted) and are chronically malnourished. Children who are below minus three standard deviations (-3 SD) from the mean of the reference population are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and is also affected by recurrent and chronic illness. Height-for-age, therefore, represents the long-term effects of malnutrition in a population and does not vary according to recent dietary intake.
The weight-for-height index measures body mass in relation to body length and describes current nutritional status. Children whose Z-scores are below minus two standard deviations (-2 SD) from the mean of the reference population are considered thin (wasted) for their height and are acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey and may be the result of inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children whose weight-for-height is below minus three standard deviations (-3 SD) from the mean of the reference population are considered severely wasted.
Overweight and obesity are other forms of malnutrition that are becoming concerns for some children in developing countries. Children whose Z-score values are more than two standard deviations (+2 SD) above the median for weight-for-height are considered overweight.
Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below minus two standard deviations (-2 SD) from the mean of the reference population are classified as underweight. Children whose weight-for-age is below minus three standard deviations (-3 SD) from the mean of the reference population are considered severely underweight.
A total of 5,120 children under age 5 were eligible to be measured for weight and height. Of these children, 96 percent had complete data on their age and on their weight and height measurements. The following analysis focuses on the 4,893 children for whom complete and valid anthropometric data were collected.
16.1.2 Measures of Child Nutritional Status
Overall, 32 percent of Cambodian children under age 5 are stunted, and 9 percent are severely stunted (Table 16.1 and Figure 16.1). Analysis by age group indicates that stunting is apparent even among children less than age 6 months (16 percent). In general, stunting increases with the age of the child, rising from 13 percent among children age 6-8 months to 40 percent among children age 36-47 months before declining to 36 percent among children age 48-59 months. There is very little difference in the level of stunting by gender. Stunting is highest when the birth interval is less than 24 months (37 percent). Size at birth is an important indicator of children’s nutritional status. Nearly 2 in 3 children (63 percent) reported to have been very small at birth are stunted. Children whose mothers are underweight are more likely to be stunted (44 percent) than children of normal weight mothers (32 percent). The disparity in stunting prevalence between rural and urban children is substantial: 34 percent of rural children are stunted, as compared with 24 percent of urban children. Variation in the nutritional status of children by province is quite evident, with stunting being highest in Preah Vihear/Stung Treng (44 percent) and Kampong Chhnang (43 percent) and lowest in Phnom Penh (18 percent). Mother’s education and wealth quintile have an inverse relationship with stunting levels. For example, the prevalence of stunting is higher among children living in the poorest households (42 percent) than among children in the richest households (19 percent).
Ten percent of children under age 5 are wasted, and 2 percent are severely wasted. There is a substantial correlation between wasting and size at birth. Babies who are very small and small at birth are more likely to be wasted (24 percent and 17 percent, respectively) than those of average or larger size at birth (9 percent). The prevalence of wasting among children of thin mothers (BMI below 18.5) is more than twice that of children whose mothers are either normal weight or overweight/obese. Wasting is higher among rural children than urban children (10 percent versus 8 percent) and is highest in Takeo and Otdar Meanchey (15 percent each). Wasting prevalence varies inconsistently by age of the child and does not differ substantially by sex. It is highest among children whose mothers have no education and those in the lowest two wealth quintiles.
Overweight and obesity affect a very small proportion of children in Cambodia. Overall, 2 percent of children below age 5 are overweight (weight-for-height more than +2 SD). Overweight among children tends to decrease with increasing age. There are no substantial differences by other characteristics.
176 • Nutrition of Children and Women Table 16.1 Nutritional status of children
Percentage of children under age 5 classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, weight-for-height, and weight-for-age, by background characteristics, Cambodia 2014
Height-for-age1 Weight-for-height Weight-for-age
Number of Not interviewed and not in
the household5 11.9 35.2 (1.5) 1.6 8.4 0.8 (0.5) 5.3 22.3 0.2 (1.2) 525
Note: Table is based on children who stayed in the household on the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO child growth standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used NCHS/CDC/WHO reference. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. Total includes 25 cases with missing information on size at birth.
1 Recumbent length is measured for children under age 2 and in the few cases when the age of the child is unknown and the child is less than 85 cm; standing height is measured for all other children.
2 Includes children who are below -3 standard deviations (SD) from the WHO child growth standards population median
3 Excludes children whose mothers were not interviewed
4 First-born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval.
5 Includes children whose mothers are deceased
6 Excludes children whose mothers were not weighed and measured, children whose mothers were not interviewed, and children whose mothers are pregnant or gave birth within the preceding 2 months. Mother’s nutritional status in terms of BMI (body mass index) is presented in Table 16.10.
7 For women who are not interviewed, information is taken from the Household Questionnaire. Excludes children whose mothers are not listed in the Household Questionnaire.
Twenty-four percent of children under age 5 are underweight (low weight-for-age), and 5 percent are severely underweight. Figure 16.1 shows that the percentage of children underweight increases steadily from 5 percent among children younger than age 2 months to more than 10 percent among children age 2-4 months, followed by a small decline among children age 6-8 months. The percentage then increases with increasing age and peaks among children age 40-42 months. This may be due to inappropriate and/or inadequate feeding practices because the percentage of underweight children begins to increase at the age when normal complementary feeding starts. The prevalence of underweight is 10 percentage points higher among rural children (25 percent) than among urban children (15 percent) (Table 16.1). More than half of the provinces in Cambodia (11 of 19) have percentages of underweight children above the national average. A mother’s wealth status and educational level are negatively correlated with the likelihood that her child is underweight. Children born to mothers in the lowest wealth quintile are more than twice as likely (31 percent) to be underweight as children born to mothers in the highest wealth quintile (13 percent).
Figure 16.1 Nutritional status of children by age
16.1.3 Trends in Children’s Nutritional Status
Trends in children’s nutritional status for the period 2000 to 2014 are shown in Figure 16.2. To allow assessment of trends, the data for 2000 and 2005 were recalculated using the 2006 WHO child growth standards. Figure 16.2 shows that there have been improvements in the nutritional status of children in the past 14 years. The percentage of children stunted fell consistently from 50 percent in 2000 to 32 percent in 2014. The percentage of children wasted declined from 17 percent in 2000 to 8 percent in 2005 before increasing to 11 percent in 2010 and subsequently dropping slightly to 10 percent in 2014.
Underweight declined from 39 percent in 2000 to 28 percent in 2005 and 2010 and then decreased to 24 percent in 2014.
Although there have been improvements in the nutritional status of Cambodian children in the past decade and a half, there is still a need for more intensive interventions.
0 5 10 15 20 25 30 35 40 45
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58
Percentage
Age (months)
Note: Stuntingreflects chronic malnutrition; wastingreflects acute malnutrition;
underweightreflects chronic or acute malnutrition or a combination of both.
Plotted values are smoothed by a five-month moving average.
Stunted
CDHS 2014 Underweight
Wasted
178 • Nutrition of Children and Women
Figure 16.2 Trends in nutritional status of children under age 5
16.2 I
NITIATION OFB
REASTFEEDINGEarly initiation of breastfeeding is encouraged for a number of reasons. Mothers benefit from early suckling because it stimulates breast milk production and facilitates the release of oxytocin, which helps the uterus contract and reduces postpartum blood loss. The first breast milk contains colostrum, which is highly nutritious and has antibodies that protect the newborn from diseases. Early initiation of breastfeeding also fosters bonding between mother and child.
Table 16.2 shows the percentage of all children born in the two years before the survey by breastfeeding status and the timing of initial breastfeeding, according to background characteristics. In the 2010 CDHS, initial breastfeeding data were collected for children of the same age (0-2 years) as in the 2014 survey; however, in the 2000 and 2005 CDHS surveys, initial breastfeeding data were collected for all children less than age 5, and thus caution should be exercised in comparing the results of the 2010 and 2014 surveys with previous survey results.
Ninety-six percent of children born in the two years preceding the survey were breastfed at some point of time. Young children living in rural areas at the time of the survey are more likely to have ever been breastfed than children living in urban areas. The proportion of children ever breastfed ranges from a low of 91 percent in Phnom Penh to a high of over 99 percent in Mondul Kiri/Ratanak Kiri and Prey Veng.
Children in the lowest wealth quintile are more likely to have ever been breastfed (98 percent) than children in the highest wealth quintile (92 percent).
Sixty-three percent of children are breastfed within one hour of birth, and 87 percent are breastfed within one day of birth.
Several background characteristics have important influences on early breastfeeding practices. For example, early initiation of breastfeeding is more common among children whose mothers delivered in a heath facility and whose birth was assisted by a health professional than among children delivered at home or by a traditional birth attendant. In addition, the proportion of children breastfed within one hour of birth is highest in Kampong Thom (85 percent) and lowest in Mondul Kiri/Ratanak Kiri (16 percent). There is no consistent association between early breastfeeding and mother’s education and wealth.
50
17
39 43
8
28 40
11
28 32
10
24
Stunted Wasted Underweight
Percentage
CDHS 2000 CDHS 2005 CDHS 2010 CDHS 2014