Linear growth trajectories in Zimbabwean infants

Ethan K Gough, Erica Em Moodie, Andrew J Prendergast, Robert Ntozini, Lawrence H Moulton, Jean H Humphrey, Amee R Manges, Ethan K Gough, Erica Em Moodie, Andrew J Prendergast, Robert Ntozini, Lawrence H Moulton, Jean H Humphrey, Amee R Manges

Abstract

Background: Undernutrition in early life underlies 45% of child deaths globally. Stunting malnutrition (suboptimal linear growth) also has long-term negative effects on childhood development. Linear growth deficits accrue in the first 1000 d of life. Understanding the patterns and timing of linear growth faltering or recovery during this period is critical to inform interventions to improve infant nutritional status.

Objective: We aimed to identify the pattern and determinants of linear growth trajectories from birth through 24 mo of age in a cohort of Zimbabwean infants.

Design: We performed a secondary analysis of longitudinal data from a subset of 3338 HIV-unexposed infants in the Zimbabwe Vitamin A for Mothers and Babies trial. We used k-means clustering for longitudinal data to identify linear growth trajectories and multinomial logistic regression to identify covariates that were associated with each trajectory group.

Results: For the entire population, the mean length-for-age z score declined from -0.6 to -1.4 between birth and 24 mo of age. Within the population, 4 growth patterns were identified that were each characterized by worsening linear growth restriction but varied in the timing and severity of growth declines. In our multivariable model, 1-U increments in maternal height and education and infant birth weight and length were associated with greater relative odds of membership in the least-growth restricted groups (A and B) and reduced odds of membership in the more-growth restricted groups (C and D). Male infant sex was associated with reduced odds of membership in groups A and B but with increased odds of membership in groups C and D.

Conclusion: In this population, all children were experiencing growth restriction but differences in magnitude were influenced by maternal height and education and infant sex, birth weight, and birth length, which suggest that key determinants of linear growth may already be established by the time of birth. This trial was registered at clinicaltrials.gov as NCT00198718.

Keywords: children; infants; longitudinal; malnutrition; prenatal; stunting.

Figures

FIGURE 1
FIGURE 1
Patient flowchart. HIV-ind, HIV indeterminate; HIV-neg, HIV negative; HIV-pos, HIV positive.
FIGURE 2
FIGURE 2
Mean (95% CI) linear growth trajectories from birth to 24 mo of age in 4 identified trajectory groups. k-Means clustering for longitudinal data was used to identify the optimal number of growth-trajectory groups of 9 possible groups. Four was chosen as the optimal number of groups. Trajectories were smoothed across 50 retained complete-data sets. The k-means method was designed to identify clusters even when they overlap because of both noise and crossing trajectories. Horizontal dashed lines indicate LAZ cutoffs for the WHO standard population median (LAZ: 0), mild stunting (LAZ <−1) and stunting (LAZ <−2). Groups are identified as follows: group A (dashed line), group B (dotted line), group C (solid line), and group D (dot-dashed line). Distributions of infants in each trajectory group were as follows: group A, 21.4% (19.4%, 23.4%); group B, 31.3% (28.9%, 33.8%); group C, 24.3% (22.2%, 26.4%); and group D, 23.0% (20.8%, 25.1%). LAZ, length-for-age z score.

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