Clinical Pediatrics: Open Access
Open Access

Did the Global COVID-19 Pandemic Change the Importance of Key Determinants for Children's Nutrition?

Payal Seth^{* *}Correspondence: Payal Seth, Department of Social Sciences, Tata Institute of Social Sciences, Mumbai, Maharashtra, India, Email:

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Introduction

The COVID-19 pandemic has had a significant impact on child under nutrition, especially in Low and Middle-Income Countries (LMIC) [1]. With the pandemic causing disruptions in agricultural supply chains, many families have struggled to access adequate food. Further, pandemic-induced job losses and subsequent declines in incomes exacerbated the affordability of nutritious diets. Finally, there was reduced access to social protection programs, such as cash transfers and food assistance, which can help to prevent under nutrition in children. With schools closed, children, especially those from marginal households, have missed out on school meals, which can be a vital source of nutrition. Hence, children from low-income families are particularly vulnerable to under nutrition as a result. Due to such pandemic-induced disruptions, our research provides empirical estimates for how the key determinants of child under nutrition have changed post-pandemic, using national and sub-nationally representation data from India. These findings can provide an evidence base for the policymakers to re-strategize investments that can cushion the impact of future pandemics on children’s under nutrition.

Even before the emergence of COVID-19, nearly 36% of children under five suffered from being underweight (one of the outcomes of child undernutrition), as per India’s National Family Health Survey (NFHS-4). India was far from achieving Sustainable Development Goal 2-to eliminate hunger and all forms of malnutrition by 2030. A recent study has predicted that even a 5% weight loss induced by the pandemic has the potential to lead to an increase of about 4.4 million additional underweight children in India [2]. The impact of being malnourished not only causes life-long consequences such as poor cognitive development, and reduced earning capacity in adulthood, but also reduces India’s prosperity in terms of loss of about 4% to gross domestic product every year. Without adequate action grounded in empirical evidence, the COVID-19 pandemic will continue to impact early-life nutrition through intergenerational consequences for child development and long-life impacts on education, disease burden, and human capital formation.

Previous literature has assessed the potential impact of the pandemic on children’s malnutrition and has pushed for swift policy action through a multisectoral strategic approach that can re-prioritize investments into sectors impacting child undernutrition that was more significantly impacted due to the COVID-19 pandemic [3-5]. We contribute to this limited literature by providing the first-of-its-kind quantifiable empirical evidence on how the relative importance of the determinants of child undernutrition has changed post-pandemic. Other LMICs like India, which also have a higher prevalence of undernourished children, could use these findings to prioritize investments that address this issue to prevent potential long-term negative consequences on both children and the economy.

Literature Review

To address this research gap, we build on the work of Seth and Jain, 2021 who had estimated the relative importance of the determinants of children’s undernutrition outcomes, prepandemic. The authors classified the driver of child undernutrition into ten groups, using the UNICEF’s framework on the Determinants of Maternal and Child Nutrition: child’s age; child’s gender; child’s infections and medicines; child’s birth characteristics; child’s food intake; child’s environment; mother’s anthropometry; her characteristics; her environment and distal or socio-economic factors. Then, using the Shapley- Owen regression decomposition econometric technique, they were able to determine the relative importance of the determinants of undernutrition outcomes for children below five years of age. The authors used the NFHS-4 (2015-16) data for the analysis.

For the purpose of this study, we use the same empirical strategy as Seth and Jain, 2021 [6]. To build on these results, we use the latest available version of the nationally and sub-nationally representative dataset of NFHS- NFHS-5 (2019-21). NFHS-5 is best suited to answer our research question as the survey happened in two phases: 22 states/Union Territories (UTs) from June 2019 to January 2020 (pre-pandemic) and 14 states/UTs from mid-November 2020 to April 2021 (post-pandemic). Hence, we can compare the entire NFHS-5 data, along with the phase-wise results with NFHS-4, to determine the change in the importance of factors impacting child undernutrition, due to the pandemic.

We also note, that, unlike the previous study which focused on two undernutrition outcomes: Stunting (i.e. low height-for-age) and underweight (i.e. low weight-for-age), we just focus on one outcome, i.e. underweight or low weight-for-age. Children’s weight-for-age is more susceptible to short-term pandemicinduced shocks [7]. Children’s weight-for-age is measured in terms of weight-for-age z score (WAZ score), which assesses a child's growth and nutritional status by comparing their weight to the weight of other children of the same age and sex. WAZ score of 0 denotes a normal child and a score below -2 indicates that the child is underweight [8].

Discussion

Change in the prevalence of underweight children

Contrary to projections, the prevalence of underweight children in India declined from 35.8% in NFHS-4 to 32% in NFHS-5. However, these broad figures mask the heterogeneity in changes in underweight within phases.

In phase 1, only six states and UTs witnessed an improvement i.e. decline in the percentage of underweight children (Figure 1, panel (a)), whereas all the states covered in phase 2 saw an improvement from NFHS-4 to NFHS-5 ( Figure 1, panel (b)). It would be pertinent to understand how the pandemic impacted data collection as well. It is possible that it led to an undercount of incidence or could just be happenstance that all the states in phase 2 were better performers than the states in phase 1.

Figure 1: Changes in the percentage of underweight children below five from NFHS-4 to NFHS-5 phase 1 and phase 2.

Change in the relative importance of determinants of underweight, post-pandemic

Figure 2 informs us that three children’s underweight determinants gained more importance from NFHS-4 to NFHS-5: Child’s gender, child’s birth characteristics, and distal factors. Similarly, two factors became less important during the same duration: Child’s age in months and environment. The distal group represents the socio-economic status of households and access to resources that play a crucial role in determining adequate access to quality foods, healthcare services, and improved living conditions, all of which have an impact on child health. Since policy interventions do not directly impact any of the factors included in this group, we emphasize the analysis and recommendations for other groups.

Figure 2: Percentage contribution of WAZ scores towards Rsquare.

Factors that became more important

We analyze the trends of change in the prevalence of underweight and WAZ scores using results from Table 1.

Table 1: Changes in WAZ score and underweight prevalence from NFHS-4 to NFHS-5.

Gender: In many LMICs like India, girls are more likely to be undernourished than boys due to traditional gender norms that favor boys over girls. As per both rounds of NFHS, the prevalence of underweight girls (and their WAZ scores) was slightly better than that of boys. Post-pandemic, the improvement in both these outcomes was more for girls than boys.

Birth characteristics-Low birth weight: Low Birth Weight (LBW) is a major risk factor for child under nutrition. LBW is defined as a birth weight of less than 2.5 kilograms and is usually the result of either preterm birth or intrauterine growth restriction. It increases children’s vulnerability to infections due to weakened immune systems. The pandemic can be hypothesized to impact LBW children disproportionately. Expectedly, NFHS data show a higher prevalence of underweight and worse WAZ scores for LBW children. Post-pandemic the decline in the prevalence of underweight in LBW children (-3.74%) was lower than that of the normal birth weight children (-3.97%). Similarly, the improvement in WAZ scores was higher for normal birth weight children, post-pandemic.

Factors that became less important

Age in months: Age in months is an important determinant of a child’s nutritional status as children below 24 months are susceptible to more infections. The pandemic was expected to disproportionately impact the younger children due to weaker immune systems and expectedly, the decline in the prevalence of underweight children from NFHS-4 to NFHS-5 was lower for children below two years (2.61 %) than for children above 2 (4.27%). Similarly, improvement in WAZ scores for children above 2 was more than for children below 2. Despite the results, age in months became less important, even before the pandemic. This result calls for a deeper analysis.

Child’s environment: Improper sanitation is a major contributor to diarrheal diseases and other infections which leads to child under nutrition. This factor is likely to have become less important as the percentage of households using improved sanitation rose from 48.5% to 70% from NFHS-4 to NFHS-5. However, this trend also masks the heterogeneity as the children who lived in communities with more than 50% open defecation rates had a higher percentage of underweight children and worse WAZ scores than children residing in communities with less than 50% OD rates in both NFHS-4 and NFHS-5. Counter intuitively, post-pandemic, there was an increase in underweight prevalence and a lower decline in WAZ scores for children living in communities with less than 50% OD rates, relative to communities with more than 50% OD rates. This finding warrants further research.

It is important to note that our findings report the increase or decrease in relative (and not absolute) importance of the abovelisted factors. Hence, it should not detract the program implementers from investment in gender, younger children, and sanitation.

Conclusion

In this paper, we analyze the change in the importance of the key determinants of child undernutrition due to the pandemic. While it is difficult to justify the decline in the prevalence of underweight children post-pandemic and the rationale behind all the factors that gained or lost importance, it is pertinent to note that children’s birth characteristics gained more importance post-pandemic. In this group, analysis of the most important variable i.e. children’s birth weight showed that children who had low birth weight suffered disproportionately more than the normal weight children. These findings can be useful for policymakers, donors, and other developmental agencies to re-orient investment to areas that were excessively impacted due to the pandemic.

Our study has limitations. At the time of the pandemic-induced national lockdown in India, 38% of the fieldwork was completed in the 14 phase 2 state/UTs. It is unclear if this 38% of the completed survey included questions on child anthropometry. Further, the trends of the changes in the importance of these sectors started shaping up pre-pandemic or during phase 1 of NFHS-5. Hence, we tread with caution and shouldn’t attribute this change entirely to the pandemic.

Nonetheless, to the best of our knowledge, our study is one of the first attempts to bridge a crucial research gap that provides quantifiable evidence for how the key determinants of child under nutrition have changed due to the pandemic. This could be a starting point for future research as they expand on this work to include variables that are impacted in the long run like stunting (or low height-for-age) or to conduct a similar analysis for women and other LMICs.

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