Public Health Nursing Vol. 34 No. 4, pp.

401–409
0737-1209/© 2016 Wiley Periodicals, Inc.
doi: 10.1111/phn.12273

REVIEW SUMMARIES

Malnutrition coupled with diarrheal

and respiratory infections among
children in Asia: A systematic review
Stephanie Brennhofer, MS, RDN,1 Elizabeth Reifsnider, PhD, RN, WHNP-BC, PHCNS-BC, FAANP,
FAAN,2 and Meg Bruening, PhD, MPH, RD,1
1
School of Nutrition and Health Promotion, Arizona State University, Phoenix, Arizona; and 2College of Nursing and Health Innovation,
Arizona State University, Phoenix, Arizona

Correspondence to:
Stephanie Brennhofer, School of Nutrition and Health Promotion, Arizona State University, 550 N 3rd St, Phoenix, AZ 85004. E-mail: stephanie.
brennhofer@asu.edu

ABSTRACT Objective: The purpose of this systematic literature review was to assess the rela-
tionship between malnutrition and respiratory and diarrheal infections among children aged five
and under living in Asian countries. Design and Sample: The design was adapted from the
PRISMA method to include case-control, cross-sectional, ecological, and experimental studies. A
review of electronic databases identified 144 articles of which 20 met the inclusion criteria. The
inclusion criteria were studies of malnourished children under the age of five with respiratory and/
or diarrheal infections, admitted to hospitals or residing in villages throughout countries in Asia,
and published between 2005 and 2015. Measures: Infection was defined as the presence of a
respiratory or diarrheal illness. Malnutrition was predominantly measured by WHO standards.
Results: Malnutrition is associated with respiratory and diarrheal infections. Children have higher
rates of mortality when both malnourished and experiencing a respiratory infection. Conclusion: Fur-
ther research needs to examine the synergetic effect of diarrheal and respiratory infections in malnour-
ished children and rates of mortality. Public health nurses (PHNs) play a critical role in the prevention
and treatment of malnutrition and infections in community and national systems. Obtaining better data
will allow PHNs to provide critical care in the most underserved areas throughout Asia.

Background be attributable to respiratory (predominantly,

Mortality. Just in a single year, approximately
6 million children under age five died worldwide
(World Health Organization, 2015b). The vast
majority of deaths were attributed to infectious and
nutritional factors (World Health Organization,
2015c). The highest rates of child mortality can be
found in sub-Saharan Africa and Southern Asia,
where seven in ten under-five deaths occur
(World Health Organization, 2015b). Despite the
decline in under-five mortality over the past two
decades, under-five mortality remains a pervasive
problem among developing nations, which can
pneumonia) and diarrheal illnesses (World Health
Organization, 2015b). Malnutrition is evident in
nearly half of all child deaths (World Health
Organization, 2015b).
Cycle of malnutrition and infection. The
association between malnutrition and infectious
diseases has long been known (Scrimshaw, Taylor,
& Gordon, 1968). However, when earlier studies
were conducted, obesity in children, especially in
developing countries, was not as widespread
(Prentice, 2006). Now with the worldwide obesity

401
402 Public Health Nursing Volume 34 Number 4
epidemic, attention may be turned away from the
dangers of malnutrition and infectious diseases
and shifted toward global obesity. This transition
should raise concern for public health profession-
als as obesity in these developing countries could
be masking underlying malnutrition as an influx
of calorically dense, yet nutrient sparse foods and
beverages are making their way into developing
nations (Doak, Adair, Bentley, Monteiro, & Pop-
kin, 2005; Popkin, Lu, & Zhai, 2002). The need
to prevent malnutrition and infectious illnesses
may not be seen as necessary in conjunction to
fighting obesity. Developing countries with limited
health care resources may be forced to carefully
allocate their resources toward what they feel are
the most pressing issues facing their countries
(Prentice, 2006). Unfortunately, obesity may be
seen as the more critical health care problem and
addressing malnutrition may be viewed as less
imperative.
Malnutrition magnifies the severity of infec-
tious diseases, as it impairs child development and
lowers nutritional reserves, compromising the
immune system, thereby increasing disease risk
(Schaible & Kaufmann, 2007). Likewise, infections
can lead to malnutrition (Schaible & Kaufmann,
2007; World Health Organization, 2015d) as energy
needs are increased during times of infections. The
metabolic response to increased energy demands
further exasperates the degree of malnutrition by
eroding the nutritional status of the child (Schaible
& Kaufmann, 2007). Inadequate nutritional status
is associated with longer periods of immuno-
compromised states and once nutrition status is
compromised, the vicious cycle of malnutrition and
infection continues and the child remains at higher
risk for additional morbidity and possible mortality
(Schaible & Kaufmann, 2007). Certain factors, such
as poverty, socioeconomic insecurity, and political
instability, fuel the cycle (Schaible & Kaufmann,
2007).
Purpose. The literature is mixed on whether
or not there is an association between malnutri-
tion and respiratory infections. Given that respira-
tory and diarrheal illnesses are the leading cause
of death under 5 years of age, the purpose of this
systematic review was to assess the relationship
between diarrheal and respiratory infections in
malnourished Asian children under the age of
July/August 2017
five. The authors could not find any systematic
review articles within at least the past 10 years
on diarrheal and respiratory infections in mal-
nourished Asian children under the age of five.
The authors then asked the following question:
What have studies found within the past 10 years
examining the association between malnutrition
and infection in children under 5 years old? A
review is needed as children are unnecessarily
dying from preventable causes. It is also impor-
tant to know which Asian countries or regions
within a country are underrepresented in the lit-
erature as it is hard for international aid efforts
to target certain places when it is uncertain as to
what is happening in understudied areas.
Methods
Design and sample
Sample selection. A review of the literature
was undertaken to identify articles from the past
10 years addressing malnutrition and infectious
diseases among children under the age of five liv-
ing in Asia. The abstracts of each article were
reviewed by two of the authors for inclusion. The
literature search was conducted in January of
2015 using the following electronic databases:
PubMed, CINAHL, ERIC, and Web of Science.
The authors limited their search to online journal
articles and did not obtain literature from other
sources. Research articles were identified using the
following search terms: malnutrition, Asia, chil-
dren, and infection. Although the focus of this
review was on children under the age of five and
only those with diarrheal and respiratory illnesses,
the literature search remained broad to maximize
the number of potential articles.
Types of studies. Inclusion criteria for the
review included original research articles written in
English that specifically addressed malnutrition by
anthropometric standards in terms of wasting, stunt-
ing, or undernutrition in children under the age of
five to be consistent with World Health Organization
(WHO) standards. Wasting, stunting, and under-
weight status were operationalized by weight-for-
height (WHZ), height-for-age (HAZ), and weight-for-
age (WAZ), respectively and were used because they
are strong and consistent anthropometrics used
 Brennhofer et al.: Malnutrition and infection in Asian children 403

worldwide (Zuguo & Grummer-Strawn, 2007). Only
studies that addressed diarrheal bacterial or viral
infections and acute respiratory illnesses were
included in this review because respiratory and diar-
rheal illnesses are the predominant causes of under-
five mortality.
Literature search. The detailed selection of
selected articles is displayed in the PRISMA flow
diagram (Figure 1) (Moher et al., 2015). There were
144 articles identified through the use of the four
electronic databases. Of the 144 articles, 114 were
excluded based on age, no respiratory/diarrheal
illness, lack of infection, lack of malnutrition or clear
definition of how malnutrition was determined, and
location. Of the 30 eligible studies remaining,
another 10 were excluded based on type of study
design (i.e., not original research). Twenty full text
articles were included in this qualitative synthesis.
Setting and sample. The 20 articles
reviewed were from six different Asian countries
(Table 1). The majority of the articles came from
Bangladesh (n = 9) and India (n = 5). All studies
were conducted in hospitals (n = 14) or within
homes (n = 6). The distribution of the diseases in
the assessed articles were as follows: diarrheal
(n = 6), respiratory (n = 8), or a combination of
respiratory and diarrheal infections (n = 6). It is
important to note that not all of the articles that
assessed respiratory and diarrheal infections sta-
ted if these illnesses occurred concomitantly, but
rather some reported on subjects that had diar-
rheal infections and others that had respiratory
infections within the same study.
Numerous types of study designs were included
in this systematic review: randomized controlled
trials (n = 3), case-control (n = 6), cohort (n = 1),
cross-sectional (n = 7), ecological (n = 2), and
descriptive (n = 1). Therefore, the rigor of these
studies were not equal. The WHO guidelines are the
pinnacle for defining malnutrition worldwide and
studies that utilized the WHO guidelines for defining
malnutrition should carry higher merit when

Records identified through Additional records identified

database searching through other sources
(n =154) (n =0)

Records excluded
(n =114)
Records after duplicates removed
Categories for excluded
(n= 144) studies:
• 35 Age
• 34 No respiratory
and/or diarrheal
Records screened disease
(n =144) • 14 No infection
• 17 No malnutrition
• 9 Location
• 5 Other
Full-text articles
assessed for eligibility
(n =30)
Full-text articles excluded,
with reasons
(n=10)
Studies included in • 6 Case studies
qualitative synthesis • 2 Commentaries
(n =20) • 2 Reviews

Diarrheal infection Respiratory infection Diarrheal and respiratory

(n =6) (n =8) infection
(n =6)

Figure 1 PRISMA Flow Diagram Describing the Article Inclusion Process

404 Public Health Nursing Volume 34 Number 4 July/August 2017

TABLE 1. Description of Included Studies

Author (Year) Description Results

Diarrheal and respiratory infections
Bardosono Cross-sectional study (n = 1,971 households) in
et al. (2007) Indonesia (northeastern and eastern Jakarta,
Banggai, and Alor-Rote). Malnutrition defined
by WHO criteria.
Chisti et al. Prospective cohort study (n = 258) in Bangladesh
(2011) (admitted to special care unit of the Dhaka
Hospital of ICDDR, B). Malnutrition defined by
WHO criteria.
Mukhopadhyay Cross-sectional study (n = 256) in India (villages). Children with single and multiple growth failures
et al. (2009) Malnutrition defined by WHO and NCHS criteria.
Nakamori et al. Cross-sectional study (n = 188) in Vietnam
(2010) (8 regions). Malnutrition defined by WHO,
CDC, and NCHS criteria.
Raj et al. (2010) Cross-sectional study (n = 19,302) in India
(nationwide in homes). Malnutrition defined
by WHO criteria.
Sattar et al. Double-blind randomized controlled trial
(2012) (n = 260) in Bangladesh (hospital in Dhaka).
Malnutrition defined by WHO criteria.
Diarrheal infections
Basu et al. Double-blind randomized controlled trial (n = 559) From day four to seven of hospitalization,
(2009) in India (Department of Pediatrics, North
Bengal Medical College and Hospital).
Malnutrition defined by IAP criteria.
Berger et al. Cross-sectional study (n = 335,034) in
(2007) Indonesia (villages). Malnutrition defined by
CDC criteria.
Ferdous et al. Ecological study (n = 2,324) in Bangladesh
(2013) (Kumudini Hospital in Mirzapur). Malnutrition
defined by WHO criteria.
Ferdous (2014) Ecological study (n = 28,948) in Bangladesh
(Dhaka Hospital of ICDDR, B). Malnutrition
defined by WHO criteria.
Roy et al. Case-control study (n = 206) in Bangladesh
(2011) (Dhaka Hospital of ICDDR, B).
Malnutrition defined by NCHS criteria.
Wasting was associated with the economic crisis.
Greater than 15% of children in the study were
classified as having very high or critical wasting,
with the highest percentage occurring in
12–23 month olds. Wasting was associated with
infectious diseases (predominantly ARI).
Long-term malnutrition was related to SES as
evidenced by low height-for-age. In Jakarta, but
not Alor-Rote, wasting was related to child
morbidity.
Patients were more likely to die (independent from
diarrhea) if presented with lobar pneumonia or if
malnourished. Children who died had higher odds
of being underweight (WAZ score) than children
who survived. However, there was no difference
between deaths and survivors on HAZ or WHZ
scores.
had more diarrhea and ARI episodes over the past
2 weeks than children with no growth failures.
Children aged 12–18.9 months had significantly
lower WAZ, HAZ, and WHZ scores than children
aged 6–11.9 months.
Children had higher odds of being stunted or
underweight, but not wasted, if born to a mother
under 18 years of age versus a mother over 18
years of age.
No differences were detected between high and low
dose vitamin A groups in terms of weight, length,
MUAC, and head circumference over a 2-week
period. ARI was more commonly seen in stunted
children versus their counterparts.
the frequency and duration of diarrhea
among those in the treatment groups were
significantly less than those in the control group.
Those who received vitamin A supplements had
lower odds of being underweight, stunted, wasted,
and having diarrhea compared to those who did
not take vitamin A.
Malnourished children had higher odds of blood in
stool and experiencing dehydration as compared to
well-nourished children.
Children from slum areas had higher odds of a
longer hospital stay, some/severe dehydration, and
death compared to children who did not live in
slums. Slum children had increased odds of being
stunted, underweight, and wasted compared to
non-slum children.
Severely malnourished patients who had
bronchopneumonia or pathogens in their blood on
admission had greater odds of mortality.

(continued)
 Brennhofer et al.: Malnutrition and infection in Asian children 405

TABLE 1. (Continued)

Author (Year) Description Results

Semba et al. Cross-sectional study (n = 286,500) in
(2007) Indonesia (Lampung, Banten, West Java,
Central Java, Lombok, and South Sulawesi).
Malnutrition defined by CDC criteria.
Respiratory infections
Bhat and Case-control study (n = 214) in India
Manjunath (district hospital). Malnutrition defined by
(2013) WHO criteria.
Chalabi (2013) Case-control study (n = 382) in Iraq
(pediatric surgical/dental units in a hospital).
Malnutrition defined by WHO, Gomez,
Waterlow, and Welcome criteria.
Chisti et al. Prospective, descriptive study (n = 1,482) in
(2014) Bangladesh (Dhaka Hospital of ICDDR, B).
Malnutrition defined by WHO criteria.
Rahman Case-control study (n = 108) in Bangladesh
(2008) (Dept of Pediatrics, Dhaka Medical College
Hospital). Malnutrition defined by WHO
criteria.
Roth et al. Case-control study (n = 50) in Bangladesh
(2010) (Hospital in Zakiganj sub-district of Sylhet).
Malnutrition defined by WHO criteria.
Savitha et al. Case-control study (n = 208) in India
(2007) (Cheluvamba Hospital in Mysore).
Malnutrition defined by IAP criteria.
Shakur et al. Cross-sectional study (n = 152) in Bangladesh
(2009) (Dhaka Shishu Hospital).
Malnutrition defined by NCHS criteria.
Tezer et al. Intervention study (n = 308) in Turkey
(2009) (hospitalized in the Ministry of Health,
Ankara Education and Research Hospital,
Department of Pediatrics). Malnutrition
defined by Gomez criteria.
Unvaccinated children were more likely to be
severely wasted, stunted, and undernourished
compared to vaccinated children. Unvaccinated
children were more likely to experience diarrhea
than vaccinated children.
Moderate/severely malnourished children had
higher odds of ARI than children who did not
present with malnutrition.
Children with ARI were more likely to weigh less
and be shorter than children without ARI.
According to the Welcome and Gomez
malnutrition classifications, cases were more likely
to be malnourished than controls. However, the
Waterlow classification found no differences
between cases and controls.
There was no association between WHZ, WAZ, and
MUAC scores between confirmed and
non-confirmed tuberculosis groups.
Serum iron was significantly lower in malnourished
children with ARI when compared to malnourished
children with no infection. Non-malnourished
non-infected children had significantly higher
serum iron levels than both malnourished children
with and without infection.
An increase in 25-hydroxycholecalciferol
(vitamin D biomarker) of 10 nmol/L decreased
the odds of ARI among infants and children.
Being underweight was not associated with ARI.
Cases were more likely to come from lower SES and
be malnourished than controls. Malnourished
children had approximately 7-fold higher odds of
contracting an ARI.
Children with ARI, PEM, and combined ARI and
PEM had higher odds of lower serum and hair
zinc status than the control group. Serum and hair
zinc were found to be negatively correlated with
PEM, and ARI and PEM, but not ARI alone.
Children with rickets were more likely to be
malnourished and have an infectious disease on
admission than children without rickets.

ARI = acute respiratory infection; CDC = Centers for Disease Control and Prevention; HAZ = height-for-age z score;
ICDDR, B = International Centre for Diarrhoeal Disease Research, Bangladesh; IAP = Indian Academy of Pediatrics;
MUAC = mid-upper arm circumference; NCHS = National Center for Health Statistics; PEM = protein energy malnutrition;
SES = socioeconomic status; WAZ = weight-for-age z score; WHO = World Health Organization; WHZ = weight-for-height
z score.

compared to the studies conducted with other
known guidelines for defining malnutrition (e.g.,
Centers for Disease Control and Prevention [CDC],
Indian Academy of Pediatrics [IAP], Gomez). Of the
10 studies that used the WHO guidelines,
inconsistencies on the study outcomes and the vari-
ety of study designs/rigor were present. Given the
variability among the studies that used the WHO
guidelines, these articles could not be effectively
synthesized to be compared with studies that used
406 Public Health Nursing Volume 34 Number 4
other guidelines. Instead articles that reported on
the outcomes between malnutrition and infectious
disease were grouped together. All articles had mal-
nutrition and infectious disease present, but some
articles had their primary focus on other factors,
such as living in slums, vaccinations, impact of
treatment, age of mother, micronutrients, and the
impact of micronutrient deficiencies, and were not
able to be successfully compared to the other stud-
ies.
Measures
Definitions of infection. Of the 20 articles
included in this review, 12 reported on diarrheal ill-
nesses. Over half of the articles (n = 7) defined
diarrhea as the presence of three or more loose
stools in the previous 24 hours. The duration of
loose stools was also used to classify participants as
having diarrhea. The presence of diarrhea for
3 days (n = 1), 1 week (n = 2), and 2 weeks (n = 2)
was used to classify subjects as suffering from a
diarrheal infection.
Fourteen of the 20 articles reviewed reported on
acute respiratory infections (ARIs), which is com-
prised of both upper and lower respiratory tract
infections. The majority of articles (n = 10) defined
respiratory infection by one or more of the following:
cough, respiratory distress/difficulty breathing,
rapid breathing, and pneumonia. Some articles were
not specific about the exact symptoms they used to
define respiratory illness, but stated that symptoms
had been recently experienced by the patient (n = 4).
Definitions of malnutrition. The majority
of articles (n = 10) defined malnutrition by the
WHO guidelines. Worldwide, the WHO malnutri-
tion guidelines are the most rigorous and accurate
for children under the age of five (Silveira,
Beghetto, Carvalho, & Mello, 2011) and identify
how children should grow in ideal conditions
(Center for Disease Control and Prevention, 2010).
The rest of the articles defined malnutrition based
on the CDC (Berger, de Pee, Bloem, Halati, &
Semba, 2007; Semba et al., 2007), National Center
for Health Statistics (NCHS) (Roy et al., 2011;
Shakur, Malek, Bano, Rahman, & Ahmed, 2009),
the IAP Classification of PEM (protein energy mal-
nutrition) (Basu, Paul, Ganguly, Chatterjee, &
Chandra, 2009; Savitha, Nandeeshwara, Pradeep
Kumar, Ul-Haque, & Raju, 2007), and the Gomez
July/August 2017
(Tezer, Siklar, Dallar, & Dogankoc, 2009) guide-
lines. Three articles used a combination of meth-
ods: one used the WHO, CDC, and NCHS
(Nakamori et al., 2010), another used the NCHS
and WHO (Mukhopadhyay, Biswas, Chakraborty,
Sadhukhan, & Banik, 2009), while the other used
the WHO, Gomez, Waterlow, and Welcome criteria
(Chalabi, 2013).
The articles that used methods other than the
WHO guidelines for malnutrition are likely not as
strong as those that followed the WHO guidelines.
The sample used to determine the CDC guidelines
was US-based and may not be representative of
growth in children internationally (Center for Dis-
ease Control and Prevention, 2010). According to
Savitha and Kondapuram, the WHO and IAP differ
significantly in how they classify stunting in boys and
girls and wasting in girls (Savitha & Kondapuram,
2012). Additionally, there are many flaws with the
Gomez method (Gueri, Gurney, & Jutsum, 1980) and
it is likely not comparable to the WHO guidelines.
Results
Malnutrition and diarrheal infections
Diarrheal infections are associated with malnutri-
tion and death. Malnourished children were more
likely to have more episodes of diarrhea
(Mukhopadhyay et al., 2009) and children with
diarrhea had higher odds of blood in stool, needing
intravenous fluids, and experiencing dehydration
(Ferdous et al., 2013). Children who died from
diarrhea had higher odds of a low WAZ score
(Chisti, Pietroni, Smith, Bardhan, & Salam, 2011).
Concomitant diarrhea and ARI were more com-
monly seen in stunted children (Sattar et al., 2012)
and was associated with greater odds of mortality
(Roy et al., 2011).
Malnutrition and respiratory infections
The majority of articles that examined malnutrition
with respiratory infections concluded that there was
an association. Malnourished children had higher
odds of ARI (Bhat & Manjunath, 2013; Savitha
et al., 2007) and more episodes of ARI (Mukhopad-
hyay et al., 2009) than nourished children. Children
with ARIs were more likely to weigh less (Chalabi,
2013), be stunted (Chalabi, 2013; Sattar et al.,
2012), and wasted than children without ARIs
 Brennhofer et al.: Malnutrition and infection in Asian children
(Bardosono, Sastroamidjojo, & Lukito, 2007). Some
researchers found no association between malnutri-
tion and incidence of ARIs (Chisti et al., 2014; Roth,
Shah, Black, & Baqui, 2010). Additionally, malnutri-
tion and respiratory illnesses were associated with
mortality. Malnourished children with respiratory
infections had higher odds of mortality (Chisti et al.,
2011; Roy et al., 2011).
Discussion
The purpose of this review was to examine the liter-
ature from the past 10 years on the relationship
between malnutrition and diarrheal and respiratory
infections among Asian children under-five. Rates
of malnutrition and disease appeared to be more
prevalent after the age of 1 year. The shift to more
severe malnutrition and infections could be related
to weaning and exposure to unclean water. Breast
milk provides infants with necessary nutrition and
once weaned, nutritional status may decline. Naka-
mori et al. (2010) noted a significant decline in
WAZ, WHZ, and HAZ scores after 12 months of
age. This could be attributed to the nutrition the
children no longer receive when they are weaned
from breast milk. In addition, children are no
longer receiving antibodies from the breast milk,
which can make them more susceptible to infec-
tious diseases (Piirainen, Pesola, Pesola, Komu-
lainen, & Vaarala, 2009). Special attention needs to
be directed toward children during this important
transition from breast milk to other forms of nutri-
tion and the introduction to unsafe drinking water
to help prevent the rise in malnutrition and infec-
tion commonly associated with this time.
A vast majority of Asian countries were not
able to be included in this systematic review. There
could be a number of reasons as to why not every
Asian country was represented. It is possible that
there are studies that have examined the relation-
ship between diarrheal and respiratory infections
and malnutrition in these countries, but they are
not published in English. Perhaps some countries
are not included because they are very war torn
and allocate their resources in other areas that are
not health related. Perhaps, research is lacking in
certain areas because the link between malnutrition
and infectious diseases has been found in many dif-
ferent countries and researchers felt that further
studies were not warranted.
407
There are several limitations to this study. This
review relied on secondary data and was subjected
to the statistics and metrics that the authors used.
Definitions of malnutrition were not consistent
among papers and the different methods used were
not always comparable. Only articles written in
English could be included in this review. Certain
countries may not make their data known to the
public. Of the articles included, many sampled from
the same area within countries (e.g., same hospital
used on many accounts) and may not be represen-
tative of the country as a whole. Given that, many
Asian countries were not included; this review can-
not speak of malnutrition and infection for the
entire continent of Asia.
Great attention needs to focus on eradicating the
associated factors that contribute to the malnutrition
and infectious disease cycle as it is unacceptable that
millions of children worldwide are continuing to die
from preventable diseases. Organizations such as the
WHO and The United Nations Children’s Emergency
Fund (UNICEF) have multiple programs aimed at
combating malnutrition, infection, and their associ-
ated factors. Despite this work, there needs to be a
rise in political commitment, funding, and leader-
ship to combat global malnutrition and infectious
disease rates (World Health Organization, 2015a), in
order to reach the millions of children who are still
at risk for death as a result of malnutrition. Efforts to
provide clean water for drinking, cooking, and bath-
ing can help prevent infections (World Health Orga-
nization, 2015c). Clean water and proper sanitary
facilities would profoundly impact rates of infectious
diseases and the concurrent effect on malnutrition
(World Health Organization, 2015d). In particular,
aid is needed in rural communities (World Health
Organization, 2015a). Urban communities are
receiving access to clean water and sanitation at
higher rates than rural communities even though
access to clean water and sanitation appears to be
improving worldwide, there are many untouched
regions in grave need of these resources (World
Health Organization, 2015a).
Public health nursing implications
It is important for public health nurses (PHNs) to
remember that malnutrition cannot only be lethal by
itself, but also by its ability to weaken a child’s
immune system, so that the child cannot fight infec-
tions as efficiently (Schaible & Kaufmann, 2007).
408 Public Health Nursing Volume 34 Number 4
Obesity can also be found in stunted children who
are malnourished (Popkin, Richards, & Montiero,
1996) and with the current research emphasis on
reducing child obesity worldwide, it is important to
remember that malnourished children, whether over
or underweight, still face higher odds of morbidity
and mortality from diarrheal and ARIs.
PHNs can work internationally at multiple levels
to effect change. At a microsystem level, promoting
breastfeeding through education to women and their
families, countering efforts of multi-national formula
companies to promote formula use as more scientific
and advanced will reduce deaths through exposure
to contaminated water. At a community level, creat-
ing momentum for change through working with
local authorities and building community capacity to
demand access to clean water can influence local
politicians. At a national level, it is critical that more
research is conducted in Asian countries, as these are
some of the most populous countries in the world
that may not be receiving adequate aid. Having bet-
ter data will help us to better prioritize public health
nursing interventions to prevent malnutrition and
mortality in vulnerable children under the age of
five. PHNs have the advantage of combining nursing
knowledge, skills, and actions along with those of
public health science to create healthier communi-
ties. It is imperative that PHNs address our responsi-
bilities to underserved populations internationally as
well as nationally.
References
Bardosono, S., Sastroamidjojo, S., & Lukito, W. (2007). Determi-
nants of child malnutrition during the 1999 economic crisis
in selected poor areas of Indonesia. Asia Pacific Journal of
Clinical Nutriton, 16(3), 512–526.
Basu, S., Paul, D. K., Ganguly, S., Chatterjee, M., & Chandra, P. K.
(2009). Efficacy of high-dose Lactobacillus rhamnosus GG
in controlling acute watery diarrhea in Indian children: A
randomized controlled trial. Journal of Clinical Gastroen-
terology, 43(3), 208–213.
Berger, S. G., de Pee, S., Bloem, M. W., Halati, S., & Semba, R. D.
(2007). Malnutrition and morbidity are higher in children
who are missed by periodic vitamin A capsule distribution
for child survival in rural Indonesia. Journal of Nutrition,
137(5), 1328–1333.
Bhat, R. Y., & Manjunath, N. (2013). Correlates of acute lower res-
piratory tract infections in children under 5 years of age in
India. International Journal of Tuberculosis and Lung Dis-
ease, 17(3), 418–422.
Center for Disease Control and Prevention. (2010). WHO Growth
Standards Are Recommended for Use in the U.S. for
Infants and Children 0 to 2 years of Age. Retrieved from
http://www.cdc.gov/growthcharts/who_charts.htm
Chalabi, D. A. (2013). Acute respiratory infection and malnutri-
tion among children below 5 years of age in Erbil
July/August 2017
governorate, Iraq. East Mediterranean Health Journal, 19
(1), 66–70.
Chisti, M. J., Graham, S. M., Duke, T., Ahmed, T., Ashraf, H., Faru-
que, A. S., et al. (2014). A prospective study of the preva-
lence of tuberculosis and bacteraemia in Bangladeshi
children with severe malnutrition and pneumonia including
an evaluation of Xpert MTB/RIF assay. PLoS ONE, 9(4),
e93776.
Chisti, M. J., Pietroni, M. A., Smith, J. H., Bardhan, P. K., & Salam,
M. A. (2011). Predictors of death in under-five children
with diarrhoea admitted to a critical care ward in an urban
hospital in Bangladesh. Acta Paediatrica, 100(12), e275–
e279.
Doak, C. M., Adair, L. S., Bentley, M., Monteiro, C., & Popkin, B.
M. (2005). The dual burden household and the nutrition
transition paradox. International Journal of Obesity, 29(1),
129–136.
Ferdous, F., Das, S. K., Ahmed, S., Farzana, F. D., Malek, M. A.,
Das, J., et al. (2014). Diarrhoea in slum children:
Observation from a large diarrhoeal disease hospital in
Dhaka, Bangladesh. Tropical Medicine and International
Health, 19(10), 1170–1176.
Ferdous, F., Das, S. K., Ahmed, S., Farzana, F. D., Latham, J. R.,
Chisti, M. J., et al. (2013). Severity of diarrhea and malnu-
trition among under five-year-old children in rural Bangla-
desh. The American Journal of Tropical Medicine and
Hygiene, 89(2), 223–228.
Gueri, M., Gurney, J. M., & Jutsum, P. (1980). The Gomez classifi-
cation. Time for a change? Bulletin of the World Health
Organization, 58(5), 773.
Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petti-
crew, M., et al. (2015). Preferred reporting items for sys-
tematic review and meta-analysis protocols (PRISMA-P)
2015 statement. Systematic Reviews, 4(1), 1.
Mukhopadhyay, D. K., Biswas, R., Chakraborty, M., Sadhukhan,
S. K., & Banik, K. K. (2009). Anthropometric failure, a
new approach to measure undernutrition: An experience
from a rural community of West Bengal, India.
Journal of the Indian Medical Association, 107(4), 211–
214, 236.
Nakamori, M., Nguyen, X. N., Nguyen, C. K., Cao, T. H., Nguyen,
A. T., Le, B. M., et al. (2010). Nutritional status, feeding
practice and incidence of infectious diseases among chil-
dren aged 6 to 18 months in northern mountainous Viet-
nam. The Journal of Medical Investigation, 57(1–2), 45–
53.
Piirainen, L., Pesola, J., Pesola, I., Komulainen, J., & Vaarala, O.
(2009). Breastfeeding stimulates total and cow’s milk-speci-
fic salivary IgA in infants. Pediatric Allergy and Immunol-
ogy, 20(3), 295–298.
Popkin, B. M., Lu, B., & Zhai, F. (2002). Understanding the nutri-
tion transition: Measuring rapid dietary changes in transi-
tional countries. Public Health Nutrition, 5(6a), 947–953.
Popkin, B. M., Richards, M. K., & Montiero, C. A. (1996). Stunting
is associated with overweight in children of four nations
that are undergoing the nutrition transition. The Journal of
Nutrition, 126(12), 3009–3016.
Prentice, A. M. (2006). The emerging epidemic of obesity in devel-
oping countries. International Journal of Epidemiology, 35
(1), 93–99.
Raj, A., Saggurti, N., Winter, M., Labonte, A., Decker, M. R.,
Balaiah, D., et al. (2010). The effect of maternal child mar-
riage on morbidity and mortality of children under 5 in
India: Cross sectional study of a nationally representative
sample. British Medical Journal, 340, b4258.
Rahman, M. A., Mannan, M. A., Rahman, M. H., Arefin, K. E., &
Azad, A. K. (2008). Influence of acute respiratory infection
on iron profile in severely malnourished children. (2008).
Mymensingh Medical Journal, 17, S52–58.
Roth, D. E., Shah, R., Black, R. E., & Baqui, A. H. (2010). Vitamin
D status and acute lower respiratory infection in early
 Brennhofer et al.: Malnutrition and infection in Asian children
childhood in Sylhet, Bangladesh. Acta Paediatrica, 99(3),
389–393.
Roy, S. K., Buis, M., Weersma, R., Khatun, W., Chowdhury, S.,
Begum, A., et al. (2011). Risk factors of mortality in severely-
malnourished children hospitalized with diarrhoea. Journal
of Health Population and Nutrition, 29(3), 229–235.
Sattar, S., Ahmed, T., Rasul, C. H., Saha, D., Salam, M. A., & Hos-
sain, M. I. (2012). Efficacy of a high-dose in addition to
daily low-dose vitamin A in children suffering from severe
acute malnutrition with other illnesses. PLoS ONE, 7(3),
e33112.
Savitha, M., & Kondapuram, N. (2012). Comparison of 2006 WHO
and Indian Academy of Pediatrics recommended growth
charts of under five Indian children. Indian Pediatrics, 49
(9), 737–739.
Savitha, M., Nandeeshwara, S., Pradeep Kumar, M., Ul-Haque, F.,
& Raju, C. (2007). Modifiable risk factors for acute lower
respiratory tract infections. Indian Journal of Pediatrics,
74(5), 477–482.
Schaible, U. E., & Kaufmann, S. H. (2007). Malnutrition and infec-
tion: Complex mechanisms and global impacts. PLoS Medi-
cine, 4(5), e115.
Scrimshaw, N. S., Taylor, C. E., & Gordon, J. E. (1968). Interactions
of nutrition and infection. Monograph Series World Health
Organization, (57), 3–329.
Semba, R. D., de Pee, S., Berger, S. G., Martini, E., Ricks, M. O., &
Bloem, M. W. (2007). Malnutrition and infectious disease
morbidity among children missed by the childhood immu-
nization program in Indonesia. Southeast Asian Journal of
Tropical Medicine and Public Health, 38(1), 120–129.
Shakur, M. S., Malek, M. A., Bano, N., Rahman, M., & Ahmed, M.
(2009). Serum and hair zinc in severely malnourished
409
Bangladeshi children associated with or without acute lower
respiratory infection. Indian Journal of Pediatrics, 76(6),
609–614.
Silveira, C., Beghetto, M., Carvalho, P., & Mello, E. (2011). Compar-
ison of NCHS, CDC and WHO growth charts in the nutri-
tional assessment of hospitalized children up to five years
old. Nutricion Hospitalaria, 26(3), 465–471.
Tezer, H., Siklar, Z., Dallar, Y., & Dogankoc, S. (2009). Early and
severe presentation of vitamin D deficiency and nutritional
rickets among hospitalized infants and the effective factors.
Turkish Journal of Pediatrics, 51(2), 110–115.
World Health Organization. (2015a). 2.4 billion people will lack
improved sanitation in 2015. Retrieved from http://
www.who.int/mediacentre/news/notes/2013/sanita-
tion_mdg_20130513/en/
World Health Organization. (2015b). Child mortality rates plunge
by more than half since 1990 but global MDG targed
missed by wide margin. Retrieved from http://
www.who.int/mediacentre/news/releases/2015/child-mor-
tality-report/en/
World Health Organization. (2015c). Global Health Observation
(GHO) data. Retrieved from http://www.who.int/gho/
child_health/en/
World Health Organization. (2015d). Water-related diseases.
Retrieved from http://www.who.int/water_sanita-
tion_health/diseases/malnutrition/en/
Zuguo, M., & Grummer-Strawn, L. M. (2007). Standard devidation
of anthropometric Z-scores as a data quality assessment
tool using the 2006 WHO growth standards: a cross coun-
try analysis. Bulletin of the World Health Organization.
Retrieved from http://www.who.int/bulletin/volumes/85/
6/06-034421/en/