Associate Editor Comments to Author:

1. The paper will need extensive language editing.

2. A salient finding is that the prevalence of undernutrition was higher among children above 5
years than under; this has important implications for policy and programming.
3. Why was the study only carried out during one month? A larger sample would have had
higher statistical power.
Definitely yes. But the human resources/volunteer from IIPAN could manage only 1 month for
the data collection due to their time constraint
4. This is a hospital-based study and the findings need to be compared to other similar studies.
In Nepal there were not much hospital based nutritional surveys, so we were compelled to
compare our finding with national survey
5. Describing the main acute and chronic diseases is important.
6. Line 16: Stunting IS one form of undernutrition. The sentence is unclear.
Yes, stunting is one form of undernutrition but it is of chronic malnutrition and SAM and MAM
are of acute malnutrition
7. Line 24: It should read 'the lowest level of wealth'.

8. Table 2: Main occupation in the last 12 months and the reasons for not working for pay could
be removed.
9. Table 3: Only the significant associations are shown? This should be indicated in the table
legend or in the text.
10. The lack of association between food security and nutritional status should be discussed in
more depth.

Small sample size and limited representation of ‘at-risk’ groups. Poor nutrition due to a medical
condition rather than food security alone. These points are mentioned in discussion.

Independent Reviewers' Comments to Author:

Reviewer: 1

Comments to the Author

This is a well written report of a well conducted cross-sectional study on a highly informative
background. General comments. Detailed data are analyzed and interpreted appropriately.
Sensible plans are expressed for the way forward in dealing with perturbations of nutrition in
children in Nepal.
Specific comments.
1. The authors should comment on the high M:F ratio which is similar to those reported from
neighboring China and India.
2. The high odds ratio for stunting in the children with chronic disease is not surprising. What is
the breakdown of the chronic diseases? This may be useful to inform strategies for prevention
and/or amelioration.
3. The high incidence of microcephaly (15%) is striking. What is the prevalence in healthy
children (i.e. is this racial)? Does it correlate with nutritional status, especially stunting?
Prevalence of microcephaly in Europe was 1.53 (95% confidence interval 1.16 to 1.96) per 10 
000 births, this is the prevalence at birth
doi: https://doi.org/10.1136/bmj.i4721 

but poor nutritional status of children contributes for microcephaly as 36.25% (29) of severely
malnourished, only 5%(1) of moderately malnourished children and none in controls had microcephaly
conducted by Tiwari et al. also.

DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20172977

4. Minor details. In line 163 change the range to 115-124 mm for MAM and in line 166 change
the range from -3 to 1.99 for MAM.
Appreciate your correction, will carry on

Reviewer: 2

Comments to the Author

Interesting article, but very difficult to read, needed to read sentences a few times to clearly
understand, most need to be rephrased. Suggest shorter sentences and language editing. See
below comments per section.

Background
Lines 40-32
• suggest restructuring; leave out the words, "for example". When was the National program
implemented?
The Nepal National Vitamin A Program (NVAP) was begun in 1993 in eight districts, 32 districts by
1997, and nationwide by 200.

The Nepal National Vitamin A Program: prototype to emulate or donor enclave?

JOHN L FIEDLER
Health Policy and Planning
Vol. 15, No. 2 (June 2000), pp. 145-156 (12 pages)
Published By: Oxford University Press

10.1093/heapol/15.2.145

Line 44
• Provide the night blindness percentage before the program.
Lines 47-49

9000 deaths and 2500 permanently blind prior to the program

10.1093/heapol/15.2.145

• Start with explaining SDG, e.g., the year initiated and the rate of stunting, wasting, and
overweight, and then give data on Nepal.

The SDGs were formulated in 2015 by the United Nations General Assembly (UNGA) as part of
the Post-2015 Development Agenda, to create a future global development framework to succeed
the Millennium Development Goals

Biermann, Frank; Kanie, Norichika; Kim, Rakhyun E (1 June 2017). "Global governance by goal-setting: the
novel approach of the UN Sustainable Development Goals". Current Opinion in Environmental Sustainability.
Open issue, part II. 26–27: 26–31. doi:10.1016/j.cosust.2017.01.010. ISSN 1877-3435

Line 60
• Do you mean that volunteers are the 'personnel' at the health centers, and that is why the
health coverage has expanded? If so, rephrase.

Skilled and trained volunteer provides both training to the staffs of rural health center as well as
direct health service to the people

Line 65-66
• Talking about nutrition programs and improved nutritional status and then health crisis is
confusing. Rephrase.

Health crisis in term of rising burden of overweight and obesity

• Suggest moving overweight percentages lines 67-68  to paragraph one, so that reader can get
the whole picture immediately.
Line 73-74

Will keep the burden of overweight and obesity in another paragraph

• 'stretched healthcare system' is in contrast with line 40. Not many countries have a nutrition
program. Please rephrase.
Line 77-79
• What is the meaning of the sentence' healthy nutritional'? Does meaning prevent overweight?
• 'be staffed' – rephrase
Lines 81-90
• Do not end a sentence with KCH; begin the next one with it. Rephrase
• From line 86: Are the top 3 hospitals referred to in Nepal? Or in Asia? Please clarify
• Provide a reference for the surveys referred to.

Kanti Children’s Hospital (2022) Overview of medical record department and trend of hospital
service of KCH. 60th Anniversary of Kanti Children’s Hospital. Kathmandu: Kanti
Children’s Hospital.
Unfortunatily the publication is not availble online

Line 92-97
• What is the role of IIPAN in this collaboration? Clarify

Methods
Was written consent obtained? In the parent's/caregiver's home language? Assent obtained for
older children and what age?
The surveys for sociodemographics – how many and provide a reference.
Were questions read to parents or participants?
Ethics approval -need to provide the number

Sociodemographics
WHO health survey no reference.
The health survey collects what type of information. The PCA part is very confusing; please
clarify.
Group 2 indicates?

Nutritional assessment
The BMI for age >+2  = split the group into >=2 overweight and >+3 obesity as done for SAM
and MAM. Very confusing to suggest instead defining for this study >+2 overweight.
MUAC growth chart available form 3 months, provide reasoning for only six months.

Statistical analysis
No mention of the  WHO anthro software in methods.

Results
Range of age in this study? Youngest and oldest?
The health index – group 3 indicates which group and what it means. The table is not clear
Explain why ethnic groups are essential in this setting, which is usually a  very sensitive point in
most countries. And which ethnic group from which area in Nepal

Nutritional indices
In methods that defined stunting as <-3 and <-2, SAM as <-3, and MAM <-2, results are not
given separately. What is the reason and rationale for not providing results per category? If
results given for both, define antrhopometry in methods as such

The difference in age groups, was it severe stunting or stunting?

Supplementary table 1 is not clear at all; it needs to be rearranged so that it gives the
information needed to understand the data
Line 220-224: very confusing; Give data under five for as BMI and then MUAC and repeat for
older. I am still unsure which is which.
Again obese or overweight, define and give accordingly.

Predictors
Regression analysis was done for stunting or severe stunting and SAM or MAM. Clarify

Discussion
Compare this to recent studies done in Nepal throughout the discussion after adjusting results
as suggested
• Bhusal, U.P., Sapkota, V.P. Socioeconomic and demographic correlates of child nutritional
status in Nepal: an investigation of heterogeneous effects using quantile regression. Global
Health 18, 42 (2022). https://doi.org/10.1186/s12992-022-00834-4
• Paudel, Manusha. (2020). Malnutrition Status Among Children in Nepal. Patan Pragya. 7. 186-
196. 10.3126/pragya.v7i1.35214.

The nutritional goal of government of Nepal was to lower the prevalence of stunting to 24%, wasting to less than 5% and
underweight to 15% by 2025.

This goal of government of Nepal is somehow matching with the trajectory prediction using the data of previous years of
NDHS surveys.
Department of Health Services (2018) Annual Report.
Kathmandu: Ministry of Health and Population, Government
of Nepal

The anticipated prevalence of stunting is 21.6% and that of underweight and wasting is 15.5% and 9% by the year 2025.
With region wise analysis, Midwestern will have the highest burden of stunting and underweight with expected prevalence
of 30.7% and 20.3% in the year 2025 while the problem of wasting will be towering in all regions and it will be much high
(almost double) compared to the goal of government of Nepal. While doing the stratification based on ecological regions
hill and Terai region will achieve the target of stunting (16.2% vs 23.8%) by 2025, only hill region will achieve the target
of underweight (6.4%) and neither of the regions will achieve the goal of wasting reduction.

doi:10.1017/S1368980021000240

Children belonging to poorer families are more prone for stunting than those born into wealthier families (AOR
1.51, CI 95% 1.23–1.87) which is further contributed with families from terai region and with uneducated mother.
doi:10.1017/S1368980021000240

Kayastha P et al. in 2021 did hospital based survey and found 14.4% stunted, 16.6% wasted, 10.8% underweight,
2.2% overweight and 2.2% obese children.

https://doi.org/10.3126/jkmc.v11i1.45486

A hospital based nutritional study done in Pakistan in 2020 showed better nutritional status of

children (21% stunting) 5 compared to the national demographic survey (37.6% stunting) 6 , done

at community level 2 years back. We have also the improved nutritional status in hospital

survey after 6 years of national survey done at community level.

5. Fatima S, Manzoor I, Joya AM, Arif S, Qayyum S. Stunting and associated factors in children

of less than five years: A hospital-based study: Stunting in children under five years of age.

Pak J Med Sci [Internet]. 2020 Mar 5 [cited 2022 Aug 31];36(3). Available from:

https://www.pjms.org.pk/index.php/pjms/article/view/1370

6. National Institute of Population Studies (NIPS) [Pakistan] and ICF. 2019. Pakistan

Demographic and Health Survey 2017-18. Islamabad, Pakistan, and Rockville, Maryland,

USA: NIPS and ICF.

Line 305 – percentage for severe stunting or stunting
Line 321-325 -decide to discuss SAM or MAM; the percentage seems like for both, discuss
separately or change the definition for this study.  
Line 393-305 – again combined.

This need to be discussed with statistician as we have results with MUAC and WHZ separately
but not either of them. Exact percentage of MAM or SAM is the total of either cut off of BMI/
WHZ or MUAC.

Suggestions for hospital programs?

Vulnerable children are which SAM or MAM?

IIPAN was mentioned in the beginning but not again. What is the role of IIPAN in the future?

Abstract
Discuss malnutrition but in manuscript SAM and MAM - clarify