This study was a community-based, cross-sectional study undertaken among the under-five children, living in urban slums of Gwalior City of Madhya Pradesh state of India. The duration of the study was from 1^st March 2018 to 28^th February 2019. The study was approved by the Institutional Ethical Review Committee of G.R. Medical College, Gwalior; M.P. (Letter number: D.NO. 506 /Bio/MC/Ethical). Informed written consent was obtained from the parents of children in selected households.

Inclusion criteria: Children from 6 months of age to under-five years and whose parents gave consent to participate in the study were included.

Exclusion criteria: Children of unwilling parents and those who were severely ill were excluded from the study.

Sample size calculation: The prevalence of underweight children was 42.8% (reports of NFHS-4; 2015-16) [16] and at 95% confidence interval with 10% relative error. The sample size was estimated by using formula; N=4PQ/L2 [17]. The minimum sample size estimated for the study was 535, which was rounded off to 550 for under-five children.

The study population was selected using multistage sampling technique. List of wards was obtained from the Municipal Corporation, Gwalior. There are a total of 66 wards. For study purpose, 25 urban slum areas were selected randomly. From each slum area, 22 under-five eligible children were selected by using simple random sampling; so that the desired sample size of 550 was met.

A questionnaire was formulated. To determine the content domain for questionnaire, an extensive review of literature was conducted. Literature review helped the researchers in identification of various research gaps in the foundation of the construct. The stage of judgement involved confirming the items by four experts of community medicine and nutrition to ensure content validity of the assessment instrument. Selection of the domain experts was done on the basis of criteria such as expert knowledge, specific training or professional experience on the subject matter.

Household survey was done. A pilot study was done and the questionnaire was finalised in local (Hindi) language. Data was collected using a semi structured, pre-designed questionnaire schedule by personal interview method. Information on household’s socioeconomic and demographic particulars was collected in all the selected households. Mothers were considered for the interview. Caste category was divided based on Madhya Pradesh government gazette [18,19]. Modified BG Prasad Classification was used to classify socio-economic condition [20].

Anthropometric measurements, such as length (up to nearest 1 mm with stadiometer SECA 213) and weight (up to nearest 100 g using a SECA weighing scale) of the children, were obtained using standard anthropometric equipment and procedures. The nutritional status of children was assessed according to Standard Deviation (SD) classification of World Health Organisation (WHO) measuring Change in Nutritional Status [21] (Geneva, Switzerland: WHO; 1983). Children with length/height-for-age below -2 SD of the WHO [22] standards were labelled as stunted; children with weight-for-age below -2 SD of the WHO standards were identified as underweight and weight for height indices below -2 SD were classified as wasting.

The data were scrutinised and entered into the Microsoft excel sheet and data cleaning was done by carrying out range and consistency checks. Descriptive and analytical statistics of the data were carried out using SPSS Windows version 16.0. Chi-square test was performed to see association between the variables. The p-value <0.05 was considered significant. Binary logistic regression analysis for outcome variables such as underweight, stunting and wasting with all the independent variables was carried out to study the association in terms of odds ratio.

A total of 550 children (male: 257, female: 293) under-five years of age were analysed in this study. Mean age of the children (in months) was 33.33±15.86. The distribution of the population based on type of undernutrition is presented in [Table/Fig-1].

Underweight: In the present study, the total prevalence of underweight was significantly associated with children belonging to Other Backward Class (OBC), Scheduled Caste (SC) and Scheduled Tribe (ST) caste, living in nuclear families, having illiterate parents and belonging to poor socio-economic group. In logistic regression analysis, it was found that children belonging to ‘others’ caste were at lesser risk as compared to those belonging to SC/ST. Those living in nuclear family had 1.8 times more risk as compared to those living in joint family. Children whose mothers were either illiterate or having primary education had nearly 6 times more risk as compared with children whose mothers were graduate or more. Children whose fathers were illiterate had 4.6 times more risk as compared with those whose fathers were graduate or more [Table/Fig-2]. Regarding the profession of father, as compared with unskilled worker, the risk of underweight was significantly less among children of fathers having other profession such as professional/semi-professional, clerical/shop-owner, skilled worker and semi-skilled worker. Children living in kuccha houses were at 3.49 times more risk as compared to those living in Pucca houses. Children were found 2.46 times more prone to underweight where firewood was used as medium of cooking food as compared to LPG. Initiation of breastfeeding within one hour of birth emerged as protective factor. Number of complementary feeds <4 per day was an important factor significantly affecting the weight of the child [Table/Fig-3]. Low birth weight (<2.5 kg), caesarean delivery, total number of antenatal visits, number of Iron Folic Acid (IFA) tablets consumed by mothers during pregnancy were significant determinants [Table/Fig-4].

Stunting: Prevalence of stunting among male and female was 60.3% and 56.3%, respectively. The prevalence of stunting was significantly higher (p<0.05) among children belonging to OBC, SC and ST community, living in nuclear families, among those children whose mother and father were illiterate and primary educated, whose fathers were unskilled and semi-skilled worker, those belonging to lower and lower middle Socio-economic Status (SES) and using wood as a medium for cooking food [Table/Fig-2]. Occupation of mother of the children was not found to be associated with stunting. General and OBC caste children were at less risk as compared with SC/ST children. As the education of mother increases risk of stunting starts declining, for illiterate mother it was 4.87 times which declined to 2.47 for intermediate educated mother as compared with graduate mother. Similar findings were reported for education of father. As compared to graduate fathers, risk of stunting among children with illiterate fathers was 3.65 times and 2.17 times for intermediate educated fathers. Professional, clerical and skilled worker were at less risk as compared with unskilled worker. Those belonging to upper and upper middle class were at significantly less risk as compared with lower SES. Children living in Kuccha houses were at 2.01 times more risk as compared to those living in Pucca houses. Children were found more prone to stunting i.e., 1.78 times where firewood was used as a medium of cooking food as compared with LPG [Table/Fig-2]. Feeding of colostrum (Not given; OR: 0.59; CI:0.26-1.35), Initiation of complementary feeding (<6 months) were insignificant factors. Low birth weight was significant risk factor for stunted child. Caesarean delivery was a protective factor for stunting. Mothers who consumed less than 90 Iron Folic Acid (IFA) tablets during pregnancy had children who were 1.7 times more prone to risk of stunting [Table/Fig-4].

Wasting: Prevalence of wasting among male and female was 28.8% and 18.8%, respectively. The prevalence of wasting was more among Muslims (24.1%) and OBC caste (28.6%). The prevalence of wasting was significantly higher (p<0.05) among male children, belonging to OBC, SC and ST community, living in nuclear families and also among those children whose mothers and fathers were illiterate or primary educated, those living in kuccha houses and using wood for cooking food. Occupation of mother of the children was not found to be associated with wasting. Male children had 1.75 times more risk of wasting as compared to female children. Surprisingly, OBC caste children were at more risk as compared to SC/ST children. Those living in kuccha houses were at more risk as compared with children living in pucca houses. Children with households using fire wood as type of cooking fuel were at 3.95 times more risk as compared with Liquefied Petroleum Gas (LPG) using households [Table/Fig-2]. In this study, risk of wasting was less among those children in whom initiation of breastfeeding started early (<1 hour) as compared with those where initiation of breastfeeding started in 5-11 hours after birth [Table/Fig-4]. Colostrum given/not given (Not given; OR: 0.64; CI: 0.21-1.91) and Immunisation status of child (Completely Immunised; OR: 0.66; CI:0.41-1.07) were found as insignificant risk factors. Low birth weight was found to be a significant risk factor. Risk was significantly less among those family where total under-5 children in family were less as 1 or 2 (for 1 child, OR: 0.26(0.10-0.66)): and for 2 children: 0.32(0.13-0.80). First born child was at less risk of wasting. Caesarean delivery was found to be a protective factor for stunting. Children with mothers consuming less than 60 IFA tablets were 3.26 times more prone to risk of wasting [Table/Fig-4].

The present study, carried out in urban slum, revealed that the prevalence of underweight, stunting and wasting was 49.1%, 58.2% and 23.5%, respectively. The NFHS -4 (2015-16) reported that prevalence of underweight, stunting and wasting was 48.5%, 42.8% and 28.0%, respectively, in Gwalior city [23]. As compared with NFHS-4, this study reported rise in stunting while fall in wasting.

Studies carried out earlier in the slums of Hyderabad by Peter R and Anil Kumar K reported the prevalence of stunting and underweight as 39.8% and 33.5%, respectively [24]. Dhatrak PP et al., conducted study in urban slum of Nagpur and found that 35% children were underweight, 22.7% were stunted and 12.7% were wasted [25]. Study conducted in Pune found that the percentages of children who were underweight, stunted and wasted were 34.3%, 58.7% and 16.9%, respectively [26]. A study conducted in central India found prevalence of stunting amongst same children as 34.77% [27]. Study conducted in Raipur city of central India reported that 20.16% were underweight, 21.16% were stunted and 13.05% were wasted [28]. Kumar D et al., found that among under five children 36.4% were underweight, 51.6% were stunted and 10.6% were wasted [29]. In the index study, higher prevalence of underweight, stunting and wasting was observed as compared to the above studies.

In this study, male children were found significantly more wasted. Peter R and Anil Kumar K also reported the odds of male children being underweight to be 1.5 times as that of females [24]. Study conducted in Namin township in Ardabil Province of Iran and Field Ganj area of Ludhiana in Punjab reported that female gender had higher risk of child malnutrition [30,31]. Study conducted by Kodavalla V et al., reported high prevalence of stunting, wasting, underweight among children belonging to SC-ST community, residing in rural areas of Madhya Pradesh [32]. Research findings showed consistency with other studies by Singh H et al., Kumar D et al., and Avachat SS et al., [10,29,33].

As per UNICEF report, it was found that inequalities existed in nutrition across socio-economic groups. Higher prevalence of underweight, stunting and wasting among illiterate parents reflected that educated parents could do more efficient management of children care, they were much aware of nutritional knowledge of children and they could utilise healthcare services more. The findings of present study were supported by some other studies. For example, studies done by Kumar D et al., and Purohit L et al., supported the present findings regarding stunting and underweight [29,34]. In the same way, studies done by Mittal A et al., and Giashuddin MS et al., supported the present findings in case of stunting and that of Swami HM et al., and Deshpande JD et al., in case of underweight [35-38].

Present study found that children whose fathers were engaged in semi-skilled or unskilled occupation were more prone to underweight and stunting. It might be due to their lower income and deprivation to provide quality foods to their family. The study findings reported that children living in kuccha houses and in households using fire wood as cooking medium were more prone to stunting, wasting and underweight. This implies that these children belong to low SES. Economic status is one of the most important factors providing the access to healthcare, education and nutritional facilities.

In this study, children in whom initiation of breastfeeding started early within one hour were at less risk for underweight, stunting and wasting. As the duration of breastfeeding started increasing from six months above the risk of underweight and wasting started declining. Kodavalla V et al., also found significant association between initiation of breastfeeding and the prevalence of underweight and wasting [32]. Higher prevalence of underweight was observed among children where initiation of breastfeeding was delayed beyond one hour. Dhatrak PP et al., and Sengupta P et al., found that lack of exclusive breastfeeding was statistically associated with malnutrition [25,31].

In this study, immunisation was not associated with underweight, stunting and wasting, similar result was reported by Sengupta P et al., [31]. It was seen that above the age of 6 months, as compared with complementary feeding only, mixture of breastfeeding with complementary feeding is a protective measure for underweight children. Children with birth weight <2.5 kg were significantly at more risk of stunting, wasting and underweight. Study conducted by Purohit L et al., Paul VK et al., Hien NN and Hoa NN, also found association with birth weight [34,39,40]. The present study found multiple predictors associated with underweight, stunting and wasting.

Data was obtained from the mothers regarding feeding practices, weaning, complementary feeding, antenatal care etc. Hence, recall bias was a major limitation.

From this study done in Gwalior city, it can be concluded that the prevalence of stunting is high among children living in slums, belonging to OBC, SC and ST caste, among children of illiterate parents, those living in nuclear family, belonging to lower SES, children of parents engaged in unskilled work, living in kuccha houses and those using firewood as medium of cooking food. Important predictors that emerged for stunting, wasting and underweight were- infant up to 6 months of age receiving breast milk (not even water), number of complementary feeds, birth weight and type of delivery. It is the need of the hour to make nutritional intervention more effective with proper growth monitoring and nutritional education. It is recommended that improving maternal nutrition during pregnancy along with maternal education, improving sanitation and environmental hygiene, access to healthcare and supplementary feeding through proper implementation of Integrated Child Development Services (ICDS) will improve nutritional status of children. As the prevalence of undernutrition is high among children from SC and ST community, improving their socio-economic status by involving them in income generating activities will improve the purchasing power and thus nutritional status of their children.