ObjectiveTo understand caregivers’ perceptions of children’s linear growth and to identify the cultural meanings and perceptions of risk associated with poor height attainment.DesignThree investigators from Bangladesh conducted twelve focus group discussions.SettingThe study was conducted in rural and slum settings in Bangladesh.SubjectsParticipants included mothers and alternative caregivers (n 81) who were recruited by household screening. No eligible, recruited subjects refused participation.ResultsCaregivers reported limited experience with growth monitoring services from the health system. Caregivers mainly use visual cues and developmental milestones to understand if children are growing properly, and recognize that children normally experience both weight gain and linear growth with age. Mothers expressed concern over children’s malnutrition and short stature, but did not discuss children’s failure to attain a ‘growth potential’ or distinguish inherited short stature from stunting. Caregivers interpret the consequences of poor height attainment as primarily social and economic and cite few health risks.ConclusionsLinear growth interpretation is determined more by community norms than by guidance from nutrition programming or the health system. Interventions to prevent or reduce linear growth failure may be perceived to have limited value where appropriate linear growth in children is determined by comparison to peers and siblings. Such perceptions may be significant barriers to programmes addressing stunting prevention in settings where many children are stunted. Efforts to raise awareness about the risks of linear growth faltering may need to consider delivering messages to caregivers that emphasize the social and economic consequences of stunting.

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Appetite in children is an important determinant of nutritional intake and growth. The information used by caregivers to understand children's appetite can help inform infant and young child feeding promotion and appetite assessment. We conducted a qualitative study to (a) explore maternal perceptions and responses to children's appetite and (b) to identify how these factors differ by type of caregiver, level of maternal experience, and urban versus rural context. We used purposive sampling to recruit mothers and alternate caregivers into 14 total focus group discussions (six to eight participants in each group; N = 95) in both urban and rural settings in Bangladesh. To understand children's appetite, caregivers monitor children's dietary patterns, emotional signs, and physical and verbal cues. Healthy appetite was observed by willingness to eat diverse foods, finish offered portions, and by acceptance of foods without excessive prompting. Child illness was cited for a cause of low appetite, which was manifested through fussiness, and avoiding commonly consumed foods. Mothers described a limited set of feeding practices (offering diverse foods, playing, and cheering children with videos) to encourage consumption when children lacked appetite. Mothers' stress related to work was noted as a barrier to identifying appetite cues. Urban mothers described a lower access to instrumental social support for child feeding but informational support than mothers in the rural setting. Understanding caregivers' perceptions of children's appetite may inform strategies to improve responsive feeding and tool development to assess changes in appetite as early indicators of change in health or nutrition status among high-risk children.

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Child undernutrition has multifactorial causes, ranging from food insecurity to etiologies refractory to conventional nutritional approaches, such as infections, environmental enteric dysfunction, and other conditions that lead to systemic inflammation. Poor appetite may be an important symptom of these causes and may be a useful marker of an undernourished child's ability to recover. We conducted a systematic review to characterize the methods and tools to measure appetite among children <5 y old in low- and middle-income countries. A systematic search of 8 databases identified 23 eligible studies published since 1995. Thirteen described methods based on direct feeding observation or quantification of nutrient intake from caregiver report, 16 described tools that assessed caregiver perceptions of appetite, and 6 reported assessments in both categories. Four studies that gauged caregiver perceptions assessed multiple appetite domains, whereas 12 assessed 1 domain—often with a single question. Only 6 studies reported validation processes, the most common of which compared an observed test meal with daily energy intake. No studies reported the use of a method or tool that was validated in multiple cultural or linguistic contexts. Although dietary intake measures and observed feeding tests have shown validity in some contexts, they are resource intensive. Subjective caregiver questionnaires may offer a more efficient appetite evaluation method, but they have been evaluated less consistently. A rigorously developed and validated tool to rapidly assess child appetite is needed and could be best addressed by a questionnaire that leverages the multiple domains of appetite. The application of interventions that target causes of undernutrition that are not amenable to food-based interventions in clinical or research contexts could be facilitated by an efficient appetite screening tool to identify appetite-related causes of undernutrition and to monitor children's response to such interventions.