Background HIV-exposed uninfected (HEU) children experience increased mortality compared with their HIV-unexposed uninfected (HUU) peers. It is unclear whether HEU children are also at increased risk for undernutrition, a modifiable risk factor for mortality. Methods We conducted a cross-sectional, population-based survey of children under 5 years of age in five health districts in Botswana. Linear mixed-effects models were used to assess continuous outcomes while generalized estimating equations were used to estimate relative risks of stunting, wasting, and underweight between HEU (n=396) and HUU (n=1,109) children. Secondary analyses examined potential mediation by low birthweight. Results The association between maternal HIV-exposure and child stunting varied significantly by child age (p<0.01). HEU children <1 year and ≥2 years of age had 1.85 (95% CI: 1.03–3.31; p=0.04) and 1.41 (95% CI: 1.06–1.88; p=0.02) times the risk of stunting compared with HUU children after multivariate adjustment, respectively. During the period of 1–2 years of age, when breastfeeding cessation occurred among HUU children, HUU children had increased risk of stunting compared with HEU children who were predominantly formula fed (RR: 1.56; 95% CI: 1.05–2.32; p=0.03). A mediation analysis estimated 67% of the excess risk of stunting among HEU children ≥2 years was attributable to low birthweight (p=0.02). There was no difference in risk of wasting or underweight. Conclusion HEU children are at increased risk of stunting compared with their HUU peers; however, interventions to increase birthweight may significantly ameliorate this excess risk. Interventions to support optimal growth during weaning are needed for all breastfed children.

The weaning period is a crucial stage in the growth and development of the infant and child. The timing of weaning, the choice of foods, their methods of preparation, and how weanlings are fed, all affect the outcome. The commercial preparation of weaning foods and the fortification of some traditional foods are seen by some as the most sustainable and cost-effective means of alleviating micronutrient deficiencies among infants and children. This may be true in industrialized countries, but the same cannot necessarily be said of poor, developing countries. Demonstrates that, even in poor communities, it is possible to combine scant food resources in a cost-effective way to formulate multimixes which would meet energy, protein and micronutrient needs, without fortification. Proposes that such approaches can be used in community nutrition education programmes to help reduce childhood malnutrition and in emergency feeding programmes.