Assessing the relative significance of key risk factors for child undernutrition in Punjab, Pakistan.

BACKGROUND: Child undernutrition remains a pressing global concern, with Pakistan among the most affected countries in South Asia. Despite recognition of its multifaceted causes, the relative importance of key risk factors remains insufficiently understood. This study investigates the relative significance of associated risk factors among preschool-age children in Punjab, Pakistan's most populous province. METHODS: Using data from the 2018 Punjab Multiple Indicator Cluster Survey (MICS), this study analyses 38,495 children aged 0-59 months. Binary logistic regression models were employed to estimate the effects of 25 risk factors on stunting, underweight, and wasting, selected through a review of literature. The analysis was conducted for the full sample (children aged 0-59 months) and two age sub-groups: infants aged 0-5 months and children aged 6-35 months, selected to reflect key developmental stages. Environmentally modifiable risk factors were ranked by effect size to identify high-priority intervention areas. RESULTS: Five key predictors were consistently associated with stunting and underweight: household poverty, low maternal education, short birth intervals, underage motherhood, and low birth weight (LBW). For wasting, significant determinants included LBW, low maternal education, incomplete vaccination, and recent fever. Among children aged 6-35 months, inadequate dietary diversity was a major contributor, while in infants (0-5 months), lack of exclusive breastfeeding and unassisted delivery were most influential. Box plot analysis revealed that older children face higher and more variable undernutrition risks, whereas infants benefit from protective factors such as breastfeeding and neonatal care-highlighting the importance of age-specific interventions. CONCLUSIONS: The findings underscore the urgent need for integrated, age-adapted strategies that address both structural and behavioural determinants of child undernutrition. Effective interventions must combine poverty reduction, maternal education, and healthcare access with targeted nutrition programs for infants and toddlers. These insights offer a critical evidence base to inform policies aimed at improving child nutrition and health in Punjab and similar contexts.