Association between household fuel use and childhood undernutrition in Pakistan: evidence from a National survey

Childhood undernutrition significantly contributes to under-five mortality in Pakistan, yet its association with household air pollution remains underexplored. This study examined associations between household cooking fuels and childhood undernutrition using data from the Pakistan Demographic and Health Survey (PDHS) 2017-2018. The final sample included 4,224 children under five years. The Composite Index of Anthropometric Failure (CIAF) was calculated using height-for-age, weight-for-age, and weight-for-height z-scores. Household air pollution exposure was assessed using mothers' self-reported primary cooking fuels. Multivariable logistic regression models examined associations with CIAF, stunting, wasting, and underweight, adjusting for demographic and socioeconomic factors. Overall, 45.4% of children experienced anthropometric failure, 37.7% had stunting, 23.6% were underweight, and 8.0% had wasting. Compared with clean fuels, polluting fuels were associated with higher odds of CIAF (OR: 1.16, 95% CI: 1.04-1.31), stunting (OR: 1.16, 95% CI: 1.03-1.31), wasting (OR: 1.13, 95% CI: 1.00-1.29), and underweight (OR: 1.17, 95% CI: 1.04-1.32). Wood and coal were associated with several outcomes, while animal dung showed stronger associations with CIAF, wasting, and underweight. Stratified analyses revealed that these associations varied across socioeconomic and residential contexts. Expanding access to clean household energy may help address childhood undernutrition in resource-limited settings.