Malnutrition in children under five years old remains a significant global health issue, characterized by inadequate intake or absorption of essential nutrients. This can lead to undernutrition (stunting, wasting, and underweight) or overnutrition (overweight) [1] - [3] . In 2021, 149.2 million children under the age of five years globally were stunted, 38.9 million were overweight and 45.4 million were wasted. Notably, almost two out of five children with stunting reside in South Asia, while another two out of five live in Sub-Saharan Africa [1] . Malnutrition has long-term impacts on physical and cognitive development, leading to a heightened risk of infections, learning disabilities, and even mortality [4] - [7] .

Children from low-income households face higher risks of malnutrition due to limited access to nutritious food, healthcare, and sanitation [5] [8] - [10] . These vulnerabilities are particularly pronounced in orphans, who often experience significant economic and psychosocial challenges after the loss of one or both parents. Orphans, especially those living in orphanages or alternative care, are at an even greater risk of malnutrition due to factors such as food insecurity, lack of parental care, and unstable living conditions [11] [12] . In fact, globally, orphans represent a substantial portion of vulnerable children, with 147 million estimated in 2022, many of whom reside in Sub-Saharan Africa [13] - [17] .

Tanzania has a considerable orphan population, with an estimated 1,696,349 orphans, including 24,000 residing in orphanages. The Arusha Region, with a population of 1,694,310 as of 2012, has about 7% of its population classified as orphans [18] . Despite notable progress in reducing malnutrition rates, undernutrition remains a public health challenge in Tanzania. Stunting affects 30% of children under five, while 12% of children are underweight [19] - [22] . Although national statistics provide a general overview of malnutrition, limited data exists regarding the nutritional status, feeding practices, and factors associated with undernutrition among orphans.

Therefore, the primary goal of this study was to offer critical insights for researchers, health policymakers, and nutrition experts by assessing the nutritional status, feeding practices, and factors contributing to undernutrition among orphans aged 6 to 59 months aiming to inform targeted interventions and improve child health outcomes.

During the study period from October 2022 to October 2023, a multistage identification process identified a total of 216 eligible participants from 75 Orphanages. Out of 75 orphanages in Arusha Region only 58 orphanages were registered for the study. Among the registered orphanages, 20 had children under the age of 5. Out of these 20, 18 orphanages consented to participate in the study. A total of 679 children within the Arusha districts were identified. However, 463 children were excluded due to not meeting the inclusion criteria. Ultimately, the study focused on the remaining 216 children who fulfilled the inclusion criteria ( Figure 1 ).

This study aimed to assess the nutritional status, feeding practices, and factors contributing to undernutrition among children in orphanages. The findings of this study revealed a concerning prevalence of stunting, underweight, and wasting, with prevalence of 23.6%, 15.3%, and 9.3%, respectively. Furthermore, the study examined feeding practices and found that 99% of the children achieved the recommended (MMF), while 89% achieved adequate (MDD).

Several factors were identified as contributors to the nutritional status of orphaned children in the studied orphanages. The age of the child, gender, number of children in the orphanage, health factors such as a history of fever two weeks prior to the survey and being on medication, caregivers’ marital status and education level, the number of caregivers in the orphanage, and the ownership status of the orphanage were all found to be significant factors.

In this study, the prevalence of stunting among orphaned children was consistent with findings from similar studies conducted in Eastern Africa, such as Sudan (20.3%) and Kenya (24.8%) [24] [25] . However, the prevalence observed in this study appeared to be higher compared to a study conducted in Nigeria, which reported a prevalence of 13.3% [26] , and a study in Ethiopia, which reported a prevalence of 12.2% [27] . Nevertheless, when comparing the prevalence from this study to other studies conducted in Africa, it was consistently lower. Several studies conducted in Ethiopia reported significantly higher prevalence ranging from 34.8% to 50.2% [28] - [30] . Additionally, the prevalence observed in this study was lower than the regional level prevalence of 30.7% reported in a general cohort of under-five children [19] .

The prevalence of stunting among orphaned children in the selected orphanage centers in the Arusha region indicates the need for targeted interventions to address growth impairment in this vulnerable population. These interventions should focus on improving the nutritional quality of their diets, promoting appropriate feeding practices, and ensuring access to essential nutrients. The variations in stunting prevalence compared to other studies highlight the importance of understanding and addressing contextual factors that contribute to differences in nutritional status.

The prevalence of underweight among orphaned children in the current study was found to be consistent with the findings of a study conducted in Ethiopia, which reported a prevalence of 12.3% [28] However, when compared to other studies, the prevalence appeared to be inconsistently lower than the 21% reported in India [31] . Furthermore, it was slightly lower than the prevalence of 25.5% reported in Ethiopia [29] . Conversely, it was higher than the prevalence of 11.7% reported in Nigeria [26] . Other sub-Saharan countries, such as Sudan and Kenya, reported lower prevalence rates at 8.1% [25] and 10.1% [24] . In Tanzania, despite limited data on orphaned and vulnerable children (OVC), the prevalence of underweight among under-five children in the Arusha region was reported at 20.1% [19] .

Similarly, the prevalence of underweight among orphaned children calls for interventions that address the specific challenges faced by this population, such as improving caregiver support and access to nutritious food. Contextual factors should be taken into account to tailor interventions effectively.

The prevalence of wasting among orphaned children in the current study was found to be consistent with the findings of a study conducted in India, which reported a prevalence of 9.8% [31] , as well as with a study in Kenya with a prevalence of 10.1% [24] . However, in Egypt, the prevalence was inconsistently higher than the reported 2.8% prevalence [32] and it was higher compared to a study in West Africa that had a prevalence of 5.6% [26] . Conversely, most studies conducted in Ethiopia reported higher prevalence rates ranging from 11.1% to 37.8% [27] [29] Nevertheless, within the same country, other studies reported lower prevalence rates of 4.7% [33] and 4.4% [28] compared to the current study. A higher Prevalence of 18.7% was reported in Sudan [25] . In Tanzania, a national study on under-five children reported a higher prevalence of 20.1%, which was greater than the prevalence observed in the current study [19] .

The consistent prevalence of wasting among orphaned children compared to certain studies suggests the need for interventions that target wasting prevention and management. Additionally, understanding the factors contributing to higher prevalence rates in specific regions can inform targeted strategies.

The observed consistencies and inconsistencies in the prevalence of, stunting, underweight and wasting in this study may be attributed to several factors, including differences in sample characteristics, geographical variations, and variations in the availability and effectiveness of interventions targeting malnutrition, as they relate to this current study.

The proportions of feeding practices observed in this study showed high rates of adequacy, with 99% of orphaned children meeting the MMF recommendation and 89% achieving MDD. These findings are consistent with a study conducted in Ghana, where the proportion of children meeting MDD was reported at 97.4% and MMF at 90% [34] . However, in Nigeria, the proportions were slightly lower, with MMF reported at 62.5% and MDD at 80% [35] . Overall, the findings suggest that efforts to promote adequate feeding practices in orphanage centers can contribute to improving the nutritional status of orphaned children. It is important for policymakers, caregivers, and stakeholders to prioritize and invest in nutrition programs and support systems to ensure the well-being of these vulnerable children.

However, it is important to note that these findings are specific to some orphaned children in the selected orphanages of the Arusha region, Tanzania. The generalizability of these proportions to other populations or regions should be done cautiously due to differences in sample characteristics, geographical variations, and variations in the availability and effectiveness of interventions targeting malnutrition.

This study identified several factors contributing to undernutrition among orphaned children. The findings of this study revealed that orphaned children who had a history of fever 2 weeks prior to the survey had significantly higher odds of experiencing wasting. This result is in line with a study conducted in Ethiopia, which also reported a similar association between fever and wasting [27] [28] . Fever is often an indicator of an underlying infection or illness, which can lead to decreased appetite, nutrient malabsorption, and increased metabolic demands. These physiological responses can contribute to inadequate nutrient intake and utilization, ultimately resulting in wasting among children. The association between fever and wasting highlights the need for effective management of febrile illnesses in these settings. Early identification, prompt treatment, and appropriate nutrition support are essential to prevent or minimize the negative impact of fever on nutritional status. This emphasizes the importance of comprehensive healthcare services that integrate both medical and nutritional interventions.

Children who were under the care of unmarried caregivers were found to have a higher risk of experiencing underweight. While limited comparative data are available to make direct comparisons, this finding suggests that unmarried caregivers may encounter additional challenges in providing adequate care and support for the child, which can contribute to a higher risk of undernutrition. Further research is needed to explore this association in more detail and investigate potential underlying mechanisms. Providing educational programs, counseling, and resources to unmarried caregivers can help them overcome the challenges they face and improve their ability to provide adequate care and support for the children under their care.

Interestingly, our study also found that having more than 10 caregivers in the center was consistently protective against undernutrition. This suggests that a higher caregiver-to-child ratio in the orphanage setting may have a positive impact on the nutritional status of the children. Having a larger number of caregivers could potentially lead to better supervision, individualized care, and increased attention to the nutritional needs of the children.

The prevalence of undernutrition among orphaned children is at a higher level of public health significance according to WHO cutoff points emphasizing the need for targeted interventions.

Despite adequate meal frequency and a diversified diet, recent illness, unmarried caregivers, and a low caregiver-to-child ratio are strongly associated with undernutrition among orphaned children in this population.

The study did not meet the desired sample size of 360 and ended up with 216 in this study period.

The study was conducted in government-licensed and registered orphanages that adhere to established standards, which may limit its representativeness of the broader population of orphans, particularly those in unregistered or informal care settings.

AIDS-Acquired Immune Deficiency Syndrome, CDC-Center for Disease Control and Prevention, HAZ-Height for Age Z score, HICs-High Income Countries, IBC-Institutionalized Based Care, JME-Joint Malnutrition Estimate, LMICs-Lower-Middle Income Countries, MDD-Minimal diatery diversity, MMF-Minimal meal frequency, NGOs-Non-Governmental Organizations, OVC-Orphans and Vulnerable Children, SAM-Severe Acute Malnutrition, SDG-Sustainable Development Goals, TNNS-Tanzania National Nutrition Survey, UNICEF-United Nations Children’s Fund, WAZ-Weight for Age Z score, WHO-World Health Organization, WHZ-Weight for height Z score.

PEM contributed to the conception, study design, data acquisition and interpretation, and drafting of the manuscript. AMS supervised and reviewed the entire research process. Additionally, ADL, MM, EL, NP, AI, LF, MS, IM, ZH provided valuable feedback and data collection on the research work and BM was involved in the analysis. All authors thoroughly reviewed and approved the final manuscript.

First and foremost, I express my deepest gratitude to God for granting me strength, grace, and sustenance throughout the preparation of this research work.

I would also like to extend my sincere appreciation to my supervisor, Dr. Aisa Shayo, for her invaluable guidance and unwavering support throughout the entire process. Her expertise, constructive feedback, and tireless efforts have played a pivotal role in shaping and refining the ideas of this work.

Additionally, I am grateful to Baraka Moshi, a Public Health Specialist at Kilimanjaro Christian Medical Centre, for his invaluable contributions and assistance in the development of this research work. His professional insights and expertise have greatly enriched the content of this work.

I also, extend my sincere gratitude to my fellow students of Masters of Medicine in Pediatrics and Child Health for their endless challenges and inputs towards the development of this work.

Finally, I extend my gratitude to the management of KCMUCo and KCMC for their support and permission to undertake this important work.

Part 1. Questions on Socio demographic characteristics.

Part 2. Question to assess the feeding practices and household food security.

Part 3. Health characteristics of the child.

Part 4. Water, sanitation and hygiene characteristics in the orphanage.

Part 5. Anthropometric measurements.