Brazilian malnutrition-related infant mortality up to 11 months.

Childhood malnutrition in Brazil has a profound impact on the physical and cognitive development of children, compromising their future and perpetuating the cycle of poverty. Moreover, death from this condition can define important aspects in the context of public health in the country. The objective of this study was to analyze and describe the peculiarities of deaths from child malnutrition in Brazil between the years 1996 and 2021. This is an ecological, epidemiological, cross-sectional, descriptive, and quantitative study of deaths due to malnutrition in children up to 11 months of age between 1996 and 2021, with the Brazilian states as the unit of analysis. The methodological strategy involved the analysis of raw data made available by the Sistema de Informações sobre Mortalidade (SIM). A total of 17.300 deaths due to malnutrition were reported in the studied population. The year 1998 had the highest number of deaths in the period, with 1.766, representing 10.2% of the notifications. The Northeast and Southeast regions presented the highest prevalence of deaths. The states of Bahia, Pernambuco, São Paulo, Minas Gerais, and Ceará had the highest number of deaths from infant malnutrition. The predominant characteristics of the victims were female, brown, with birth weight between 2500 and 3999 g, and age up to 3 months. Young pregnant women (between 15 and 29 years old) and those with a medium level of education were the most predisposed. Among deliveries, gestations between 37 and 41 weeks, single gestations, and vaginal deliveries were relevant in determining mortality. In conclusion, it is crucial to adopt prevention measures and access to education to eradicate mortality from child malnutrition in Brazil.


INTRODUCTION
Infant mortality is one of the main indicators for assessing the health of a population. The analysis of infant mortality, considering its quantitative and qualitative aspects, as well as its determinants, makes it possible to evaluate the quality of public policies on child health and the care provided to pregnant women during pregnancy and childbirth 1 . In this scenario, deaths related to child malnutrition stand out.
According to the United Nations International Children's Emergency Fund (UNICEF), at least 250 million children suffer from malnutrition 2 . In addition, the World Health Organization (WHO) states that 45% of deaths among children under the age of five are related to malnutrition 3 .
It is a multifactorial disease with a complex etiology characterized by an imbalance between the body's energy and nutrient supply and demand. Thus, both deficiencies and excesses of micro-and macronutrients can lead to malnutrition 4 . The disease can be associated with socioeconomic, environmental, and maternal conditions related to infant feeding practices, morbidity, and access to health services 5,6 . Childhood malnutrition, diagnosed by stunting, is a major health problem in developing countries. This condition is associated with an increased risk of infectious diseases and early mortality, impaired neuro-sensory-motor development, poor school performance, and reduced adult productivity [7][8][9] .
Knowing that factors such as the level of economic development, distribution of wealth, political stability, priorities in public spending, and the sociocultural pattern of a country can influence the prevalence of child malnutrition 6,9,10 . Thus, the set of determinants of child death from malnutrition is very broad and complex, and there is a network of interactions among these determinants that needs to be better understood.
Therefore, the objective of this study was to analyze and describe the peculiarities of deaths from child malnutrition in Brazil between the years 1996 and 2021.

METHODOLOGY
This is an ecological, epidemiological, cross-sectional, descriptive, and Statistical analysis of the raw number of deaths was performed using GraphPad Prism 6®. The normality of the number of reports over the study period was assessed using the Kolmogorov-Smirnov test, which found a parametric distribution of the data.
Data were subjected to one-way analysis of variance (ANOVA) and Tukey's multiple comparison test for comparison between groups. Values p<0.05 were considered significant.

RESULTS
In Brazil, 17.300 deaths due to malnutrition in children under 1 year of age were reported between January 1996 and December 2021.
The column graph in Figure 1 represents Infant mortality rates were not significantly different. Caption: ****Statistical analysis revealed significant differences in the number of deaths per year over the study period. Source: Author's preparation with data from the SIM 12 .
As for the specific distribution of deaths by region of the country, the Northeast region presented the highest prevalence of cases with 49.1%, followed by the Southeast with 23.33%, the North with 14.77%, the South with 7.06%, and the Midwest with 5.73%.  Source: Author's preparation with data from the SIM 12 . Table 1 shows the sociodemographic profile of malnutrition deaths among the children included in this study. Female, brown, with a birth weight between 2500 and 10.046 Caption: "n" is the raw number of notifications related to the described feature. Source: Author's preparation with data from SIM 12 . Table 2 shows the characteristics of pregnancy and delivery. Young pregnant women (between 15 and 29 years of age) and those with a medium level of education were the most predisposed. Among births, pregnancies between 37 and 41 weeks, singleton pregnancies, and vaginal deliveries were relevant in determining mortality.

Malnutrition-related infant mortality in Brazil up to 11 months of age
Oliveira et. al. It is worth noting that although malnutrition is highly prevalent in the North and Northeast regions concerning mortality, this trend has decreased in recent years, as noted by França et al. 15 in a survey conducted in 1990 and 2015. However, it is understood that these regions have higher rates due to increased poverty and social inequality 14 .

Brazilian Journal of Implantology and Health Sciences
The fact that most deaths are concentrated in the first three months of life underscores the importance of factors related to pregnancy, childbirth, and the postpartum period in reducing infant mortality to a level compatible with the country's economic development. The strengthening of the perinatal care network, with continuity of comprehensive care from prenatal care of pregnant women to neonatal care, is a strategy that has been progressively reorganized in the country 19,20 .
Maternal education has long been considered an important determinant of child mortality. In this study, we found that the mothers had a medium level of education. Therefore, it is understood that mothers with higher levels of education have more knowledge and give more importance to the cleanliness of the home, eating habits, and hygienic habits regarding the child 21 .
In addition, those who do not work are close to their babies for a long time and feed them adequately, especially with breast milk in the first months of life 21

CONCLUSIONS
The reduction of malnutrition-related mortality among children under 11 months of age in Brazil is of immense public health importance. Over the years, the concerted efforts of the government, health professionals, and various stakeholders have led to remarkable progress in addressing this critical issue. The decline in child mortality rates reflects increased access to health services, improved nutritional interventions, and targeted public health campaigns aimed at raising awareness of the importance of proper nutrition during infancy.
The results of this study underscore the importance of prioritizing and investing in strategies to address malnutrition in young children. The observed decline in mortality rates represents not only improved child survival but also a society that values the health and well-being of its future generation. By addressing the underlying determinants of malnutrition, such as poverty, food insecurity, and inadequate health infrastructure, Brazil has demonstrated its commitment to promoting child health and reducing health inequalities. Sustained efforts are needed to further reduce mortality and ensure equitable access to quality health care and nutritional support for all children in Brazil.