title: Do girls have a nutritional disadvantage compared with boys? Statistical models of breastfeeding and food consumption inequalities among Indian siblings.
abstract: BACKGROUND
  India is the only nation where girls have greater risks of under-5 mortality than boys. We test whether female disadvantage in breastfeeding and food allocation accounts for gender disparities in mortality.
  
  
  RESULTS
  Secondary, publicly available anonymized and de-identified data were used; no ethics committee review was required. Multivariate regression and Cox models were performed using Round 3 of India's National Family and Health Survey (2005-2006; response rate = 93.5%). Models were disaggregated by birth order and sibling gender, and adjusted for maternal age, education, and fixed effects, urban residence, household deprivation, and other sociodemographics. Mothers' reported practices of WHO/UNICEF recommendations for breastfeeding initiation, exclusivity, and total duration (ages 0-59 months), children's consumption of 24 food items (6-59 months), and child survival (0-59 months) were examined for first- and secondborns (n = 20,395). Girls were breastfed on average for 0.45 months less than boys (95% CI: = 0.15 months to 0.75 months, p = 0.004). There were no gender differences in breastfeeding initiation (OR = 1.04, 95% CI: 0.97 to 1.12) or exclusivity (OR = 1.06, 95% CI: 0.99 to 1.14). Differences in breastfeeding cessation emerged between 12 and 36 months in secondborn females. Compared with boys, girls had lower consumption of fresh milk by 14% (95% CI: 79% to 94%, p = 0.001) and breast milk by 21% (95% CI: 70% to 90%, p<0.000). Each additional month of breastfeeding was associated with a 24% lower risk of mortality (OR = 0.76, 95% CI: 0.73 to 0.79, p<0.000). Girls' shorter breastfeeding duration accounted for an 11% increased probability of dying before age 5, accounting for about 50% of their survival disadvantage compared with other low-income countries.
  
  
  CONCLUSIONS
  Indian girls are breastfed for shorter periods than boys and consume less milk. Future research should investigate the role of additional factors driving India's female survival disadvantage.
authors.affiliation: Department of Sociology, Oxford University, Oxford, United Kingdom.
authors.forename: Jasmine
authors.initials: J
authors.lastname: Fledderjohann
authors.affiliation: South Asia Chronic Disease Network, Public Health Foundation of India, New Delhi, India.
authors.forename: Sutapa
authors.initials: S
authors.lastname: Agrawal
authors.affiliation: Department of Sociology, Oxford University, Oxford, United Kingdom; South Asia Chronic Disease Network, Public Health Foundation of India, New Delhi, India.
authors.forename: Sukumar
authors.initials: S
authors.lastname: Vellakkal
authors.affiliation: Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, United States of America.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Basu
authors.affiliation: Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Oona
authors.initials: O
authors.lastname: Campbell
authors.affiliation: Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Pat
authors.initials: P
authors.lastname: Doyle
authors.affiliation: South Asia Chronic Disease Network, Public Health Foundation of India, New Delhi, India; Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom.
authors.forename: Shah
authors.initials: S
authors.lastname: Ebrahim
authors.affiliation: Department of Sociology, Oxford University, Oxford, United Kingdom; South Asia Chronic Disease Network, Public Health Foundation of India, New Delhi, India.
authors.forename: David
authors.initials: D
authors.lastname: Stuckler
mesh_terms: D001942:Breast Feeding / Q000706:statistics & numerical data*; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007194:India; D007223:Infant; D053208:Kaplan-Meier Estimate; D008297:Male; D015233:Models, Statistical; D015596:Nutrition Assessment; D009749:Nutrition Surveys; D016017:Odds Ratio; D012307:Risk Factors; D012737:Sex Factors; D035781:Siblings