Acute Malnutrition in Under-Five Children in KwaZulu-Natal, South Africa: Risk Factors and Implications for Dietary Quality

Background/Objectives: Despite ongoing national interventions, pockets of acute malnutrition persist in rural settings of South Africa, contributing to disproportionate rates of child morbidity and mortality. This study aimed to identify risk factors associated with acute malnutrition among under-five children attending primary healthcare facilities in Msinga, KwaZulu-Natal Province, with a specific focus on dietary diversity and selected infant and young child feeding indicators. Methods: A cross-sectional, facility-based study was conducted among 415 mother–child pairs attending five randomly selected PHC facilities in the Msinga sub-district. Participants were selected using a multistage sampling design from a sampling frame of 18,797 under-five children. Of the 551 mother–child pairs approached; the final analytic sample comprised 415 observations. Data were collected through structured interviews, anthropometric assessments, and dietary diversity scores (DDS). Data were analyzed using Stata 18, and Poisson regression was applied to identify risk factors. Results: The prevalence of acute malnutrition was 29% based on weight-for-height/length z-scores (WHZ/WLZ) and 27% based on mid–upper-arm circumference z-scores (MUACZ). Children aged ≥36 months had significantly higher prevalence of acute malnutrition (aPR = 1.62; 95% CI: 1.15–2.10). Children from households with five or more members had reduced risk (aPR = 0.66; 95% CI: 0.45–0.74), and those born full-term showed a strong protective association (aPR = 0.39; 95% CI: 0.23–0.64). Maternal age was associated with reduced risk, with children of mothers aged 25–34 years (aPR = 0.67; 95% CI: 0.48–0.93) and ≥35 years (aPR = 0.58; 95% CI: 0.35–0.84) experiencing significantly lower prevalence. Mixed feeding was significantly associated with reduced risk (aPR = 0.86; 95% CI: 0.55–1.17), while a DDS ≥4 was protective (aPR = 0.41; 95% CI: 0.04–0.84). Consumption of protein-rich foods was notably low, with only 21% consuming flesh foods and 10% consuming eggs. Conclusions: Acute malnutrition in under-five children was significantly associated with poor diet quality, older age, low household income, and mixed feeding practices. Protective factors included full-term pregnancy, larger households, older maternal age, and adequate dietary diversity, highlighting the importance of targeted, multisectoral interventions.