Malnutrition and Catch-Up Growth during Childhood and Puberty (N&G 2024)

Effect of milk protein and whey permeate in large quantity lipid-based nutrient
supplement on linear growth and body composition among stunted children: a
randomized 2 × 2 factorial trial in Uganda

Comments: Milk proteins (MPs) are believed to stimulate growth factors due to their complete
amino acid profile, and their consumption has been linked to promoting linear
growth and lean mass development. However, MPs are relatively expensive, and their inclusion in food supplements increases costs. Whey permeate (WP), a residual by-product from whey processing containing lactose and bioavailable minerals, is considered to have potential prebiotic effects and to positively influence lean mass gain and bone mineralization.

Mbabazi et al. [2] conducted an elegant randomized, double-blind trial among 12- to
59-month-old stunted children (height Z-score < −2) in Uganda. The study aimed to compare the effects of four large quantity lipid-based nutrient supplement (LNS) formulations on linear growth and body composition.

The study randomized 750 children to a 12-week intervention with one of the four formulations based on MPs, soy protein, WP, or maltodextrin (n = 600). Children in the control group (n = 150) were randomized to receiving no supplement.

Key findings of this study showed that neither MPs nor WP in LNS formulations significantly affected the height increment, although MPs exhibited a trend toward enhancing fat-free mass index. Nevertheless, compared to the unsupplemented group, the LNS supplementation had clear positive effects on growth and changes in body composition. Children in the unsupplemented group showed a decline in height Z-score and an increase in fat mass index, whereas those receiving any LNS demonstrated an increase in height Z-score and fat-free mass. The main limitations of this study include the lack of blinding of caregivers regarding LNS supplementation versus no supplementation, and the short duration of the intervention (12 weeks).

Several previous studies suggest that consumption of MPs may improve linear growth
[16, 17]. Other studies, however, did not find an effect of MPs on linear growth, but did observe an impact on weight gain and lean mass gain [18, 19]. The inconsistent findings across studies can be attributed to multiple factors. These factors include differences in the dietary composition of the supplementation (such as differences in protein quantity and quality, as well as the amount and composition of other macro-and micronutrients), characteristics of the study population (such as the age range of participants and the degree of malnutrition), and the study design (including the length of the intervention, the control intervention or lack thereof, and compliance with the intervention).

Interestingly, this study’s results revealed an interaction between consumption of WP
and breastfeeding. WP positively affected linear growth in breastfed children but
negatively affected non-breastfed children. The authors suggest that the high lactose content of WP may explain this difference. Breastfed children, who possess significantly more lactobacilli and bifidobacteria, capable of fermenting lactose to short-chain fatty acids, may benefit from the high lactose content of WP, enhancing linear growth. However, in non-breastfed children with different microbiota, the high lactose content of WP might lead to energy loss or osmotic diarrhea, thus hampering growth.

Prolonged egg supplement advances growing child’s growth and gut microbiota

Plasma mineral status after a six-month intervention providing one egg per day to
young Malawian children: a randomized controlled trial

Infant age at egg introduction and malnutrition-related child growth in the United
States

Comments: Eggs are a common and affordable food consumed worldwide, serving as a natural source of numerous nutrients. Each egg provides approximately 60–90 kcal and
about 6–8 g of high-quality protein. Eggs are also naturally abundant in B vitamins,
vitamin A, vitamin D, folate, biotin, pantothenic acid, selenium, iodine, phosphorus,
choline, and other essential minerals and trace elements.

Recently, three studies conducted by Suta et al. [3], Perez-Plazola et al. [4], and Mi et al.
[5] have explored the effects of egg consumption on various pediatric populations.
Suta et al. [3] investigated the impacts of an 8-month egg supplementation on growth
and microbiota among 8- to 14-year-old children (n = 635) attending six rural schools
in Thailand. The participants were randomly divided into three groups: 

1. The whole egg group, who consumed an additional 10 eggs per week
2. The protein substitute group, who consumed yolk-free egg substitutes equivalent
to the nutritional content of 10 eggs per week
3. The control group, who received standard school lunches according to the Thai
school lunch program

The findings revealed that whole egg supplementation yielded a more effective intervention compared to protein substitutes and standard school lunches. It led to improvements in weight, height, and gut microbiota, without adverse effects on blood lipoproteins. One limitation of this study was the omission of an evaluation of pubertal status, which could potentially impact the study outcomes.

Perez-Plazola et al. [4] conducted a randomized controlled trial nested within the Mazira study [20], with the aim of evaluating the effects of egg consumption on plasma mineral status in infants aged 6–9 months from rural Malawi, a population characterized by high rates of stunting and underweight. Participants were randomly assigned to either receive one egg per day for 6 months or undergo no intervention. The analysis encompassed 187 children in the intervention group and 200 children in the control group. Anthropometric data, 24-h dietary recalls, and venous blood to evaluate plasma minerals (magnesium, copper, iron, selenium, and zinc) were collected at baseline and 6-month follow-up.

The results showed a high prevalence of mineral deficiencies at baseline and after the
intervention, especially zinc deficiency (∼60%) in the study cohort. Both at baseline
and at the end of the study, there were no differences between the groups in plasma magnesium, selenium, copper, and zinc levels. However, iron levels, which were com-
parable at baseline, were significantly lower in the egg intervention group compared to the control group at the end of the study. The authors proposed a potential explanation for this finding, attributing it to the presence of egg proteins like phosvitin, ovalbumin, and ovotransferrin, which can reduce iron bioavailability through chelation, thereby decreasing its absorption in processes intended to prevent microbial growth in eggs. Notably, the egg intervention did not lead to improvements in any of the evaluated minerals.

It should be noted that the researchers were unable to determine total calcium levels
or the intervention’s impact on calcium levels due to technical issues. An additional
limitation was the inability to measure mineral concentrations within protein carriers
like lipoproteins (for selenium) or body stores. It is possible that there was an increase
in total body mineral content that wasn’t accounted for in the study analysis.
This study’s findings suggest that egg intervention alone did not suffice to address
the micronutrient deficits in this nutritionally vulnerable population.

Mi et al. [5] conducted a prospective cohort study based on a US national cohort
known as the Infant Feeding Practices Study II, along with its Year 6 Follow-Up Study.
The study aimed to investigate the potential associations between the age at which
infants were introduced to eggs and later malnutrition-related growth outcomes at
12 months and 6 years. The analysis included data from 1,716 mother-child dyads. The authors also explored interactions involving child sex, maternal race, ethnicity, mater-
nal educational level, history of breastfeeding, and formula feeding.

Within the study cohort, it was observed that 75.52% of infants were introduced to
eggs at 12 months or earlier, while the remaining 24.48% were not yet introduced by
12 months. Mothers of infants not yet introduced to eggs by 12 months tended to
have an older age at pregnancy, possess higher educational levels, and enjoy higher
family incomes. These mothers were also more likely to be married, were nonsmokers,
and had a lower preconception body mass index.

The study results demonstrated that delaying the introduction of eggs to infants was
associated with a lower height Z-score and a higher risk of stunting at 6 years of age.
The relationship between the age of egg introduction and growth outcomes at 12
months was different among boys and girls: later introduction of eggs was associated
with a lower mean weight for height Z-score at 12 months in girls, but not in boys. This
suggests that delaying egg introduction during infancy might be related to a reduced
risk of obesity at 12 months in female infants.

The main limitation of this study was the relatively high attrition rates – 40% at 12
months and 49% at 6 years. Such attrition rates are typical in long-term prospective
cohort studies and could potentially introduce a significant selection bias.

This study suggests a beneficial effect of early egg introduction on long-term linear
growth in children living in medium- to high-income developed countries, such as the United States. Interestingly, mothers with higher educational levels and higher family incomes tended to introduce their children to eggs at a later age.

The results of these three extensive studies, conducted among diverse sociodemo-
graphic pediatric populations, hold significant importance. Notably, two of these studies [3, 5] suggest the positive effects of early egg consumption on growth indicators. These effects are observed both in children at high risk of malnutrition and in developed nations such as the United States.

However, child growth is influenced by a multitude of factors. Apart from egg consumption, aspects like complementary foods, overall dietary quality, and living conditions play crucial roles in determining child growth trajectories. This could potentially explain the lack of significant findings in the study by Perez-Plazola et al. [8] that focused on infants with elevated malnutrition rates from rural Malawi.

More research is needed to determine other nutritionally relevant ways and addition-
al strategies, together with egg consumption, to improve nutritional status and growth parameters, especially in nutritionally at-risk pediatric populations.

Long-term impact of multiple micronutrient supplementation on micronutrient status, hemoglobin level, and growth in children 24 to 59 months of age: a non-randomized community-based trial from Pakistan

Comments: Deficiencies in essential micronutrients are widespread among children under five worldwide and particularly in low- and middle-income countries. A community-centered, nonrandomized clinical study by Khan et al. [6] was conducted in children aged 24–59 months from a food-insecure area in Pakistan from January 2018 to June 2019.

The study aimed to assess the impact of a micronutrient supplementation on plasma micronutrient levels, hemoglobin concentration, and anthropometric measurements.

The children in the intervention arm (n = 58) received a multimicronutrient powder
(one sachet per day) for 1 year, and children in the control group (n = 53) received no supplementation. The results of this study showed that a 1-year micronutrient supplementation improved plasma micronutrient status (specifically vitamin A, vitamin D, and zinc), hemoglobin levels, and weight status parameters, including weight Z-score and weight-for-height Z-score, compared to the control group. However, there was no effect of the intervention on the height Z-score and stunting rate.

This study suggests that micronutrient supplementation is a cost-effective way to address undernutrition in vulnerable areas. The main strength of this study, compared to other similar intervention studies, is the very high compliance rate, and zero loss of follow-up over the study course. However, a major limitation of this study is the absence of random allocation.

Influence of vitamin D supplementation on growth, body composition, and
pubertal development among school-aged children in an area with a high
prevalence of vitamin D deficiency: a randomized clinical trial

Comments:  Vitamin D plays a crucial role in bone health and other physiological processes related to growth and metabolism. Vitamin D deficiency is prevalent among children living in temperate climates and has been associated with stunting, obesity, and early activation of the hypothalamic-pituitary-gonadal axis.

This randomized, double-blind, placebo-controlled study by Ganmaa et al. [7] aimed
to determine whether providing weekly doses of vitamin D could influence linear
growth, body composition, and pubertal development of 6- to 13-year-old children (n = 8,851) living in Ulaanbaatar, Mongolia, where vitamin D deficiency is highly prevalent. The intervention included weekly oral doses of vitamin D3, 14,000 IU, or placebo for 3 years. 

The outcomes of the study indicated that vitamin D supplementation successfully raised the levels of 25(OH)D into the desired physiological range. However, the intervention did not result in any significant changes in terms of height Z-score, body mass index Z-score, waist-to-height ratio, percentage of body fat, fat mass, fat-free mass, or pubertal development. These findings held true for the entire study population, and also when analyzing different subgroups based on factors such as sex, age at baseline, estimated calcium intake, baseline 25(OH)D concentration, or presence vs absence of stunting at baseline.

The main strengths of this study include a large sample size, its long duration, and the
very low attrition rate (∼8% over 3 years). In addition, the supplementation regimen
was highly effective in correcting vitamin D deficiency in the intervention arm of the
trial. However, this study does come with certain limitations. The limitations include the wide age range of the children at baseline, which posed challenges due to variations in growth trajectories resulting from the large interpersonal heterogeneity in pubertal timing and tempo. Another limitation is the use of self-assessed pubertal status. Furthermore, the study only measured 25(OH)D concentrations at baseline and at the end of the study (3 years from baseline), without considering potential seasonal fluctuations.

It is worth noting that the results of this study differed from those of two other randomized clinical trials conducted earlier by the same researchers in Mongolia [21]. In these trials, there was an improvement in growth among children receiving vitamin D compared to those receiving placebo. This discrepancy might be due to variations in participant age, study outcome measures, and the different dosage and duration of vitamin D supplementation used. Additional randomized controlled trials, comparing the effects of different vitamin D supplementation regimens in different pediatric populations on anthropometric outcomes, are needed to resolve this discrepancy.

A comprehensive intervention package improves the linear growth of children
under 2-years-old in rural Bangladesh: a community-based cluster randomized
controlled trial

Comments: This important pragmatic trial by Ara et al. [8] included a package of direct and indirect nutrition interventions on linear growth and dietary diversity among 6- to 12-month-old children in rural Bangladesh. In this 1-year community-based cluster randomized controlled trial, 412 mother-infant pairs in 12 clusters (representing sub-district units with ultrapoor households with children under 24 months of age) were randomly assigned to receive monthly food vouchers (for eggs, milk, semolina, sugar, and oil) to prepare egg and milk-based snacks for their children, along with multiple micronutrient powder, counseling on child feeding and handwashing, or regular government health communication alone (control, n = 206; treatment, n = 206). The primary and secondary outcomes were differences in children’s length gain and dietary diversity. The effect of intervention on child growth (linear growth primarily) was examined using a mixed effect linear regression model. Mean weight and length of the children were comparable between groups at baseline. Around 90% of the children in both groups were breastfed. After receiving intervention for 12 months, length-for-
age Z-score increased by 0.37 (confidence interval: 0.24, 0.51; p < 0.001) and risk of stunting reduced by 73% (odds ratio: 0.27; confidence interval: 0.13, 0.58; p = 0.001).
This comprehensive intervention package improved the growth and dietary diversity
of predominantly breastfed children in extremely poor Bangladeshi households and
provided important evidence for policy.

This trial is one of several studies employing packages of interventions using community-based platforms for delivery. In a similar study in rural Pakistan, Soofi et al. [22] used a combination of prenatal and postnatal interventions and demonstrated a major impact on stunting. A similar study deploying home visits in Yogyakarta, Indonesia, also led to significant increase in maternal knowledge, growth parameters, and developmental outcomes [23]. These studies deploying low-cost strategies have comparable benefits to those observed after large-scale evaluation of commodities such as lipid supplements [24] or a much more ambitious package of interventions in India with health, nutrition, psychosocial support, and water, sanitation, and hygiene interventions delivered during preconception, pregnancy, and early childhood periods on birth outcomes and on linear growth at 24 months [25]. The benefit of delivering indirect and nutrition interventions is consonant with the observations from several real-life exemplar countries where improved linear growth in children is associated with investments that address social determinants of health such as poverty, women empowerment, environmental health, and direct nutrition interventions in programs [26], all important for global policy.

Reviews

Do vegetarian diets provide adequate nutrient intake during complementary
feeding? A systematic review

The period of complementary feeding (CF, age 6–24 months) is characterized by rapid growth, during which infants are susceptible to both nutrient deficiencies and excesses. Accordingly, the World Health Organization (WHO) advises that infants should be provided with a well-balanced diet containing all essential nutrients to support their growth and proper psychomotor development.

The rising popularity of vegetarianism among young people in developed countries has led to a growing number of parents introducing a CF diet that either partially or completely excludes animal foods for their infants. Consequently, there is considerable interest in understanding the potential effects of early introduction of vegetarian or vegan diets on various health outcomes. In adults, some benefits of vegetarian and vegan diets have been described, but there remains lack of data regarding their effects in children. The aim of this systematic review by Simeone et al. [9] was to evaluate the existing data on the impact of various vegetarian CF diets on growth, psycho-motor development, vitamin deficiencies, and communicable and noncommunicable diseases.

The study focused on healthy infants, born at term with normal birth weight, residing
in Western developed countries. The defined exposure was a CF diet with limited or eliminated animal products (following a vegetarian or vegan diet), while the comparator was a CF diet that included animal-sourced foods.

Overall, the quality of the studies reviewed was low, and there was a limited number
of interventional studies due to ethical constraints (i.e., deliberately exposing infants to elimination diets). The analyses revealed a higher percentage of infants with stunted growth and wasting in the group exposed to little or no animal-sourced foods during CF, compared to the omnivorous group (with a moderate level of certainty). In terms of neurodevelopmental outcomes, there was very limited evidence available. It appears that the risk of adverse outcomes was not higher in the exposure group compared to the control group, but the grade of evidence was low. A large number of case reports described nutritional deficiencies in infants following various vegetarian diets, which resulted in severe neurologic consequences. No long-term data were available. The authors did not find sufficient evidence regarding the relative risk of developing vitamin deficiencies or communicable or noncommunicable diseases when exposed to vegetarian or vegan diets.

This study highlights important evidence, and also the lack of such evidence, regarding various elimination diets before the age of 2 years and concludes that there is insufficient data to support recommendation of vegetarian or vegan diets during CF.

Effectiveness of food-based intervention to improve the linear growth of children
under five: a systematic review and meta-analysis

Comments: Various food intervention strategies have been developed over the years and across the globe, each aiming to address different variables such as locally available family foods, energy and micronutrient priorities, obtainable resources, and food sources. Numerous original studies have investigated the effects of food interventions on stunting and other malnutrition-related outcomes; however, not all studies and interventions yield equal impacts on stunting. Effectiveness may vary according to the baseline characteristics of the intervention group, the nutritional content of the food-based intervention, and the duration of intervention, among other factors.

This systematic review and meta-analysis by Mamun et al. [10] were conducted to
merge findings from existing studies on the effectiveness of food-based interventions in the reduction of stunting, in children under the age of 5 years. The search for relevant studies encompassed databases such as Scopus, Web of Science, PubMed, ScienceDirect, and ProQuest from 2000 to 2022. Only randomized controlled studies meeting specific inclusion and exclusion criteria were included in the systematic review and meta-analysis. Out of the 1,125 studies initially identified, only 15 studies involving 15,909 participants met the criteria and were included. All 15 studies were randomized controlled trials.

The analyses revealed that food-based interventions led to an improvement in linear growth (mean difference: 0.20, 95% confidence interval: 0.04–0.35, p = 0.01). However, no significant difference was found in the change in underweight status between the intervention and control groups (mean difference: 0.25; confidence interval: −0.15 to 0.64; p = 0.22). Similarly, no significant improvement in child wasting was found between the intervention and control groups (mean difference: 0.09; confidence interval: −0.02 to 0.20; p = 0.12). Additionally, the study findings support a greater impact of animal protein compared to plant-based sources on linear growth.

The findings of this study can provide a valuable resource both for those designing future research in this field and for policymakers aiming to reduce stunting by effective interventions.

Nutrition in school-age children: a rationale for revisiting priorities

Comments: Nutrition and growth during the first 1,000 days of life, and during early childhood up to 5 years of age, have rightfully gained significant attention in recent decades. However, the school-age years (age 5–15 years) also represent a crucial and final window of opportunity to exert a meaningful influence on growth, development, and the resulting health outcomes in adulthood. Unfortunately, this period has not been studied as extensively as the earlier years of life in this context. Insufficient research in this age group can be attributed, in part, to the lack of clarity and consistency in terminology. Terms such as “early childhood,” “middle childhood,” “late childhood,” “school age,” “adolescence,” and “young adulthood” often overlap and merge.

This review by Saavedra and Prentice [11] aims to underscore the pivotal aspects of growth, development, and nutrition during these transformative school-age years, while also highlighting the existing challenges and knowledge gaps. It advocates for increased and more targeted attention to nutrition during this important phase to optimize this final opportunity for investment in influencing growth, nutrition, and ultimately, overall health and cognitive outcomes.

Microbiota and growth among infants and children in low-income and middle-
income settings

Comments: This review by Njunge and Walson [12] evaluated the role of intestinal microbiota innrelation to childhood growth and also assessed interventions targeting the gut microbiota to impact growth in children in low- and middle-income countries. Evidence suggests that the diversity and maturation of the infant microbiota is linked with the development of the immune system and host-microbe symbiosis. Infants lacking Bifidobacterium longum subsp. Infantes, which predominates the breastfed microbiome, demonstrate immune activation with potential adverse effects on the gut. Conversely, supplementation with B longum subsp. Infantes is linked to increased immune tolerance and improved growth among undernourished children. Dietary patterns during pregnancy may also influence the selection of gut microbial species that impact infant health and growth.

These interesting findings have generated a lot of interest in understanding the relationship between environmental factors and the role of age in maturation and diversification of microbiome among children living in rural and urban settings in low and middle-income countries [27], and the relationship between diets and gut microbiome [28]. Others have evaluated the potential impact of nutritional supplements in the growth and suppression of healthy microbiome [29]. However, the most promising studies appear to be microbiome-directed complimentary foods containing local ingredients as a novel strategy to reduce dysbiosis, promote gut microbiota development, especially among undernourished children, and improve growth [30, 31]. Several studies are underway to evaluate how these strategies, using scalable nutritional commodities, could impact linear growth and development in low- and middle-income countries [32].

Large Cross-Sectional Studies

Estimates and trends of zero vegetable or fruit consumption among children aged
6–23 months in 64 countries

Comments: The role of fruits and vegetables (FV) in a balanced diet for children is well recognized, and while dietary diversity is often measured, it does not fully capture the relative intake of FV. The WHO and UNICEF established a new infant and young child feeding indicator: zero vegetable or fruit (ZVF) consumption among children aged 6–23 months. Allen et al. [13] estimated the prevalence, trends, and factors associated with ZVF consumption using nationally representative, cross-sectional data on child health and nutrition from 125 Demographic and Health Surveys. Prevalence of ZVF consumption was calculated by country, region, and globally. Using a pooled estimate of the most recent survey available in each country, the authors estimated the global prevalence of ZVF consumption as 45.7%, with the highest prevalence in West and Central Africa (56.1%) and the lowest in Latin America and the Caribbean (34.5%). Recent trends in ZVF consumption also varied across countries (16 decreasing, eight increasing, and 14 no change). Country trends in ZVF consumption represented diverse patterns of food consumption over time and may be affected by the timing of surveys. The authors noted that children from wealthier households and children of
mothers who were employed, more educated, and had access to media were less
likely to consume ZVF.

These findings underscore the scale and importance of balanced diets across countries among young children. These have important implications for policy given the importance of dietary diversification and school feeding programs globally addressing optimal nutrition and obesity prevention across the continuum from under five to school-age children and adolescents, and nutrition recommendations across childhood.

Other systematic reviews have also highlighted suboptimal dietary patterns and low
intake of FV among adolescent girls globally [33]. The analysis of the global school
health survey data also underscored the wide prevalence of poor dietary habits among adolescents in Southeast Asia [34]. It must also be recognized that while generally considered low cost, FV are often expensive and often beyond the reach of poor families, especially those not engaged in subsistence farming [35]. In such circumstances, poverty alleviation strategies and conditional cash transfers can improve food security and dietary diversity related to FV intake [36]. Such benefits have also been demonstrated from trials of parenting interventions in adolescents and can also be integrated with additional interventions [37].

Patterns in child stunting by age: a cross-sectional study of 94 low- and middle-
income countries

Comments: Karlsson et al. [14] estimated the relationship between stunting prevalence and age for children 0–59 months old in 94 low- and middle-income countries. While the over-all stunting prevalence was 32%, they found higher stunting prevalence among older children until around 28 months of age, presumably from longer exposure times and accumulation of adverse exposures to undernutrition and infections. Stunting prevalence and gradient of the rise in stunting prevalence by age varied across world regions, countries, living standards, and sex. Poorer countries and households had a higher prevalence at all ages and a sharper positive age gradient before age 2. Boys had higher stunting prevalence, but had peak stunting prevalence at lower ages than girls. Stunting prevalence was similar for boys and girls after around age 45 months. The age for which stunting prevalence was the highest was fairly consistent across countries. In most countries, the stunting prevalence was lower for older children after around 28 months, presumably mostly due to further adverse exposures being less detrimental for older children, and catch-up growth. These results suggest that
programs to prevent undernutrition and infections should focus on younger children
to optimize impact in reducing stunting prevalence. Importantly, however, since some catch-up growth may be achieved after age 2, screening around this time can be beneficial.

As other studies have repeatedly underscored as well, child stunting prevalence is primarily used as an indicator of impeded physical growth due to undernutrition, often starting with the mother and affecting fetal growth and a consequence of repeated early exposure to infections in the wake of poor diets and infant feeding [38]. Regardless of pathways, stunting significantly increases the risk of mortality, morbidity, and cognitive problems, particularly when occurring during the first 1,000 days of life, encompassing conception to age 2 years. As a risk factor for adverse outcomes, early childhood stunting has well-recognized consequences for human capital [39]. Close attention to maternal health, nutrition, and environmental factors is key to addressing the problem at scale, and, as several countries have shown, can be achieved within a few decades [40].

Long-Term Outcomes from Cohort Studies

Short stature and language development in the United Kingdom: a longitudinal
analysis of children from the Millennium Cohort Study

Comments: Many studies conducted in low- and middle-income countries have established significant links between linear growth in the initial 6 months of life and cognitive outcomes during adolescence and adulthood. While stunting is predominantly observed in low- and middle-income countries, there is growing evidence that poor linear growth also serves as an indicator of socioeconomic disadvantage in high-income countries [41]. Limited information exists concerning the long-term consequences of poor early-life linear growth in high-income countries.

This present study by Freer et al. [15] utilized longitudinal data from the UK Millennium Cohort Study, which comprises children born in the United Kingdom between 2000 and 2002. The authors examined verbal and language development from age 3 to age 11 to investigate whether diminished stature is correlated with impaired language development within a contemporary, high-income society.

The study gathered information on 15,406 children who met the criteria for analysis. In the final sample, 514 (4.1%) children were classified as having short stature (height Z-score ≤ −2). Children with short stature exhibited lower birth weights, younger maternal ages, lower income quintiles, residence in areas with lower Index of Multiple Deprivation scores, a decreased likelihood of maternal education at a higher level, lower chances of having been breastfed, and increased exposure to secondhand smoke.

Within the study cohort, an association was observed between short stature and poorer performance in language testing between ages 3 and 11 years. Children with short stature exhibited language scores approximately one-quarter of a standard deviation lower than those with normal height. Although the association between short stature and language development weakened after accounting for maternal, child, and deprivation factors, it remained a significant predictor of diminished language development.

Among children with short stature at age 3 years who experienced height catch-up by age 5 years, better language test scores were observed compared to those who still had short stature at age 5 years. However, there was still a discernible lag in language attainment when compared to children who had never experienced short stature. Academic performance was also assessed at age 14 and at age 17 years, and again, associations between short stature and language development as well as mathematical proficiency were found. The precise mechanisms underlying the link between early-life linear growth and subsequent cognitive outcomes remain incompletely understood.

This large, longitudinal study is based on a national cohort of children born in the twenty-first century in the United Kingdom, and its data are robust. The follow-up period is longer than in most other similar studies [41]. Underlying mechanisms for the associations between poor growth and cognitive development have yet to be discovered in future studies. In the meantime, this study suggests that early-life stunning may help to identify children who can benefit from intervention to support cognitive development.

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