Stunting in Developing Countries

Stunting in Developing Countries

Introduction

Globally, over 148 million children under five are stunted (i.e., weight-for-age Z-score 2 standard deviations below the WHO growth reference standard) [1, 2]. Although 30 million fewer children are stunted compared to a decade ago, the progress is insufficient. The majority of stunted children live in Asia (52%) and Africa (43%), and these two regions are predicted to have the bulk of the ∼40 million “missed” children under five in 2030, as they are unlikely to meet the global target of reducing the global prevalence of stunting to 13.5% by 2030 [1, 2].

Since the onset of the Sustainable Development Goals (SDGs) in 2012, all countries committed to reducing stunting by 2024 as part of their efforts to achieve SDG 2, aimed at ending all forms of hunger [3]. However, the 2023 Joint Child Malnutrition Estimates showed that only about a third of countries are making progress toward this target [2]. Focusing solely on stunting targets overlooks and diminishes the complexity of interaction between the different forms of malnutrition that often coexist among children in impoverished communities in low- and middle-income countries. This has direct implications for the design of interventions, policy, and implementation strategies that focus on individual forms of malnutrition, instead of using an integrated approach to address them all. As stunting often stems from inadequate antenatal nutrition and infant feeding practices, poor access to clean water and sanitation, and recurrent childhood illnesses [3], efforts toward addressing the gaps in antenatal and early childhood nutrition and health for mothers and their infants using an integrated approach are crucial.

In the recently launched Lancet series for the small vulnerable newborns (SVNs), paper 4
summarizes evidence-based antenatal and intrapartum interventions to prevent SVN births and/or improve maternal and infant outcomes when SVNs are born [4]. By increasing coverage of the eight proven preventative interventions (including multiple micronutrient supplements, balanced protein and energy supplements, aspirin, treatment of syphilis, education for smoking cessation, prevention of malaria in pregnancy, treatment of asymptomatic bacteriuria, and progesterone provided vaginally) in all 81 low- and middle income countries, we could prevent stunting in 4.5 million children (2.9%) by 2030 [4]. In addition, by combining these preventative interventions with childhood nutritional supplements (omega-3 fatty acid supplements, zinc supplements, and calcium supplements), stunting could be averted in 8.5 million stunted children (5.4%) [4] by 2030. The authors reported that this would lead to an additional 0.529 million extra years of schooling and
∼USD 7.269 billion more in lifetime earnings [4]. The potential impact is significant, yet challenges persist in increasing the coverage and ensuring the implementation fidelity of these interventions [5].

Finally, “big data” (e.g., satellite-derived data) is increasingly being used to inform healthcare strategies. Village-level data, with the most detailed administrative perspective, provide valuable insights into the socioeconomic and environmental determinants influencing the achievement of the SDGs [6]. Analyzing the spatial patterns of environmental variables at this level and their links to child malnutrition provides a more in-depth exploration of key factors in the causal pathway that could lead to more targeted policies for the most vulnerable communities within a region or country [6].

Planetary Health Insights into Childhood Stunting

Impact of floods on undernutrition among children under five years of age in low-
and middle-income countries: a systematic review

Comments: Agabiirwe et al. conducted a systematic review to map out existing evidence of the impact of floods on undernutrition in children under 5 years of age in low- and middle-income countries. All the studies were from South Asia (Bangladesh, India, Nepal, and Pakistan). Stunting was the most frequently reported form of undernutrition in flood-affected regions, with severe and recurrent floods showing the most significant impacts on stunting. In India, a community-based survey (rated as fair; lack of sufficient time between exposure and outcome) conducted 1 month after the floods reported that children living in repeatedly flooded communities were more likely to be underweight (adjusted prevalence rate [APR] = 1.86, 95% confidence interval [CI]:
1.04–3.30) and stunted (APR = 1.60, 95% CI: 1.05–2.44) but not wasted (APR = 1.2, 95%
CI: 0.61–2.42) relative to those in the nonflooded villages. In the 1-year follow-up
study (study rated as “Good”), a significant increase in the prevalence of underweight (APR = 1.48, 95% CI: 1.21–1.81) and wasting (APR = 2.30, 95% CI: 1.86–2.85) was reported but not stunting, for communities that were flooded twice (2006 and 2008) relative to the nonflooded communities. A more recent study (rated as “Good”) reported an increased risk of stunting (odds ratio [OR] = 1.04, 95% CI: 1.01–1.07) for children exposed to seasonal (monsoon) floods in infancy. In Bangladesh, a study conducted 2 months after the floods (rated as “Fair”) observed a 2-fold (OR = 2.18) in-
crease in stunting for children living in villages very severely exposed. In another follow-up study conducted 15 months after the floods (a year after a baseline of 2 months after floods), severe and moderate levels of flood exposure were observed as predictors of stunting (OR = 8.210, 95% CI: 1.194–56.464) and wasting (OR = 25.06, 95% CI: 1.81–347.45), respectively. The only study conducted 6 months after floods reported a significant increase in underweight prevalence compared to before (p <0.001). Factors associated with child undernutrition in the flood-affected areas included age, gender, diarrhea, maternal and paternal education, maternal age, house hold size, land ownership, and socioeconomic status. Stunting was the most frequently reported form of undernutrition over the long term following floods. The quality of the evidence was fairly weak, with the main challenge lying in the inability of the studies to establish causal pathways for the observed effects, lack of sufficient time between exposure and outcome, use of unreliable outcome assessment tools
(e.g., the National Center for Health Statistics median reference standard), and use of
unreliable outcome data and selection bias.

Is stunting in children under five associated with the state of vegetation in the Democratic Republic of the Congo? Secondary analysis of Demographic Health Survey data and the satellite-derived leaf area index

Comments: This was a secondary data analysis of 5,241 children from the Democratic Republic of the Congo Demographic Health Survey 2013–2014 to measure the association between forest cover (here, leaf area index [LAI]) and under five childhood stunting, focusing on the differences between children living in rural versus urban environments. The LAI is a biophysical variable that measures the total green leaf area per unit of horizontal ground surface area. The median LAI value was 4.21 m2/m2. Children living in an area with a higher LAI (4.21 m2/m2 and above) were compared with those living in an area with a lower LAI (<4.21 m2/m2), that is, the reference group. The key findings
showed that children in communities surrounded by high LAI values have lower odds of being stunted (OR = 0.63; 95% CI: 0.47–0.86) than those exposed to low LAI values. The association still held when the exposure was analyzed as a continuous variable (OR = 0.84; 95% CI: 0.74–0.95). When stratified in rural and urban areas, a significant association was only observed in rural areas (OR = 0.6; 95% CI: 0.39–0.81) but not in urban areas (OR = 0.9; 95% CI: 0.5–0.5). Children from wealthier households were less likely to be stunted by a factor of 0.22 (95% CI: 0.14–0.34), 0.57 (95% CI: 0.42–0.78), and 0.76 (95% CI: 0.59–0.98) for wealthiest, wealthy, and middle-class households, respectively. The child’s age, mother’s previous birth interval, and work status were not associated with stunting. The association between LAI and childhood stunting is statistically significant and negative in rural areas (OR = 0.6; 95% CI: 0.39–0.81); however, this association does not hold in urban areas (OR = 0.9; 95% CI: 0.5–1.5), where the mother’s work status and previous birth interval are not associated with stunting. In urban areas, children whose mothers had secondary-level education had lower odds of being stunted compared to those whose mothers only had primary-level education. Previous birth intervals of 24–35 months and >35 months are associated with lower odds of being stunted in a rural area, OR 0.7 (95% CI: 0.52–0.96) and 0.7 (95% CI:0.56–0.97), respectively. In a rural area, being from the wealthiest and wealthier households reduced the odds of being stunted by a factor of 0.2 (95% CI: 0.06–0.82) and 0.5 (95% CI: 0.36–0.78), respectively, while in an urban area, only the wealthiest households are associated with lower stunting (OR = 0.3; 95% CI: 0.2–0.6). In conclusion, the association observed between LAI and stunting was attributed to the fact that forest vegetation is the primary source of local and affordable foods, especially in rural areas. The lack of association between childhood stunting and the LAI in urban areas is probably due to the low prevalence of stunting there compared to rural areas and the high deforestation in urban areas, reducing LAI value below 4.21 m2/m2. Despite controlling for many possible confounders, the main limitation of this study is its inability to inform the temporality of the cause and effect or its susceptibility to
retaining a residual confounding. Though the study findings are limited to children under 5 years living in the Democratic Republic of the Congo, they can be used to inform policies on integrating forest conservation to improve nutritional status and combat stunting in children in rural areas.

Climate change and food systems: linking adaptive capacity and nutritional needs of low-income households in Ghana

Comments: In this quantitative cross-sectional study conducted in northern Ghana, Issahaku et al.
utilized the sustainable livelihoods framework to investigate the connection between household adaptive capacity – assessed through human, physical, financial, and social capital – and climate change as well as its impact on nutritional requirements of low-income households. It explores how the poor adaptive capacity of low-income households acts as a barrier to meeting nutritional requirements. The study focused on 288 households with at least one child under five. The overall prevalence of stunting among children was 39.2%. Findings showed a negative correlation between household adaptive capacity and stunting in children (β −1.125; OR 0.263; p < 0.01).
This means that a child from a household with a high adaptive capacity was about four times (3.8, p < 0.01) more likely to be nonstunted than a child from a low adaptive capacity household. Of significant note, the study population’s biggest driver of low adaptive capacity was low financial capital (37.9%). Regarding human capital, remittances and livestock ownership were the two most significant drivers of variation in adaptive capacity. Children from households that adopted new crop varieties were more than two times (2.3; p < 0.05) more likely to be normal (nonstunted) than chil-
dren from households that did not. Children from households that adapted dry season farming via irrigation technology were six times (6.1; p < 0.05) less likely to be stunted than children from households that did not. Furthermore, children from households that adopted mulching were found to be seven times (7.4) less likely to be stunted than those from households that did not. These adaptive practices increased household income and food availability, impacting food security and nutrition. However, children from households involved in hairdressing, fitting mechanics, and building masonry were 2.6 times more likely to be stunted than their counterparts. While adaptive capacity is essential for predicting nutritional needs and improving food and nutrition security, it interacts with other factors. Therefore, it should be considered part of a spectrum of determinants influencing malnutrition.

Projecting the impact of air pollution on child stunting in India – synergies and trade-offs between climate change mitigation, ambient air quality control, and clean cooking access (air pollution)

Comments: Dimitrova et al. investigated the correlations between early-life exposure to ambient
particulate matter (PM2.5) and the use of polluting cooking fuels, as well as stunting among 203,870 children under the age of 5 years in India. In the subsequent phase of the study, the researchers developed a static microsimulation model to analyze childhood stunting, utilizing data from the National Family Health Survey, multidimensional population projections, and projections of ambient PM2.5 concentrations, clean fuel usage, and per capita income levels derived from an integrated assessment model. After adjusting for confounding factors, they showed that in utero exposure to ambient PM2.5 was significantly associated with increased odds of childhood stunting (OR: 1.04, 95% CI: 1.03–1.05 per 10 μg/m3 increase in PM2.5). Conversely, using clean cooking fuel, compared to polluting fuels, was linked to reduced odds of stunting (OR:0.81, 95% CI: 0.79–0.84). Female children, those residing in urban areas, born to less educated mothers, belonging to socially disadvantaged castes, and living in lower-income households exhibited greater susceptibility to the detrimental effects of PM2.5 on linear growth (p < 0.05). Adjusting for additional covariates, such as the month of birth to account for seasonal variations in exposures, had minimal impact on the estimated effects of exposure. Projected data indicated a decrease in maternal PM2.5 exposure and an increase in clean cooking over time reduced the risk of childhood stunting.

Spatial variations of village-level environmental variables from satellite big data
and implications for public health-related sustainable development goals

Comments: Liu et al. [6] aimed to demonstrate the potential of high-resolution satellite data to provide valuable insights into different socioeconomic and environmental factors relevant to achieving the Sustainable Development Goals. The primary focus was child malnutrition indicators – stunting, underweight, and wasting – and the authors demonstrated the utilization of a cloud platform for deriving village-level environmental variables from big satellite datasets. Spatial data analysis revealed distinct patterns of environmental variables across the study area, with each village group showing different statistics. The study also explored the correlations between these environmental variables – normalized difference vegetation index (NDVI), rainfall (RF), elevation, slope, and land surface temperature (LST) – and child malnutrition indicators. All three malnutrition indicators showed negative correlations with NDVI, RF, elevation, and slope. This indicates that higher levels of NDVI (β −0.269; −0.382; −0.468), RF (β−0.365; −0.370; −0.431), elevation (β −0.639; −0.654; −0.387), and slope (β −0.725;−0.782; −0.568) were associated with lower prevalences of child stunting, underweight, and wasting, respectively. On the other hand, there was a positive correlation
between malnutrition indicators and LST (stunting β 0.627; underweight β 0.792; and wasting β 0.822), suggesting that higher LST was associated with higher rates of child malnutrition. Additionally, the study found that stunting and underweight showed stronger correlations with slope, elevation, and LST, while wasting exhibited stronger correlations with LST and slope compared to NDVI and RF. Furthermore, NDVI, LST, and rainfall showed stronger correlations with wasting compared to underweight and stunting. In contrast, elevation and slope were more strongly correlated with stunting and underweight than wasting. Overall, the findings suggest that environ-
mental factors, such as vegetation, rainfall, elevation, slope, and LST, significantly influence child malnutrition at the village level in India.

Impact of Maternal Nutrition and Health on Stunting and Subsequent Implications

Maternal height-standardised prevalence of stunting in 67 low- and middle-income
countries

Comments: Karlsson et al. argued that, as parental height is a major determinant of stunting, the
variation in adult height may, therefore, account for the variation in the prevalence of stunting across low- and middle-income countries (LMICs). Karlsson et al. estimated the maternal height standardized prevalence of stunting (SPS) in 67 LMICs and the parental height SPS in 20 LMICs to understand this from a policy perspective. SPS is the standardized prevalence of stunting and is calculated by rescaling the sampling weights, to sum up the probability density within each stratum of maternal height in the Multicentre Growth Reference Study reference population. These estimates were compared with the crude prevalence of stunting (CPS) using data from 575,767 children under five from 67 demographic and health surveys. On average, the mothers in the sample were 157.4 cm tall, with variations observed across regions. The shortest maternal heights were observed in Guatemala (148.5 cm), whereas the tallest were in West Africa, particularly Senegal (163.6 cm). When comparing maternal heights between the study sample and the Multicentre Growth Reference Study, mothers in the study sample were generally shorter, except for seven countries, predominantly in
sub-Saharan Africa. The findings revealed that the average CPS across the LMICs was 27.8% (95% CI 27.5–28.1), with the highest prevalence in Burundi (51%) and the lowest in the Dominican Republic (7.1%). After standardizing maternal height, SPS was 23.3% (95% CI 23.0–23.6) in the pooled sample. Burundi had the highest SPS (41.3%), along with Niger (41.9%) and Chad (41.3%). Peru had the lowest SPS (5.8%), followed by the Dominican Republic (6.4%). The most considerable deterioration in the ranking of countries according to the prevalence of stunting after standardizing maternal
height was for West African countries, such as Mali, Gambia, and Senegal. Countries in South Asia, such as Nepal, Bangladesh, India, and Pakistan, improved their rankings. In terms of correlation, maternal height SPS demonstrated better associations than CPS with various child health indicators, including diarrhea, anemia, under five, and child mortality rates. In conclusion, SPS is a more sensitive indicator of health outcomes. The findings also underscore the role of maternal height in understanding child malnutrition.

Stunting at birth: linear growth failure at an early age among newborns in Hawassa city public health hospitals, Sidama region, Ethiopia: a facility-based cross-sectional study

Comments: Ejigu et al. conducted a facility-based cross-sectional study to investigate the prevalence of stunting at birth, low birth weight (<2,500 g), and their coexistence among newborns delivered across the public hospitals of Hawassa city, Ethiopia (n = 371). Ejigu et al. found that 35.6% of newborns were stunted, and 24.6% were having low birth weight. Among the newborns, 5.8% had only low birth weight, 16.9% had only stunting, and 18.8% had both stunting and low birth weight. The study also evaluated antenatal and postnatal factors associated with stunting at birth. Maternal adverse antenatal exposures, including living in food-insecure households (adjusted odds ratio [AOR] 2.56; 95% CI 1.46, 4.49) and accessing inadequate dietary diversity (AOR 4.03; 95% CI 2.18, 7.48), were predictors of stunting at birth. Newborns of mothers with a mid-upper arm circumference of less than 23 cm had a 2-fold increased risk of being stunted at birth compared to those born to mothers with mid-upper arm circumference ≥23 cm (AOR 2.13; 95% CI 1.13, 4.01). Similarly, newborns of mothers with a birthing interval of less than 24 months had more than double the risk of being stunted at birth compared to those born to mothers with a birth interval of ≥24 months (AOR 2.55; 95% CI 1.39, 4.69). Infants with low birth weight were 11 times more likely to be stunted at birth compared to normal-weight babies (AOR 10.9; 95% CI 5.85,20.30). The findings underscore the importance of addressing maternal health, nutrition, and household factors to improve newborns’ nutritional status and overall health in Ethiopia and similar settings. Existing community-based interventions to improve maternal nutrition, household food security, and birth spacing should be strengthened to help reduce the burden of stunting at birth and its associated com-
plications.

The Concurrent Presence of Stunting with Other Forms of Malnutrition

How can nutrition research better reflect the relationship between wasting and stunting in children? Learnings from the wasting and stunting project

Comments: The Emergency Nutrition Network (ENN) has conducted extensive research on the relationship between wasting and stunting, two forms of malnutrition in children often treated separately despite sharing common risk factors and frequently occurring in the same child. The ENN initiated the Wasting and Stunting project to understand better these conditions and their implications for policies and programs. Lessons learned from the project included identifying and targeting high-risk individuals, such as those with concurrent wasting and stunting, who face a significant mortality risk. Anthropometric measures like weight-for-age and mid-upper arm circumference have shown promise in identifying high-risk children. Longitudinal data analysis has shown that episodes of wasting can contribute to later episodes of stunting, emphasizing the importance of preventing wasting to prevent stunting. Additionally, Sadler et al. suggested that it was crucial to report the combined extent of wasting and stunting and measure the incidence of wasting to understand their burden better. The project stated that diverse pathways and factors drive different forms of undernutrition, including maternal factors, early markers, seasonality, age, and sex. Overall, future research should focus on the processes of wasting and stunting, explore risk factors in different contexts, use diagnostic criteria to identify high-risk children, prioritize seasonality, utilize longitudinal data, and develop innovative markers for early identification and monitoring of undernutrition risks. Collaboration and coherent research investments were also discussed as crucial to addressing wasting and stunting effectively.

Associations between stunting, wasting and body composition: a longitudinal study in 6- to 15-month-old Kenyan children

Comments: Konyole et al. aimed to investigate the association between undernutrition (stunting
and wasting) and body composition in early life. This longitudinal study was nested in a randomized controlled nutrition trial. Konyole et al. used deuterium dilution to assess fat mass (FM) and fat-free mass (FFM) among children between ages 6 and 15 months. Findings showed that out of 499 children enrolled in the study between 6 and 15 months, breastfeeding rates declined from 99 to 87%, while stunting rates increased from 13 to 32%. However, wasting remained stable at 2–3%. A comparison made with the length-for-age Z-score (LAZ) showed that stunted children exhibited
a 1.12 kg (95% CI: 0.88, 1.36; p < 0.001) lower FFM at 6 months, which increased to 1.59 kg (95% CI: 1.25, 1.94; p < 0.001) at 15 months. Further analysis of the fat-free mass index showed that the deficit in FFM was less than proportional to children’s height at 6 months (p < 0.060) though not significant at 15 months (p < 0.40). Although stunting was associated with 0.28 kg lower FM at 6 months (95% CI: 0.09, 0.47; p = 0.004), neither of these negative associations was observed at 15 months, nor was it associated with stunting at any time point. Overall, differences in FFM were observed, while no differences were detected for FM and FFM index. The author concluded that children with a low length-for-age Z-score and a weight-for-length Z-score may have long-term health consequences because of reduced lean tissue suffered due to undernutrition.

The coexistence of stunting and overweight or obesity in Ethiopian children: prevalence, trends and associated factors

Comments: Sahiledengle et al. conducted a cross-sectional study in Ethiopia to examine the prevalence, trends, and factors associated with the coexistence of stunting and overweight or obesity (CSO) among children aged 0–59 months. The study included a total of 23,756 children in the analysis. CSO was defined as a child being stunted (height-for-age Z-score below −2 standard deviation) and overweight or obese (weight-for-height Z-score above 2 standard deviation). The prevalence of stunting, overweight or obesity, and CSO among children under five was 43.12% (95% CI: 42.50, 43.75%), 2.62% (95% CI: 2.42, 2.83%), and 1.33% (95% CI: 1.18, 1.48%), respectively.
The percentage of CSO children was reported to have declined from 2.36% (95% CI: 1.94–2.85) in 2005 to 0.87% (95% CI: 0.07–1.07) in 2011, and the same appeared to have increased slightly to 1.34% (95% CI: 1.13–1.59) in 2016. Children who were currently breastfeeding (AOR: 1.64, 95% CI: 1.01–2.72), born to an overweight mother (AOR: 2.65, 95% CI: 1.19–5.88), and lived in families with 1–4 household members (AOR: 1.52, 95% CI: 1.02–2.26) were significantly positively associated with CSO. At the community level, the odds of having CSO were higher among children included in the
Ethiopia Mini Demographic and Health Survey 2005 (AOR: 4.38, 95% CI: 2.42–7.95). Overall, the study findings indicate that the double burden of malnutrition must be addressed concurrently through targeted interventions. Early identification of at-risk children, including those born to overweight women and those living with multiple household members, is essential to combating the double burden of malnutrition.

The effect of wasting and stunting during severe acute malnutrition in infancy on insulin sensitivity and insulin clearance in adult life

Comments: In this retrospective cohort study of 40 Afro-Caribbean survivors of severe acute malnutrition nondiabetic adults, Thompson et al. aimed to investigate the association between wasting and/or stunting in adults and glucose disposal rate (M) and insulin clearance (MCR) in adulthood. The 20 marasmus survivors (MS) and 20 kwashiorkor survivors (KS) had been admitted with severe malnutrition between ages 6 and 18 months. It was hypothesized that wasting and stunting were associated with lower glucose rate disposal and insulin clearance in adulthood. At admission, findings showed that children with marasmus had significantly lower weight-for-height Z-
scores (−3.8 ± 0.9 vs. −2.2 ± 1.4; p < 0.001) and height-for-age Z-scores (−4.6 ± 1.1 vs. −3.4 ± 1.5; p = 0.0092) than those with Kwashiorkor. MS had higher fasting glucose concentrations in adulthood than KS, even after adjusting for age and sex (p ≤ 0.001). However, there was no difference in M and MCR among the adult MS, KS, and controls (p > 0.3). Neither the weight-for-height Z-score nor the height-for-age Z-score was associated with insulin sensitivity, MCR, or fasting adiponectin (p > 0.35), even in overweight or obese adults (p > 0.34). Even after adjusting for fat mass, the weight-for-
height Z-score was not associated with M (r = 0.12, p = 0.54) and MCR (r = −0.08, p = 0.66). Similarly, the height-for-age Z-score was not associated with M (r = 0.16, P = 0.35) and MCR (r = −0.08, p = 0.65) after adjustment of fat mass. Developmental factors like intrauterine growth restriction may influence beta cell mass and function.

The study limitations were the small sample size, lack of data regarding beta cell function, and the absence of C-peptide data to support the claim that basal insulin secretion was unaffected by the insulin infusion during the clamp. The authors concluded that wasting and stunting in early childhood are not associated with differences in insulin sensitivity and insulin clearance in lean young adult severe acute malnutrition survivors, possibly due to adequate nutritional recovery. Instead, the glucose intolerance in MS is mainly attributed to beta cell dysfunction. Finally, there is a need to estimate hepatic insulin clearance and pancreatic islet function in this cohort and carry out follow-up studies in obese survivors of malnutrition.

Linear Growth Trajectories in LMICS and Their Impact on Stunting

Linear growth spurts are preceded by higher weight gain velocity and followed by
weight slowdowns among rural children in Burkina Faso: a longitudinal study

Comments: Cliffer et al. conducted a clustered trial in Burkina Faso using monthly anthropometric
measurements of 5,039 children aged 6–28 months who were followed up for 18 months between August 2014 and December 2016 as part of a geographically clustered trial comparing the cost of effectiveness of 4 supplementary food in preventing stunting and wasting in children aged 6–23 months in Sanmatenga Province. Cliffer et al. aimed to evaluate how changes in one growth parameter impact others and identify critical age ranges when growth rates influence each other. Monthly anthropometric assessments were conducted, including recumbent length, weight, and mid-upper arm circumference. Overall, the findings showed that boys exhibited poorer growth and morbidity parameters than girls, yet linear growth seasonality did not differ by gender. Faster ponderal growth occurred when average linear growth increased within the same month (0.07–0.13 increase in weight velocity Z-score [WVZ] per unit increase in concurrent length velocity Z-score [LVZ]). Notably, faster linear growth (0.21–0.72 increase in LVZ per unit increase in WVZ) was associated with faster ponderal growth, either preceding or happening concurrently. However, faster linear growth in children 9–14 months old was associated with slower future ponderal growth (0.009–0.02 decrease in WVZ per unit increase in lagged LVZ). Girls aged 6–8 months exhibited the highest linear growth with increased weight gain. There was a strong association between linear and ponderal growth velocity, with conditions affecting one parameter and the other roughly simultaneously. Due to the slower linear growth process, the effects in weight are seen first. Furthermore, the slowest ponderal growth velocity coincided with peak morbidity, subsequently followed by the slowest linear growth velocity. The main limitation is the lack of longitudinal data on
food security and diet diversity, key exposures that influence growth velocity and morbidity. Cliffer et al. concluded that a systems approach to improve living conditions (sanitation, hygiene infrastructure, access to nutritious foods) and address community-level deficiencies that constrain growth would help address growth faltering. Moreover, the best way to understand the temporal dependencies between linear and ponderal growth is by assessing growth velocity and changes in growth drivers.

They also did not assess the associated neurodevelopmental outcomes of these children at any point during the 18 months of follow-up.

Interventions for Stunted Children

Postnatal Interventions
 

Preventive small-quantity lipid-based nutrient supplements reduce severe wasting and severe stunting among young children: an individual participant data meta analysis of randomised controlled trials

Comments: This meta-analysis by Dewey et al. included data from 14 randomized controlled trials to investigate the impact of small-quantity lipid-based nutrient supplements (SQ-LNSs) on the prevalence of severe wasting (weight-for-length Z-score < −3) and severe stunting (length-for-age Z-score < −3) in children aged 6–24 months. The analysis, which involved 34,373 participants for severe wasting and 36,795 participants for severe stunting, showed consistent positive effects of SQ-LNSs across the studies. The findings demonstrated that the provision of SQ-LNSs resulted in a relative reduction of 31% in severe wasting (prevalence ratio [PR]: 0.69; 95% CI: 0.55–0.86) and 17% in severe stunting (PR: 0.83; 95% CI: 0.78–0.90) at the end of the study. The study-level characteristics did not significantly modify the effects of SQ-LNSs. However, there were indications that the supplements had greater effects in locations with higher burdens of wasting or stunting or where water quality and sanitation were poorer.

The authors concluded that incorporating SQ-LNSs into preventive interventions to promote healthy child growth and development will likely reduce the rates of severe wasting and stunting.

Effect of milk protein and whey permeate in large-quantity lipid-based nutrient supplements on early child development among children with stunting: a randomised 2 × 2 factorial trial in Uganda

Comments: This randomized, double-blind, 2 × 2 controlled trial by Mbabazi et al. assessed the effects of milk protein (MP) and whey permeate (WP) and lipid-based nutrient supplement (LNS) on linear growth and body composition among 750 stunted children. Findings showed that unsupplemented children had a 0.06 (95% CI [0.02, 0.10]; p = 0.015) decline in height-for-age Z-score, accompanied by 0.29 (95% CI [0.20, 0.39]; p < 0.001) kg/m2 increase in fat mass index, but 0.06 (95% CI [−0.002; 0.12]; p = 0.057) kg/m2 decline in fat-free mass index. There were no interactions between MP and WP. The main effects of MP were 0.03 cm (95% CI [−0.10, 0.16]; p = 0.662) in height and 0.2 mm (95% CI [−0.3, 0.7]; p = 0.389) in knee-heel length. The main effects of WP were −0.08 cm (95% CI [−0.21, 0.05]; p = 220) and −0.2 mm (95% CI [−0.7; 0.3]; p = 403),
respectively. Interactions were found between WP and breastfeeding with respect to linear growth (p < 0.02) due to positive effects among breastfed and negative effects among non-breastfed children. Overall, LNS resulted in 0.56 cm (95% CI [0.42, 0.70]; p< 0.001) height increase, corresponding to 0.17 (95% CI [0.13, 0.21]; p < 0.001) height-for-age Z-score increase and 0.21 kg (95% CI [0.14, 0.28]; p < 0.001) weight increase, of which 76.5% (95% CI [61.9; 91.1]) was fat-free mass. Using height-adjusted indicators, LNS increased fat-free mass index (0.07 kg/m2, 95% CI [0.0001; 0.13]; p = 0.049) but not fat mass index (0.01 kg/m2, 95% CI [−0.10, 0.12]; p = 0.800). The main limitations were the lack of blinding of caregivers and the short study duration. The authors concluded that adding dairy to LNS has no additional effects on linear growth or body composition in stunted children aged 12–59 months. However, regardless of milk, LNS supplementation promotes linear catch-up growth and fat-free mass accretion, but not fat mass.

Antenatal Interventions

Fortified balanced energy-protein supplementation during pregnancy, lactation, and infant growth in rural Burkina Faso: a 2 × 2 factorial individually randomised controlled trial

Comments: In this 2 × 2 factorial individually randomized controlled trial (MISAME-III) by Argaw et al. conducted in rural Burkina Faso, the efficacy of daily fortified balanced energy protein (BEP) supplementation during pregnancy and lactation on infant growth was evaluated. The study recruited 1,897 pregnant women aged 15–40 with a gestational age of less than 21 weeks. The women were randomly assigned to one of the two prenatal interventions: (i) fortified BEP supplements and iron-folic acid (IFA) tablets (intervention group) or (ii) IFA alone, which is the standard care during pregnancy (control group). Concurrently, the same women were randomized to receive either postnatal fortified BEP supplementation during the first 6 months postpartum along with IFA for the first 6 weeks (intervention group) or postnatal IFA alone for 6 weeks postpartum (control group). The primary postnatal study outcome was the length-for-age Z-score (LAZ) at 6 months. The results showed that prenatal BEP supplementation led to a significantly higher LAZ (0.11 standard deviation, 95% CI [0.01–0.21], p = 0.032) and lower stunting prevalence (3.18 percentage points, 95% CI [−5.86–−0.51], p = 0.020) at 6 months of age. However, postnatal BEP supplementation did not significantly affect LAZ or stunting at 6 months. Nevertheless, postnatal BEP supplementation did result in a modest improvement in the rate of monthly LAZ increment during
the first 12 months postpartum (0.01 Z-score/month, 95% CI [0.00–0.02], p = 0.030). At 6 months, no significant effects were observed on secondary outcomes related to stunting, wasting, being underweight, anemia, or hemoglobin concentration. In conclusion, this study demonstrated that prenatal BEP supplementation positively impacted infant linear growth and stunting. However, postnatal BEP supplementation did not significantly impact these outcomes at 6 months postpartum. The findings contribute to the growing evidence that nutrition interventions targeting women in
the prenatal period are likely to be more impactful in improving linear growth among infants than those delivered during the postnatal period in resource-limited settings like rural Burkina Faso.

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