Stunted growth

Stunted growth or stunting is a reduced growth rate in human development. It is a primary manifestation of malnutrition (or more precisely undernutrition) and recurrent infections, such as diarrhea and helminthiasis, in early childhood and even before birth, due to malnutrition during fetal development brought on by a malnourished mother. The definition of stunting according to the World Health Organisation (WHO) is for the "height for age" value to be less than two standard deviations of the WHO Child Growth Standards median.^[1]

As of 2012 an estimated 162 million children under 5 years of age, or 25%, were stunted in 2012. More than 90% of the world's stunted children live in Africa and Asia, where respectively 36% and 56% of children are affected.^[2] Once established, stunting and its effects typically become permanent. Stunted children may never regain the height lost as a result of stunting, and most children will never gain the corresponding body weight. Living in an environment where many people defecate in the open due to lack of sanitation, is an important cause of stunted growth in children, for example in India.^[3]

Impacts

Stunted growth in children has the following public health impacts apart from the obvious impact of shorter stature of the person affected:

• greater risk for illness and premature death^[1]
• may result in delayed mental development and therefore poorer school performance and later on reduced productivity in the work force^[1]
• reduced cognitive capacity
• Women of shorter stature have a greater risk for complications during child birth due to their smaller pelvis, and are at risk of delivering a baby with low birth weight^[1]
• Stunted growth can even be passed on to the next generation (this is called the "intergenerational cycle of malnutrition")^[1]

Causes

Children living in unsanitary conditions in an urban slum in India, at risk of diarrhea and stunted growth

Child next to open sewer in slum in Kampala, Uganda, at risk of diarrhea and stunted growth

The causes for stunting are principally very similar if not the same as the causes for malnutrition in children. Most stunting happens during the 1,000-day period that spans from conception to a child's second birthday. The three main causes of stunting in South Asia, and probably in most developing countries, are poor feeding practices, poor maternal nutrition, and poor sanitation.

Feeding practices

Inadequate complementary child feeding and a general lack of vital nutrients beside pure caloric intake is one cause for stunted growth. Children need to be fed diets which meet the minimum requirements in terms of frequency and diversity in order to prevent undernutrition.

Maternal nutrition

Poor maternal nutrition during pregnancy and breastfeeding can lead to stunted growth of their children. Women who are underweight or anemic during pregnancy, are more likely to have stunted children which perpetuates the inter-generational transmission of stunting.

Sanitation

There is most likely a link between children's linear growth and household sanitation practices. The ingestion of high quantities of fecal bacteria by young children through putting soiled fingers or household items in the mouth leads to intestinal infections. This affect children's nutritional status by diminishing appetite, reducing nutrient absorption, and increasing nutrient losses.

The diseases recurrent diarrhoea and intestinal worm infections (helminthiasis) which are both linked to poor sanitation have been shown to contribute to child stunting. The evidence that a condition called environmental enteropathy also stunts children is not conclusively available yet, although the link is plausible and several studies are underway on this topic.^[4] Environmental enteropathy is a syndrome causing changes in the small intestine of persons and can be brought on due to lacking basic sanitary facilities and being exposed to faecal contamination on a long-term basis.^[4]

Research on a global level has found that the proportion of stunting that could be attributed to five or more episodes of diarrhoea before two years of age was 25%.^[5] Since diarrhoea is closely linked with water, sanitation and hygience (WASH), this is a good indicator for the connection between WASH and stunted growth. To what extent improvements in drinking water safety, toilet use and good handwashing practices contribute to reduce stunting depends on the how bad these practices were prior to interventions.

Diagnosis

Growth stunting is identified by comparing measurements of children's heights to the World Health Organization 2006 growth reference population: children who fall below the fifth percentile of the reference population in height for age are defined as stunted, regardless of the reason. The lower than fifth percentile corresponds to less than two standard deviations of the WHO Child Growth Standards median.

As an indicator of nutritional status, comparisons of children's measurements with growth reference curves may be used differently for populations of children than for individual children. The fact that an individual child falls below the fifth percentile for height for age on a growth reference curve may reflect normal variation in growth within a population: the individual child may be short simply because both parents carried genes for shortness and not because of inadequate nutrition. However, if substantially more than 5% of an identified child population have height for age that is less than the fifth percentile on the reference curve, then the population is said to have a higher-than-expected prevalence of stunting, and malnutrition is generally the first cause considered.

Prevention

Three main things are needed to reduce stunting:^[6]

• a kind of environment where political commitment can thrive (also called an "enabling environment")
• applying several nutritional modifications or changes in a population on a large scale which have a high benefit and a low cost
• a strong foundation that can drive change (food security, empowerment of women and a supportive health environment through increasing access to safe water and sanitation).

To prevent stunting, it is not just a matter of providing better nutrition but also access to clean water, improved sanitation (hygienic toilets) and hand washing at critical times (summarised as "WASH"). Without provision of toilets, prevention of tropical intestinal diseases, which may affect almost all children in the developing world and lead to stunting will not be possible.^[7]

Studies have looked at ranking the underlying determinants in terms of their potency in reducing child stunting and found in the order of potency:^[8]

• percent of dietary energy from non-staples (greatest impact)
• access to sanitation and women’s education
• access to safe water
• women’s empowerment as measured by the female-to-male life expectancy ratio
• per capita dietary energy supply

Three of these determinants should receive attention in particular: access to sanitation, diversity of calorie sources from food supplies, and women’s empowerment. A study by the Institute of Development Studies has stressed that: "The first two should be prioritized because they have strong impacts yet are farthest below their desired levels".^[8]

The goal of UN agencies, governments and NGO is now to optimise nutrition during the first 1000 days of a child’s life, from pregnancy to the child’s second birthday, in order to reduce the prevalence of stunting.^[9] The first 1000 days in a child's life are a crucial "window of opportunity" because the brain develops rapidly, laying the foundation for future cognitive and social ability. Furthermore, it is also the time when young children are the most at risk of infections that lead to diarrhoea. It is the time when they stop breast feading (weaning process), begin to crawl, put things in their mouths and become exposed to faecal matter from open defecation and environmental enteropathies.^[9]

Epidemiology

World map showing % of children under height for age (i.e. with stunted growth)

According to the World Health organisation if less than 20% of the population is affected by stunting, this is regarded as  "low prevalence" in terms of public health significance.^[1] Values of 40% or more are regarded as very high prevalence, and values in between as medium to high prevalence.^[1]

UNICEF has estimated that: "Globally, more than one quarter (26 per cent) of children under 5 years of age were stunted in 2011 – roughly 165 million children worldwide."^[10] and "In sub-Saharan Africa, 40 per cent of children under 5 years of age are stunted; in South Asia, 39 per cent are stunted."^[10] The four countries with the highest prevalence are Timor-Leste, Burundi, Niger and Madagascar where more than half of children under 5 years old are stunted.^[10]

Research

The Water and Sanitation Program of the World Bank has investigated links between lack of sanitation and stunting in Vietnam and Lao PDR.^[11] For example in Vietnam it was found that lack of sanitation in rural villages in mountainous regions of Vietnam led to five-year-old children being 3.7 cm shorter than healthy children living in villages with good access to sanitation.^[12] This difference in height is irreversible and matters a great deal for a child’s cognitive development and future productive potential.

One study conducted in a rural area in Zimbabwe illustrates the impact malnutrition has on growth. The area is known for poor farming conditions and prevalent malnourishment. Children ages 6–17 in the area were assessed for height, weight, and body mass index (BMI). The data recorded was compared with both American and other African countries average heights. Compared with the American averages, the Zimbabwean boys' height and weight dropped as low as the 10th percentile in some age groups and showed no sign of catch-up growth during the mid-teens. Zimbabwean girls' height and weight were not as low, but did drop as low as the 25th percentile. However, catch-up growth did occur during mid-teens and by 16 and 17, the girls average was close to the 50th percentile. Olivier, Semproli, Pettener, and Toselli, sums it up by saying that "the adverse socioeconomic environment and the low levels of food availability compromise and probably delay the physical development of the affected children in all phases of growth." Also, these data support the theory that lower than average size at early ages could be due to an adaptive mechanism reacting to low food intake.^[13]

See also

• Malnutrition in children
• Failure to thrive

References

External links

• Stop stunting, regional conference on nutrition in South Asia (website slow to load)
• Alive and Thrive, program website