Stunting is not a synonym of malnutrition

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Abstract

WHO documents characterize stunting as, "…impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation." The equation of stunting with malnutrition is common. This contrasts with historic and modern observations indicating that growth in height is largely independent of the extent and nature of the diet.

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Maternal and child undernutrition and overweight in low-income and middle-income countries

Robert E Black, Cesar G Victora, Susan P. Walker … (2013)

The Lancet, 382(9890), 427-451

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Impact of maternal education about complementary feeding and provision of complementary foods on child growth in developing countries

Aamer Imdad, Mohammad Yakoob, Zulfiqar Bhutta (2011)

Background Childhood undernutrition is prevalent in low and middle income countries. It is an important indirect cause of child mortality in these countries. According to an estimate, stunting (height for age Z score < -2) and wasting (weight for height Z score < -2) along with intrauterine growth restriction are responsible for about 2.1 million deaths worldwide in children < 5 years of age. This comprises 21 % of all deaths in this age group worldwide. The incidence of stunting is the highest in the first two years of life especially after six months of life when exclusive breastfeeding alone cannot fulfill the energy needs of a rapidly growing child. Complementary feeding for an infant refers to timely introduction of safe and nutritional foods in addition to breast-feeding (BF) i.e. clean and nutritionally rich additional foods introduced at about six months of infant age. Complementary feeding strategies encompass a wide variety of interventions designed to improve not only the quality and quantity of these foods but also improve the feeding behaviors. In this review, we evaluated the effectiveness of two most commonly applied strategies of complementary feeding i.e. timely provision of appropriate complementary foods (± nutritional counseling) and education to mothers about practices of complementary feeding on growth. Recommendations have been made for input to the Lives Saved Tool (LiST) model by following standardized guidelines developed by Child Health Epidemiology Reference Group (CHERG). Methods We conducted a systematic review of published randomized and quasi-randomized trials on PubMed, Cochrane Library and WHO regional databases. The included studies were abstracted and graded according to study design, limitations, intervention details and outcome effects. The primary outcomes were change in weight and height during the study period among children 6-24 months of age. We hypothesized that provision of complementary food and education of mother about complementary food would significantly improve the nutritional status of the children in the intervention group compared to control. Meta-analyses were generated for change in weight and height by two methods. In the first instance, we pooled the results to get weighted mean difference (WMD) which helps to pool studies with different units of measurement and that of different duration. A second meta-analysis was conducted to get a pooled estimate in terms of actual increase in weight (kg) and length (cm) in relation to the intervention, for input into the LiST model. Results After screening 3795 titles, we selected 17 studies for inclusion in the review. The included studies evaluated the impact of provision of complementary foods (±nutritional counseling) and of nutritional counseling alone. Both these interventions were found to result in a significant increase in weight [WMD 0.34 SD, 95% CI 0.11 – 0.56 and 0.30 SD, 95 % CI 0.05-0.54 respectively) and linear growth [WMD 0.26 SD, 95 % CI 0.08-0.43 and 0.21 SD, 95 % CI 0.01-0.41 respectively]. Pooled results for actual increase in weight in kilograms and length in centimeters showed that provision of appropriate complementary foods (±nutritional counseling) resulted in an extra gain of 0.25kg (±0.18) in weight and 0.54 cm (±0.38) in height in children aged 6-24 months. The overall quality grades for these estimates were that of ‘moderate’ level. These estimates have been recommended for inclusion in the Lives Saved Tool (LiST) model. Education of mother about complementary feeding led to an extra weight gain of 0.30 kg (±0.26) and a gain of 0.49 cm (±0.50) in height in the intervention group compared to control. These estimates had been recommended for inclusion in the LiST model with an overall quality grade assessment of ‘moderate’ level. Conclusion Provision of appropriate complementary food, with or without nutritional education, and maternal nutritional counseling alone lead to significant increase in weight and height in children 6-24 months of age. These interventions can significantly reduce the risk of stunting in developing countries and are recommended for inclusion in the LiST tool.

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Childhood body composition in relation to body mass index.

L Maynard, W Wisemandle, A. F. Roche … (2001)

The aim is to describe body composition in relation to body mass index (BMI; body weight/stature(2)) to provide health care professionals insight into the meaning, significance, and limitations of BMI as an index of adiposity during childhood. Data from 387 healthy, white children 8 to 18 years of age from the Fels Longitudinal Study were analyzed. Measurements were scheduled annually and each child was examined 1 to 11 times, totaling 1748 observations. Total body fat (TBF) and fat-free mass (FFM) were determined from hydrodensitometry. Stature and weight were measured using standard methods and BMI and the components of BMI, TBF/stature(2), and FFM/stature(2) were calculated. Analyses included correlations between BMI and body composition variables; age-related patterns of BMI, TBF/stature(2), and FFM/stature(2); and annual changes in BMI, TBF/stature(2), and FFM/stature(2). Generally, correlations between BMI and body composition variables were strong and significantly different from zero. Means for BMI throughout childhood were similar for boys and girls, although significantly larger values were observed for girls at ages 12 to 13 years. Age-related patterns of TBF/stature(2) and FFM/stature(2) differed between sexes. In each sex, annual increases in BMI were driven primarily by increases in FFM/stature(2) until late adolescence, with increases in TBF/stature(2) contributing to a larger proportion of the BMI increases in girls than in boys. Unlike adults, annual increases in BMI during childhood are generally attributed to the lean rather than to the fat component of BMI. Because the properties of BMI vary during childhood, health care professionals must consider factors such as age and sex when interpreting BMI.