Stunted growth

From Wikipedia, the free encyclopedia
Stunted growth
Other namesStunting, nutritional stunting
World map in 2016: Share of children who are stunted
SpecialtyPediatrics

Stunted growth, also known as stunting or linear growth failure, is defined as impaired growth and development manifested by low height-for-age.[1] It is a primary manifestation of malnutrition (or more precisely chronic 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 Organization (WHO) is for the "height-for-age" value to be less than two standard deviations of the median of WHO Child Growth Standards.[2] Stunted growth is usually associated with poverty, unsanitary environmental conditions, maternal undernutrition, frequent illness, and/or inappropriate feeding practice and care during early years of life.

Prevalence of stunting in children under 5 years by region (2020-2022)

As of 2020, an estimated 149 million children under 5 years of age, are stunted worldwide.[3] More than 85% of the world's stunted children live in Africa and Asia.[4] 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.[5]

Health effects[edit]

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[2]
  • Delayed neurocognitive development and therefore poorer school performance and later on reduced productivity in the work force[2]
  • Reduced cognitive capacity
  • Future risk of obesity[6]
  • 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[2]
  • Stunted growth can be passed to the next generation, known as the "intergenerational cycle of malnutrition"[2]

The impact of stunting on child development has been established in multiple studies.[7] If a child is stunted at age 2 they will have higher risk of poor cognitive and educational achievement in life, with subsequent socio-economic and inter-generational consequences.[8][7] Multi-country studies have also suggested that stunting is associated with reductions in schooling, decreased economic productivity and poverty.[9] Stunted children also display higher risk of developing chronic non-communicable conditions such as diabetes and obesity as adults.[8][9] If a stunted child undergoes substantial weight gain after age 2, there is a higher chance of becoming obese. This is believed to be caused by metabolic changes produced by chronic malnutrition, that can produce metabolic imbalances if the individual is exposed to excessive or poor quality diets as an adult.[8][9] This can lead to higher risk of developing other related non-communicable diseases such as hypertension, coronary heart disease, metabolic syndrome and stroke.[8][9] At societal level, stunted individuals do not fulfill their physical and cognitive developmental potential and will not be able to contribute maximally to society. Stunting can therefore limit economic development and productivity, and it has been estimated that it can affect a country's GDP up to 3%.[8][7][9]

Stunting is highly prevalent in low- and middle income countries (LMICs) and has severe consequences including increased risk of infections,[10] mortality[11][12] and loss of human capital.[10][13] The global prevalence of stunting decreased from 33% to 23% between 2000 and 2016.[14] Meanwhile, 37% of children in South Asia are stunted, and due to a large population size, the region bears about 40% of the global burden of stunting.[15]

Causes[edit]

The prevalence of child stunting generally increases as cities become smaller and moving away from urban centres while child wasting and overweight are lower and exhibit less evident trends across the rural-urbann continuum.
The prevalence of child stunting generally increases as cities become smaller and moving away from urban centres while child wasting and overweight are lower and exhibit less evident trends across the rural-urbann continuum.
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

In many publications, the causes for stunting are considered very similar if not the same as the causes for malnutrition in children. However, this is not uncontradicted. Recent evidence stresses that stunting may not be taken as a synonym of malnutrition,[16] but as the natural condition of human height in non-Westernized societies. [17]

Almost all stunting occurs within the 1,000-day period that spans from conception to a child's second birthday,[18][19] which constitutes a window of opportunity for growth promotion.[20] The recognition of pre-natal factors underlines the inter-generational aspects of growth,[21] and the need for early interventions.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. A recent risk assessment analysis for 137 developing countries found that the leading risk factors for stunting were fetal growth restriction (birth weight <10th centile) followed by unimproved sanitation and diarrhea. It was estimated that 22% of stunting cases were attributable to environmental factors while 14% were attributable to child nutrition.[22] In addition, looking at trends from 1970 to 2012 for 116 countries, women’s education, gender equality and finally quantity and quality of foods available at the country level have been instrumental in reducing stunting rates, while income growth and governance have played facilitating roles.[23]

Feeding practices[edit]

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.[24] Exclusive breastfeeding is recommended for the first six months of life and complementary feeding of nutritious food alongside breastfeeding for children aged six months to 2-years-old. Prolonged exclusive breastfeeding is associated with undernutrition because breast milk alone is nutritionally insufficient for children over six months old.[25][26] Breastfeeding in long time with inadequate complementary feeding leads to growth failure due to insufficient nutrients which are essential for childhood development. The relationship between undernutrition and prolonged duration of breastfeeding is mostly observed among children from poor households and whose parents are uneducated as they are more likely to continue breast-feeding without meeting minimum dietary diversity requirement.[27]

Maternal nutrition[edit]

Poor maternal nutrition during pregnancy and breastfeeding can lead to stunted growth of their children. Proper nutrition for mothers during the prenatal and postnatal period is important for ensuring healthy birth weight and for healthy childhood growth. Prenatal causes of child stunting are associated with maternal undernutrition. Low maternal BMI predisposes the fetus to poor growth leading to intrauterine growth retardation, which is strongly associated with low birth weight and size.[28] Women who are underweight or anemic during pregnancy, are more likely to have stunted children which perpetuates the inter-generational transmission of stunting. Children born with low birthweight are more at risk of stunting.[24] However, the effect of prenatal undernutrition can be addressed during the postnatal period through proper child feeding practices.[28]

Maternal undernutrition increases the risk of stunting at 2 years age.[18] Based on data from 19 birth cohorts from LMICs, 20% of stunting is attributed to being born small-for-gestational-age (SGA).[29] Further, estimated stunting at 2 years attributed to fetal growth restriction and preterm birth in 2011 was 33% in all developing countries and 41% in South Asia.[22] Restricted pre- and postnatal growth are in turn important determinants of short adult height,[30] increasing the likelihood of the next generation also being stunted.[31]

Sanitation[edit]

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 diarrhea and intestinal worm infections (helminthiasis) which are both linked to poor sanitation have been shown to contribute to child stunting.[citation needed]

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%.[32] Since diarrhoea is closely linked with water, sanitation and hygiene (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.

Environmental enteropathy[edit]

The condition termed environmental enteropathy is proposed as an immediate causal factor of childhood stunting.[33][34] This is an asymptomatic small intestinal disorder characterized by chronic gut inflammation, reduced absorptive surface area, and disruption of intestinal barrier function.[35][36] This small bowel disorder is attributable to sustained exposure to intestinal pathogens caused by faecal contamination of food and water.[37][38][34] Recent evidence confirmed a causal relationship between stunted growth and environmental enteropathy in children.[39] Several studies are also underway to examine the link between this condition and stunted growth.[37][40][41] The exact pathogenesis of environmental enteropathy causing linear growth failure is unclear, but it is hypothesized that chronic inflammatory state and impaired absorption associated with this condition may inhibit bone growth and affect the linear growth during early years of life.[42]

Diagnosis[edit]

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.[citation needed]

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.[citation needed]

Prevention[edit]

Three main things are needed to reduce stunting:[43]

  • 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, 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.[44]

Studies have looked at ranking the underlying determinants in terms of their potency in reducing child stunting and found in the order of potency:[23]

  • percent of dietary energy from non-staples (greatest impact)
  • access to sanitation and women's education
  • access to safe water
  • per capita dietary energy supply

Three of these determinants should receive attention in particular: access to sanitation, and diversity of calorie sources from food supplies. 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".[23]

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.[45] 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.[46] 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 feeding (weaning process), begin to crawl, put things in their mouths and become exposed to faecal matter from open defecation and environmental enteropathies.[45]

Dietary interventions to improve stunting[edit]

Previous interventions to reduce stunting have shown modest effects. Multiple micronutrient supplementation shows only small benefits for linear growth[47] and results from studies supplementing lipid based nutrient supplements (LNS) to children are inconclusive.[48][49] Educational interventions to improve complementary feeding may achieve behavioral change but have no or small effects on growth.[50][51] Further, studies on the effect of micronutrient fortification, increased availability of key nutrients or increased energy density of complementary foods on stunting also show heterogenous results.[52] It is estimated that education interventions, if optimally designed and implemented, could reduce stunting by 0.6 z-scores while food-based interventions could reduce stunting by 0.5 z-scores,[52] which is moderate compared to the average global growth deficit.[53] Finally, the Lancet-series on maternal and child nutrition estimated that the impact of all existing interventions designed to improve nutrition and prevent related diseases in mothers and children, could reduce stunting at 3 years by merely 36%.[54] Hence, factors explaining the shortfall in observed associations between child feeding practices and nutrient intake and linear growth, have increasingly been the focus of scientific interest.[55]

Recent works showed promise that intervention with egg may improve linear growth in children.[56][57] Comprehensive intervention package containing eggs also found to be effective in improving linear growth in children.[58] However, the effect of egg intervention may not persist for longer period.[59] Therefore, intervention programs should consider egg intervention for a longer period with emphasis on overall diet quality and improvement of environmental conditions.[citation needed]

Pregnant and lactating mothers[edit]

Ensuring proper nutrition of pregnant and lactating mothers is essential.[7] Achieving so by helping women of reproductive age be in good nutritional status at conception is an excellent preventive measure.[7] A focus on the pre-conception period has recently been introduced as a complement to the key phase of the 1000 days of pregnancy and first two years of life.[7] An example of this are attempts to control anemia in women of reproductive age.[7] A well-nourished mother is the first step of stunting prevention, decreasing chances of the baby being born of low birth-weight, which is the first risk factor for future malnutrition.[7]

Balanced protein–energy supplementation in pregnancy seem to improve birth weight of children, with greater effects in undernourished women.[60] Meanwhile, micronutrient supplements and lipid based nutrient supplements (LNS) (providing both macro-and micronutrients) during pregnancy have shown mixed effects on birth weight and -length.[61][62] Similarly, studies supplementing LNS to mothers during pregnancy and lactation and their children during the complementary feeding period show heterogeneous results for stunting.[63][64]

After birth, in terms of interventions for the child, early initiation of breastfeeding, together with exclusive breastfeeding for the first 6 months, are pillars of stunting prevention.[7] Introducing proper complementary feeding after 6 months of age together with breastfeeding until age 2 is the next step.[7]

Policy interventions[edit]

In summary, key policy interventions for the prevention of stunting are:

  • Improvement in nutrition surveillance activities to identify rates and trends of stunting and other forms of malnutrition within countries.[7] This should be done with an equity perspective, as it is likely that stunting rates will vary greatly between different population groups. The most vulnerable should be prioritized. The same should be done for risk factors such as anemia, maternal under-nutrition, food insecurity, low birth-weight, breastfeeding practices etc. By collecting more detailed information, it is easier to ensure that policy interventions really address the root causes of stunting.
  • Political will to develop and implement national targets and strategies in line with evidence-based international guidelines as well as contextual factors.[7]
  • Designing and implementing policies promoting nutritional and health well-being of mothers and women of reproductive age.[7] The main focus should be on the 1000 days of pregnancy and first two years of life, but the pre-conception period should not be neglected as it can play a significant role in ensuring the fetus and baby's nutrition.
  • Designing and implementing policies promoting proper breastfeeding and complementary feeding practice[7] (focusing on diet diversity for both macro and micronutrients). This can ensure optimal infant nutrition as well as protection from infections that can weaken the child's body. Labor policy ensuring mothers have the chance to breastfeed should be considered where necessary.
  • Introducing interventions addressing social and other health determinants of stunting, such as poor sanitation and access to drinking water, early marriages, intestinal parasite infections, malaria and other childhood preventable disease[7] (referred to as “nutrition-sensitive interventions”), as well as the country's food security landscape. Interventions to keep adolescent girls in school can be effective at delaying marriage with subsequent nutritional benefits for both women and babies.[7] Regulating milk substitutes is also very important to ensure that as many mothers as possible breastfeed their babies, unless a clear contraindication is present.[7]
  • Broadly speaking, effective policies to reduce stunting require multisectoral approaches, strong political commitment, community involvement and integrated service delivery.[7]

Epidemiology[edit]

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.[2] Values of 40% or more are regarded as very high prevalence, and values in between as medium to high prevalence.[2]

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."[65] 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."[65] 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.[65]

The 2020 edition of FAO's Near East and North Africa − Regional Overview of Food Security and Nutrition found that in 2019 22.5 percent of children under the age of five were stunted, 9.2 percent were wasted, and 9.9 percent were overweight across several Arab and North African countries.[66][67]

Trends[edit]

As of 2015, it was estimated that there were 156 million stunted children under 5 in the world, 90% of them living in low and low-middle income countries.[68] 56% of these were in Asia, and 37% in Africa.[68] It is possible that some of these children concurrently had other forms of malnutrition, including wasting and stunting, and overweight and stunting. No statistics are currently available for these combined conditions. Stunting has been on the decline for the past 15 years, but this decline has been too slow. As a comparison, there were 255 million stunted children in 1990, 224 in 1995, 198 in 2000, 182 in 2005, 169 in 2010, and 156 in 2016.[68] The decline is happening, but it is uneven geographically, it is unequal among different groups in society, and prevalence of stunting remains at unacceptably high numbers.[68] Too many children who are not able to fulfill their genetic physical and cognitive developmental potential. A research paper published in January 2020, which mapped stunting, wasting and underweight in children in low- and middle-income countries, predicted that only five countries would meet global targets for reducing malnutrition by 2025 in all second administrative subdivisions.[4]

Over the period 2000–2015, Asia reduced its stunting prevalence from 38 to 24%, Africa from 38 to 32%, and Latin America and the Caribbean from 18 to 11%.[68] This equates to a relative reduction of 36, 17 and 39% respectively, indicating that Asia and Latin America and the Caribbean have displayed much larger improvements than Africa, which needs to address this issue with much more effort if it is to win the battle against a problem that has been crippling its development for decades. Of these regions, Latin America and the Caribbean are on track to achieve global targets set with global initiatives such as the United Nations Millennium Development Goals and the World Health Assembly targets (see following section on global targets).[68]

Sub-regional stunting rates are as follows: In Africa, the highest rates are observed in East Africa (37.5%).[68] All other Sub-Saharan sub-regions also have high rates, with 32.1% in West Africa, 31.2% in Central Africa, and 28.4% in Southern Africa.[68] North Africa is at 18%, and the Middle East at 16.2%.[68] In Asia, the highest rate is observed in South Asia at 34.4%.[68] South-East Asia is at 26.3%. Pacific Islands also display a high rate at 38.2%. Central and South America are respectively at 15.6 and 9.9%.[68] South Asia, given its very high population at over 1 billion and high prevalence rate of stunting, is the region currently hosting the highest absolute number of children with stunting[68] (60 million plus).

Looking at absolute numbers of children under 5 affected by stunting, it is obvious why current efforts and reductions are insufficient. The absolute number of stunted children has increased in Africa from 50.4 to 58.5 million in the time 2000–2015.[68] This is despite the reduction in percentage prevalence of stunting, and is due to the high rates of population growth. The data therefore indicate that the rate of reduction of stunting in Africa has not been able to counterbalance the increased number of growing children that fall into the trap of malnutrition, due to population growth in the region. This is also true in Oceania, unlike Asia and Latin America and the Caribbean where substantial absolute reductions in the number of stunted children have been observed[68] (for example, Asia reduced its number of stunted children from 133 million to 88 million between 2000 and 2015).

The reduction in stunting is closely linked to poverty reduction and the will and ability of governments to set up solid multisectoral approaches to reduce chronic malnutrition. Low income countries are the only group with more stunted children today than in the year 2000.[68] Conversely, all other countries (high-income, upper-middle income, lower-middle income) have achieved reductions in the numbers of stunted children.[68] This sadly perpetuates a vicious cycle of poverty and malnutrition, whereby malnourished children are not able to maximally contribute to economic development as adults, and poverty increases chances of malnutrition.

Research[edit]

The Water and Sanitation Program of the World Bank has investigated links between lack of sanitation and stunting in Vietnam and Lao PDR.[69] An example is in Vietnam where the 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.[69] This difference in height is irreversible and matters a great deal for a child's cognitive development and future productive potential.[citation needed]

Review articles[edit]

The Lancet has published two comprehensive series on maternal and child nutrition, in 2008[9] and 2013.[8] The series review the epidemiology of global malnutrition and analyze the state of the evidence for cost-effective interventions that should be scaled-up to achieve impact and global targets. In the first of such series,[9] investigators define the importance of the 1000 day and identify child malnutrition as being responsible for one third of all child deaths worldwide. This finding is key in that it points at malnutrition as a key determinant of child mortality that is often overlooked. When a child dies of pneumonia, malaria or diarrhea (some of the causes of child mortality in the world), it may well be that malnutrition is a key contributing factor that prevents the body from successfully fighting the infection and recovering from these diseases.[9]

In the follow-up series in 2013,[8] the focus on undernutrition is expanded to the increasing burden of obesity in both high, middle and low income countries. Several countries with high levels of child stunting and undernutrition are starting to display worrisome increasing trends of child obesity concurrently, due to increased wealth and the persistence of significant inequalities.[8] The challenges these countries face are particularly difficult as they require intervening on two levels on what has come to be called “double burden of malnutrition”.[8] As an example, in India 30% of children under 5 years of age are stunted, and 20% are overweight. Neglecting these nutritional problems is not an option anymore if countries are to escape poverty traps and provide opportunities to their people to live fulfilling productive lives without stunting.[8]

Nutritional interventions such as dietary supplementation and nutritional education have the potential to decrease stunting.[70]

Examples[edit]

The 2012 World Health Assembly, with its 194 member states, convened to discuss global issues of maternal, infant and young child nutrition, and developed a plan with 6 targets for 2025.[7] The first of such targets aims to reduce by 40% the number of children who are stunted in the world, by 2025. This would correspond to 100 million stunted children in 2025. At the current reduction rate, the predicted number in 2025 will be 127 million, indicating the need to scale-up and intensify efforts if the global community is to reach its goals.[7]

The World Bank estimates that the extra cost to achieve the reduction goal will be $8.50 yearly per stunted child, for a total of $49.6 Billion for the next decade.[71] Stunting has been shown to be one of the most cost-effective global health problems to invest in, with an estimated return on investment of $18 for every dollar spent thanks to its impact on economic productivity.[71] Despite the evidence in favor of investing in the reduction of stunting, current investments are too low at about $2.9 billion per year, with $1.6 billion coming from Governments, $0.2 billion from donors, and $1.1 paid by individuals.[71]

Sustainable Development Goals[edit]

In 2015, the United Nations and its member states agreed on a new sustainable development agenda to promote prosperity and reduce poverty, putting forward 17 Sustainable Development Goals (SDGs) to be achieved by 2030.[72] SDG 2 aims to “End hunger, achieve food security and improved nutrition, and promote sustainable agriculture”. Sub-goal 2.2. aims to “by 2030 end all forms of malnutrition, including achieving by 2025 the internationally agreed targets on stunting and wasting in children under five years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women, and older persons”.

The global community has recognized more and more the critical importance of stunting during the past decade. Investments to address it have increased but remain far from being sufficient to solve it and unleash the human potential that remains trapped in malnutrition.

The "Scaling Up Nutrition Movement (SUN)" movement is the main network of governments, non-governmental and international organizations, donors, private companies and academic institutions working together in pursuit of improved global nutrition and a world without hunger and malnutrition.[73] It was launched at the UN General Assembly of 2010 and it calls for country-led multi-sectoral strategies to address child malnutrition by scaling-up evidence-based interventions in both nutrition specific and sensitive areas. As of 2016, 50 countries have joined the SUN Movement with strategies that are aligned with international frameworks of action.[73]

Brazil[edit]

Brazil displayed a remarkable reduction in the rates of child stunting under age 5, from 37% in 1974, to 7.1% in 2007.[7] This happened in association with impressive social and economic development that reduced the numbers of Brazilians living in extreme poverty (less than $1.25 per day) from 25.6% in 1990 to 4.8% in 2008.[7] The successful reduction in child malnutrition in Brazil can be attributed to strong political commitment that led to improvements in the water and sanitation system, increased female schooling, scale-up of quality maternal and child health services, increased economic power at family level (including successful cash transfer programs), and improvements in food security throughout the country.[7]

Bangladesh[edit]

Nearly one-third of the children under five years of age are stunted in Bangladesh and 9% are severely stunted.[74] The country is on track in reducing the prevalence of stunted growth. If the current trend continues, the prevalence would be 21% in 2025, while the target is 27%.[75] Maternal undernutrition and increased pathogen load in the intestine are the major risk factors of stunting in Bangladeshi children.[76] Daily supplementation with egg, cow milk, and micronutrient powder found to be effective in improving linear growth of children in a community-based trial in Bangladesh.[57]

Peru[edit]

After a decade (1995–2005) in which stunting rates stagnated in the country, Peru designed and implemented a national strategy against child malnutrition called crecer ("grow"), which complemented a social development conditional cash-transfer program called juntos, which included a nutritional component.[7] The strategy was multisectoral in that it involved the health, education, water, sanitation and hygiene, agriculture and housing sectors and stakeholders.[7] It was led by the Government and the Prime Minister himself, and included non-governmental partners at both central, regional and community level. After the strategy was implemented, stunting went from 22.9% to 17.9% (2005–2010), with very significant improvements in rural areas where it had been more difficult to reduce stunting rates in the past.[7]

India (Maharashtra)[edit]

The State of Maharashtra in Central-Western India has been able to produce an impressive reduction in stunting rates in children under 2 years of age from 44% to 22.8% in the 2005–2012 period.[7] This is particularly remarkable given the immense challenges India has faced to address malnutrition, and that the country hosts almost half of all stunted children under 5 in the world.[7][38] This was achieved through integrated community-based programs that were designed by a central advisory body that promoted multisectoral collaboration, provided advice to policy-makers on evidence-based solutions, and advocated for the key role of the 1000 days (pregnancy and first two years of life).[7]

Nepal[edit]

In Nepal, short maternal stature,[77] low maternal education,[78][79] poor access to health services[79] and poverty[77][78] are strong determinants for stunting. However, in Nepal, stunting has decreased from 57% in 2001 to 36% in 2016, with lower prevalence in urban than in rural settings.[80]

See also[edit]

References[edit]

 This article incorporates text by Marianne Sandsmark Morseth available under the CC BY-SA 3.0 license.

  1. ^ "Malnutrition". www.who.int. Retrieved 2023-02-15.
  2. ^ a b c d e f g "Nutrition Landscape Information System (NLiS)". WHO. Retrieved 12 November 2014.
  3. ^ nina (2022-07-06). "The State of Food Security and Nutrition in the World 2022". UNICEF DATA. Retrieved 2023-02-15.
  4. ^ a b Local Burden of Disease Child Growth Failure Collaborators (January 2020). "Mapping child growth failure across low- and middle-income countries". Nature. 577 (7789): 231–234. Bibcode:2020Natur.577..231L. doi:10.1038/s41586-019-1878-8. PMC 7015855. PMID 31915393.
  5. ^ Spears, D. (2013). How much international variation in child height can sanitation explain? - Policy research working paper. The World Bank, Sustainable Development Network, Water and Sanitation Program
  6. ^ De Sanctis V, Soliman A, Alaaraj N, Ahmed S, Alyafei F, Hamed N (February 2021). "Early and Long-term Consequences of Nutritional Stunting: From Childhood to Adulthood". Acta Bio-Medica. 92 (1): e2021168. doi:10.23750/abm.v92i1.11346. PMC 7975963. PMID 33682846.
  7. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac "World Health Assembly Global Nutrition Targets 2025: Stunting Policy Brief, World Health Organization 2014" (PDF). Archived from the original (PDF) on September 9, 2014.
  8. ^ a b c d e f g h i j "Maternal and child nutrition". Series from the Lancet journals. June 2013.
  9. ^ a b c d e f g h "Maternal and child undernutrition". Series from the Lancet journals. January 2008.
  10. ^ a b Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, et al. (January 2008). "Maternal and child undernutrition: global and regional exposures and health consequences". Lancet. 371 (9608): 243–260. doi:10.1016/S0140-6736(07)61690-0. PMID 18207566. S2CID 3910132.
  11. ^ McDonald CM, Olofin I, Flaxman S, Fawzi WW, Spiegelman D, Caulfield LE, et al. (April 2013). "The effect of multiple anthropometric deficits on child mortality: meta-analysis of individual data in 10 prospective studies from developing countries". The American Journal of Clinical Nutrition. 97 (4): 896–901. doi:10.3945/ajcn.112.047639. PMID 23426036.
  12. ^ Olofin I, McDonald CM, Ezzati M, Flaxman S, Black RE, Fawzi WW, et al. (2013). "Associations of suboptimal growth with all-cause and cause-specific mortality in children under five years: a pooled analysis of ten prospective studies". PLOS ONE. 8 (5): e64636. Bibcode:2013PLoSO...864636O. doi:10.1371/journal.pone.0064636. PMC 3667136. PMID 23734210.
  13. ^ Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev HS (January 2008). "Maternal and child undernutrition: consequences for adult health and human capital". Lancet. 371 (9609): 340–357. doi:10.1016/S0140-6736(07)61692-4. PMC 2258311. PMID 18206223.
  14. ^ "Levels and trends in child malnutrition" (PDF). United Nations Children's Fund; World Health Organization; World Bank Group. 2017. Retrieved 12 May 2017.
  15. ^ Stop Stunting in South Asia. A common Narrative on Marternal and Child Nutrition. UNICEF Regional Office for South Asia (Report). Kathmandu, Nepal: United Nation's Children's fund. 2015.
  16. ^ Scheffler C, Hermanussen M, Bogin B, et al. (March 2020). "Stunting is not a synonym of malnutrition". Eur J Clin Nutr. 74 (3): 377–386. doi:10.1038/s41430-019-0439-4. PMID 31142828.
  17. ^ Scheffler C, Hermanussen M (May 2022). "Stunting is the natural condition of human height". Am J Hum Biol. 34 (5): e23693. doi:10.1002/ajhb.23693. PMID 34761833. S2CID 243987638.
  18. ^ a b Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. (August 2013). "Maternal and child undernutrition and overweight in low-income and middle-income countries". Lancet. 382 (9890): 427–451. doi:10.1016/S0140-6736(13)60937-X. PMID 23746772. S2CID 12237910.
  19. ^ Allen LH (2012). "Global dietary patterns and diets in childhood: implications for health outcomes". Annals of Nutrition & Metabolism. 61 (Suppl 1): 29–37. doi:10.1159/000346185. PMID 23343945. S2CID 8299631.
  20. ^ Victora CG, de Onis M, Hallal PC, Blössner M, Shrimpton R (March 2010). "Worldwide timing of growth faltering: revisiting implications for interventions". Pediatrics. 125 (3): e473–80. doi:10.1542/peds.2009-1519. PMID 20156903. S2CID 21204674.
  21. ^ Martorell R, Zongrone A (July 2012). "Intergenerational influences on child growth and undernutrition". Paediatric and Perinatal Epidemiology. 26 (Suppl 1): 302–14. doi:10.1111/j.1365-3016.2012.01298.x. PMID 22742617. S2CID 28533635.
  22. ^ a b Danaei G, Andrews KG, Sudfeld CR, Fink G, McCoy DC, Peet E, et al. (November 2016). "Risk Factors for Childhood Stunting in 137 Developing Countries: A Comparative Risk Assessment Analysis at Global, Regional, and Country Levels". PLOS Medicine. 13 (11): e1002164. doi:10.1371/journal.pmed.1002164. PMC 5089547. PMID 27802277.
  23. ^ a b c Smith LC, Haddad L (April 2015). "Reducing Child Undernutrition: Past Drivers and Priorities for the Post-MDG Era". World Development. 68: 180–204. doi:10.1016/j.worlddev.2014.11.014.
  24. ^ a b A Balalian A, Simonyan H, Hekimian K, Deckelbaum RJ, Sargsyan A (December 2017). "Prevalence and determinants of stunting in a conflict-ridden border region in Armenia - a cross-sectional study". BMC Nutrition. 3: 85. doi:10.1186/s40795-017-0204-9. PMC 7050870. PMID 32153861.
  25. ^ Caulfield LE, Huffman SL, Piwoz EG (January 1999). "Interventions to Improve Intake of Complementary Foods by Infants 6 to 12 Months of Age in Developing Countries: Impact on Growth and on the Prevalence of Malnutrition and Potential Contribution to Child Survival". Food and Nutrition Bulletin. 20 (2): 183–200. doi:10.1177/156482659902000203. ISSN 0379-5721.
  26. ^ Issaka AI, Agho KE, Page AN, Burns PL, Stevens GJ, Dibley MJ (October 2015). "Determinants of suboptimal complementary feeding practices among children aged 6-23 months in four anglophone West African countries". Maternal & Child Nutrition. 11 (Suppl 1): 14–30. doi:10.1111/mcn.12194. PMC 6860259. PMID 26364789.
  27. ^ Akombi BJ, Agho KE, Hall JJ, Wali N, Renzaho AM, Merom D (August 2017). "Stunting, Wasting and Underweight in Sub-Saharan Africa: A Systematic Review". International Journal of Environmental Research and Public Health. 14 (8): 863. doi:10.3390/ijerph14080863. PMC 5580567. PMID 28788108. Material was copied from this source, which is available under a Creative Commons Attribution 4.0 International License.
  28. ^ a b Akhtar S (October 2016). "Malnutrition in South Asia-A Critical Reappraisal". Critical Reviews in Food Science and Nutrition. 56 (14): 2320–2330. doi:10.1080/10408398.2013.832143. PMID 25830938. S2CID 205691877.
  29. ^ Christian P, Lee SE, Donahue Angel M, Adair LS, Arifeen SE, Ashorn P, et al. (October 2013). "Risk of childhood undernutrition related to small-for-gestational age and preterm birth in low- and middle-income countries". International Journal of Epidemiology. 42 (5): 1340–1355. doi:10.1093/ije/dyt109. PMC 3816349. PMID 23920141.
  30. ^ Li H, Stein AD, Barnhart HX, Ramakrishnan U, Martorell R (June 2003). "Associations between prenatal and postnatal growth and adult body size and composition". The American Journal of Clinical Nutrition. 77 (6): 1498–505. doi:10.1093/ajcn/77.6.1498. PMID 12791630.
  31. ^ Prendergast AJ, Humphrey JH (November 2014). "The stunting syndrome in developing countries". Paediatrics and International Child Health. 34 (4): 250–65. doi:10.1179/2046905514Y.0000000158. PMC 4232245. PMID 25310000.
  32. ^ Walker CL, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, et al. (April 2013). "Global burden of childhood pneumonia and diarrhoea". Lancet. 381 (9875): 1405–1416. doi:10.1016/S0140-6736(13)60222-6. PMC 7159282. PMID 23582727.
  33. ^ Owino V, Ahmed T, Freemark M, Kelly P, Loy A, Manary M, Loechl C (December 2016). "Environmental Enteric Dysfunction and Growth Failure/Stunting in Global Child Health". Pediatrics. 138 (6): e20160641. doi:10.1542/peds.2016-0641. PMID 27940670. S2CID 19436395.
  34. ^ a b Budge S, Parker AH, Hutchings PT, Garbutt C (April 2019). "Environmental enteric dysfunction and child stunting". Nutrition Reviews. 77 (4): 240–253. doi:10.1093/nutrit/nuy068. PMC 6394759. PMID 30753710.
  35. ^ Denno DM, Tarr PI, Nataro JP (December 2017). "Environmental Enteric Dysfunction: A Case Definition for Intervention Trials". The American Journal of Tropical Medicine and Hygiene. 97 (6): 1643–1646. doi:10.4269/ajtmh.17-0183. PMC 5805039. PMID 29016294.
  36. ^ Marie C, Ali A, Chandwe K, Petri WA, Kelly P (September 2018). "Pathophysiology of environmental enteric dysfunction and its impact on oral vaccine efficacy". Mucosal Immunology. 11 (5): 1290–1298. doi:10.1038/s41385-018-0036-1. PMID 29988114. S2CID 256559217.
  37. ^ a b Velleman Y, Pugh I (2013). "Under-nutrition and water, sanitation and hygiene - Water, sanitation and hygiene (WASH) play a fundamental role in improving nutritional outcomes". Briefing Note. UK: WaterAid and Share. A successful global effort to tackle under-nutrition must include WASH.
  38. ^ a b Chambers R, von Medeazza G (2014). Reframing Undernutrition: Faecally-Transmitted Infections and the 5 As. IDS Working Paper 450 (Report). Brighton: Institute of Development Studies (IDS).
  39. ^ Chen RY, Kung VL, Das S, Hossain MS, Hibberd MC, Guruge J, et al. (July 2020). "Duodenal Microbiota in Stunted Undernourished Children with Enteropathy". The New England Journal of Medicine. 383 (4): 321–333. doi:10.1056/NEJMoa1916004. PMC 7289524. PMID 32706533.
  40. ^ Cumming O, Cairncross S (May 2016). "Can water, sanitation and hygiene help eliminate stunting? Current evidence and policy implications". Maternal & Child Nutrition. 12 (Suppl 1): 91–105. doi:10.1111/mcn.12258. PMC 5084825. PMID 27187910.
  41. ^ Ngure FM, Reid BM, Humphrey JH, Mbuya MN, Pelto G, Stoltzfus RJ (January 2014). "Water, sanitation, and hygiene (WASH), environmental enteropathy, nutrition, and early child development: making the links". Annals of the New York Academy of Sciences. 1308 (1): 118–128. Bibcode:2014NYASA1308..118N. doi:10.1111/nyas.12330. PMID 24571214. S2CID 21280033.
  42. ^ Millward DJ (June 2017). "Nutrition, infection and stunting: the roles of deficiencies of individual nutrients and foods, and of inflammation, as determinants of reduced linear growth of children". Nutrition Research Reviews. 30 (1): 50–72. doi:10.1017/S0954422416000238. PMID 28112064. S2CID 206289300.
  43. ^ "The Lancet series on Maternal and Child Nutrition". The Lancet. 6 June 2013. Retrieved 8 November 2014.
  44. ^ Humphrey JH (September 2009). "Child undernutrition, tropical enteropathy, toilets, and handwashing". Lancet. 374 (9694): 1032–1035. doi:10.1016/s0140-6736(09)60950-8. PMID 19766883. S2CID 13851530.
  45. ^ a b Flachenberg F, Kopplow R (2014). "How to better link WASH and nutrition programmes". Concern Worldwide Technical Briefing Note. Archived from the original on 2015-12-28.
  46. ^ Lake A (2017-01-14). "The first 1,000 days of a child's life are the most important to their development - and our economic success". World Economic Forum. Retrieved 2021-09-11.
  47. ^ Ramakrishnan U, Goldenberg T, Allen LH (November 2011). "Do multiple micronutrient interventions improve child health, growth, and development?". The Journal of Nutrition. 141 (11): 2066–75. doi:10.3945/jn.111.146845. PMID 21956959.
  48. ^ Iannotti LL, Dulience SJ, Green J, Joseph S, François J, Anténor ML, Lesorogol C, Mounce J, Nickerson NM (January 2014). "Linear growth increased in young children in an urban slum of Haiti: a randomized controlled trial of a lipid-based nutrient supplement". The American Journal of Clinical Nutrition. 99 (1): 198–208. doi:10.3945/ajcn.113.063883. PMC 3862455. PMID 24225356.
  49. ^ Maleta KM, Phuka J, Alho L, Cheung YB, Dewey KG, Ashorn U, et al. (August 2015). "Provision of 10-40 g/d Lipid-Based Nutrient Supplements from 6 to 18 Months of Age Does Not Prevent Linear Growth Faltering in Malawi". The Journal of Nutrition. 145 (8): 1909–1915. doi:10.3945/jn.114.208181. PMID 26063066.
  50. ^ Menon P, Nguyen PH, Saha KK, Khaled A, Sanghvi T, Baker J, et al. (October 2016). "Combining Intensive Counseling by Frontline Workers with a Nationwide Mass Media Campaign Has Large Differential Impacts on Complementary Feeding Practices but Not on Child Growth: Results of a Cluster-Randomized Program Evaluation in Bangladesh". The Journal of Nutrition. 146 (10): 2075–2084. doi:10.3945/jn.116.232314. PMC 5037872. PMID 27581575.
  51. ^ Rawat R, Nguyen PH, Tran LM, Hajeebhoy N, Nguyen HV, Baker J, et al. (April 2017). "Social Franchising and a Nationwide Mass Media Campaign Increased the Prevalence of Adequate Complementary Feeding in Vietnam: A Cluster-Randomized Program Evaluation". The Journal of Nutrition. 147 (4): 670–679. doi:10.3945/jn.116.243907. PMC 5368587. PMID 28179488.
  52. ^ a b Dewey KG, Adu-Afarwuah S (April 2008). "Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries". Maternal & Child Nutrition. 4 (Suppl 1): 24–85. doi:10.1111/j.1740-8709.2007.00124.x. PMC 6860813. PMID 18289157.
  53. ^ Shrimpton R, Victora CG, de Onis M, Lima RC, Blössner M, Clugston G (May 2001). "Worldwide timing of growth faltering: implications for nutritional interventions". Pediatrics. 107 (5): E75. doi:10.1542/peds.107.5.e75. PMID 11331725.
  54. ^ Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, et al. (February 2008). "What works? Interventions for maternal and child undernutrition and survival". Lancet. 371 (9610): 417–440. doi:10.1016/S0140-6736(07)61693-6. PMID 18206226. S2CID 18345055.
  55. ^ McKay S, Gaudier E, Campbell DI, Prentice AM, Albers R (September 2010). "Environmental enteropathy: new targets for nutritional interventions". International Health. 2 (3): 172–80. doi:10.1016/j.inhe.2010.07.006. PMID 24037697.
  56. ^ Iannotti LL, Lutter CK, Stewart CP, Gallegos Riofrío CA, Malo C, Reinhart G, et al. (July 2017). "Eggs in Early Complementary Feeding and Child Growth: A Randomized Controlled Trial". Pediatrics. 140 (1): e20163459. doi:10.1542/peds.2016-3459. PMID 28588101. S2CID 24732575.
  57. ^ a b Mahfuz M, Alam MA, Das S, Fahim SM, Hossain MS, Petri WA, et al. (February 2020). "Daily Supplementation With Egg, Cow Milk, and Multiple Micronutrients Increases Linear Growth of Young Children with Short Stature". The Journal of Nutrition. 150 (2): 394–403. doi:10.1093/jn/nxz253. hdl:2292/59199. PMID 31665385.
  58. ^ Ara G, Sanin KI, Khanam M, Sarker MS, Tofail F, Nahar B, et al. (December 2022). "A comprehensive intervention package improves the linear growth of children under 2-years-old in rural Bangladesh: a community-based cluster randomized controlled trial". Scientific Reports. 12 (1): 21962. Bibcode:2022NatSR..1221962A. doi:10.1038/s41598-022-26269-w. PMC 9763408. PMID 36536016.
  59. ^ Iannotti LL, Chapnick M, Nicholas J, Gallegos-Riofrio CA, Moreno P, Douglas K, et al. (April 2020). "Egg intervention effect on linear growth no longer present after two years". Maternal & Child Nutrition. 16 (2): e12925. doi:10.1111/mcn.12925. PMC 7083396. PMID 31849201.
  60. ^ Imdad A, Bhutta ZA (July 2012). "Maternal nutrition and birth outcomes: effect of balanced protein-energy supplementation". Paediatric and Perinatal Epidemiology. 26 (Suppl 1): 178–90. doi:10.1111/j.1365-3016.2012.01308.x. PMID 22742610.
  61. ^ Huybregts L, Roberfroid D, Lanou H, Menten J, Meda N, Van Camp J, Kolsteren P (December 2009). "Prenatal food supplementation fortified with multiple micronutrients increases birth length: a randomized controlled trial in rural Burkina Faso". The American Journal of Clinical Nutrition. 90 (6): 1593–600. doi:10.3945/ajcn.2009.28253. PMID 19812173. S2CID 10474629.
  62. ^ Adu-Afarwuah S, Lartey A, Okronipa H, Ashorn P, Zeilani M, Peerson JM, Arimond M, Vosti S, Dewey KG (April 2015). "Lipid-based nutrient supplement increases the birth size of infants of primiparous women in Ghana". The American Journal of Clinical Nutrition. 101 (4): 835–46. doi:10.3945/ajcn.114.091546. PMID 25833980.
  63. ^ Dewey KG, Mridha MK, Matias SL, Arnold CD, Cummins JR, Khan MS, Maalouf-Manasseh Z, Siddiqui Z, Ullah MB, Vosti SA (April 2017). "Lipid-based nutrient supplementation in the first 1000 d improves child growth in Bangladesh: a cluster-randomized effectiveness trial". The American Journal of Clinical Nutrition. 105 (4): 944–957. doi:10.3945/ajcn.116.147942. hdl:10361/8919. PMID 28275125. S2CID 25969492.
  64. ^ Ashorn P, Alho L, Ashorn U, Cheung YB, Dewey KG, Gondwe A, et al. (June 2015). "Supplementation of Maternal Diets during Pregnancy and for 6 Months Postpartum and Infant Diets Thereafter with Small-Quantity Lipid-Based Nutrient Supplements Does Not Promote Child Growth by 18 Months of Age in Rural Malawi: A Randomized Controlled Trial". The Journal of Nutrition. 145 (6): 1345–1353. doi:10.3945/jn.114.207225. PMID 25926413.
  65. ^ a b c UNICEF (2013). Improving child nutrition : the achievable imperative for global progress. United Nations Children’s Fund (UNICEF), New York, USA. ISBN 978-92-806-4686-3. Archived from the original on May 13, 2013.
  66. ^ Near East and North Africa Regional Overview of Food Security and Nutrition 2020. Enhancing resilience of food systems in the Arab States. Cairo: FAO. 2021. doi:10.4060/cb4902en. ISBN 978-92-5-134471-2. S2CID 241502462. Archived from the original on 2023-01-15. Retrieved 2023-01-15.
  67. ^ NENA Regional Network on Nutrition-sensitive Food System. Empowering women and ensuring gender equality in agri-food systems to achieve better nutrition − Technical brief. Cairo: FAO. 2023. doi:10.4060/cc3657en. ISBN 978-92-5-137438-2. Archived from the original on 2022-12-17. Retrieved 2023-01-15.
  68. ^ a b Quattri M, Smets S, Inthavong V (2014). "Investing in the Next Generation - Children grow taller, and smarter, in rural, mountainous villages of Lao PDR where all community members use improved sanitation" (PDF). WSP (Water and Sanitation Program). USA: World Bank.
  69. ^ Goudet SM, Bogin BA, Madise NJ, Griffiths PL (June 2019). "Nutritional interventions for preventing stunting in children (birth to 59 months) living in urban slums in low- and middle-income countries (LMIC)". The Cochrane Database of Systematic Reviews. 6 (6): CD011695. doi:10.1002/14651858.CD011695.pub2. PMC 6572871. PMID 31204795.
  70. ^ a b c Procee P (May 2013). Integrated Safeguards Data Sheet (Appraisal Stage)-Guangxi Laibin Water Environment Project-P126817 (Report). The World Bank. pp. 1–9.
  71. ^ "United Nations Sustainable Development Goals". UN-DESA/DSD. 1 December 2014. Archived from the original on 4 January 2017.
  72. ^ a b "Working together in the fight against malnutrition in all its forms". scalingupnutrition.org.
  73. ^ "Bangladesh Demographic and Health Survey 2017-18". The DHS Program. National Institute of Population Research and Training (NIPORT). Ministry of Health and Family Welfare. October 2020.
  74. ^ Fahim SM, Hossain MS, Sen S, Das S, Hosssain M, Ahmed T, et al. (December 2021). "Nutrition and Food Security in Bangladesh: Achievements, Challenges, and Impact of the COVID-19 Pandemic". The Journal of Infectious Diseases. 224 (Supplement_7): S901–S909. doi:10.1093/infdis/jiab473. PMC 8687095. PMID 34668556.
  75. ^ MAL-ED Network Investigators (October 2017). "Childhood stunting in relation to the pre- and postnatal environment during the first 2 years of life: The MAL-ED longitudinal birth cohort study". PLOS Medicine. 14 (10): e1002408. doi:10.1371/journal.pmed.1002408. PMC 5656304. PMID 29069076.
  76. ^ a b Kim R, Mejía-Guevara I, Corsi DJ, Aguayo VM, Subramanian SV (August 2017). "Relative importance of 13 correlates of child stunting in South Asia: Insights from nationally representative data from Afghanistan, Bangladesh, India, Nepal, and Pakistan". Social Science & Medicine. 187: 144–154. doi:10.1016/j.socscimed.2017.06.017. PMID 28686964.
  77. ^ a b Devkota MD, Adhikari RK, Upreti SR (May 2016). "Stunting in Nepal: looking back, looking ahead". Maternal & Child Nutrition. 12 (Suppl 1): 257–9. doi:10.1111/mcn.12286. PMC 5084730. PMID 27187924.
  78. ^ a b Cunningham KH, Singh A, Karmacharya C, Rana PR (2017). "Maternal and Child Nutrition in Nepal: Examining drivers of progress from the mid- 1990s to 2010s". Global Food Security. 13: 30–37. doi:10.1016/j.gfs.2017.02.001.
  79. ^ Nepal demographic and health survey 2016. Ministry of Health; New ERA; ICF. (Report). Kathmandu, Nepal: Ministry of Health. 2017.

External links[edit]