An estimated 165 million children are stunted due to the combined effects of poor nutrition, repeated infection and inadequate psychosocial stimulation. The complementary feeding period, generally corresponding to age 6–24 months, represents an important period of sensitivity to stunting with lifelong, possibly irrevocable consequences. Interventions to improve complementary feeding practices or the nutritional quality of complementary foods must take into consideration the contextual as well as proximal determinants of stunting. This review presents a conceptual framework that highlights the role of complementary feeding within the layers of contextual and causal factors that lead to stunted growth and development and the resulting short‐ and long‐term consequences. Contextual factors are organized into the following groups: political economy; health and health care systems; education; society and culture; agriculture and food systems; and water, sanitation and environment. We argue that these community and societal conditions underlie infant and young child feeding practices, which are a central pillar to healthy growth and development, and can serve to either impede or enable progress. Effectiveness studies with a strong process evaluation component are needed to identify transdisciplinary solutions. Programme and policy interventions aimed at preventing stunting should be informed by careful assessment of these factors at all levels.
This paper outlines the economic rationale for investments that reduce stunting. We present a framework that illustrates the functional consequences of stunting in the 1000 days after conception throughout the life cycle: from childhood through to old age. We summarize the key empirical literature around each of the links in the life cycle, highlighting gaps in knowledge where they exist. We construct credible estimates of benefit–cost ratios for a plausible set of nutritional interventions to reduce stunting. There are considerable challenges in doing so that we document. We assume an uplift in income of 11% due to the prevention of one fifth of stunting and a 5% discount rate of future benefit streams. Our estimates of the country‐specific benefit‐cost ratios for investments that reduce stunting in 17 high‐burden countries range from 3.6 (DRC) to 48 (Indonesia) with a median value of 18 (Bangladesh). Mindful that these results hinge on a number of assumptions, they compare favourably with other investments for which public funds compete.
In 2012, the World Health Organization adopted a resolution on maternal, infant and young child nutrition that included a global target to reduce by 40% the number of stunted under‐five children by 2025. The target was based on analyses of time series data from 148 countries and national success stories in tackling undernutrition. The global target translates to a 3.9% reduction per year and implies decreasing the number of stunted children from 171 million in 2010 to about 100 million in 2025. However, at current rates of progress, there will be 127 million stunted children by 2025, that is, 27 million more than the target or a reduction of only 26%. The translation of the global target into national targets needs to consider nutrition profiles, risk factor trends, demographic changes, experience with developing and implementing nutrition policies, and health system development. This paper presents a methodology to set individual country targets, without precluding the use of others. Any method applied will be influenced by country‐specific population growth rates. A key question is what countries should do to meet the target. Nutrition interventions alone are almost certainly insufficient, hence the importance of ongoing efforts to foster nutrition‐sensitive development and encourage development of evidence‐based, multisectoral plans to address stunting at national scale, combining direct nutrition interventions with strategies concerning health, family planning, water and sanitation, and other factors that affect the risk of stunting. In addition, an accountability framework needs to be developed and surveillance systems strengthened to monitor the achievement of commitments and targets.
Concerns about the increasing rates of obesity in developing countries have led many policy makers to question the impacts of maternal and early child nutrition on risk of later obesity. The purposes of the review are to summarise the studies on the associations between nutrition during pregnancy and infant feeding practices with later obesity from childhood through adulthood and to identify potential ways for preventing obesity in developing countries. As few studies were identified in developing countries, key studies in developed countries were included in the review. Poor prenatal dietary intakes of energy, protein and micronutrients were shown to be associated with increased risk of adult obesity in offspring. Female offspring seem to be more vulnerable than male offspring when their mothers receive insufficient energy during pregnancy. By influencing birthweight, optimal prenatal nutrition might reduce the risk of obesity in adults. While normal birthweights (2500–3999 g) were associated with higher body mass index (BMI) as adults, they generally were associated with higher fat‐free mass and lower fat mass compared with low birthweights (<2500 g). Low birthweight was associated with higher risk of metabolic syndrome and central obesity in adults. Breastfeeding and timely introduction of complementary foods were shown to protect against obesity later in life in observational studies. High‐protein intake during early childhood however was associated with higher body fat mass and obesity in adulthood. In developed countries, increased weight gain during the first 2 years of life was associated with a higher BMI in adulthood. However, recent studies in developing countries showed that higher BMI was more related to greater lean body mass than fat mass. It appears that increased length at 2 years of age was positively associated with height, weight and fat‐free mass, and was only weakly associated with fat mass. The protective associations between breastfeeding and obesity may differ in developing countries compared to developed countries because many studies in developed countries used formula feeding as a control. Future research on the relationship between breastfeeding, timely introduction of complementary feeding or rapid weight gain and obesity are warranted in developing countries. The focus of interventions to reduce risk of obesity in later life in developing countries could include: improving maternal nutritional status during pregnancy to reduce low birthweight; enhancing breastfeeding (including durations of exclusive and total breastfeeding); timely introduction of high‐quality complementary foods (containing micronutrients and essential fats) but not excessive in protein; further evidence is needed to understand the extent of weight gain and length gain during early childhood are related to body composition in later life.
Inadequate feeding and care may contribute to high rates of stunting and underweight among children in rural families in India. This cluster‐randomized trial tested the hypothesis that teaching caregivers appropriate complementary feeding and strategies for how to feed and play responsively through home‐visits would increase children's dietary intake, growth and development compared with home‐visit‐complementary feeding education alone or routine care. Sixty villages in Andhra Pradesh were randomized into three groups of 20 villages with 200 mother–infant dyads in each group. The control group (CG) received routine Integrated Child Development Services (ICDS); the complementary feeding group (CFG) received the ICDS plus the World Health Organization recommendations on breastfeeding and complementary foods; and the responsive complementary feeding and play group (RCF&PG) received the same intervention as the CFG plus skills for responsive feeding and psychosocial stimulation. Both intervention groups received bi‐weekly visits by trained village women. The groups did not differ at 3 months on socioeconomic status, maternal and child nutritional indices, and maternal depression. After controlling for potential confounding factors using the mixed models approach, the 12‐month intervention to the CFG and RCF&PG significantly (P < 0.05) increased median intakes of energy, protein, Vitamin A, calcium (CFG), iron and zinc, reduced stunting [0.19, confidence interval (CI): 0.0–0.4] in the CFG (but not RCF&PG) and increased (P < 0.01) Bayley Mental Development scores (mean = 3.1, CI: 0.8–5.3) in the RCF&PG (but not CFG) compared with CG. Community‐based educational interventions can improve dietary intake, length (CFG) and mental development (RCF&PG) for children under 2 years in food‐secure rural Indian families.
Good clinical practice recommends folic acid supplementation 1 month prior to pregnancy and during the first trimester to prevent congenital malformations. However, high rates of fetal growth and development in later pregnancy may increase the demand for folate. Folate and vitamins B12 and B6 are required for DNA synthesis and cell growth, and are involved in homocysteine metabolism. The primary aim of this study was to determine if maternal folate, vitamin B12, vitamin B6 and homocysteine concentrations at 18–20 weeks gestation are associated with subsequent adverse pregnancy outcomes, including pre‐eclampsia and intrauterine growth restriction (IUGR). The secondary aim was to investigate maternal B vitamin concentrations with DNA damage markers in maternal lymphocytes. A prospective observational study was conducted at the Women's and Children's Hospital, Adelaide, South Australia. One hundred and thirty‐seven subjects were identified prior to 20 weeks gestation as at high or low risk for subsequent adverse pregnancy outcome by senior obstetricians. Clinical status, dietary information, circulating micronutrients and genome damage biomarkers were assessed at 18–20 weeks gestation. Women who developed IUGR had reduced red blood cell (RBC) folate (P < 0.001) and increased plasma homocysteine concentrations (P < 0.001) compared with controls. Maternal DNA damage, represented by micronucleus frequency and nucleoplasmic bridges in lymphocytes, was positively correlated with homocysteine (r = 0.179, P = 0.038 and r = 0.171, P = 0.047, respectively). Multivariate regression analysis revealed RBC folate was a strong predictor of IUGR (P = 0.006). This study suggests that low maternal RBC folate and high homocysteine values in mid pregnancy are associated with subsequent reduced fetal growth.
The objectives of this study were to quantify the prevalence of vitamin D insufficiency and deficiency in pregnancy, explore associated risk factors and discuss the public health implications. The study used retrospective analysis of randomly selected data. This is the first report on serum vitamin D levels in an unselected multi‐ethnic population of pregnant women collected between April 2008 and March 2009. Women with sufficient stored serum were randomly selected from among all women who delivered between April 2008 and March 2009. Serum vitamin D levels were determined using liquid chromatography coupled to tandem mass spectrometry. Vitamin D levels were analysed with respect to ethnicity (marking skin tone), calendar quartile, body mass index (BMI), trimester and parity. Deficiency was defined as 75 nmol L−1. Three hundred and forty‐six women were included and represented the total population regarding skin tone, quartile, BMI, gestation and parity. Overall, 18% [95% confidence interval (CI): 15–23%] of sample women had adequate vitamin D levels; 36% were deficient, 45% insufficient. Among women with dark skin, only 8% (95% CI: 5–12%) had adequate levels compared with 43% (95% CI: 33–53%) of those with light skin. Obese women were found have significantly lower vitamin D levels than non‐obese women. Vitamin D deficiency and insufficiency are prevalent year‐round among pregnant women in North West London, especially those with darker skin. Existing supplementation guidelines should be supported; however, other measures are required to improve status among all women.
Suboptimal complementary feeding practices contribute to a rapid increase in the prevalence of stunting in young children from age 6 months. The design of effective programmes to improve infant and young child feeding requires a sound understanding of the local situation and a systematic process for prioritizing interventions, integrating them into existing delivery platforms and monitoring their implementation and impact. The identification of adequate food‐based feeding recommendations that respect locally available foods and address gaps in nutrient availability is particularly challenging. We describe two tools that are now available to strengthen infant and young child‐feeding programming at national and subnational levels. ProPAN is a set of research tools that guide users through a step‐by‐step process for identifying problems related to young child nutrition; defining the context in which these problems occur; formulating, testing, and selecting behaviour‐change recommendations and nutritional recipes; developing the interventions to promote them; and designing a monitoring and evaluation system to measure progress towards intervention goals. Optifood is a computer‐based platform based on linear programming analysis to develop nutrient‐adequate feeding recommendations at lowest cost, based on locally available foods with the addition of fortified products or supplements when needed, or best recommendations when the latter are not available. The tools complement each other and a case study from Peru illustrates how they have been used. The readiness of both instruments will enable partners to invest in capacity development for their use in countries and strengthen programmes to address infant and young child feeding and prevent malnutrition.
Stunting, a form of undernutrition, is the best measure of child health inequalities as it captures multiple dimensions of children's health, development and the environment where they live. The aim of this study was to quantify the predictors of childhood stunting in Nigeria. This study used data obtained from the 2008 Nigeria Demographic and Health Survey (NDHS). A total of 28 647 children aged 0–59 months included in NDHS in 2008 were analysed in this study. We applied multilevel multivariate logistic regression analysis in which individual‐level factors were at the first level and community‐level factors at the second level. The percentage change in variance of the full model accounted for about 46% in odds of stunting across the communities. The present study found that the following predictors increased the odds of childhood stunting: male gender, age above 11 months, multiple birth, low birthweight, low maternal education, low maternal body mass index, poor maternal health‐seeking behaviour, poor household wealth and short birth interval. The community‐level predictors found to have significant association with childhood stunting were: child residing in community with high illiteracy rate and North West and North East regions of the country. In conclusion, this study revealed that both individual‐ and community‐level factors are significant determinants of childhood stunting in Nigeria.
The concept of a focused ethnographic study (FES) emerged as a new methodology to answer specific sets of questions that are required by agencies, policymakers, programme planners or by project implementation teams in order to make decisions about future actions with respect to social, public health or nutrition interventions, and for public–private partnership activities. This paper describes the FES on complementary feeding that was commissioned by the Global Alliance for Improved Nutrition and highlights findings from studies conducted in three very different country contexts (Ghana, South Africa and Afghanistan) burdened by high levels of malnutrition in older infants and young children (IYC). The findings are analysed from the perspective of decision‐making for future interventions. In Ghana, a primary finding was that in urban areas the fortified, but not instant cereal, which was being proposed, would not be an appropriate intervention, given the complex balancing of time, costs and health concerns of caregivers. In both urban and rural South Africa, home fortification products such as micronutrient powders and small quantity, lipid‐based nutrient supplements (LNS) are potentially feasible interventions, and would require thoughtful behaviour change communication programmes to support their adoption. Among the important results for future decision‐making for interventions in Afghanistan are the findings that there is little cultural recognition of the concept of special foods for infants, and that within households food procurement for IYC are in the hands of men, whereas food preparation and feeding are women's responsibilities.
Infant's age at introduction to certain complementary foods (CF) has in previous studies been associated with islet autoimmunity, which is an early marker for type 1 diabetes (T1D). Various maternal sociodemographic factors have been found to be associated with early introduction to CF. The aims of this study were to describe early infant feeding and identify sociodemographic factors associated with early introduction to CF in a multinational cohort of infants with an increased genetic risk for T1D. The Environmental Determinants of Diabetes in the Young study is a prospective longitudinal birth cohort study. Infants (N = 6404) screened for T1D high risk human leucocyte antigen‐DQ genotypes (DR3/4, DR4/4, DR4/8, DR3/3, DR4/4, DR4/1, DR4/13, DR4/9 and DR3/9) were followed for 2 years at six clinical research centres: three in the United States (Colorado, Georgia/Florida, Washington) and three in Europe (Sweden, Finland, Germany). Age at first introduction to any food was reported at clinical visits every third month from the age of 3 months. Maternal sociodemographic data were self‐reported through questionnaires. Age at first introduction to CF was primarily associated with country of residence. Root vegetables and fruits were usually the first CF introduced in Finland and Sweden and cereals were usually the first CF introduced in the United States. Between 15% and 20% of the infants were introduced to solid foods before the age of 4 months. Young maternal age (<25 years), low educational level (<12 years) and smoking during pregnancy were significant predictors of early introduction to CF in this cohort. Infants with a relative with T1D were more likely to be introduced to CF later.
Little is known about the dietary patterns of toddlers. This period of life is important for forming good dietary habits later in life. Using dietary data collected via food frequency questionnaire (FFQ) at 2 years of age, we examined the dietary patterns of children from the Avon Longitudinal Study of Parents and Children (ALSPAC). Principal component analysis was performed for 9599 children and three patterns were extracted: ‘family foods’ associated with traditional British family foods such as meat, fish, puddings, potatoes and vegetables; ‘sweet and easy’ associated with foods high in sugar (sweets, chocolate, fizzy drinks, flavoured milks) and foods requiring little preparation (crisps, potatoes, baked beans, peas, soup); ‘health conscious’ associated with fruit, vegetables, eggs, nuts and juices. We found clear associations between dietary pattern scores and socio‐demographic variables, with maternal education being the most important. Higher levels of education were associated with higher scores on both the ‘family foods’ and the ‘health conscious’ patterns, and decreased scores on the ‘sweet and easy’ pattern. Relationships were evident between dietary pattern scores and various feeding difficulties and behaviours. Notably, children who were introduced late to lumpy (chewy) solids (after 9 months) scored lower on both the ‘family foods’ and the ‘health conscious’ patterns. Further analyses are required to determine the temporal relationship between perceived feeding difficulties and behaviours, and it will be important to assess the contribution of the age of introduction to lumpy solids to these relationships.
This study aimed to estimate intake of individual polyunsaturated fatty acids (PUFAs), identify major dietary sources of PUFAs and estimate the proportion of individuals consuming fish among US children 12–60 months of age, by age and race and ethnicity. The study employed a cross‐sectional design using US National Health and Nutrition Examination Survey data. Representative sample of US population based on selected counties. Subjects: 2496 US children aged 12–60 months. Mean daily intake of n‐6 PUFAs and eicosapentaenoic acid (EPA) varied by age, with children 12–24 months of age having lower average intakes (mg or g day−1) than children 49–60 months of age and the lowest n6 : n3 ratio, upon adjustment for energy intake. Docosahexaenoic acid (DHA) intake was low (20 mg day−1) compared to typical infant intake and did not change with age. Compared to non‐Hispanic white children, Mexican American children had higher DHA and arachidonic acid (AA) intake. In the previous 30 days, 53.7% of children ever consumed fish. Non‐Hispanic black children were more likely than non‐Hispanic white children to have consumed fish (64.0% vs. 53.0%). Results indicate low prevalence of fish intake and key n‐3 PUFAs, relative to n‐6 fatty acids, which suggests room for improvement in the diets of US children. More research is needed to determine how increasing dietary intakes of n‐3 PUFAs like DHA could benefit child health.
The risk of stunted growth and development is affected by the context in which a child is born and grows. This includes such interdependent influences as the political economy, health and health care, education, society and culture, agriculture and food systems, water and sanitation, and the environment. Here, we briefly review how factors linked with the key sectors can contribute to healthy growth and reduced childhood stunting. Emphasis is placed on the role of agriculture/food security, especially family farming; education, particularly of girls and women; water, sanitation, and hygiene and their integration in stunting reduction strategies; social protection including cash transfers, bearing in mind that success in this regard is linked to reducing the gap between rich and poor; economic investment in stunting reduction including the work with the for‐profit commercial sector balancing risks linked to marketing foods that can displace affordable and more sustainable alternatives; health with emphasis on implementing comprehensive and effective health care interventions and building the capacity of health care providers. We complete the review with examples of national and subnational multi‐sectoral interventions that illustrate how critical it is for sectors to work together to reduce stunting.
Internationally, women give mixed reports regarding professional support during the early establishment of breastfeeding. Little is known about the components of midwifery language and the support practices, which assist or interfere with the early establishment of breastfeeding. In this study, critical discourse analysis has been used to describe the language and practices used by midwives when supporting breastfeeding women during the first week after birth. Participant observation at two geographically distant Australian health care settings facilitated the collection of 85 observed audio‐recorded dyadic interactions between breastfeeding women and midwives during 2008–2009. Additionally, 23 interviews with women post discharge, 11 interviews with midwives and four focus groups (40 midwives) have also been analysed. Analysis revealed three discourses shaping the beliefs and practices of participating midwives. In the dominant discourse, labelled ‘Mining for Liquid Gold’, midwives held great reverence for breast milk as ‘liquid gold’ and prioritised breastfeeding as the mechanism for transfer of this superior nutrition. In the second discourse, labelled ‘Not Rocket Science’, midwives constructed breastfeeding as ‘natural’ or ‘easy’ and something which all women could do if sufficiently committed. The least well‐represented discourse constructed breastfeeding as a relationship between mother and infant. In this minority discourse, women were considered to be knowledgeable about their needs and those of their infant. The language and practices of midwives in this approach facilitated communication and built confidence. These study findings suggest the need for models of midwifery care, which facilitate relationship building between mother and infant and mother and midwife.
The aim of this study was to determine the concentrations of alpha‐ and gamma‐tocopherols in human breast milk samples from different periods of lactation and to compare them with tocopherol content in commercially available formulas for infants at corresponding ages. The study included 93 breast milk samples obtained on the 2nd (colostrum, n = 17), 14th (n = 30), 30th (n = 27) and 90th day of lactation (n = 19), along with 90 samples of commercially available initial and follow‐on infant formulas. Concentrations of tocopherols were determined using normal‐phase high‐performance liquid chromatography. Depending on the stage of lactation, human breast milk contained 2.07–9.99 mg L−1 of alpha‐tocopherol and 0.22–0.60 mg L−1 of gamma‐tocopherol. Breast milk concentrations of alpha‐tocopherol decreased with the time of lactation, while significant differences in gamma‐tocopherol concentration were observed only between the 14th and 30th day of lactation. There was no significant correlation between the dietary intake of vitamin E and its estimated breast milk concentration, also in women who declared vitamin supplementation. Compared with colostrum, infant formulas were characterised by significantly lower concentrations of alpha‐tocopherol and vitamin E. This finding indicates the need of additional vitamin E supplementation of bottle‐fed infants during the initial 2–3 days of life.
Current UK Department of Health guidelines recommend that infants are introduced to complementary foods at around 6 months of age. Intake of complementary foods should be gradual, should incorporate a range of tastes and should be based around family foods. The infant should be ‘developmentally ready’, able to sit up, grasp objects and chew. Introduction to complementary foods in the UK is typically via purée and spoon‐feeding although an alternative approach is growing in popularity. The baby‐led weaning approach advocates bypassing purées and allowing infants to self‐feed foods in their solid form from the start of weaning. Research surrounding this method is sparse, and it is not advocated in Department of Health literature but understanding, if not advocacy of the method, is needed for health professionals faced with questions from parents. Here, 36 mothers of an infant aged 12–18 months who followed baby‐led weaning completed a semi‐structured interview examining their attitudes, beliefs and behaviours towards the approach. Key themes included following infant cues of readiness, hunger and satiety, exposure to textures and tastes and experiences, both positive and negative of following the method. The findings are considered in relation to Department of Health weaning guidelines and literature pertaining to the development of eating styles and weight gain in young children. Overall, the study offers an insight into this emerging method for child health practitioners raising questions as to the use or potential adaptation of key principles of the methods.
This study assessed the quality of care provided by community health workers (CHWs) in managing cases of severe acute malnutrition (SAM) according to a treatment algorithm. A mixed methods approach was employed to provide perspectives on different aspects of quality of care, including technical competence and acceptability to caretakers. CHWs screened children at community level using a mid‐upper arm circumference measurement, and treated cases without medical complications. Fifty‐five case management observations were conducted using a quality of care checklist, with 89.1% (95% confidence interval: 77.8–95.9%) of CHWs achieving 90% error‐free case management or higher. Caretakers perceived CHWs' services as acceptable and valuable, with doorstep delivery of services promoting early presentation in this remote area of Bangladesh. Integration of the treatment of SAM into community‐based health and nutrition programs appears to be feasible and effective. In this setting, well‐trained and supervised CHWs were able to effectively manage cases of SAM. These findings suggest the feasibility of further decentralization of treatment from current delivery models for community‐based management of acute malnutrition.
Breastfeeding during infancy is associated with a range of short‐ and long‐term health benefits. We examine whether breastfeeding in the first 2 months of life is associated with structural markers of brain development in infants from the general population. This study was embedded within the Generation R study. Cranial ultrasounds were obtained at approximately 7 weeks post‐natal age. The diameter of the gangliothalamic ovoid, corpus callosum length, ventricular volume and head circumference were measured. Maternal reports of breastfeeding were obtained at 2 months of age. We examined associations in relation to current breastfeeding practices (exclusively breastfed, n = 318, breast‐ and bottle‐fed, n = 119, and bottle‐fed, n = 243). Analyses were adjusted for head size and relevant covariates. Secondary analyses were conducted for breastfeeding history (exclusively breastfed, n = 318, breast‐ and bottle‐fed, n = 281, and never breastfed, n = 81). Exclusive breastfeeding was associated with more optimal brain development compared with babies who were bottle‐fed or never breastfed. Results were most consistent for gangliothalamic ovoid diameter. Larger gangliothalamic ovoid diameters were evident in babies who were exclusively breastfed compared with bottle‐fed babies [difference between means (95% confidence interval) = 0.21(0.02, 0.39), P = 0.02]. Smaller ventricular volume and larger head circumference were also found for exclusively breastfed babies. Breastfeeding was not significantly associated with corpus callosum length. Maternal reports of breastfeeding are associated with more mature brain development within the first 2 months of life. Results are most consistent for gangliothalamic ovoid diameter, a subcortical structure rich in docosahexaenoic acid. Findings also pointed to non‐specific neural developmental advantage for exclusively breastfed babies.