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 Med. 2017 Oct 25;14(10):e1002408. doi: 10.1371/journal.pmed.1002408. eCollection 2017 Oct.


Background: Stunting is the most prevalent manifestation of childhood malnutrition. To characterize factors that contribute to stunting in resource-poor settings, we studied a priori selected biological and social factors collected longitudinally in a cohort of newborns.

Methods and findings: We enrolled 1,868 children across 7 resource-poor settings in Bangladesh, Brazil, India, Nepal, Peru, South Africa, and Tanzania shortly after birth and followed them for 24 months between 2 November 2009 and 28 February 2014. We collected longitudinal anthropometry, sociodemographic factors, maternal-reported illnesses, and antibiotic use; child feeding practices; dietary intake starting at 9 months; and longitudinal blood, urine, and stool samples to investigate non-diarrheal enteropathogens, micronutrients, gut inflammation and permeability, and systemic inflammation. We categorized length-for-age Z-scores into 3 groups (not stunted, ≥-1; at risk, <-1 to -2; and stunted, <-2), and used multivariable ordinal logistic regression to model the cumulative odds of being in a lower length-for-age category (at risk or stunted). A total of 1,197 children with complete longitudinal data were available for analysis. The prevalence of having a length-for-age Z-score below -1 increased from 43% (range 37%-47% across sites) shortly after birth (mean 7.7 days post-delivery, range 0 to 17 days) to 74% (16%-96%) at 24 months. The prevalence of stunting increased 3-fold during this same time period. Factors that contributed to the odds of being in a lower length-for-age category at 24 months were lower enrollment weight-for-age (interquartile cumulative odds ratio = 1.82, 95% CI 1.49-2.23), shorter maternal height (2.38, 1.89-3.01), higher number of enteropathogens in non-diarrheal stools (1.36, 1.07-1.73), lower socioeconomic status (1.75, 1.20-2.55), and lower percent of energy from protein (1.39, 1.13-1.72). Site-specific analyses suggest that reported associations were similar across settings. While loss to follow-up and missing data are inevitable, some study sites had greater loss to follow-up and more missing data than others, which may limit the generalizability of the findings.

Conclusions: Neonatal and maternal factors were early determinants of lower length-for-age, and their contribution remained important throughout the first 24 months of life, whereas the average number of enteropathogens in non-diarrheal stools, socioeconomic status, and dietary intake became increasingly important contributors by 24 months relative to neonatal and maternal factors.

MeSH terms

  • Age Factors
  • Anthropometry / methods
  • Bangladesh / epidemiology
  • Body Height
  • Brazil / epidemiology
  • Child, Preschool
  • Demography
  • Developing Countries / statistics & numerical data
  • Eating*
  • Environment
  • Female
  • Growth Disorders* / diagnosis
  • Growth Disorders* / epidemiology
  • Growth Disorders* / etiology
  • Humans
  • India / epidemiology
  • Infant
  • Infant, Newborn
  • Longitudinal Studies
  • Male
  • Maternal Health / statistics & numerical data*
  • Nepal / epidemiology
  • Nutrition Assessment
  • Peru / epidemiology
  • Risk Assessment / methods
  • Risk Assessment / statistics & numerical data
  • Risk Factors
  • Socioeconomic Factors
  • South Africa / epidemiology
  • Tanzania / epidemiology

Grant support

This study was supported by the Bill and Melinda Gates Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.