View source for Stunted growth

{{short description|Reduced growth rate in human development}}
{{for-multi|stunting of growth in plants|Stunt (botany)|causes other than malnutrition|Short stature|the TV episode|Stunted (Entourage)}}
{{Infobox medical condition
| name = Stunted growth
| synonyms = Stunting, nutritional stunting
| image = Share of children who are stunted, 1, OWID.svg
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| caption = World map in 2016 showing the percentage of children who are stunted in each country
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| field = [[Pediatrics]]
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}}'''Stunted growth''', also known as '''stunting''' or '''linear growth failure''', is defined as [[impaired growth]] and development manifested by low height-for-age.<ref name=":0">{{Cite web |title=Malnutrition |url=https://www.who.int/health-topics/malnutrition |access-date=2023-02-15 |website=www.who.int |language=en}}</ref> Stunted growth is often caused by [[malnutrition]], and can also be caused by [[Endogeny (biology)|endogenous]] factors such as chronic [[Food security|food insecurity]] or [[Exogeny|exogenous]] factors such as [[Parasitic disease|parasitic infection]]. Stunting is largely irreversible if occurring in the first 1000 days from [[Fertilisation|conception]] to two years of age.<ref>{{Cite journal |last1=Gabain |first1=Isobel L. |last2=Ramsteijn |first2=Anouschka S. |last3=Webster |first3=Joanne P. |date=March 2023 |title=Parasites and childhood stunting – a mechanistic interplay with nutrition, anaemia, gut health, microbiota, and epigenetics |url=https://linkinghub.elsevier.com/retrieve/pii/S1471492222003099 |journal=Trends in Parasitology |volume=39 |issue=3 |pages=167–180 |doi=10.1016/j.pt.2022.12.004 |pmid=36707340 |issn=1471-4922 |via=Elsevier Science Direct|hdl=2164/20336 |hdl-access=free }}</ref> The international definition of childhood stunting is a child whose height-for-age value is at least two [[standard deviation]]s below the median of the [[World Health Organization]]'s (WHO) Child Growth Standards.<ref>{{Cite journal |last1=de Onis |first1=Mercedes |last2=Dewey |first2=Kathryn G. |last3=Borghi |first3=Elaine |last4=Onyango |first4=Adelheid W. |last5=Blössner |first5=Monika |last6=Daelmans |first6=Bernadette |last7=Piwoz |first7=Ellen |last8=Branca |first8=Francesco |date=September 2013 |title=The World Health Organization's global target for reducing childhood stunting by 2025: rationale and proposed actions |journal=Maternal & Child Nutrition |language=en |volume=9 |issue=S2 |pages=6–26 |doi=10.1111/mcn.12075 |issn=1740-8695 |pmc=6860845 |pmid=24074315}}</ref> Stunted growth is associated with [[poverty]], maternal [[Undernutrition in children|undernutrition]], poor health, frequent illness, or inappropriate feeding practices and care during the early years of life.<ref name=":0" />
Among children under five years of age, the global stunting prevalence declined from 26.3% in 2012 to 22.3% in 2022. It is projected that 19.5% of all children under five will be stunted in 2030.<ref name=":3">{{Cite book |last1=FAO |url=https://openknowledge.fao.org/handle/20.500.14283/cd1254en |title=The State of Food Security and Nutrition in the World 2024 |last2=IFAD |last3=UNICEF |last4=WFP |last5=WHO |date=2024 |publisher=FAO; IFAD; UNICEF; WFP; WHO |isbn=978-92-5-138882-2 |language=English |doi=10.4060/cd1254en}}</ref><ref>{{Cite web |last=nina |date=2022-07-06 |title=The State of Food Security and Nutrition in the World 2022 |url=https://data.unicef.org/resources/sofi-2022/ |access-date=2023-02-15 |website=UNICEF DATA |language=en-US}}</ref> More than 85% of the world's stunted children live in Asia and Africa.<ref name = "LBDCGFC_2020">{{cite journal | title = Mapping child growth failure across low- and middle-income countries | journal = Nature | volume = 577 | issue = 7789 | pages = 231–234 | date = January 2020 | pmid = 31915393 | pmc = 7015855 | doi = 10.1038/s41586-019-1878-8 | vauthors = ((Local Burden of Disease Child Growth Failure Collaborators)) | bibcode = 2020Natur.577..231L }}</ref> Once stunting occurs, its effects are often long-lasting. Stunted children generally do not recover lost height, and they may experience long-term impacts on [[body composition]] and overall health.

[[File:PREVALENCE OF STUNTING IN CHILDREN UNDER 5 YEARS BY REGION.svg|thumb|Prevalence of stunting in children under 5 years by region]]

== Health effects ==
Stunted growth in children has the following public health impacts:
* Greater risk for illness and [[Infant mortality|premature death]]<ref name="WHO">{{Cite web |title=Nutrition Landscape Information System (NLiS) |url=http://apps.who.int/nutrition/landscape/help.aspx?menu=0&helpid=391&lang=EN |access-date=12 November 2014 |publisher=WHO}}</ref>
* Delayed cognitive development, and poor school performance<ref name="WHO" />
* Reduced [[intelligence quotient]]
* Future risk of [[obesity]]<ref>{{cite journal | vauthors = De Sanctis V, Soliman A, Alaaraj N, Ahmed S, Alyafei F, Hamed N | title = Early and Long-term Consequences of Nutritional Stunting: From Childhood to Adulthood | journal = Acta Bio-Medica | volume = 92 | issue = 1 | pages = e2021168 | date = February 2021 | pmid = 33682846 | doi = 10.23750/abm.v92i1.11346 | pmc = 7975963 }}</ref>
* Women of shorter stature have a greater risk for complications during childbirth due to their smaller [[pelvis]] and are at risk of delivering a baby with low birth weight<ref name="WHO" />
* Stunted growth can be passed to the next generation, known as the "intergenerational cycle of malnutrition"<ref name="WHO" />

Studies have reliably established a link between early-life stunting and long-term developmental challenges.<ref name="World Health Assembly Global Nutrition Targets 2025" /> If a child is stunted at the age of 2, they tend to have a higher risk of poor cognitive and educational achievement in life, with subsequent socioeconomic and intergenerational consequences.<ref name="Series from the Lancet journals_2013" /><ref name="World Health Assembly Global Nutrition Targets 2025" /> Multi-country studies have also suggested that stunting is associated with reductions in schooling, decreased economic productivity, and poverty.<ref name="Series from the Lancet journals_2008" /> Stunted children also display higher risk of developing chronic non-communicable conditions such as diabetes and [[obesity]] as adults.<ref name="Series from the Lancet journals_2013" /><ref name="Series from the Lancet journals_2008" /> If a stunted child undergoes substantial weight gain after age 2, this can lead to obesity. 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.<ref name="Series from the Lancet journals_2013" /><ref name="Series from the Lancet journals_2008" /> The development of obesity can lead to a higher risk of developing other related non-communicable diseases such as [[hypertension]], [[Coronary artery disease|coronary heart disease]], [[metabolic syndrome]], and [[stroke]].<ref name="Series from the Lancet journals_2013" /><ref name="Series from the Lancet journals_2008" />

On a societal level, stunted individuals may have physical and/or cognitive delays, affecting their performance in their careers. Stunting can therefore limit economic development and productivity, and it has been estimated that it can affect a country's [[Gross domestic product|GDP]] by up to 3%.<ref name="Series from the Lancet journals_2013" /><ref name="World Health Assembly Global Nutrition Targets 2025" /><ref name="Series from the Lancet journals_2008" />

Stunting is prevalent in [[Global North and Global South|the Global South]] and has severe consequences, including increased risk of infections and death.<ref name="pmid23426036">{{cite journal | vauthors = McDonald CM, Olofin I, Flaxman S, Fawzi WW, Spiegelman D, Caulfield LE, Black RE, Ezzati M, Danaei G | display-authors = 6 | title = The effect of multiple anthropometric deficits on child mortality: meta-analysis of individual data in 10 prospective studies from developing countries | journal = The American Journal of Clinical Nutrition | volume = 97 | issue = 4 | pages = 896–901 | date = April 2013 | pmid = 23426036 | doi = 10.3945/ajcn.112.047639 | doi-access = free }}</ref> The global percentage of stunted growth decreased from 33% to 22.3% between 2000 and 2022.<ref name=":1">{{Cite book |last=FAO |url=https://openknowledge.fao.org/handle/20.500.14283/cd2971en |title=World Food and Agriculture – Statistical Yearbook 2024 |date=2024 |publisher=FAO |isbn=978-92-5-139255-3 |language=English |doi=10.4060/cd2971en}}</ref><ref>{{cite web | work = United Nations Children's Fund; World Health Organization; World Bank Group. | title = Levels and trends in child malnutrition. | date = 2017 | url = https://data.unicef.org/wp-content/uploads/2017/06/JME-2017_brochure_June-25.pdf | access-date = 12 May 2017 }}</ref> The largest drop took place in Asia, from 37.1% in 2000 to 28.2% in 2012 and 22.3% in 2022.<ref name=":1" /> Despite global progress, the prevalence of child stunting was greater than 30% in 28 countries in 2022 (most of which are in sub-Saharan Africa).<ref name=":1" />

== Causes ==

[[File:The prevalence of child stunting generally increases as cities become smaller and moving away from urban centres; child wasting and overweight are lower and exhibit less evident trends across the rural-urbann continuum.svg|250px|right|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.]]
[[File:Children in unsanitary conditions in slum in India (3150664558).jpg|thumb|Children living in unsanitary conditions in an urban slum in India are at risk of diarrhea and stunted growth]]
[[File:Child in slum in Kampala (Uganda) next to open sewage (3110617133).jpg|thumb|A child next to an open sewer in a slum in [[Kampala]], [[Uganda]].]]
{{Further|Undernutrition in children}}
In many publications, the causes for stunting are considered very similar, if not the same, as the causes for [[Undernutrition in children|malnutrition in children]]. However, some contradict this notion. Recent evidence suggests that stunting may not be taken as a synonym for malnutrition,<ref name="C Scheffler_2019">{{cite journal | vauthors = Scheffler C, Hermanussen M, Bogin B, etal. | title = Stunting is not a synonym of malnutrition | journal = Eur J Clin Nutr | volume = 74 | pages = 377–386 | date = March 2020 | issue = 3 | pmid = 31142828 | doi = 10.1038/s41430-019-0439-4 | doi-access = free }}</ref> but as the natural condition of human height in non-[[Westernized]] societies.<ref name="C Scheffler_2022">{{cite journal | vauthors = Scheffler C, Hermanussen M | title = Stunting is the natural condition of human height | journal = Am J Hum Biol | volume = 34 | pages = e23693 | date = May 2022 | issue = 5 | pmid = 34761833 | doi = 10.1002/ajhb.23693 | s2cid = 243987638 | doi-access = free }}</ref>

Almost all stunting occurs within the 1,000-day period that spans from conception to a child's second birthday,<ref name="Black_2013">{{cite journal | vauthors = Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-McGregor S, Katz J, Martorell R, Uauy R | display-authors = 6 | title = Maternal and child undernutrition and overweight in low-income and middle-income countries | journal = Lancet | volume = 382 | issue = 9890 | pages = 427–451 | date = August 2013 | pmid = 23746772 | doi = 10.1016/S0140-6736(13)60937-X | s2cid = 12237910 }}</ref><ref name="pmid23343945">{{cite journal | vauthors = Allen LH | title = Global dietary patterns and diets in childhood: implications for health outcomes | journal = Annals of Nutrition & Metabolism | volume = 61 | issue = Suppl 1 | pages = 29–37 | date = 2012 | pmid = 23343945 | doi = 10.1159/000346185 | s2cid = 8299631 | doi-access = free }}</ref> which constitutes a window of opportunity for growth promotion.<ref name="pmid20156903">{{cite journal | vauthors = Victora CG, de Onis M, Hallal PC, Blössner M, Shrimpton R | title = Worldwide timing of growth faltering: revisiting implications for interventions | journal = Pediatrics | volume = 125 | issue = 3 | pages = e473–80 | date = March 2010 | pmid = 20156903 | doi = 10.1542/peds.2009-1519 | s2cid = 21204674 }}</ref> The recognition of prenatal factors underlines the intergenerational aspects of growth,<ref name="pmid22742617">{{cite journal | vauthors = Martorell R, Zongrone A | title = Intergenerational influences on child growth and undernutrition | journal = Paediatric and Perinatal Epidemiology | volume = 26  | issue = Suppl 1| pages = 302–14 | date = July 2012 | pmid = 22742617 | doi = 10.1111/j.1365-3016.2012.01298.x | s2cid = 28533635 | doi-access = free }}</ref> 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 below the 10th percentile) 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.<ref name="Danaei_2016">{{cite journal | vauthors = Danaei G, Andrews KG, Sudfeld CR, Fink G, McCoy DC, Peet E, Sania A, Smith Fawzi MC, Ezzati M, Fawzi WW | display-authors = 6 | title = Risk Factors for Childhood Stunting in 137 Developing Countries: A Comparative Risk Assessment Analysis at Global, Regional, and Country Levels | journal = PLOS Medicine | volume = 13 | issue = 11 | pages = e1002164 | date = November 2016 | pmid = 27802277 | pmc = 5089547 | doi = 10.1371/journal.pmed.1002164 | doi-access = free }}</ref> In addition, looking at trends from 1970 to 2012 for 116 countries, women’s education, gender equality, and finally, the 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.<ref name="Smith_2015" />

=== Feeding practices ===
Inadequate complementary child feeding and a general lack of vital nutrients besides pure caloric intake are some causes of stunted growth. Children need to be fed diets that meet the minimum requirements in terms of frequency and diversity to prevent undernutrition.<ref name="A Balalian_2017">{{cite journal | vauthors = A Balalian A, Simonyan H, Hekimian K, Deckelbaum RJ, Sargsyan A | title = Prevalence and determinants of stunting in a conflict-ridden border region in Armenia - a cross-sectional study | journal = BMC Nutrition | volume = 3 | pages = 85 | date = December 2017 | pmid = 32153861 | pmc = 7050870 | doi = 10.1186/s40795-017-0204-9 | doi-access = free }}</ref> Exclusive [[breastfeeding]] is recommended for the first six months of life and nutritious food alongside breastfeeding for children aged six months to two years old. Prolonged exclusive breastfeeding is associated with undernutrition because breast milk alone is nutritionally insufficient for children over six months old.<ref>{{Cite journal| vauthors = Caulfield LE, Huffman SL, Piwoz EG |date=January 1999|title=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|journal=Food and Nutrition Bulletin|volume=20|issue=2|pages=183–200|doi=10.1177/156482659902000203|issn=0379-5721|doi-access=free}}</ref><ref>{{cite journal | vauthors = Issaka AI, Agho KE, Page AN, Burns PL, Stevens GJ, Dibley MJ | title = Determinants of suboptimal complementary feeding practices among children aged 6-23 months in four anglophone West African countries | journal = Maternal & Child Nutrition | volume = 11 | issue = Suppl 1 | pages = 14–30 | date = October 2015 | pmid = 26364789 | pmc = 6860259 | doi = 10.1111/mcn.12194 }}</ref> Breastfeeding for a 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 with uneducated parents, as they are more likely to continue breastfeeding without meeting the minimum dietary diversity requirement.<ref>{{cite journal | vauthors = Akombi BJ, Agho KE, Hall JJ, Wali N, Renzaho AM, Merom D | title = Stunting, Wasting and Underweight in Sub-Saharan Africa: A Systematic Review | journal = International Journal of Environmental Research and Public Health | volume = 14 | issue = 8 | pages = 863 | date = August 2017 | pmid = 28788108 | pmc = 5580567 | doi = 10.3390/ijerph14080863 | doi-access = free }} [[File:CC-BY icon.svg|50px]] Material was copied from this source, which is available under a [https://creativecommons.org/licenses/by/4.0/ Creative Commons Attribution 4.0 International License].
</ref>

=== Maternal nutrition ===
Poor maternal nutrition during pregnancy and breastfeeding can lead to stunted growth of children. Proper nutrition for mothers during the prenatal and postnatal period is important for ensuring healthy birth weight and healthy childhood growth. Prenatal causes of child stunting are associated with maternal [[undernutrition]]. Low maternal [[Body mass index|BMI]] predisposes the fetus to poor growth leading to intrauterine growth retardation, which is strongly associated with low birth weight and size.<ref name="Akhtar_2016">{{cite journal | vauthors = Akhtar S | title = Malnutrition in South Asia-A Critical Reappraisal | journal = Critical Reviews in Food Science and Nutrition | volume = 56 | issue = 14 | pages = 2320–2330 | date = October 2016 | pmid = 25830938 | doi = 10.1080/10408398.2013.832143 | s2cid = 205691877 }}</ref> Women who are underweight or anemic during pregnancy are more likely to have stunted children, which perpetuates the intergenerational transmission of stunting. Children born with low birth weight are more at risk of stunting.<ref name="A Balalian_2017" /> However, the effect of prenatal undernutrition can be addressed during the postnatal period through proper child feeding practices.<ref name="Akhtar_2016" />

Maternal undernutrition increases the risk of stunting at 2 years of age.<ref name="Black_2013"/> Based on data from 19 birth cohorts from low and middle income countries, 20% of stunting is attributed to being born small-for-gestational-age (SGA).<ref name="pmid23920141">{{cite journal | vauthors = Christian P, Lee SE, Donahue Angel M, Adair LS, Arifeen SE, Ashorn P, Barros FC, Fall CH, Fawzi WW, Hao W, Hu G, Humphrey JH, Huybregts L, Joglekar CV, Kariuki SK, Kolsteren P, Krishnaveni GV, Liu E, Martorell R, Osrin D, Persson LA, Ramakrishnan U, Richter L, Roberfroid D, Sania A, Ter Kuile FO, Tielsch J, Victora CG, Yajnik CS, Yan H, Zeng L, Black RE | display-authors = 6 | title = Risk of childhood undernutrition related to small-for-gestational age and preterm birth in low- and middle-income countries | journal = International Journal of Epidemiology | volume = 42 | issue = 5 | pages = 1340–1355 | date = October 2013 | pmid = 23920141 | pmc = 3816349 | doi = 10.1093/ije/dyt109 }}</ref> Further, an estimated 33% of stunting at 2 years was attributed to fetal growth restriction and preterm birth in 2011 in developing countries, and 41% in South Asia.<ref name="Danaei_2016"/> Restricted pre- and postnatal growth are in turn important determinants of short adult height,<ref name="pmid12791630">{{cite journal | vauthors = Li H, Stein AD, Barnhart HX, Ramakrishnan U, Martorell R | title = Associations between prenatal and postnatal growth and adult body size and composition | journal = The American Journal of Clinical Nutrition | volume = 77 | issue = 6 | pages = 1498–505 | date = June 2003 | pmid = 12791630 | doi = 10.1093/ajcn/77.6.1498  | doi-access = free }}</ref> increasing the likelihood of the next generation experiencing stunted growth.<ref name="pmid25310000">{{cite journal | vauthors = Prendergast AJ, Humphrey JH | title = The stunting syndrome in developing countries | journal = Paediatrics and International Child Health | volume = 34 | issue = 4 | pages = 250–65 | date = November 2014 | pmid = 25310000 | pmc = 4232245 | doi = 10.1179/2046905514Y.0000000158 }}</ref>

=== Sanitation ===
One notable contribution to stunted growth is a lack of [[sanitation]]—an example of this is countries where [[public defecation]] is practiced.<ref>Spears, D. (2013). [http://www.susana.org/en/resources/library/details/1795 How much international variation in child height can sanitation explain? - Policy research working paper]. The World Bank, Sustainable Development Network, Water and Sanitation Program</ref> 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 affects children's nutritional status by diminishing appetite, reducing nutrient absorption, and increasing nutrient loss.<ref name=":2">{{Cite journal |last=Parvin |first=Tahmina |last2=Thomas |first2=Elizabeth D. |last3=Bhuyian |first3=Md Sazzadul Islam |last4=Uddin |first4=Ismat Minhaj |last5=Hasan |first5=Md Tasdik |last6=Rahman |first6=Zillur |last7=Barman |first7=Indrajeet |last8=Zohura |first8=Fatema |last9=Masud |first9=Jahed |last10=Sultana |first10=Marzia |last11=Westin |first11=Anne |last12=Johura |first12=Fatema-Tuz |last13=Monira |first13=Shirajum |last14=Biswas |first14=Shwapon Kumar |last15=Sack |first15=David A. |date=2021-06-07 |title=Fecal Contamination on the Household Compound and in Water Sources are Associated with Subsequent Diarrhea in Young Children in Urban Bangladesh (CHoBI7 Program) |url=https://pmc.ncbi.nlm.nih.gov/articles/PMC8274748/ |journal=The American Journal of Tropical Medicine and Hygiene |volume=105 |issue=1 |pages=261–266 |doi=10.4269/ajtmh.20-1516 |issn=1476-1645 |pmc=8274748 |pmid=34097647}}</ref>

Research on a global level has found that the proportion of stunting that could be attributed to five or more episodes of diarrhea before two years of age was 25%.<ref>{{cite journal | vauthors = Walker CL, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, O'Brien KL, Campbell H, Black RE | display-authors = 6 | title = Global burden of childhood pneumonia and diarrhoea | journal = Lancet | volume = 381 | issue = 9875 | pages = 1405–1416 | date = April 2013 | pmid = 23582727 | pmc = 7159282 | doi = 10.1016/S0140-6736(13)60222-6 }}</ref> Since diarrhea is closely linked with water, sanitation, and hygiene ([[WASH]]), this is a good indicator of the connection between WASH and stunted growth.<ref name=":2" /> To what extent improvements in drinking water safety, [[toilet]] use and good [[handwashing]] practices contribute to reducing stunting depending on how bad these practices were prior to interventions.

=== Environmental enteropathy ===
The condition termed [[environmental enteropathy]] is proposed as an immediate causal factor of childhood stunting.<ref>{{cite journal | vauthors = Owino V, Ahmed T, Freemark M, Kelly P, Loy A, Manary M, Loechl C | title = Environmental Enteric Dysfunction and Growth Failure/Stunting in Global Child Health | journal = Pediatrics | volume = 138 | issue = 6 | pages = e20160641 | date = December 2016 | pmid = 27940670 | doi = 10.1542/peds.2016-0641 | s2cid = 19436395 | doi-access = free }}</ref><ref name="pmid30753710">{{cite journal | vauthors = Budge S, Parker AH, Hutchings PT, Garbutt C | title = Environmental enteric dysfunction and child stunting | journal = Nutrition Reviews | volume = 77 | issue = 4 | pages = 240–253 | date = April 2019 | pmid = 30753710 | pmc = 6394759 | doi = 10.1093/nutrit/nuy068 }}</ref> This is an asymptomatic small intestinal disorder characterized by chronic gut inflammation, reduced absorptive surface area, and disruption of intestinal barrier function.<ref>{{cite journal | vauthors = Denno DM, Tarr PI, Nataro JP | title = Environmental Enteric Dysfunction: A Case Definition for Intervention Trials | language = EN | journal = The American Journal of Tropical Medicine and Hygiene | volume = 97 | issue = 6 | pages = 1643–1646 | date = December 2017 | pmid = 29016294 | pmc = 5805039 | doi = 10.4269/ajtmh.17-0183 }}</ref><ref>{{cite journal | vauthors = Marie C, Ali A, Chandwe K, Petri WA, Kelly P | title = Pathophysiology of environmental enteric dysfunction and its impact on oral vaccine efficacy | journal = Mucosal Immunology | volume = 11 | issue = 5 | pages = 1290–1298 | date = September 2018 | pmid = 29988114 | doi = 10.1038/s41385-018-0036-1 | s2cid = 256559217 | doi-access = free }}</ref> This small bowel disorder can be attributed to sustained exposure to intestinal pathogens caused by fecal contamination of food and water.<ref name="Velleman_2013" /><ref name="Chambers">{{cite report | vauthors = Chambers R, von Medeazza G | date = 2014 | url = https://sanitationlearninghub.org/resource/reframing-undernutrition-faecally-transmitted-infections-and-the-5-as/ | title = Reframing Undernutrition: Faecally-Transmitted Infections and the 5 As | work = IDS Working Paper 450 | location = Brighton | publisher = Institute of Development Studies (IDS) }}</ref><ref name="pmid30753710"/> Recent evidence confirmed a causal relationship between stunted growth and [[environmental enteropathy]] in children.<ref>{{cite journal | vauthors = Chen RY, Kung VL, Das S, Hossain MS, Hibberd MC, Guruge J, Mahfuz M, Begum SM, Rahman MM, Fahim SM, Gazi MA, Haque R, Sarker SA, Mazumder RN, Di Luccia B, Ahsan K, Kennedy E, Santiago-Borges J, Rodionov DA, Leyn SA, Osterman AL, Barratt MJ, Ahmed T, Gordon JI | display-authors = 6 | title = Duodenal Microbiota in Stunted Undernourished Children with Enteropathy | journal = The New England Journal of Medicine | volume = 383 | issue = 4 | pages = 321–333 | date = July 2020 | pmid = 32706533 | pmc = 7289524 | doi = 10.1056/NEJMoa1916004 }}</ref> Several studies are also underway to examine the link between this condition and stunted growth.<ref name="Velleman_2013">{{cite web | vauthors = Velleman Y, Pugh I | date = 2013 | url = http://www.susana.org/en/resources/library/details/1794 | title = Under-nutrition and water, sanitation and hygiene - Water, sanitation and hygiene (WASH) play a fundamental role in improving nutritional outcomes. | quote = A successful global effort to tackle under-nutrition must include WASH. | work = Briefing Note | publisher = WaterAid and Share| location = UK }}</ref><ref name="pmid27187910">{{cite journal | vauthors = Cumming O, Cairncross S | title = Can water, sanitation and hygiene help eliminate stunting? Current evidence and policy implications | journal = Maternal & Child Nutrition | volume = 12 | issue = Suppl 1 | pages = 91–105 | date = May 2016 | pmid = 27187910 | pmc = 5084825 | doi = 10.1111/mcn.12258  }}</ref><ref name="pmid24571214">{{cite journal | vauthors = Ngure FM, Reid BM, Humphrey JH, Mbuya MN, Pelto G, Stoltzfus RJ | title = Water, sanitation, and hygiene (WASH), environmental enteropathy, nutrition, and early child development: making the links | journal = Annals of the New York Academy of Sciences | volume = 1308 | issue =  1| pages = 118–128 | date = January 2014 | pmid = 24571214 | doi = 10.1111/nyas.12330 | bibcode = 2014NYASA1308..118N | s2cid = 21280033 }}</ref> The exact parthenogenesis of [[environmental enteropathy]] causing linear growth failure is unclear, but it is hypothesized that a chronic inflammatory state and impaired absorption associated with this condition may inhibit bone growth and affect linear growth during the early years of life.<ref>{{cite journal | vauthors = Millward DJ | title = Nutrition, infection and stunting: the roles of deficiencies of individual nutrients and foods, and of inflammation, as determinants of reduced linear growth of children | journal = Nutrition Research Reviews | volume = 30 | issue = 1 | pages = 50–72 | date = June 2017 | pmid = 28112064 | doi = 10.1017/S0954422416000238 | s2cid = 206289300 }}</ref>

== Diagnosis ==
Growth stunting is identified by comparing measurements of children's heights to the [[World Health Organization]] 2006 growth reference population: children who fall below the fifth [[percentile]] of the reference population in height for age are defined as stunted, regardless of the reason. The lower than fifth percentile corresponds to less than two standard deviations of the WHO Child Growth Standards median.{{citation needed|date=April 2023}}

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 [[gene]]s 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|date=April 2023}}

== Prevention ==
Three main factors are needed to reduce stunting:<ref>{{Cite web|url = http://www.thelancet.com/series/maternal-and-child-nutrition|title = The Lancet series on Maternal and Child Nutrition|date = 6 June 2013|access-date = 8 November 2014|publisher = The Lancet}}</ref>
* an 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 [[toilet]]s), and hand washing at critical times (summarized 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.<ref>{{cite journal | vauthors = Humphrey JH | title = Child undernutrition, tropical enteropathy, toilets, and handwashing | journal = Lancet | volume = 374 | issue = 9694 | pages = 1032–1035 | date = September 2009 | pmid = 19766883 | doi = 10.1016/s0140-6736(09)60950-8 | s2cid = 13851530 }}</ref>

Studies have looked at ranking the underlying determinants in terms of their potency in reducing child stunting and found, in the order of potency:<ref name="Smith_2015">{{cite journal | vauthors = Smith LC, Haddad L | title = Reducing Child Undernutrition: Past Drivers and Priorities for the Post-MDG Era | journal = World Development | date = April 2015 | volume = 68 | pages = 180–204 | doi = 10.1016/j.worlddev.2014.11.014 | doi-access = free }}</ref>
* 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".<ref name="Smith_2015" />

The goal of UN agencies, governments, and NGOs is now to optimize 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.<ref name="Flachenberg_2014">{{cite web | vauthors = Flachenberg F, Kopplow R | date = 2014 | url = https://www.concern.net/resources/how-better-link-wash-and-nutrition-programmes | title = How to better link WASH and nutrition programmes | archive-url = https://web.archive.org/web/20151228034729/https://www.concern.net/resources/how-better-link-wash-and-nutrition-programmes |archive-date=2015-12-28 | work = Concern Worldwide Technical Briefing Note }}</ref> 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.<ref>{{Cite web| vauthors = Lake A |date=2017-01-14|title=The first 1,000 days of a child's life are the most important to their development - and our economic success|url=https://www.weforum.org/agenda/2017/01/the-first-1-000-days-of-a-childs-life-are-the-most-important-to-their-development-and-our-economic-success/|access-date=2021-09-11|website=World Economic Forum|language=en}}</ref> Furthermore, it is also the time when young children are the most at risk of infections that lead to [[diarrhea]]. It is the time when they stop breast feeding (weaning process), begin to crawl, put things in their mouths and become exposed to fecal matter from [[open defecation]] and environmental [[Enteropathy|enteropathies]].<ref name="Flachenberg_2014" />

=== Dietary interventions to improve stunting ===
Previous interventions to reduce stunting have shown modest effects. Multiple [[micronutrient supplementation|micro-nutrient supplementation]] shows only small benefits for linear growth<ref name="pmid21956959">{{cite journal | vauthors = Ramakrishnan U, Goldenberg T, Allen LH | title = Do multiple micronutrient interventions improve child health, growth, and development? | journal = The Journal of Nutrition | volume = 141 | issue = 11 | pages = 2066–75 | date = November 2011 | pmid = 21956959 | doi = 10.3945/jn.111.146845 | doi-access = free }}</ref> and results  from studies supplementing lipid based nutrient supplements (LNS) to children are inconclusive.<ref name="pmid24225356">{{cite journal | vauthors = Iannotti LL, Dulience SJ, Green J, Joseph S, François J, Anténor ML, Lesorogol C, Mounce J, Nickerson NM | title = Linear growth increased in young children in an urban slum of Haiti: a randomized controlled trial of a lipid-based nutrient supplement | journal = The American Journal of Clinical Nutrition | volume = 99 | issue = 1 | pages = 198–208 | date = January 2014 | pmid = 24225356 | pmc = 3862455 | doi = 10.3945/ajcn.113.063883 }}</ref><ref name="pmid26063066">{{cite journal | vauthors = Maleta KM, Phuka J, Alho L, Cheung YB, Dewey KG, Ashorn U, Phiri N, Phiri TE, Vosti SA, Zeilani M, Kumwenda C, Bendabenda J, Pulakka A, Ashorn P | display-authors = 6 | title = 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 | journal = The Journal of Nutrition | volume = 145 | issue = 8 | pages = 1909–1915 | date = August 2015 | pmid = 26063066 | doi = 10.3945/jn.114.208181 | doi-access = free }}</ref> [[Education|Educational interventions]]  to improve complementary feeding may achieve behavioral change but have no or small effects on growth.<ref name="pmid27581575">{{cite journal | vauthors = Menon P, Nguyen PH, Saha KK, Khaled A, Sanghvi T, Baker J, Afsana K, Haque R, Frongillo EA, Ruel MT, Rawat R | display-authors = 6 | title = 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 | journal = The Journal of Nutrition | volume = 146 | issue = 10 | pages = 2075–2084 | date = October 2016 | pmid = 27581575 | pmc = 5037872 | doi = 10.3945/jn.116.232314 }}</ref><ref name="pmid28179488">{{cite journal | vauthors = Rawat R, Nguyen PH, Tran LM, Hajeebhoy N, Nguyen HV, Baker J, Frongillo EA, Ruel MT, Menon P | display-authors = 6 | title = Social Franchising and a Nationwide Mass Media Campaign Increased the Prevalence of Adequate Complementary Feeding in Vietnam: A Cluster-Randomized Program Evaluation | journal = The Journal of Nutrition | volume = 147 | issue = 4 | pages = 670–679 | date = April 2017 | pmid = 28179488 | pmc = 5368587 | doi = 10.3945/jn.116.243907 }}</ref> Further, studies on the effect of micro-nutrient fortification, increased availability of key nutrients or increased energy density of complementary foods on stunting also show heterogeneous results.<ref name="Dewey_2008">{{cite journal | vauthors = Dewey KG, Adu-Afarwuah S | title = Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries | journal = Maternal & Child Nutrition | volume = 4 | issue = Suppl 1 | pages = 24–85 | date = April 2008 | pmid = 18289157 | pmc = 6860813 | doi = 10.1111/j.1740-8709.2007.00124.x }}</ref> 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,<ref name="Dewey_2008"/> which is moderate compared to the  average global growth deficit.<ref name="pmid11331725">{{cite journal | vauthors = Shrimpton R, Victora CG, de Onis M, Lima RC, Blössner M, Clugston G | title = Worldwide timing of growth faltering: implications for nutritional interventions | journal = Pediatrics | volume = 107 | issue = 5 | pages = E75 | date = May 2001 | pmid = 11331725 | doi = 10.1542/peds.107.5.e75 | doi-access = free }}</ref> Finally, the [[The Lancet|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%.<ref name="pmid18206226">{{cite journal | vauthors = Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, Shekar M | display-authors = 6 | title = What works? Interventions for maternal and child undernutrition and survival | journal = Lancet | volume = 371 | issue = 9610 | pages = 417–440 | date = February 2008 | pmid = 18206226 | doi = 10.1016/S0140-6736(07)61693-6 | s2cid = 18345055 }}</ref> 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.<ref name="pmid24037697">{{cite journal | vauthors = McKay S, Gaudier E, Campbell DI, Prentice AM, Albers R | title = Environmental enteropathy: new targets for nutritional interventions | journal = International Health | volume = 2 | issue = 3 | pages = 172–80 | date = September 2010 | pmid = 24037697 | doi = 10.1016/j.inhe.2010.07.006 | doi-access = free }}</ref>

Recent works showed promise that intervention with egg may improve linear growth in children.<ref>{{cite journal | vauthors = Iannotti LL, Lutter CK, Stewart CP, Gallegos Riofrío CA, Malo C, Reinhart G, Palacios A, Karp C, Chapnick M, Cox K, Waters WF | display-authors = 6 | title = Eggs in Early Complementary Feeding and Child Growth: A Randomized Controlled Trial | journal = Pediatrics | volume = 140 | issue = 1 | pages = e20163459 | date = July 2017 | pmid = 28588101 | doi = 10.1542/peds.2016-3459 | s2cid = 24732575 | url = https://escholarship.org/uc/item/9gq0c883 | doi-access = free }}</ref><ref name="Daily Supplementation With Egg, Cow">{{cite journal | vauthors = Mahfuz M, Alam MA, Das S, Fahim SM, Hossain MS, Petri WA, Ashorn P, Ashorn U, Ahmed T | display-authors = 6 | title = Daily Supplementation With Egg, Cow Milk, and Multiple Micronutrients Increases Linear Growth of Young Children with Short Stature | journal = The Journal of Nutrition | volume = 150 | issue = 2 | pages = 394–403 | date = February 2020 | pmid = 31665385 | doi = 10.1093/jn/nxz253 | doi-access = free | hdl = 2292/59199 | hdl-access = free }}</ref> Comprehensive intervention package containing eggs also found to be effective in improving linear growth in children.<ref>{{cite journal | vauthors = Ara G, Sanin KI, Khanam M, Sarker MS, Tofail F, Nahar B, Chowdhury IA, Boitchi AB, Gibson S, Afsana K, Askari S, Ahmed T | display-authors = 6 | title = A comprehensive intervention package improves the linear growth of children under 2-years-old in rural Bangladesh: a community-based cluster randomized controlled trial | journal = Scientific Reports | volume = 12 | issue = 1 | pages = 21962 | date = December 2022 | pmid = 36536016 | pmc = 9763408 | doi = 10.1038/s41598-022-26269-w | bibcode = 2022NatSR..1221962A }}</ref> However, the effect of egg intervention may not persist for longer period.<ref>{{cite journal | vauthors = Iannotti LL, Chapnick M, Nicholas J, Gallegos-Riofrio CA, Moreno P, Douglas K, Habif D, Cui Y, Stewart C, Lutter CK, Waters WF | display-authors = 6 | title = Egg intervention effect on linear growth no longer present after two years | journal = Maternal & Child Nutrition | volume = 16 | issue = 2 | pages = e12925 | date = April 2020 | pmid = 31849201 | pmc = 7083396 | doi = 10.1111/mcn.12925 }}</ref> Therefore, intervention programs should consider egg intervention for a longer period with emphasis on overall diet quality and improvement of environmental conditions.{{citation needed|date=April 2023}}

=== Pregnant and lactating mothers ===
Ensuring proper nutrition of pregnant and lactating mothers is essential.<ref name="World Health Assembly Global Nutrition Targets 2025">{{cite web |title= World Health Assembly Global Nutrition Targets 2025: Stunting Policy Brief, World Health Organization 2014 |url= https://www.who.int/nutrition/topics/globaltargets_stunting_policybrief.pdf |archive-url= https://web.archive.org/web/20140909031918/http://www.who.int/nutrition/topics/globaltargets_stunting_policybrief.pdf|url-status=dead|archive-date=September 9, 2014}}</ref> Achieving so by helping women of reproductive age be in good nutritional status at conception is an excellent preventive measure.<ref name="World Health Assembly Global Nutrition Targets 2025" /> 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.<ref name="World Health Assembly Global Nutrition Targets 2025" /> An example of this are attempts to control anemia in women of reproductive age.<ref name="World Health Assembly Global Nutrition Targets 2025" /> 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.<ref name="World Health Assembly Global Nutrition Targets 2025" />

Balanced protein–energy supplementation in pregnancy seem to improve birth weight of  children, with greater effects in undernourished women.<ref name="pmid22742610">{{cite journal | vauthors = Imdad A, Bhutta ZA | title = Maternal nutrition and birth outcomes: effect of balanced protein-energy supplementation | journal = Paediatric and Perinatal Epidemiology | volume = 26 | issue = Suppl 1 | pages = 178–90 | date = July 2012 | pmid = 22742610 | doi = 10.1111/j.1365-3016.2012.01308.x | doi-access = free }}</ref> 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.<ref name="pmid19812173">{{cite journal | vauthors = Huybregts L, Roberfroid D, Lanou H, Menten J, Meda N, Van Camp J, Kolsteren P | title = Prenatal food supplementation fortified with multiple micronutrients increases birth length: a randomized controlled trial in rural Burkina Faso | journal = The American Journal of Clinical Nutrition | volume = 90 | issue = 6 | pages = 1593–600 | date = December 2009 | pmid = 19812173 | doi = 10.3945/ajcn.2009.28253 | s2cid = 10474629 | doi-access = free }}</ref><ref name="pmid25833980">{{cite journal | vauthors = Adu-Afarwuah S, Lartey A, Okronipa H, Ashorn P, Zeilani M, Peerson JM, Arimond M, Vosti S, Dewey KG | title = Lipid-based nutrient supplement increases the birth size of infants of primiparous women in Ghana | journal = The American Journal of Clinical Nutrition | volume = 101 | issue = 4 | pages = 835–46 | date = April 2015 | pmid = 25833980 | doi = 10.3945/ajcn.114.091546 | doi-access = free }}</ref> Similarly, studies supplementing LNS to mothers during pregnancy and lactation and their  children during the complementary feeding period show heterogeneous results for  stunting.<ref name="pmid28275125">{{cite journal | vauthors = Dewey KG, Mridha MK, Matias SL, Arnold CD, Cummins JR, Khan MS, Maalouf-Manasseh Z, Siddiqui Z, Ullah MB, Vosti SA | title = Lipid-based nutrient supplementation in the first 1000 d improves child growth in Bangladesh: a cluster-randomized effectiveness trial | journal = The American Journal of Clinical Nutrition | volume = 105 | issue = 4 | pages = 944–957 | date = April 2017 | pmid = 28275125 | doi = 10.3945/ajcn.116.147942 | s2cid = 25969492 | hdl = 10361/8919 | hdl-access = free }}</ref><ref name="pmid25926413">{{cite journal | vauthors = Ashorn P, Alho L, Ashorn U, Cheung YB, Dewey KG, Gondwe A, Harjunmaa U, Lartey A, Phiri N, Phiri TE, Vosti SA, Zeilani M, Maleta K | display-authors = 6 | title = 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 | journal = The Journal of Nutrition | volume = 145 | issue = 6 | pages = 1345–1353 | date = June 2015 | pmid = 25926413 | doi = 10.3945/jn.114.207225 | doi-access = free }}</ref>

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.<ref name="World Health Assembly Global Nutrition Targets 2025" /> Introducing proper complementary feeding after 6 months of age together with breastfeeding until age 2 is the next step.<ref name="World Health Assembly Global Nutrition Targets 2025" />

=== Public health interventions ===
In summary, key public health 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.<ref name="World Health Assembly Global Nutrition Targets 2025" /> 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 birthweight, 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.<ref name="World Health Assembly Global Nutrition Targets 2025" />
* Designing and implementing policies promoting nutritional and health well-being of mothers and women of reproductive age.<ref name="World Health Assembly Global Nutrition Targets 2025" /> 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<ref name="World Health Assembly Global Nutrition Targets 2025" /> (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<ref name="World Health Assembly Global Nutrition Targets 2025" /> (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.<ref name="World Health Assembly Global Nutrition Targets 2025" /> Regulating milk substitutes is also very important to ensure that as many mothers as possible breastfeed their babies, unless a clear contraindication is present.<ref name="World Health Assembly Global Nutrition Targets 2025" />
* Broadly speaking, effective policies to reduce stunting require multisectoral approaches, strong political commitment, community involvement and integrated service delivery.<ref name="World Health Assembly Global Nutrition Targets 2025" />

== Epidemiology ==

According to the World Health organization if less than 20% of the population is affected by stunting, this is regarded as "low prevalence" in terms of public health significance.<ref name="WHO" /> Values of 40% or more are regarded as very high prevalence, and values in between as medium to high prevalence.<ref name="WHO" />

UNICEF has estimated that: "Globally, more than one quarter (26 percent) of children under 5 years of age were stunted in 2011 – roughly 165 million children worldwide."<ref name="UNICEF_2013">{{cite book|last1=UNICEF|title=Improving child nutrition : the achievable imperative for global progress|date=2013|publisher=United Nations Children’s Fund (UNICEF), New York, USA|isbn=978-92-806-4686-3|url=http://www.unicef.org/publications/index_68661.html|archive-url=https://web.archive.org/web/20130513170829/http://www.unicef.org/publications/index_68661.html|url-status=dead|archive-date=May 13, 2013}}</ref> 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."<ref name="UNICEF_2013" /> 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.<ref name="UNICEF_2013" />

The 2020 edition of [[Food and Agriculture Organization|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.<ref>{{Cite book |url=https://doi.org/10.4060/cb4902en |title=Near East and North Africa Regional Overview of Food Security and Nutrition 2020. Enhancing resilience of food systems in the Arab States |publisher=FAO |year=2021 |isbn=978-92-5-134471-2 |location=Cairo |doi=10.4060/cb4902en |access-date=2023-01-15 |archive-url=https://web.archive.org/web/20230115174925/https://www.fao.org/documents/card/en/c/cb4902en |archive-date=2023-01-15 |url-status=live |s2cid=241502462}}</ref><ref name="FAO-2023 2">{{Cite book |url=https://www.fao.org/documents/card/en/c/cb6226en |title=NENA Regional Network on Nutrition-sensitive Food System. Empowering women and ensuring gender equality in agri-food systems to achieve better nutrition − Technical brief |publisher=FAO |year=2023 |isbn=978-92-5-137438-2 |location=Cairo |doi=10.4060/cc3657en |access-date=2023-01-15 |archive-url=https://web.archive.org/web/20221217185019/https://www.fao.org/documents/card/en/c/cb6226en/ |archive-date=2022-12-17 |url-status=live}}</ref>

=== Trends ===
==== 1990s to 2015 ====
As of 2015, an estimated 156 million children under the age of 5 years old in the world were stunted, 90% of them living in low and low-middle income countries.<ref name="Levels and trends in child malnutrition">{{Cite web|url=http://data.unicef.org/wp-content/uploads/2016/09/UNICEF-Joint-Malnutrition-brochure.pdf|title=Levels and trends in child malnutrition | work = UNICEF / WHO / World Bank Group Joint Child Malnutrition Estimates | date = 2016 }}</ref> Roughly 56% of these children were in Asia and 37% in Africa.<ref name="Levels and trends in child malnutrition" /> It is possible that some of these children concurrently had other forms of malnutrition, including [[wasting]] or being [[overweight]]. No statistics were available for these combined conditions. Stunting had been on the decline for the past 35 years - in 2016, there were 156 million stunted children, compared to 255 million in 1990.<ref name="Levels and trends in child malnutrition" /> However, the decline of stunting was geographically uneven and unequal among different groups in society.<ref name="Levels and trends in child malnutrition" /> 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.<ref name = "LBDCGFC_2020" /> Among children under five years of age, the global stunting prevalence declined from 26.3% in 2012 to 22.3% in 2022. It was projected that 19.5 percent of all children under five will be stunted in 2030.<ref name=":3" />

Over the period 2000–2015, Asia saw a reduction in stunting prevalence from 38 to 24%; with Africa moving from 38 to 32%; along with Latin America and the Caribbean moving from 18 to 11%.<ref name="Levels and trends in child malnutrition" /> This equated to a relative reduction of 36%, 17% and 39% respectively, indicating that Asia and Latin America and the Caribbean had displayed much larger reductions than Africa. Of these regions, Latin America and the Caribbean were on track to achieve global targets set with global initiatives such as United Nations Millennium Development Goals and World Health Assembly targets (see following section on global targets).<ref name="Levels and trends in child malnutrition" />

In Africa, the highest rates of stunting were observed in East Africa (37.5%).<ref name="Levels and trends in child malnutrition" /> Other sub-regions also had high rates, with 32.1% in West Africa, 31.2% in Central Africa, and 28.4% in Southern Africa.<ref name="Levels and trends in child malnutrition" /> North Africa is at 18%, and the Middle East at 16.2%.<ref name="Levels and trends in child malnutrition" /> In Asia, the highest rate was observed in the south at 34.4%.<ref name="Levels and trends in child malnutrition" /> South-East Asia is at 26.3%. Pacific Islands also displayed a high rate at 38.2%. Central and South America were at 15.6 and 9.9% respectively.<ref name="Levels and trends in child malnutrition" /> South Asia, given its high population and high prevalence of stunting, was the region currently containing the highest absolute number of children with stunting.<ref name="Levels and trends in child malnutrition" />

The number of stunted children increased in Africa from 50.4 to 58.5 million from 2000 to 2015.<ref name="Levels and trends in child malnutrition" /> This was despite the reduction in percentage prevalence of stunting and was due to the high rates of population growth. The data therefore indicates that the rate of reduction of stunting in Africa was able to counterbalance the increased number of growing children that fell into the trap of malnutrition due to population growth in the region, creating a cycle. This was also true in Oceania, unlike Asia and Latin America and the Caribbean where substantial absolute reductions in the number of stunted children were observed.<ref name="Levels and trends in child malnutrition" />

The reduction in stunting was 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 were the only group with more stunted children today than in the year 2000.<ref name="Levels and trends in child malnutrition" /> Conversely, all other countries (high-income, upper-middle income, lower-middle income) achieved reductions in the numbers of stunted children.<ref name="Levels and trends in child malnutrition" /> This perpetuated a [[cycle of poverty]] and malnutrition, whereby malnourished children were not able to maximally contribute to economic development as adults, and poverty increases chances of malnutrition.

==== 2015 to 2022 ====
By 2022, the number of stunted children under the age of 5 had gone down to 148.1 million (22% of children across the globe).<ref>{{cite web |url=https://cdn.who.int/media/docs/default-source/nutrition-and-food-safety/events/2024/webinar---stunting-in-focus---challenges--successes--and-a-path-forward-to-2030-presentation.pdf?sfvrsn=c49fb30e_9 |title=Stunting in focus: challenges, successes, and a path forward to 2030 |author=<!--Not stated--> |date=2022 |website=World Health Organisation |publisher= |access-date=March 25, 2025}}</ref>
 
Between 2020 and 2021, the maximum statistics dropped from 60% in Burundi and 55% in several other countries, to 55% in Burundi and 50% in several other countries; the extreme rate of child morality had changed from 21% in Sierra Leone to 12% in Niger (according to UNICEF).<ref>{{cite web |url=https://ourworldindata.org/grapher/share-of-children-younger-than-5-who-suffer-from-stunting |title=Share of children who are stunted |author=<!--Not stated--> |date= |website=Our World in Data |publisher= |access-date=March 25, 2025}}</ref> The WHO has also noted that while global stunting rates have been reduced over time, the decline has slowed down in rural areas and areas experiencing crises.<ref>{{cite web |url=https://iris.who.int/bitstream/handle/10665/260202/9789241513647-eng.pdf |title=Reducing Stunting in Children: Equity considerations for achieving the Global Nutrition Targets 2025 |author=<!--Not stated--> |date= |website=World Health Organisation |publisher= |access-date=March 25, 2025}}</ref>

==Research==
The [[Water and sanitation program|Water and Sanitation Program]] of the [[World Bank]] has investigated links between lack of sanitation and stunting in Vietnam and Lao PDR.<ref name="Quattri_2014">{{cite web | vauthors = Quattri M, Smets S, Inthavong V | date = 2014 | url = https://www.wsp.org/sites/wsp.org/files/publications/WSP-LaoPDR-Stunting-Research-Brief.pdf | title = Investing in the Next Generation - Children grow taller, and smarter, in rural, mountainous villages of Lao PDR where all community members use improved sanitation | work = WSP (Water and Sanitation Program) | publisher = World Bank | location = USA }}</ref> 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&nbsp;cm shorter than healthy children living in villages with good access to sanitation.<ref name="Quattri_2014" /> This difference in height is irreversible and matters a great deal for a child's cognitive development and future productive potential.<ref name="Quattri_2014" />

===Review articles===
''[[The Lancet]]'' has published two comprehensive series on maternal and child nutrition, in 2008<ref name="Series from the Lancet journals_2008">{{cite web|work = Series from the Lancet journals | title = Maternal and child undernutrition | date = January 2008 |url=http://www.thelancet.com/series/maternal-and-child-undernutrition}}</ref> and 2013.<ref name="Series from the Lancet journals_2013">{{cite web|work = Series from the Lancet journals | title = Maternal and child nutrition | date = June 2013 |url=http://www.thelancet.com/series/maternal-and-child-nutrition}}</ref> 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,<ref name="Series from the Lancet journals_2008" /> 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.<ref name="Series from the Lancet journals_2008" />

In the follow-up series in 2013,<ref name="Series from the Lancet journals_2013" /> the focus on undernutrition is expanded to the increasing burden of obesity in 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.<ref name="Series from the Lancet journals_2013" /> 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”.<ref name="Series from the Lancet journals_2013" /> 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.<ref name="Series from the Lancet journals_2013" />

Nutritional interventions such as dietary supplementation and nutritional education have the potential to decrease stunting.<ref>{{cite journal | vauthors = Goudet SM, Bogin BA, Madise NJ, Griffiths PL | title = Nutritional interventions for preventing stunting in children (birth to 59 months) living in urban slums in low- and middle-income countries (LMIC) | journal = The Cochrane Database of Systematic Reviews | volume = 6 | issue = 6 | pages = CD011695 | date = June 2019 | pmid = 31204795 | pmc = 6572871 | doi = 10.1002/14651858.CD011695.pub2 }}</ref>

==Examples==
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.<ref name="World Health Assembly Global Nutrition Targets 2025" /> 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.<ref name="World Health Assembly Global Nutrition Targets 2025" />

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.<ref name="Procee_2013">{{Cite report | vauthors = Procee P | title = Integrated Safeguards Data Sheet (Appraisal Stage)-Guangxi Laibin Water Environment Project-P126817. | publisher = The World Bank | date = May 2013 | url = https://documents.worldbank.org/en/publication/documents-reports/documentdetail/600071468022131581/integrated-safeguards-data-sheet-appraisal-stage-guangxi-laibin-water-environment-project-p126817 | pages = 1–9 }}</ref>  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.<ref name="Procee_2013" /> 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.<ref name="Procee_2013" />

=== Sustainable Development Goals ===
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.<ref>{{Cite web|url=https://sustainabledevelopment.un.org/?page=view&nr=164&type=230&menu=2059 | archive-url = https://web.archive.org/web/20170104204850/https://sustainabledevelopment.un.org/?page=view&nr=164&type=230&menu=2059 | archive-date = 4 January 2017 |title=United Nations Sustainable Development Goals | date = 1 December 2014 | work = UN-DESA/DSD }}</ref>  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.<ref name="scalingupnutrition.org">{{Cite web|url=https://scalingupnutrition.org/|title=Working together in the fight against malnutrition in all its forms|website=scalingupnutrition.org}}</ref>  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.<ref name="scalingupnutrition.org" />

===Brazil===
Brazil displayed a remarkable reduction in the rates of child stunting under age 5, from 37% in 1974, to 7.1% in 2007.<ref name="World Health Assembly Global Nutrition Targets 2025" /> 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.<ref name="World Health Assembly Global Nutrition Targets 2025" /> 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.<ref name="World Health Assembly Global Nutrition Targets 2025" />

===Bangladesh===
Nearly one-third of the children under five years of age are stunted in Bangladesh and 9% are severely stunted.<ref>{{Cite journal | publisher = National Institute of Population Research and Training (NIPORT). Ministry of Health and Family Welfare |title=Bangladesh Demographic and Health Survey 2017-18 | journal = The DHS Program | date = October 2020  |url= https://dhsprogram.com/publications/publication-FR344-DHS-Final-Reports.cfm |language=en}}</ref> 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%.<ref>{{cite journal | vauthors = Fahim SM, Hossain MS, Sen S, Das S, Hosssain M, Ahmed T, Rahman SM, Rahman MK, Alam S | display-authors = 6 | title = Nutrition and Food Security in Bangladesh: Achievements, Challenges, and Impact of the COVID-19 Pandemic | journal = The Journal of Infectious Diseases | volume = 224 | issue = Supplement_7 | pages = S901–S909 | date = December 2021 | pmid = 34668556 | pmc = 8687095 | doi = 10.1093/infdis/jiab473 }}</ref> Maternal undernutrition and increased pathogen load in the intestine are the major risk factors of stunting in Bangladeshi children.<ref>{{cite journal | title = Childhood stunting in relation to the pre- and postnatal environment during the first 2 years of life: The MAL-ED longitudinal birth cohort study | journal = PLOS Medicine | volume = 14 | issue = 10 | pages = e1002408 | date = October 2017 | pmid = 29069076 | pmc = 5656304 | doi = 10.1371/journal.pmed.1002408 | author1 = MAL-ED Network Investigators | doi-access = free }}</ref> Daily supplementation with [[Eggs as food|egg]], cow [[milk]], and micronutrient powder found to be effective in improving linear growth of children in a community-based trial in Bangladesh.<ref name="Daily Supplementation With Egg, Cow"/>

===Peru===
After a decade (i.e., 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'' that included a nutritional component.<ref name="World Health Assembly Global Nutrition Targets 2025" /> The strategy was multisectoral in that it involved the health, education, water, sanitation and hygiene, agriculture and housing sectors and stakeholders.<ref name="World Health Assembly Global Nutrition Targets 2025" /> 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.<ref name="World Health Assembly Global Nutrition Targets 2025" />

===India (Maharashtra)===
The State of Maharashtra in Central-Western India has been able to produce a large reduction in stunting rates in children under 2 years of age from 44% to 22.8% in the period from 2005 to 2012.<ref name="World Health Assembly Global Nutrition Targets 2025" /> 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.<ref name="World Health Assembly Global Nutrition Targets 2025" /><ref name="Chambers" /> This was achieved through integrated community-based programs that were designed by a central advisory body that promoted multisectoral collaboration, provided advice to policymakers on evidence-based solutions, and advocated for the key role of the 1000 days (pregnancy and first two years of life).<ref name="World Health Assembly Global Nutrition Targets 2025" />

=== Nepal ===
In Nepal, short maternal stature,<ref name="Kim_2017">{{cite journal | vauthors = Kim R, Mejía-Guevara I, Corsi DJ, Aguayo VM, Subramanian SV | title = Relative importance of 13 correlates of child stunting in South Asia: Insights from nationally representative data from Afghanistan, Bangladesh, India, Nepal, and Pakistan | journal = Social Science & Medicine | volume = 187 | issue = | pages = 144–154 | date = August 2017 | pmid = 28686964 | doi = 10.1016/j.socscimed.2017.06.017 }}</ref> low maternal education,<ref name="Devkota_2016">{{cite journal | vauthors = Devkota MD, Adhikari RK, Upreti SR | title = Stunting in Nepal: looking back, looking ahead | journal = Maternal & Child Nutrition | volume = 12 | issue = Suppl 1 | pages = 257–9 | date = May 2016 | pmid = 27187924 | pmc = 5084730 | doi = 10.1111/mcn.12286 }}</ref><ref name="Cunningham_2017">{{cite journal | vauthors = Cunningham KH, Singh A, Karmacharya C, Rana PR | title = Maternal and Child Nutrition in Nepal: Examining drivers of progress from the mid- 1990s to 2010s. | journal = Global Food Security | date = 2017 | volume = 13 | pages = 30–37 | doi = 10.1016/j.gfs.2017.02.001 | doi-access = free | bibcode = 2017GlFS...13...30C }}</ref> poor access to health services<ref name="Cunningham_2017"/> and poverty<ref name="Kim_2017"/><ref name="Devkota_2016"/> 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.<ref>{{cite report | work = Ministry of Health; New ERA; ICF. | title = Nepal demographic and health survey 2016 | location = Kathmandu, Nepal | publisher = Ministry of Health | date = 2017 }}</ref>

=== Philippines ===

In the Philippines, one in three children below five years old is stunted.<ref>{{Cite journal |last1=Guirindola |first1=Mildred |last2=Goyena |first2=Eva |last3=Maniego |first3=Ma. Lynell Valdeabella |date=April 2021 |title=Risk factors of stunting during the complementary feeding period 6-23 months in the Philippines |url=https://www.researchgate.net/publication/351522700 |journal=Malaysian Journal of Nutrition |pages=134–137 |via=ResearchGate}}</ref> Even though the country's economic growth has steadily increased by 4% annually, almost a third of Filipino children have stunted growth. The prevalence of stunting declined during the early 2000s but has remained the same since then, with the 2019 rate (28.8 percent) only marginally lower than that of 2008.<ref>{{Cite journal |last1=Mbuya |first1=Nkosinathi V |last2=Demombynes |first2=Gabriel |last3=Piza |first3=Sharon Faye A. |last4=Adona |first4=Ann Jillian V. |date=2021 |title=Undernutrition in the Philippines – Scale Scope and Opportunities for Nutrition Policy and Programming |url=https://openknowledge.worldbank.org/server/api/core/bitstreams/109a9f76-1d3f-587b-8f0a-0f0a54021cdd/content |journal=International Bank for Reconstruction and Development/ World Bank |pages=35–36}}</ref> Researchers attribute the problem to micro-nutrient deficiencies brought on by poverty, maternal under-education, food insecurity, and poor environmental conditions.<ref>{{Cite journal |last1=Ulep |first1=Valerie |last2=Uy |first2=Jhanna |last3=Casas |first3=Lyle Daryll D. |last4=Capanzana |first4=Mario V. |last5=Nkoroi |first5=Alice |last6=Galera Jr. |first6=Rene Gerard |last7=Carpio |first7=Maria Evelyn |last8=Tan |first8=Frederich |date=February 2023 |title=The Determinants of the Socioeconomic Inequality and the Trajectory of Child Stunting in the Philippines |url=https://pidswebs.pids.gov.ph/CDN/document/pidsdps2304.pdf |journal=Philippine Institute for Development Studies}}</ref> To address stunting and other health and food security issues, the Philippine Plan of Action for Nutrition (PPAN) was established as an umbrella initiative to meet health and nutrition targets in the country by 2028.<ref>{{Cite journal |last1=Capanzana |first1=Mario V. |last2=Demombynes |first2=Gabriel |last3=Gubbins |first3=Paul |date=June 2020 |title=Why Are So Many Children Stunted in the Philippines? |url=https://hdl.handle.net/10986/33989 |journal=Policy Research Working Paper |language=en |doi=10.1596/1813-9450-9294 |via=Open Knowledge Repository|hdl=10986/33989 |hdl-access=free }}</ref> Since 2015, there has been a decline in stunting across all age groups, from infants to teenagers, with the most significant improvement observed among 5 to 10-year-olds, dropping from 31.2 percent in 2015 to 19.7 percent in 2021.<ref>{{Cite web |date=2023-09-26 |title=The Philippines renews its commitment to nutrition with updated action plan - Philippines {{!}} ReliefWeb |url=https://reliefweb.int/report/philippines/philippines-renews-its-commitment-nutrition-updated-action-plan |access-date=2024-04-22 |website=reliefweb.int |language=en}}</ref>

== See also ==
* [[Compensatory growth]]
* [[Failure to thrive]]
*[[Food security]]
* [[Global Alliance for Improved Nutrition]]
* [[Undernutrition in children]]

== Sources ==
{{Free-content attribution
| title = The State of Food Security and Nutrition in the World 2024
| author = FAO, IFAD, UNICEF, WFP and WHO
| publisher = FAO
| documentURL = https://openknowledge.fao.org/handle/20.500.14283/cd1254en
| license = CC BY 4.0
}}

== References ==
{{CC-notice|cc=bysa3|url=https://oda.oslomet.no/oda-xmlui/handle/10642/7102|author= Marianne Sandsmark Morseth}}
{{Reflist}}

== External links ==
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* [http://stopstunting.org/ Stop stunting], regional conference on nutrition in South Asia (website slow to load)
* [http://aliveandthrive.org/ Alive and Thrive], program website
* [https://vizhub.healthdata.org/lbd/cgf# Visualizing child growth failure from 2000-2017], interactive visualization

{{Infants and their care|state=expanded}}
{{Nutritional pathology}}

{{DEFAULTSORT:Stunted growth}}
[[Category:Malnutrition]]
[[Category:Growth disorders]]
[[Category:Sanitation]]