Child stunting in South Asia. Why doesit matter?

The linear growth of healthy

children from birth tofiveyears of age is remarkably similar the world over (Mul-ticenter Growth
Reference Study Group 2006). Yet,the latest globalfigures indicate that ~25% of childrenunder
agefive (i.e. 159 million) have stunted growth be-cause of chronic nutrition deprivation
(UNICEF,WHO, WBG 2016). Stunting—a height-for-age below2 standard deviations of the median
height-for-agein the Child Growth Standards of the World Health Or-ganization —happens early in
life. There is now broadagreement that most stunting happens during thefirstthousand days—
from conception through thefirst twoyears of life—although additional linear growth falter-ing
may still happen after thefirst two years of life(Leroyet al. 2014).In their paper in this special issue
de Onis andBranca, from the World Health Organization, remindus that besides early beginnings,
stunting also has far-reaching consequences (de Onis & Branca 2016). It isestimated that stunting is
the cause of about one millionchild deaths annually. For the children who survive,stunting in
infancy and early childhood causes lastingdamage, including increased morbidity, poor
cognitionand educational performance in childhood, short stat-ure in adulthood, increased risk of
perinatal and neona-tal death for women, lower productivity and reducedearnings in adults and—
when accompanied by excessive weight gain later in childhood—increasedrisk of chronic diseases.
Therefore, it is accurate tosay that stunting hampers the development of entire so-cieties (Victoraet
al. 2008; Dewey & Begum 2016;Blacket al. 2013; de Onis & Branca 2016).The latest available data
indicate that 38% of SouthAsia’schildrenunderfive years of age are stunted.Levels of child stunting
in South Asia are comparableto those in sub-Saharan Africa (37%) and three timeshigher than those
in East Asia and the Pacific (12%)or Latin America (11%). The high prevalence ofstunting and the
region’s large child population (26%of the world’schildrenunderfive) means that SouthAsia, with
about 40% of the global burden of stunting,is the epicentre of the global stunting crisis (United Na-
tions Children’s Fund, UNICEF 2015a,b). Recent anal-yses indicate that three main drivers of child
stunting inSouth Asia are the poor diets of children in thefirstyears of life, the poor nutrition of
women before andduring pregnancy and the prevailing poor sanitationpractices in households and
communities (Smith &Haddad 2016). With this evidence in mind, UNICEF Regional Of-fice for
South Asia convened a regional conference inNew Delhi, India under the theme:Stop Stunting :Im-
proving Child Feeding,Women’s Nutrition and House-hold Sanitation in South Asia(November 10 –
12,2014). The Conference provided a knowledge-for-ac-tion platform with three objectives: (1)
share state-of-the-art researchfindings on the causes of child stuntingand its consequences for
child growth and developmentand the sustainable growth and development of SouthAsian nations;
(2) discuss better practices and the costand benefits of scaling up programmes to improve
childfeeding, women’s nutrition and household sanitation in South Asia; and (3) identify
implications for sectoraland cross-sectoral advocacy, policy, programme and re-search to accelerate
progress in reducing child stuntingin South Asia.The Regional Conference was attended by about
200participants representing national governments and re-gional organizations as well as bilateral,
multilateraland non-governmental development partners, repre-sentatives of research and
academic institutions and re-source persons from South Asia and globally. Thisspecial issue
ofMaternal and Child Nutritionincludesthe guest presentations made at the Conference and aseries
of invited papers that were developed in prepara-tion for or as a follow up to the Conference.

The challenge of improving childfeedingMost stunting happens in thefirst 1000

days, from con-ception to age two years, when children’slineargrowthis most sensitive to nutrition
deprivation and environ-mental stress. During thefirst 500 days, from concep-tion to about 6
months of age, the child is entirelydependent for its nutrition on the mother, either viathe placenta
during pregnancy or via breastmilk duringthe initial 6-month exclusive breastfeeding
period.However, the largest proportion of stunting occurs dur-ing the complementary feeding
period (6–23months),the ~500-day transition time from exclusivebreastfeeding in thefirst 6
months of life, to consuminga wide range of family foods while breastfeeding con-tinues. Adequate
complementary feeding is critical tosupport optimal physical growth and brain development in
children. Complementary foods need to be nu-trient-rich and be fed frequently to prevent
stunting.The most recent data indicate that fewer than 25% ofchildren 6–23 months old in
Afghanistan, Bangladesh,India, Nepal and Pakistan are fed diets that meet theminimum
requirements in terms of frequency and di-versity (United Nations Children’s Fund,
UNICEF2015a,b).Addressing this subject, Dewey reviews in this spe-cial issue the various options for
improving the dietsof pregnant and lactating women and their children inthefirst two years of life.
These options include dietarydiversification and increased intake of nutrient-richfoods for women,
improved complementary foods andfeeding practices for children and micronutrient sup-plements,
fortified foods and products specifically de-signed for infants, young children, pregnant
womenand lactating women. Dewey’s review indicates thatthese interventions, both prenatal and
postnatal, can have a positive impact on child growth. However, thereis significant heterogeneity
in linear growth response tosuch interventions. Such variation is likely to be relatedto the potential
to benefit (i.e. is the population under-nourished?) and the potential to respond to
improvednutrition (i.e. are there other factors constraining lineargrowth?). Hence, the importance
of understanding theaetiology of poor linear growth and stunting and theneed for integrated
approaches that address the poten-tially multifactorial aetiology of stunting (Dewey 2016).In their
paper, Paintal and Aguayo remind us thatoptimal infant and young child feeding (IYCF) prac-tices
are particularly crucial when children are sick orconvalescent as children’s nutritional status can
deteri-orate rapidly if the additional nutrient requirements as-sociated with illness and
convalescence are not met andnutrients are diverted from growth and developmenttowards the
immune response. Their review of surveyand research evidence shows that in South Asia,
IYCFpractices during common childhood illnesses are farfrom optimal. Most children continue to be
breastfedwhen they are sick, but few are breastfed more fre-quently, as recommended. In addition,
restriction orwithdrawal of complementary foods during illness isfrequent because of children ’s
anorexia (perceived orreal), poor awareness of caregivers ’about the feeding needs of sick children,
traditional beliefs/behavioursand/or sub-optimal counselling and support by healthworkers (Paintal
& Aguayo 2016).Evidence from the region suggests that large-scaleimprovements in IYCF are
possible when interventionsare designed for and delivered at scale. Sanghviet al.re-view the
experience of the Alive & Thrive programmein Bangladesh, which focused on a population of
8.5million mothers and their families/communities. After4 years of implementation, the
programme docu-mented rapid and significant improvements in keybreastfeeding and
complementary feeding practices.Promotion strategies reached a high percent of the pri-ority
groups through repeated contacts. Scale-up wasachieved by mainstreaming tools and strategies in
thework of government programmes and local NGOimplementing partners with an extensive
community-based platform. Improving the performance of front-line workers and volunteers in
delivering timely, high-quality counselling to mothers while reinforcing interpersonal counselling
with mass media campaigns,advocacy and community mobilization were central tothe success of
the programme (Sanghviet al. 2016).Similarly, Haselowet al.review the evolution andimpact of the
enhanced homestead food production(EHFP) programme, which aims to increase year-round
availability and intake of diverse nutrient-richfoods while promoting optimal feeding and
nutritionpractices in poor households. Programme evaluationin Bangladesh, Cambodia, Indonesia,
Nepal and thePhilippines indicates that EHFP had a positive impacton poor households ’year round
food production, foodconsumption–particularly among women and children6–59months of age–
and food security. Results fromrandomized and non-randomized programme evalua-tions in
Bangladesh and Nepal have shown significantimprovements in a range of practices known
toimpact positively child growth, with reductions inchild stunting ranging from 10.5% to 18.0%
(Haselowet al. 2016). It is clear from this set of papers that despite the chal-lenges, there are good
programme examples in SouthAsia that may be replicated and scaled up to
accelerateimprovements in IYCF. These must, however, beadapted to new settings other than their
originatingcontext, and more evidence must be built around theseadaptations to strengthen the
regional evidence base.

Stop stunting in South Asia: what isnext?As we mention in our introduction, this
special issue ofMaternal and Child Nutritioncaptures much of whatwas discussed in preparation for
and during the Re-gional Conference:Stop Stunting :Improving ChildFeeding,Women’s Nutrition and
Household Sanitationin South Asia. As a summary to the rich discussions thattook place during the
conference, we requested ShawnBaker, Director for Nutrition at the Bill and MelindaGates
Foundation, to share his views about what works,what is missing, and what is next to stop stunting
inSouth Asia. His views, in the form of 10take home mes-sagesare a good conclusion to this
overview paper.Message 1: Children from all regions of the worldhave similar potential for
growth and developmentin early childhood

Child stunting is a powerful marker of failed develop-ment. In nations where stunting has declined
many things have worked in favour of children. Conversely,wherever stunting remains high,
development is failingchildren. Children’s growth is a mirror of the state of asociety and stunting is
possibly the most sensitive indi-cator of overall societal equity and well-being. There-fore, it makes
perfect sense that child stunting be oneof the lead nutrition indicators for the post-2015 Sus-
tainable Development Goals.Message 2: Stunting is an outrage that demands aresponse
commensurate with the damage it isdoing to children and nations

Stunting has declined in South Asia but still compro-mises the future of 38% of underfives–almost
65 mil-lion children–and the future of the region as a whole.Good physical growth and brain
development are ev-ery child’s birth right. Stunted children do not have avoice and their plight is so
ubiquitous that it is viewedas the‘normal’state of affairs. However, evidence fromwithin and outside
the region proves that large scale de-clines in stunting –formillionsofchildrenatatime–can be
achieved. Message 3: We need to create‘anewnormal’for the drivers of child stunting in
South Asia

This new state of affairs needs to comprise a new nor-mal for child feeding that includes age-
appropriatefoods for infants and young children, and ensures qual-ity, quantity and safety; a new
normal for women’slivesthat includes good nutrition, healthy height, healthyweight, no anaemia
and the right to make decisions af-fecting their lives; andfinally, a new normal for house-hold
hygiene and sanitation practices that includesaccess to safe water and sanitation, washing with
soapat critical times, and the end of open defecation.Message 4. South Asian countriescan
afford to actandcannot afford the cost of inaction

Evidence shows that economic growth alone will notimprove stunting without commensurate
investmentsin other accompanying interventions. We need to movefrom expecting that economic
growth will‘trickledown’to making strategic investments on evidencebased large scale programmes
that place their emphasisof the most vulnerable children and populations. SouthAsian countries
need to seize the opportunity of eco-nomic growth to invest in the future of children. It willcost, but
it is an investment that‘locks in the potential’,with benefits that far exceed the cost.Message 5.
The one-thousand days from conceptionto age two years are a key window in
whichinterventions to prevent stunting should focus

A growing number of national nutrition programmesare responding to the challenge of child

stunting by fo-cusing on thegoldenone-thousand days and ensuringthat children under two years of
age and their mothersmeet their nutrient needs. Nutrient density and diet di-versity for children
and women are of the essence. Ev-idence shows that they can be improved at scale using amix of
interventions that includes locally-availablefoods, fortified foods, and supplementary foods
wherefood insecurity is a problem. Message 6: Act now and for the future. Multipledrivers
need multiple actionsIt

is essential that we deliver known solutions at scale toaddress the underlying causes of stunting:
child feeding,women’s nutrition and household sanitation. However,it will be crucial that we
partner with kindred spirits toaddress the more distal and inter-generational driversof child stunting
in South Asia: adolescent marriageand pregnancy, women’s illiteracy and poor decisionmaking
power, and household poverty and social exclu-sion. It will be essential to define the roles and
respon-sibilities of each sector in reducing child stunting and,importantly, to co-locate the
interventions of all sectors.Message 7: We need to start with focus and scale inmind

The response to child stunting in South Asia needs tobe commensurate with the scale of the
problem. Multi-ple platforms can be used to deliver the interventionsthat will stop stunting:
antenatal care visits, institutionaldeliveries, adolescent-focused programmes, mother-and-child
services, home visits and community-based programmes, social protection schemes and
women’smi-cro-credit programmes are a few examples. Scaling up im-proved hygiene and
sanitation practices and ending opendefecation will be essential to ensure that improved nutri-ent
intakes result into improved growth outcomes.