Child undernutrition: opportunities beyond the first 1000 days
Authors: Andreas Georgiadis, Mary E Penny
Journal: The Lancet Public Health (2017)

Stunting—an indicator of linear growth retardation that results in low height-for-age—reflects poor growth and development in children, which is a major public health concern in developing countries.1Black RE Victora CG Walker SP et al.Maternal and child undernutrition and overweight in low-income and middle-Income countries.Lancet. 2013; 6: 15-39Google Scholar Stunting often begins in utero and increases, on average, for at least the first 2 years after birth. The first 1000 days between conception and a child's second birthday has been identified as the most crucial window of opportunity for interventions.1Black RE Victora CG Walker SP et al.Maternal and child undernutrition and overweight in low-income and middle-Income countries.Lancet. 2013; 6: 15-39Google Scholar Evidence suggests that stunting is largely irreversible after the first 1000 days, leading to an intergenerational cycle of poor growth and development, in which women who were stunted in childhood remain stunted as adults and tend to have stunted offspring.1Black RE Victora CG Walker SP et al.Maternal and child undernutrition and overweight in low-income and middle-Income countries.Lancet. 2013; 6: 15-39Google Scholar However, evidence indicates that accelerated linear growth in childhood and adolescence following stunting in infancy (ie, catch-up growth) can occur.2Crookston BT Schott W Cueto S et al.Postinfancy growth, schooling, and cognitive achievement: young lives.Am J Clin Nutr. 2013; 98: 1555-1563Crossref PubMed Scopus (136) Google Scholar, 3Fink G Rockers PC Childhood growth, schooling, and cognitive development: further evidence from the Young Lives study.Am J Clin Nutr. 2014; 100: 182-188Crossref PubMed Scopus (104) Google Scholar, 4Bhargava A Protein and micronutrient intakes are associated with child growth and morbidity from infancy to adulthood in the Philippines.J Nutr. 2016; 146: 133-141Crossref PubMed Scopus (22) Google Scholar Evidence from the Young Lives international cohort study2Crookston BT Schott W Cueto S et al.Postinfancy growth, schooling, and cognitive achievement: young lives.Am J Clin Nutr. 2013; 98: 1555-1563Crossref PubMed Scopus (136) Google Scholar in Ethiopia, India, Peru, and Vietnam, found that around 50% of children who were stunted at age 1 year showed improvements in height and were no longer stunted at age 8 years in the absence of an intervention. Other longitudinal observational studies4Bhargava A Protein and micronutrient intakes are associated with child growth and morbidity from infancy to adulthood in the Philippines.J Nutr. 2016; 146: 133-141Crossref PubMed Scopus (22) Google Scholar have also reported catch-up growth in childhood. Could adolescence represent a crucial window for interventions after the first 1000 days? In particular, interventions that improve the nutritional status of adolescent girls, a group that is especially susceptible to the effects of undernutrition, could potentially break the intergenerational cycle of poor growth and development in low-income and middle-income countries.1Black RE Victora CG Walker SP et al.Maternal and child undernutrition and overweight in low-income and middle-Income countries.Lancet. 2013; 6: 15-39Google Scholar, 5Prentice AM Ward KA Goldberg GR et al.Critical windows for nutritional interventions against stunting.Am J Clin Nutr. 2013; 97: 911-918Crossref PubMed Scopus (309) Google Scholar However, the mechanism by which intergenerational benefits might be realised through interventions at this age is unclear. Moreover, whether these benefits might result from interventions that promote catch-up growth in adolescent girls remains unknown. This uncertainty exists despite the argument that adolescence—a period characterised by rapid growth that is second only to that of infancy—presents an opportunity for catch-up growth5Prentice AM Ward KA Goldberg GR et al.Critical windows for nutritional interventions against stunting.Am J Clin Nutr. 2013; 97: 911-918Crossref PubMed Scopus (309) Google Scholar, 6Das JK Salam RA Thornburg KL et al.Nutrition in adolescents; physiology, metabolism, and nutritional needs.Ann N Y Acad Sci. 2017; 1393: 21-33Crossref PubMed Scopus (185) Google Scholar and greater adult height,4Bhargava A Protein and micronutrient intakes are associated with child growth and morbidity from infancy to adulthood in the Philippines.J Nutr. 2016; 146: 133-141Crossref PubMed Scopus (22) Google Scholar and that improved adult height in mothers is expected to lead to better outcomes in offspring.4Bhargava A Protein and micronutrient intakes are associated with child growth and morbidity from infancy to adulthood in the Philippines.J Nutr. 2016; 146: 133-141Crossref PubMed Scopus (22) Google Scholar Evidence4Bhargava A Protein and micronutrient intakes are associated with child growth and morbidity from infancy to adulthood in the Philippines.J Nutr. 2016; 146: 133-141Crossref PubMed Scopus (22) Google Scholar, 5Prentice AM Ward KA Goldberg GR et al.Critical windows for nutritional interventions against stunting.Am J Clin Nutr. 2013; 97: 911-918Crossref PubMed Scopus (309) Google Scholar, 7Georgiadis A Benny L Duc LT et al.Growth recovery and faltering through early adolescence in low- and middle-income countries: determinants and implications for cognitive development.Soc Sci Med. 2017; 179: 81-90Crossref PubMed Scopus (31) Google Scholar has provided support for these hypotheses. For example, analysis8Sokolovic N Selvam S Srinivasan K et al.Catch-up growth does not associate with cognitive development in Indian school-age children.Eur J Clin Nutr. 2014; 68: 14-18Crossref PubMed Scopus (20) Google Scholar of Young Lives data shows that among 12-year-old girls with height below the WHO standard for their age group, on average, 40% of the height deficit was recovered by age 19 years. Furthermore, children with mothers who were stunted as adults were about 15% more likely to be stunted as infants and to remain stunted through early adolescence than children with mothers who were not stunted as adults.8Sokolovic N Selvam S Srinivasan K et al.Catch-up growth does not associate with cognitive development in Indian school-age children.Eur J Clin Nutr. 2014; 68: 14-18Crossref PubMed Scopus (20) Google Scholar Another important question for policy is whether improvements in nutrition beyond the first 1000 days do not only remedy growth, but also deficits in cognitive development that are associated with early undernutrition. Some evidence from observational studies3Fink G Rockers PC Childhood growth, schooling, and cognitive development: further evidence from the Young Lives study.Am J Clin Nutr. 2014; 100: 182-188Crossref PubMed Scopus (104) Google Scholar, 4Bhargava A Protein and micronutrient intakes are associated with child growth and morbidity from infancy to adulthood in the Philippines.J Nutr. 2016; 146: 133-141Crossref PubMed Scopus (22) Google Scholar, 7Georgiadis A Benny L Duc LT et al.Growth recovery and faltering through early adolescence in low- and middle-income countries: determinants and implications for cognitive development.Soc Sci Med. 2017; 179: 81-90Crossref PubMed Scopus (31) Google Scholar supports an association between accelerated growth in childhood and adolescence and cognitive achievement. Indeed, among children who were stunted at age 1 year, those who were not stunted at age 8 years performed better in achievement tests compared with children who were stunted at both ages.3Fink G Rockers PC Childhood growth, schooling, and cognitive development: further evidence from the Young Lives study.Am J Clin Nutr. 2014; 100: 182-188Crossref PubMed Scopus (104) Google Scholar However, a few studies have assessed the effect of recovery from stunting on cognitive achievement in children aged between 5 and 8 years and evidence from existing studies3Fink G Rockers PC Childhood growth, schooling, and cognitive development: further evidence from the Young Lives study.Am J Clin Nutr. 2014; 100: 182-188Crossref PubMed Scopus (104) Google Scholar, 8Sokolovic N Selvam S Srinivasan K et al.Catch-up growth does not associate with cognitive development in Indian school-age children.Eur J Clin Nutr. 2014; 68: 14-18Crossref PubMed Scopus (20) Google Scholar has been mixed. A meta-analysis9Sudfield CR McCoy DC Danaei G et al.Linear growth and child development in low- and middle-income countries: a meta-analysis.Pediatrics. 2015; 135: e1266-e1275Crossref PubMed Scopus (239) Google Scholar showed that nutrition interventions had a positive effect after age 2 years, but this effect was considerably smaller than the effect of interventions before age 2 years. More research is needed to establish a causal link between catch-up growth after the first 1000 days and cognitive development. Although the first 1000 days is a crucial stage for future growth and development and the most important period for interventions against stunting, accelerated linear growth can occur at later ages and might reverse stunting, particularly during adolescence, and this might present another opportunity for interventions aiming to break the intergenerational cycle of child undernutrition. We declare no competing interests.