Childhood stunting remains a major challenge, especially in low- to middle-income countries. Even in those countries where the percentage of stunted children has gone down, the absolute number of cases has increased, and in some countries like Malawi, there remain regions where the percentage can be up to 50%. Multiple intervention trials have demonstrated some benefits of food supplementation, social and behavior change communication strategies, as well as improved water and hygiene practices. Many of these studies have focused on children over the age of two, so Christian and colleagues conducted a study using younger children to determine if this type of intervention strategy would be more effective when applied earlier in life. Their study outcomes are reported in the November 2020 issue of The Journal of Nutrition.

The study population used were from two neighboring districts in rural Malawi and included over 2400 children at baseline and study end. In one of the districts no interventions were used, and in the other children (6-23 months) received a daily fortified, small-quantity lipid-based nutritional supplement (110 kcal and 2.6 g protein), and their families were provided with behavior change messaging dealing with optimal infant feeding as well as water, sanitation and hygiene practices. Program impacts were determined by comparing stunting in each of the two districts.

Mean weight, weight-for-length z-score, and arm circumferences were improved by the intervention, but there was no change in mean length-for-age or prevalence of stunting. Morbidity measures, including the prevalence of fever and malaria, were reduced by the intervention. The interventions also improved diet diversity scores for the children and feeding and hand-washing practices were improved as well. These data led the authors to conclude that although there were multiple benefits derived from the program, the ultimate goal of reducing stunting was not achieved.

In a commentary on this article, Dewey discusses some of the explanations for why stunting was not reduced by the interventions in this study. They include maternal factors that contributed to a high prevalence of stunting at 6 months of age, high rates of pre- and postnatal infection, maternal short stature, and fetal growth restrictions. Dewey points out the importance of study designs that promote effective evaluation of interventions to promote healthy growth during the critical first 1000 days of life.


Christian P, Hurley KM, Phuka J, Kang Y, Ruel-Bergeron J, Buckland AJ, Mitra M, Wu L, Klemm R, West KP Jr. Impact evaluation of a comprehensive nutrition program for reducing stunting in children aged 6-23 months in rural Malawi. The Journal of Nutrition, Volume 150, Issue 11, November 2020, Pages 3024–3032,

Dewey KG. Reducing child stunting: Moving forward on evaluating effectiveness of programs. The Journal of Nutrition, Volume 150, Issue 11, November 2020, Pages 2843–2845,

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