Childhood stunting in relation to the pre- and postnatal environment during the first 2 years of life: The MAL-ED longitudinal birth cohort study

MAL-ED Network Investigators, Benjamin J.J. McCormick

Research output: Contribution to journalArticlepeer-review

93 Citations (Scopus)


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

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

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

Original languageEnglish
Pages (from-to)e1002408
JournalPLoS Medicine
Issue number10
Publication statusPublished - 25 Oct 2017

Bibliographical note

Benjamin J. McCormick: MAL-ED Network Investigator meeting ICMJE authorship criteria; member of the writing group; contributed to data and sample collection and management.


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


Dive into the research topics of 'Childhood stunting in relation to the pre- and postnatal environment during the first 2 years of life: The MAL-ED longitudinal birth cohort study'. Together they form a unique fingerprint.

Cite this