Terry Talks:  Solving the Puzzle of Childhood Stunting
(Discussion Guide)

Your Guide for Further Learning and Conversation

This supplemental guide is packed with more valuable information on environmental enteropathy and childhood stunting, as well as discussion questions that you can work though with your team to begin determining how you can take action to positively impact the lives of the children in your community.

Let’s Get Started!

Index

KEY POINTS OF CHILDHOOD HEALTH AND STUNTING

THE IMPACT OF POVERTY ON EARLY CHILDHOOD DEVELOPMENT

HEIGHT AND HEALTH

WATER, SANITATION, AND HYGIENE’S IMPACT ON CHILD GROWTH

ENVIRONMENTAL ENTEROPATHY: THE MISSING PIECE OF THE STUNTING PUZZLE

EFFECTIVE WASH INTERVENTIONS

KEY POINTS OF CHILDHOOD HEALTH AND STUNTING

  • Globally, 165 million children (24%) under age five are stunted and at risk of not meeting their full potential.
  • Stunting is a risk factor for poor survival, childhood and adult health, learning capacity, and adult productivity.
  • WASH is associated with 2.4 million deaths annually due to diarrhea and the malnutrition that frequently follows.
  • Childhood is about building a strong foundation for lifelong physical and mental health and building readiness to succeed in school.

THE IMPACT OF POVERTY ON EARLY CHILDHOOD DEVELOPMENT

Poverty can impact a child’s early development which can undermine the educational achievement of children, productivity in adulthood and continues to contribute to the inter-generational poverty that we see globally. Exposure to the risks from poverty begins early in life and can lead to growing differences and widening developmental trajectories of children.

While there has been significant gains in child survival in recent years, prevention of growth faltering and developmental impairment remain persistent in low and middle income countries. Poor cognitive stimulation, stunting, iodine deficiency and iron-deficiency anemia have all been identified as key risk factors that prevent children from reaching their full developmental potential. But until recently there has been little mention of the effects of hygienic and sanitary conditions of the physical environment on child development.

Conversation Question:

What are some of the factors that can impact and delay a child’s development?

HEIGHT AND HEALTH

Height is a reflection of adequate nutrition during pregnancy and the first few years of life. During these early years, nutritional requirements are very high to support the rapid growth and development of the baby. Maternal stunting increases the risk for the fetus, newborn and for child health outcomes. Stunting has been shown to have long-term negative consequences on health, including for future generations. Stunted mothers give birth to small babies who grow up to give birth to small babies and so the cycle continues.

Conversation Questions:

Why do we worry so much about height? Does height really matter?

 

Globally, we see that in several regions height-for-age are already very low at birth and decline sharply during the first 24 months of life with little improvement after this age. Diets with poor nutritional quality during pregnancy, infancy and the early years lead to insufficient nutrition intake. Frequent infections during the first 2 years of life also contribute to the risk of becoming stunted during this period.

An estimated 165 million children under the age of 5 in low and middle income countries are at risk of not achieving their full developmental potential partly due to undernutrition. Undernutrition affects brain development directly and also affects physical growth, motor development, and physical activity. This in turn influences brain development through both the caregiver’s behavior with the child and the child’s interaction with their environment.

Being stunted at 24 months has been shown to result in starting school at an older age, achieving one year less of schooling overall, and a 16 percent increased risk of failing at least one grade in school. 1 It has also been shown to lead to poorer cognitive performance and lower school achievement throughout middle childhood. 2

Stunting often goes unrecognized by families who live in communities where short stature is so common that it seems normal.

Although stunting is clearly linked to malnutrition, maternal and child dietary interventions alone have not impacted growth as expected.

WATER, SANITATION, AND HYGIENE’S IMPACT ON CHILD GROWTH

Poor water, sanitation and hygiene (WASH) conditions are linked to 2.4 million deaths annually due to diarrhea and the malnutrition that often follows. However, The Lancet Maternal and Child Nutrition Series estimated that at most WASH interventions would only reduce stunting by 2.4%.

Malnutrition doesn’t just occur when there isn’t enough food – repeated infections and bouts of diarrhea make it difficult for a child’s body to absorb nutrients. Studies show that stunting is more common in places with high rates of open defecation because fecal matter contaminates the food, water and general environment, making children frequently ill, and can permanently damage children’s intestines and their ability to absorb nutrients and fight off infections.

Conversation Question:

Why do you think water, sanitation, and hygiene impact child growth?

 

The connection between nutrition, stunting, and WASH is complex. Unsafe water, poor sanitation, and hygiene are directly linked to undernutrition through diarrhea, intestinal worms and environmental enteropathy. Contamination of the home with animal and human feces is prevalent in poor households. People and animals carry feces from the outside into the home and into the direct environment of infants and young children’s play and feeding areas. Fecal contamination of children’s play and feeding environments is a constant and cumulative health risk during the critical window of children’s growth and development.

Diarrhea is a consequence of poor WASH, and is a leading cause of death in children. Repeated episodes of diarrhea contribute to undernutrition by hindering the absorption of nutrients. Children who are undernourished are also at high risk of suffering more frequent and severe episodes of diarrhea creating a vicious cycle.

Without appropriate sanitation and hygiene, worm infections are spread through contact with or ingestion of soil contaminated with human feces that contain worm eggs. Worm infections can lead to anemia, poor growth, and poor cognitive development.

ENVIRONMENTAL ENTEROPATHY: THE MISSING PIECE OF THE STUNTING PUZZLE

Environmental Enteropathy (EE) is a chronic condition affecting the structure and function of the small intestine. EE has been found to be related to chronic exposure to bacteria and poor water, sanitation, and hygiene conditions. This condition may be a major cause of poor growth because of the poor nutrient absorption and chronic low-level inflammation of the intestines.

Analysis from 65 country studies show that open defecation explains 54% of the international difference in children’s height. The link is stronger when open defecation and population density is high. This might explain the “Asian enigma” that despite economic growth, children in Asia are shorter on average than those in Africa, who are poorer. 3

Evidence does not support the common assumption that children in certain ethnic groups are naturally short. When young children are nurtured in healthy environments and their caregivers follow recommended health, nutrition, and care practices, their average growth patterns are very similar regardless of race or ethnic backgrounds.

Conversation Question:

How can you help break the cycle of oral-fecal contamination that causes EE and the chronic stunting that can impact our children for life?

EFFECTIVE WASH INTERVENTIONS

While WASH interventions have focused on improved sanitation, water treatment, and maternal hand washing, none of these interventions address the important needs of the very young child. In order to address the needs of the young child, the following Baby WASH interventions are suggested:

  • Use a protective play space, washable matt, or playpen to protect a child from contaminated soil and animal feces (especially chickens)
  • Wash infant hands periodically with soap and water when outside of the protective play space
  • Ensure caregivers wash hands with soap after contact with feces and before preparing or serving food
  • Safely dispose of children’s feces
  • Treat water
  • Avoid feeding leftover food to children, or be sure to reheat before serving

 

Conversation Question:

What are some practical action steps to promote Baby WASH interventions in your community?

1 Kar B, Rao S, Chandramouli B. Cognitive development in children with chronic protein energy malnutrition. Behavioral and Brain Functions 2008;4(1):31.

2 Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B. Developmental potential in the first 5 years for children in develoing countries. Lancet 2007 Jan 6;369(9555):60-70.

3 Spears D (2013) How much international variation in child height can sanitation explain? The World Bank, Sustainable Development Network, Water and Sanitation Program. Accessed 9/26/16 from: http://sanitationdrive2015.org/wp-content/uploads/2013/09/sanitation-height.pdf.