Globally in 2013, 161 million children under the age of five years (U-5 children) had a height-for-age Z score more than 2 standard deviations (SD) below the median of WHO Multicentre Growth Reference Study (MGRS) Child Growth Standard (termed ‘stunting’), and half of these children resided in Asia [
1]. Although the stunting prevalence is decreasing worldwide, reductions in South Asia have been slower (36% since 1990) compared to 57% reduction in Europe and more than 70% in East Asia and the Pacific [
2]. Stunted children have higher mortality [
3], lower academic attainments [
4], short stature as adults [
5], reduced economic productivity [
6], reduced cognition [
7] and have a higher risk of cardio-metabolic diseases in adulthood [
8], all contributing to the ‘stunting syndrome’ [
9], and the trans-generational cycle of undernutrition and poverty [
10]. Thus, stunting is a major public health problem in South Asia. In Bangladesh, the latest Demographic and Health Survey (2014) [
11] reports that stunting prevalence has decreased to 36.1%. Despite a reduction in the past decade [
12], national stunting prevalence remains high [
13], with higher levels in rural areas (37.9%) and among the poorest populations (50.2%). Trends also show widespread geographic disparity - stunting has declined by about 2–3 percentage point per year in most regions except no change in
Sylhet division, the north-eastern region [
11].
Although unaddressed by the Millennium Development Goals, reduction of stunting prevalence became the focus of several high-profile nutrition initiatives such as Scaling Up Nutrition (SUN, 2010) [
14], World Health Assembly 2012 [
15] and Nutrition for Growth 2013 [
16]. The World Health Assembly 2012 has a target of 40% reduction of U-5 stunting by 2025. Hence, the recent Sustainable Development Goals (SDGs) adopted by the UN in 2015 included stunting reduction as one of their goals (SDG 2.2) [
17].
The critical window of opportunity
Childhood stunting is considered to have in utero origins [
18]. The first 1000 days of life (conception to postpartum two years) is regarded as a critical ‘window of opportunity’ for growth and development [
19]. The long-term interactions of both proximal (i.e. biological and environmental) and distal (i.e. socioeconomic) factors play significant roles during this period in influencing the linear growth of children [
20]. The proximal factors of childhood stunting in South Asia include undernourished mothers, limited dietary diversity during pregnancy, poor infant and young child feeding practices (IYCF) including suboptimal breastfeeding and/or complementary feeding, and inappropriate sanitation and hygiene [
21]. However, even short-term improvements in nutritional status (in utero and postnatal) can result in substantial mean height gain of the child even within a single generation [
22].
Relevance of the present study
We have adapted five preventive interventions to create our own interventions bundles, based on Bhutta et al.’s list considering feasibility of scale-up in low resource settings and targeting the first 1000 days of life (from conception to two years of age). Our interventions include, a) Behaviour change communication (BCC) on nutrition and health-related practices during pregnancy; b) BCC on exclusive breastfeeding (EBF) for postnatal first 6 months; c) BCC on age-specific complementary feeding (CF) with continued breastfeeding thereafter till 23 completed months; d) Nutritional supplementation during pregnancy (PNS) with preventive doses of micronutrients, and partial provision of protein and lipids; e) Nutritional supplementation for children (CFS) during 6 to 23 completed months of age, with preventive doses of micronutrients, and partial provision of protein and lipids. In essence, this randomized controlled trial provides a crucible to see how different nutritional interventions interact when delivered in bundled packages in community settings to affect linear growth of the child from conception to two years of age compared to the comparison arm where routines practices will run unhindered.
Study aim and hypothesis
This study aims to test the effectiveness of the intervention bundle(s) on improving length-for-age Z score (LAZ) of children at two years of age. We hypothesised that our intervention bundle(s) would cause a change of at least 0.4 in mean LAZ of children, translating to at least 30% reduction in stunting in that arm(s), compared to that in the comparison arm.