Stunting and the First 1,000 Days

A child who looks small for their age is not always just "a small child". When poor feeding and repeated illness go on for months, a child's body slows its growth. Doctors call this stunting, and it is one of the most common nutrition problems affecting young children.

What is stunting?

The World Health Organization (WHO) defines stunting as low height for age. WHO says it is the result of long-term or repeated undernutrition, and is usually linked to poor living conditions, poor health and nutrition in the mother, frequent illness, and poor feeding and care in early life.

Stunting is different from wasting. Wasting means low weight for height, and WHO says it usually points to recent, severe weight loss, often after not getting enough food or after an illness such as diarrhoea. A child can be stunted, wasted, or both.

Why do the first 1,000 days matter so much?

WHO describes the first 1,000 days as the period from conception to a child's second birthday, and says getting nutrition right in this window gives the best possible start in life with long-term benefits. Stunting matters because, in WHO's words, it holds children back from reaching their physical and mental potential. WHO also reports that nearly half of all deaths in children under five are linked to undernutrition.

How common is stunting in Pakistan?

Pakistan's National Nutrition Survey 2018, reported by UNICEF, found that four in ten children under five are stunted, and nearly two in every ten children under five are wasted. Globally, WHO counted 149 million stunted children under five in 2022.

What can families do in the first 1,000 days?

Most of what protects a child is ordinary, everyday care:

• Look after the mother's health and food during pregnancy. WHO lists poor maternal health and nutrition as a cause of stunting.
• Breastfeed only breast milk for the first six months, which is what WHO advises, and keep breastfeeding to two years or beyond.
• Start other foods at around six months. WHO says that around this age a baby's need for energy and nutrients starts to go beyond what breast milk alone gives.
• Feed often enough. WHO advises 2 to 3 meals a day from 6 to 8 months, and 3 to 4 meals a day from 9 to 23 months, with 1 to 2 extra snacks as needed.
• Offer a variety of nutritious foods, including meat, poultry, fish, eggs and dairy where possible, rather than only thin porridge or tea and biscuits.
• Keep food clean. WHO says food should be stored and prepared hygienically and given with clean hands and clean utensils, not in bottles and teats.
• Treat illness early. Repeated infections and diarrhoea are part of why children stop growing.

Can stunting be reversed?

Height already lost in early childhood is very hard to make up, which is why WHO puts so much weight on the first 1,000 days. That is not a reason to give up on an older child. Better feeding, treating infections and regular growth monitoring still improve a child's health, energy and school performance.

When to see a doctor

Have your child weighed and measured at your clinic, and keep the growth chart. See a health worker if:

• Your child is not gaining weight, is losing weight, or has stopped growing taller.
• Your child looks much smaller or thinner than other children the same age.
• Your child keeps refusing food, or has diarrhoea again and again.

WHO treats a child aged 6 to 59 months as having severe acute malnutrition if the mid-upper arm circumference is under 115 mm, weight-for-height is more than 3 standard deviations below the WHO standard, or there is swelling in both feet that leaves a dent when pressed. Any of these means the child needs a full assessment and treatment now, not next month.

If a child is limp, unable to feed, unconscious or struggling to breathe, call Rescue 1122 where available, or go to the nearest hospital emergency department.