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Int J Epidemiol. 2013 Oct;42(5):1340-55. doi: 10.1093/ije/dyt109. Epub 2013 Aug 6.

Risk of childhood undernutrition related to small-for-gestational age and preterm birth in low- and middle-income countries.

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Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA, Department of Nutrition, University of North Carolina, Chapel Hill, NC, USA, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh, Department of International Health, University of Tampere, School of Medicine, Tampere, Finland, Programa de Pós-graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Pelotas, Brazil, MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, UK, Departments of Global Health and Population, Nutrition, and Epidemiology, Harvard School of Public Health, Boston, MA, USA, Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA, Pennington Biomedical Research Center, Baton Rouge, LA, USA, Woman and Child Health Research Center, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerpen, Belgium, Department of Food Safety and Food Quality, Ghent University, Sint-Pietersnieuwstraat 25, B 9000 Ghent, Belgium, Diabetes Unit, King Edward Memorial Hospital and Research Centre, Pune, India, Center for Global Health Research, KEMRI, Kisumu, Kenya, KEMRI/CDC Research and Public Health Collaboration, Kisumu, Kenya, Epidemiology Research Unit, CSI Holdsworth Memorial Hospital, Mysore, India, Tianjin Women's and Children's Health Center, Tianjin, China, Institute for Global Health, UCL Institute of Child Health, London, UK, International Maternal and Child Health, Uppsala University, Uppsala, Sweden, Human Sciences Research Council and the Developmental Pathways for Health Research Programme, University of the Witwatersrand, Johannesburg, South Africa, Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA, Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool UK, Centers for Disease Control and Prevention, Kenya, Department of Global Health, Ge



Low- and middle-income countries continue to experience a large burden of stunting; 148 million children were estimated to be stunted, around 30-40% of all children in 2011. In many of these countries, foetal growth restriction (FGR) is common, as is subsequent growth faltering in the first 2 years. Although there is agreement that stunting involves both prenatal and postnatal growth failure, the extent to which FGR contributes to stunting and other indicators of nutritional status is uncertain.


Using extant longitudinal birth cohorts (n=19) with data on birthweight, gestational age and child anthropometry (12-60 months), we estimated study-specific and pooled risk estimates of stunting, wasting and underweight by small-for-gestational age (SGA) and preterm birth.


We grouped children according to four combinations of SGA and gestational age: adequate size-for-gestational age (AGA) and preterm; SGA and term; SGA and preterm; and AGA and term (the reference group). Relative to AGA and term, the OR (95% confidence interval) for stunting associated with AGA and preterm, SGA and term, and SGA and preterm was 1.93 (1.71, 2.18), 2.43 (2.22, 2.66) and 4.51 (3.42, 5.93), respectively. A similar magnitude of risk was also observed for wasting and underweight. Low birthweight was associated with 2.5-3.5-fold higher odds of wasting, stunting and underweight. The population attributable risk for overall SGA for outcomes of childhood stunting and wasting was 20% and 30%, respectively.


This analysis estimates that childhood undernutrition may have its origins in the foetal period, suggesting a need to intervene early, ideally during pregnancy, with interventions known to reduce FGR and preterm birth.


Foetal growth restriction; childhood; preterm birth; stunting; wasting

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