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com
ADC Online First, published on May 3, 2017 as 10.1136/archdischild-2016-311050
Original article

Evidence-based approaches to childhood

stunting in low and middle income countries:
a systematic review
Muttaquina Hossain,1 Nuzhat Choudhury,1 Khaleda Adib Binte Abdullah,1
Prasenjit Mondal,1 Alan A Jackson,2 Judd Walson,3 Tahmeed Ahmed1

▸ Additional material is ABSTRACT

published online only. To view Objective We systematically evaluated health and What is already known on this topic?
please visit the journal online
(http://dx.doi.org/10.1136/ nutrition programmes to identify context-specific
archdischild-2016-311050). interventional packages that might help to
▸ A combination of nutrition-specific and
1 prioritise the implementation of programmes for
Stunting Research Platform, nutrition-sensitive interventions appears
Nutrition and Clinical Services reducing stunting in low and middle income
necessary in order to optimise programmes to
Division, ICDDR, Dhaka, countries (LMICs).
reduce stunting.
Bangladesh
2
Methods Electronic databases were used to
Southampton General systematically review the literature published between
Hospital, Southampton, UK
3
Department of Global Health, 1980 and 2015. Additional articles were identified from
University of Washington, the reference lists and grey literature. Programmes were
What this study adds?
Seattle, USA identified in which nutrition-specific and nutrition-
sensitive interventions had been implemented for
Correspondence to ▸ Nutrition education and counselling, growth
children under 5 years of age in LMICs. The primary
Dr Muttaquina Hossain,
Nutrition and Clinical Services outcome was a change in stunting prevalence, estimated monitoring and promotion, immunisation,
Division, International Centre as the average annual rate of reduction (AARR). A realist water, sanitation and hygiene and social safety
for Diarrhoeal Disease approach was applied to identify mechanisms net programmes appear to be the most
Research, 68 Shahid Tajuddin underpinning programme success in particular contexts commonly included interventions of an effective
Ahmed Sarani, Mohakhali,
and settings. package in most low and middle income
Dhaka 1212, Bangladesh;
[email protected] Findings Fourteen programmes, which demonstrated countries settings.
reductions in stunting, were identified from 19 LMICs. ▸ Single interventions reduced stunting only in
Received 18 April 2016 The AARR varied from 0.6 to 8.4. The interventions countries with specific disease burden.
Revised 21 September 2016 ▸ Intervention worked best when country,
Accepted 2 December 2016
most commonly implemented were nutrition education
and counselling, growth monitoring and promotion, community and programme context were taken
immunisation, water, sanitation and hygiene, and social into account.
safety nets. A programme was considered to have
effectively reduced stunting when AARR≥3%.
Successful interventions were characterised by a
combination of political commitment, multi-sectoral mortality and impacts negatively on both physical
collaboration, community engagement, community- growth and cognitive development; as well as
based service delivery platform, and wider programme increased risk of obesity and other metabolic com-
coverage and compliance. Even for similar interventions plications in later life. Separately and together these
the outcome could be compromised if the context lead to lower economic productivity, and con-
differed. strained social function.2 Thus, stunting appears a
Interpretation For all settings, a combination of direct impediment towards achieving the sustain-
interventions was associated with success when they able development goals.
included health and nutrition outcomes and social The most vulnerable period for the establishment
safety nets. An effective programme for stunting of lifelong stunting is the first 1000 days from con-
reduction embraced country-level commitment ception. Thereafter, it appears increasingly difficult
together with community engagement and programme to reverse adverse influences ultimately leading to
context, reflecting the complex nature of exposures of adults of shorter stature.3 In targeting the first
relevance. 1000 days, both global movements and regional
PROSPERO registration number programmes have sought to take nutrition interven-
CRD42016043772. tions to scale by supporting nutrition governance.4
However, these initiatives appear less successful
than anticipated in achieving the desired reduction
To cite: Hossain M, in stunting in LMICs.5
Choudhury N, Adib Binte
Abdullah K, et al. Arch Dis
INTRODUCTION Globally, stunting has decreased at approximately
Child Published Online First: Stunting1 is the most common manifestation of 1.8% per year.6 indicating that it will only decrease
[please include Day Month chronic undernutrition during childhood in low by 18% in the next 10 years, failing to achieve the
Year] doi:10.1136/ and middle income countries (LMICs). It has been goal set by the World Health Assembly.7 This is
archdischild-2016-311050 associated with increased risk of morbidity and consistent with data suggesting that scaling up

Hossain M, et al. Arch Dis Child 2017;0:1–7. doi:10.1136/archdischild-2016-311050 1

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Original article

Figure 1 Definition of
nutrition-specific and
nutrition-sensitive interventions and
programmes (adapted from Ruel and
Alderman9).

existing nutrition-specific interventions would reduce stunting interest was changes in stunting prevalence following a pro-
by about 20%.8 A combination of nutrition-specific and gramme intervention among children under 5 years of age.
nutrition-sensitive interventions appears necessary in order to
optimise reductions in stunting (figure 1).9 The population, intervention, comparators and outcomes
This review sought to identify studies from LMICs where framework
combined programmatic interventions have been evaluated. It
identifies the programmes and the components of nutrition Population Intervention Comparison Outcome
interventions in which there had been demonstrable success Children aged Nutrition-specific and Programmes other Stunting
between 0 and nutrition-sensitive than nutrition reduction
leading to a reduction in stunting. In addition, we sought to 59 months interventions implemented intervention
determine correlates of success among programmes for particu- either alone or in combination
lar contexts and settings by using the realist approach. The
purpose was to provide a synthesis of the available evidence that The reviewers/authors followed ‘Preferred Reporting Items
could assist policy makers and donors in prioritising the use of for Systematic Reviews and Meta-analyses (PRISMA)’ checklist
resources for implementation of interventions to prevent and during this review (see online supplementary appendix 2).11
control stunting in resource limited settings by considering of a Titles and abstracts were screened by two authors independently
mix of factors for the country, community and programme (MH and KABA). All titles and abstracts from each search were
contexts. examined, matched and then the relevant articles were obtained
for review (figure 2). To ensure consistency a calibration exercise
METHODS was conducted. The reviewers agreed on the criteria and
Data sources applied them to a sample of 20% of the retrieved studies to
A comprehensive search strategy was designed a priori and demonstrate adequate inter-examiner agreement (κ: 0.70–0.75).
applied to electronic bibliographic databases, including Medline The reviewers read each study independently and any disagree-
(Pub Med), WHO Regional databases, Google’s Scholar data- ments were resolved through discussion or, where necessary,
bases and the Cochrane Library with specific key words/con- through consultation with a third team member (PM).
cepts: ‘stunting’, ‘linear growth failure’, ‘stunting reduction
programme’, ‘intervention’, ‘approach’ and ‘low and middle Data extraction
income countries’ (see online supplementary appendix 1). The Two reviewers (MH and KABA) independently extracted both
search was limited to literature published between 1 January quantitative and qualitative data on: the number of programme
1980 and 31 March 2015. MeSH headings were used where components implemented, the baseline rate of stunting preva-
available. Published and unpublished references and grey litera- lence, the stunting prevalence following the period of the pro-
ture sources were searched electronically and manually. gramme intervention and the rate of stunting reduction over
time. They used standardised forms, checklists, note taking and
Study eligibility criteria annotation to compile the data from studies employing diverse
This review considered all studies involving human subjects interventional packages across multiple settings and geograph-
under 5 years of age (0–59 months), published in the English ical locations. During study selection and data extraction the
language. It had a focus on public health programmes that reviewers were not blinded to authorship, journal of publication
implemented nutrition-specific and nutrition-sensitive interven- or the trial results.
tions to reduce stunting, mostly in a community-based setting9
in LMIC’s,10 and where there were data on baseline and Methodological quality assessment
follow-up or end line stunting status. Studies without any com- The quality of the individual studies that were included was
ponents of nutrition intervention, individual randomised con- assessed by two reviewers (MH and KABA) independently for
trolled trials (RCTs) and those in which linear growth or both experimental (RCT) and observational (cross-sectional)
stunting had not been measured were excluded. The outcome of studies. The possible risk of bias in RCT was assessed using the
2 Hossain M, et al. Arch Dis Child 2017;0:1–7. doi:10.1136/archdischild-2016-311050
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Original article

Figure 2 Flow diagram for the

literature search.

Cochrane Collaboration tool12 and quality assessment of cross- the components had been implemented in the greater number
sectional studies was assessed with a modified version of the of effective programmes in order to provide an indication of the
Newcastle-Ottawa Scale.13 Judgments as to the possible risk of consistency with which the individual components appeared to
bias was rated as ‘high risk’ or ‘low risk’ for the extracted infor- contribute to the reduction in stunting (see online
mation for each of the six domains of RCT (see online supplementary appendices 6 and 7). We applied the realist
supplementary appendix 3). The scale scores for observational approach in assessing the programme context and underlying
studies ranged from 0 (lowest grade) to 7 (highest grade). mechanisms which might explain the programme’s success in
Observational studies with scores at or above the median (equal reducing stunting.16 With further discussion and critical review
to or greater than 5) were classified as high quality studies (see of the programme evaluation reports and grey literature we
online supplementary appendix 4). Risk of bias across studies identified several contextual factors of probable relevance.
was assessed using the approach outlined by the ‘Grading of These were themed for the different underlying contexts into
Recommendations Assessment Development and Evaluation’ broad key concepts or connections, which were considered to
(GRADE) working group.14 The quality of evidence was assessed capture the likely mechanism(s) behind successful programme
as high, moderate and low or very low (see online supplementary outcome (stunting reduction) (figure 3).
appendix 5), and any disagreement was resolved by discussion or
where necessary by consultation with a third author. Protocol and registration
A full protocol for the study was completed by the authors
Data analysis prior to commencement of the study (see online supplementary
To enable comparisons to be made among the different studies, appendix 8) and can be accessed at http://www.crd.york.
the average annual rate of reduction (AARR) was derived, as ac.uk/PROSPERO/display_record.asp?ID=CRD42016043772.
described in detail elsewhere.15 For the purpose of our investi- Registration no: CRD42016043772.
gation, we considered a programme to be effective if an AARR
for stunting that was equal to or greater than the median Role of the funding source
AARR. We further characterised the individual nutrition-related The funding institution had no role in the design and develop-
components of each specific programme to determine which of ment, data extraction, analysis and interpretation of the data, or
Hossain M, et al. Arch Dis Child 2017;0:1–7. doi:10.1136/archdischild-2016-311050 3
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Original article

Figure 3 Realist review framework.

preparation, review, or approval of the paper. The correspond- (Malawi, Niger and sub-Saharan Africa) where there was high
ing author had full access to all the data in the study and had malaria prevalence. The majority of SSN programmes were
final responsibility for the decision to submit for publication. implemented in Latin American countries and targeted poor
beneficiaries. The AARR in these countries varied widely
RESULTS (between 2.2% and 6.7%), even when the individual compo-
Identification and selection of the literature nents for the intervention appeared similar (nutrition education
An initial search combining all key words yielded the titles of and counselling, vitamin A supplementation, immunisation,
6267 articles. The full text of 111 papers were screened and WASH, food security and SSN). Programmes which recruited
assessed for eligibility after removal of duplicates (based on younger children (0–36 months) from poor rural households
author name, article title, year of publication and journal name) and which were implemented in areas with no other health pro-
and clearly unrelated articles. A further 27 papers were identified grammes (Bangladesh, Peru and sub-Saharan Africa) reduced
from reference lists and the grey literature. After removal of ineli- stunting more effectively than others (Ethiopia, Haiti, India,
gible studies, 18 papers were included in the review (figure 2). In Malawi and Mexico) (table 1).
this way, 14 programmes were identified in 19 LMICs where
nutrition-specific approaches had been implemented, either Contextual factors behind programme outcome
alone or in combination with nutrition-sensitive interventions, to A realist approach was used to examine contextual factors
reduce stunting. which were considered to be the drivers for successful pro-
gramme outcome (reduction of stunting). We identified four key
Description of included studies and risk of bias assessment concepts underpinning the connection between programme
All but one of the studies were cross-sectional. Most studies tar- intervention and outcome. This analysis suggests that a stunting
geted children under 5 years of age living in poor households reduction programme becomes effective (AARR of stunting at
from rural areas. The programmes were implemented between least 3%) where there is an evidence of strong political commit-
1986 and 2010, from countries in Asia, Latin America and ment, multi-sectoral collaboration between government, non-
Africa. None of the programmes enabled comparison with a government, national and international organisation, active
true control area in which there had been no intervention. community engagement, and where the programme is delivered
Included studies generated evidence of moderate quality (11 out through community-based platforms with high coverage and
of 17 included observational studies and 1 RCT) with low risk compliance (≥5 out of 7 programme). These underlying factors
of bias (see online supplementary appendices 3–5). were clearly identified in five of seven programmes in which
stunting was effectively reduced (table 2).
Nutrition intervention programme and stunting reduction
The effect of the different interventions in reducing stunting DISCUSSION
varied widely across the studies, with decreases in the AARR of Summary of evidence
stunting ranging from 0.6 to 8.4 (median 3) percentage points This systematic review identifies that in order to achieve success
per year. Programmes with AARR of stunting of at least 3 with interventions designed to reduce stunting in LMICs
(median AARR) from baseline were considered to have been requires a combination of factors and components which
effective. We identified seven effective programmes. In Asia, together provide a suitable context. Nutrition education and
programmes in Bangladesh and Vietnam achieved AARR of counselling, GMP, immunisation, WASH, and SSN programmes
stunting of 4.5%. In Latin America, Brazil demonstrated the were the components most frequently included in the interven-
highest AARR of 8.4%. The Millennium Villages programme in tion packages. The programmes appear most successful where
nine sub-Saharan countries achieved AARR of 7%. For success- strong political commitment and multi-sectoral collaboration
ful programmes, both nutrition-specific and nutrition-sensitive between government, non-government, national and inter-
interventions were combined. These were found in three out of national organisations exist and where programmes are deliv-
seven programmes with interventions that included nutrition ered through community service delivery platforms with active
education and counselling, immunisation, growth monitoring community engagement.
and promotion (GMP), water, sanitation and hygiene (WASH) Although nutrition is necessary, interventions that focus solely
and social safety net (SSN) interventions (see online on nutrition are likely to be insufficient in themselves for many
supplementary appendices 6 and 7). Programmes to prevent and of the global contexts where there is the need to reduce stunt-
treat malaria were implemented only in African countries ing. This review has shown that in most settings a combination
4 Hossain M, et al. Arch Dis Child 2017;0:1–7. doi:10.1136/archdischild-2016-311050
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Table 1 Nutrition intervention/programmes in low and middle income countries

Geographic Study population and Time Effective
region Country Author, year Programme name Study design setting period Programme components AARR programme

Asia Bangladesh Smith et al17 Strengthening household ability Cross-sectional Children 6–24 months, 2006–2010 Nutrition education and counselling; GMP; Vit A and IFS; 4.5 Yes

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to respond to development surveys poorest household immunisation; HFP, access to local health facilities;
opportunities (Shouhardo) sanitation; women empowerment; PFSA; SSN
Bangladesh Arifeen et al18 Integrated management of Cluster Rural children 0–59 months 2000–2007 Nutrition education and counselling; GMP; IMCI 2.9 No
childhood illness (IMCI) randomised trial
programme
Cambodia Ikeda et al19 National nutrition programme Cross-sectional Children 0–59 months 2000–2010 IYCF; MNP; IMCI; parental education; HFP; WASH; 1.03 No
surveys reduction of maternal tobacco use
India Haddad et al20 Integrated child development Cross-sectional Children 6–24 months, 2006–2012 Nutrition education and counselling; IYCF; Vit A and IFS; 2.2 No
services programme surveys poorest household immunisation; IMCI; FF and FS; deworming; PFSA; SSN;
HFP; women empowerment, child psychosocial stimulation;
community kitchen and garden; telemedicine; WASH;
Nepal Bilukha et al21 The vita-mix-it distribution Pre–post design Bhutanese children 2007–2010 Nutrition education and counselling; MNP; FS; GMP; 4 Yes
programme 6–59 months, Nepal immunisation; deworming
refugee camps
Vietnam Khan et al22 National childhood malnutrition Cross-sectional Children 0–59 months 1990–2004 Immunisation; IMCI; PFSA; HFP; WASH 4.3 Yes
control programme surveys
Latin America Brazil Lima et al23; National health and nutrition Cross-sectional Children 0–59 months, poor 1986–2006 PFSA; SSN; IMCI; parental education; WASH; HFP 8.4 Yes
Monteiro et al24; programme surveys household
Victora et al25
Haiti Ayoya et al26 National health and nutrition Cross-sectional Children 0–59 months, poor 2006–2012 IYCF; Vit A and IFS; IMCI, immunisation; IMCI; FF; SSN; 1.05 No
programme surveys household HFP; WASH
Mexico Rivera et al27; Oportunidades programme Cross-sectional Children 0–24 months, poor 1988–2006 Nutrition education and counselling; immunisation, GMP; 2.9 No
Leroy et al28 surveys household FS and FF; SSN, women empowerment
Peru Lechtig et al29 The good start in life Before-and-after Rural poor children 2000–2004 Nutrition education and counselling; GMP; IYCF; Vit A and 4.3 Yes
programme design 0–36 months IFS; immunisation; FF; WASH, child psychosocial stimulation
Africa Ethiopia Fenn et al30 The child caring practices Cross-sectional Children 6–36 months, poor 2004–2009 Nutrition education and counselling; IYCF; MNP; IMCI; 2.42 No
project surveys household immunisations; SSN; HFP
Malawi Kalimbira et al31 Integrated community-based Cross-sectional Rural children 6–59 months, 1996–2005 Nutrition education and counselling; Vit A and IFS; FF; 2.4 No
micronutrient and health surveys poor household deworming; malaria prevention and treatment; WASH; HIV
programme testing and referral
Niger Amouzou et al32 Child survival programme Cross-sectional Children 0–59 months, poor 1998–2009 Malaria prevention and treatment 3.3 Yes
surveys household
Sub-Saharan Remans et al ; 33
Millennium village Cross-sectional Rural children 0–24 months, 2006–2009 Nutrition education and counselling; GMP; IYCF; Vit A and 6.7 Yes
Africa Pronyk et al34 surveys poor household IFS; MNP; immunisations; IMCI; PFSA; access to local
healthcare; WASH; telemedicine; malaria prevention and

Original article
treatment, SSN
AARR, average annual rate of reduction; FF, food fortification; FS, food supplementation; GMP, child growth monitoring and promotion; HFP, health and family planning services; IYCF, infant and young child feeding; MNP, multiple micronutrient powder;
PFSA, Poverty and food security alleviation; SSN, Social safety net; Vit A and IFS, vitamin A and iron-folic acid supplementation; WASH, water, sanitation and hygiene.
5
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Original article

Table 2 Key concepts/connections linked to programme context and outcome

Key concepts/ Derived from following No. of implemented No. of effective
connections context/theme Programme implemented in LMIC’s programmes programme (≥3 AARR)

Country level Economic growth Bangladesh, India, Brazil, Mexico, Cambodia 6 2

Strong political will Bangladesh, India, Nepal, Vietnam, Brazil, Haiti, Malawi, 10 6
Niger, Peru, sub-Saharan Africa
Budget allocation India, Vietnam, Haiti, Ethiopia, Niger, sub-Saharan Africa 6 3
Multi-sectoral collaboration Bangladesh, Cambodia, India, Nepal, Vietnam, Haiti, Peru, 10 5
Malawi, Niger, Sub-Saharan Africa
Community level Community engagement Bangladesh, India, Nepal, Haiti, Peru, Ethiopia, Malawi, 10 5
Niger, Sub-Saharan Africa
Programme level Community-based delivery platform Bangladesh, India, Nepal, Haiti, Peru, Ethiopia, Malawi, 10 5
Niger, Sub-Saharan Africa
Wider programme coverage Bangladesh, India, Nepal, Vietnam, Brazil, Mexico, Cambodia, 9 5
Malawi, Niger, Sub-Saharan Africa
Programme compliance Bangladesh, India, Nepal, Vietnam, Brazil, Mexico, Cambodia, 9 5
Malawi, Niger, Sub-Saharan Africa
Presence of other health/nutrition India, Nepal, Mexico, Ethiopia 4 1
programme
Other Social media involvement Bangladesh, India, Niger 3 1
Environment (natural calamity, Bangladesh, Brazil, Ethiopia, Sub-Saharan Africa 4 3
disease outbreak, etc)
AARR, average rate of reduction; LMICs, low and middle income countries.

of nutrition-specific and nutrition-sensitive approaches is policies,35 leading to the design and implementation of suitable
needed for best effect. Even though combined interventional large scale nutrition-related programmes. At the community
packages result in the greatest reductions in stunting (4.3–8.4 level, community engagement enables better community-based
AARR), there is not necessarily a fixed combination of interven- service delivery with wider coverage and beneficiary compli-
tions that consistently demonstrate greatest benefit in all con- ance, enabling programme level interventions to achieve greater
texts. Thus, for Bangladesh, Peru and nine sub-Saharan African degrees of stunting reduction.36 This review supports the
countries there was effective reduction of stunting with nutrition acknowledgement by WHO that programmes addressing the
education and counselling, vitamin supplementation, immunisa- contextual factors achieved better reductions in stunting, more
tion, WASH, food security and SSN programmes. However, the quickly.37
same combinations of interventions were not similarly effective
in Ethiopia, Haiti, India, Malawi or Mexico.20 26 28 30 31 The Strengths and weaknesses of this review
difference may be explained by the need for more secure target- There are several important strengths to this analysis. The
ing of younger children from rural household, and also the review was carried out systematically using established PRISMA
effects of other programmes or interventions in either the same and GRADE guidelines. A realist approach was adopted in
or a neighbouring community. It is clear that in addition to geo- evaluating underlying factors which could account for the mech-
graphical location, the organisation, administration and delivery anistic basis underlying programme success. This approach
of the intervention, as well as the population being targeted has further helped to structure the evidence to inform recommenda-
an effect on the overall effectiveness of the intervention. tions on stunting reduction in different programmes employing
However, there may be some settings in which a dominant risk diverse interventional packages across multiple settings and
factor accounts for much of the population attributable fraction geographies. Standardised methods were used to calculate the
of stunting and where a simple intervention can have profound AARR for all countries.
impact. For example, malaria prevention and treatment has The review does have limitations. We included studies pub-
shown significant benefit in reducing stunting in regions with lished in peer-reviewed journals and may have missed important
high malarial burden.32–34 unpublished data as a result of publication bias. Studies pub-
The available evidence would not support the suggestion that lished in languages other than English were not included, which
any one single intervention or fixed combination of interven- may have resulted in language bias. Finally, because many pro-
tions is likely to achieve universal success across all settings in grammes combined interventions, it was not possible to attri-
assuring consistent reductions in stunting. It also became clear bute the level of stunting reduction directly to the effect of any
during our analysis that when there was a seeming difference in single intervention.
the effect of individual components, it was likely that the
context for other related intervention components had changed, CONCLUSION AND RECOMMENDATION
altering the overall balance of possible beneficial mechanisms. Programmes that combine nutrition-specific and nutrition-
The evidence supports the suggestion that programme managers sensitive interventions, particularly those with strong health
and policy makers should identify and implement context spe- access and safety net components, appear to be most effective in
cific intervention packages by addressing all three connections reducing stunting in LMICs. Given the complex nature of these
(country, community and programme) to achieve effective stunt- diverse intervention packages, strong political commitment,
ing reduction. At country level, Government’s strong political multi-sectoral collaboration, community-based service delivery
commitment and multi-sectoral collaboration between national platforms and wider programme coverage and compliance are
and international agencies provides a high level supportive all likely critical components of effective stunting reduction pro-
framework for the formulation and coordination of appropriate grammes. Programme managers and policy makers should
6 Hossain M, et al. Arch Dis Child 2017;0:1–7. doi:10.1136/archdischild-2016-311050
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Original article

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Hossain M, et al. Arch Dis Child 2017;0:1–7. doi:10.1136/archdischild-2016-311050 7

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Evidence-based approaches to childhood

stunting in low and middle income countries:
a systematic review
Muttaquina Hossain, Nuzhat Choudhury, Khaleda Adib Binte Abdullah,
Prasenjit Mondal, Alan A Jackson, Judd Walson and Tahmeed Ahmed

Arch Dis Child published online May 3, 2017

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