Stunting Persists despite Optimal Feeding: Are Toilets Part of the Solution?

Children in developing countries have an average length-for-age that is already below the World Health Organization standard at birth and show a further decline in linear growth over the first 24 months of life; however, complementary feeding interventions have only a modest impact on growth. Children living in conditions of poor sanitation and hygiene are frequently exposed to pathogenic microbes through feco-oral transmission. Acute diarrhea represents only the tip of the 'enteric disease iceberg', with a substantial underlying burden of chronic, subclinical enteropathy. Environmental enteric dysfunction (EED) is characterized by disturbance in small intestinal structure and impaired gut barrier function, enabling microbial translocation and chronic systemic inflammation, which may impair growth. Gut damage appears to arise early in infancy and markers of intestinal inflammation, intestinal permeability and systemic immune activation are inversely associated with linear growth. Reducing feco-oral microbial transmission by improving water, sanitation and hygiene (WASH) may theoretically prevent or ameliorate EED and improve linear growth; ongoing trials are exploring this hypothesis. Given the complex interplay of factors leading to stunting, multisectoral interventions are likely required. Improving WASH in addition to infant feeding may be one approach to improve the growth and developmental potential of infants in developing countries.