title: Growth faltering in rural Gambian children after four decades of interventions: a retrospective cohort study.
abstract: Growth faltering remains common in children in sub-Saharan Africa and is associated with substantial morbidity and mortality. Due to a very slow decline in the prevalence of stunting, the total number of children with stunting continues to rise in sub-Saharan Africa. Identification of effective interventions remains a challenge.
  
  
  
  We analysed the effect of 36 years of intensive health interventions on growth in infants and young children from three rural Gambian villages. Routine growth data from birth to age 2 years were available for 3659 children between 1976 and 2012. Z scores for weight-for-age, length-for-age, weight-for-length, mid-upper-arm circumference, and head circumference were calculated using the WHO 2006 growth standards. Seasonal patterns of mean Z scores were obtained by Fourier regression. We additionally defined growth faltering as fall in Z score between 3 months and 21 months of age.
  
  
  
  We noted secular improvements in all postnatal growth parameters (except weight-for-length), accompanied by declines over time in seasonal variability. The proportion of children with underweight or stunting at 2 years of age halved during four decades of the study period, from 38·7% (95% CI 33·5-44·0) for underweight and 57·1% (51·9-62·4) for stunting. However, despite unprecedented levels of intervention, postnatal growth faltering persisted, leading to poor nutritional status at 24 months (length-for-age Z score -1·36, 95% CI -1·44 to -1·27, weight-for-age Z score -1·20, -1·28 to -1·11, and head circumference Z score -0·51, -0·59 to -0·43). The prevalence of stunting and underweight remained unacceptably high (30·0%, 95% CI 27·0-33·0, for stunting and 22·1%, 19·4 to 24·8, for underweight).
  
  
  
  A combination of nutrition-sensitive and nutrition-specific interventions has achieved a halving of undernutrition rates, but despite these intensive interventions substantial growth faltering remains. We need to understand the missing contributors to growth faltering to guide development of new interventions.
  
  
  
  UK Medical Research Council, UK Department for International Development.
authors.affiliation: MRC Unit The Gambia, Banjul, The Gambia; MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Helen M
authors.initials: HM
authors.lastname: Nabwera
authors.affiliation: MRC Unit The Gambia, Banjul, The Gambia; MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Fulford
authors.affiliation: MRC Unit The Gambia, Banjul, The Gambia; Division of Women's Health, King's College London, London, UK.
authors.forename: Sophie E
authors.initials: SE
authors.lastname: Moore
authors.affiliation: MRC Unit The Gambia, Banjul, The Gambia; MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, London, UK. Electronic address: aprentice@mrc.gm.
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Prentice
mesh_terms: D000886:Anthropometry; D049628:Body Size; D005260:Female; D005714:Gambia / Q000453:epidemiology; D006130:Growth Disorders / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control; D006293:Health Promotion; D006801:Humans; D007223:Infant; D008297:Male; D044342:Malnutrition / Q000150:complications / Q000628:therapy; D009752:Nutritional Status; D015995:Prevalence; D012189:Retrospective Studies; D012424:Rural Population; D013851:Thinness / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control