Does early linear growth failure influence later school performance? A cohort study in Karonga district, northern Malawi

Socioeconomic pattern of breastfeeding in sub-Saharan Africa: an individual participant data meta-analysis of six longitudinal cohorts

Background

Breastfeeding rates in sub-Saharan Africa (SSA) are declining, and at the current rate, only four African countries will meet the WHO's 2030 exclusive breastfeeding target. We examined the association between maternal socioeconomic status (SES) and breastfeeding practices in SSA.

Methods

Six cohorts in Ethiopia, Malawi, Uganda and Zambia, with 11 863 participants, were analysed. Data for the cohorts were collected between 2000 and 2021, covering births from 2000 to 2019. SES exposures were maternal education and household income. Breastfeeding outcomes included ever breastfed, early initiation of breastfeeding (Ethiopia only), exclusive breastfeeding for ≥4 months or ≥6 months, and continued breastfeeding for ≥1 year. Risk ratios from multivariable Poisson regression models for individual cohorts were pooled in a random-effects meta-analysis to assess the effects of SES on breastfeeding, adjusting for confounders.

Results

Meta-analysis found no evidence of a difference in ever breastfeeding between mothers with secondary or tertiary education and those with primary/no education. Mothers with secondary education (adjusted risk ratio (aRR)=1.11, 95% CI=1.01 to 1.21) and those from middle-wealth households (aRR=1.12, 95% CI=1.01 to 1.24) were more likely to initiate breastfeeding early than those with primary/no education or low household wealth, but there was no evidence of association in the tertiary education and higher-wealth groups. The association between maternal education and exclusive breastfeeding for ≥4 months and ≥6 months varied across cohorts, with no evidence of association in most cohorts. Overall, household wealth was not associated with exclusive breastfeeding for ≥4 months or ≥6 months. The meta-analysis showed no evidence of association between household wealth and breastfeeding for ≥1 year, but mothers with tertiary education were less likely (aRR=0.93, 95% CI=0.88 to 0.99) to breastfeed for ≥1 year than those with primary or no education.

Conclusion

We observed no clear socioeconomic pattern in breastfeeding, contrasting with patterns observed in high-income countries.

The Psychological, Cognitive, and Behavioural Effects of Starvation in Humans: A Scoping Review

BACKGROUND

Research has highlighted the physical complications of starvation, but there is less research examining the psychological effects of starvation in humans.

AIMS

This scoping review synthesises literature on the non-physical effects of starvation in humans.

METHOD

Following PRISMA-ScR guidelines, we searched MEDLINE, PsycINFO, and Global Health for studies published between 1946 and 2023 examining the non-physical effects of starvation in individuals aged 2-79 years, including those who were starved, malnourished, stunted, wasted, underweight, had a restrictive eating disorder, or were raised in famine conditions.

RESULTS

From 16,555 abstracts, 851 articles on the effects of malnutrition were reviewed, and 318 were included. Among these, 35% focused on children and adolescents, 25.5% on adults with comorbid illnesses, 17% on older adults, 13% on those with eating disorders, 6% on adults without comorbidities, and 3.5% on famine survivors. Cognitive impairments were the most frequently reported effects in children. In adults and older adults, depression and anxiety were common, along with reduced cognitive functioning, reduced quality of life, social withdrawal, impaired sleep and impaired sexual functioning. Individuals with eating disorders experienced depression, anxiety, obsessive-compulsive symptoms, emotion regulation difficulties, and cognitive impairment.

CONCLUSIONS

There is extensive evidence showing the detrimental non-physical consequences of starvation in children and adults. These findings should inform research, clinical interventions, and educational materials addressing the effects of insufficient nutrition, including in those with restrictive eating disorders.

Association between birth length, linear growth velocities, and primary school achievement at age 10 years: evidence from the Ethiopian iABC birth cohort

BACKGROUND

Childhood is a period marked by dynamic growth. Evidence of the association between childhood linear growth and school achievement comes mostly from cross-sectional data. We assessed associations between birth length, childhood linear growth velocities, and stunting with school achievement.

METHODS

Newborns were recruited into the Ethiopian infant Anthropometry and Body Composition (iABC) birth cohort and followed from birth to 10 years. Velocities from 0 to 6 years were computed using linear spline mixed effect modelling. Stunting (height-for-age < -2 z-scores) was assessed at the ages of 1, 2, 4, 5, and 6 years. School achievement was measured by having a high (≥ 80%) combined high math, English, and science (MES) score and being at appropriate grade-for-age. Logistic regression models assessed associations between birth length, linear growth velocities and stunting with school achievement.

RESULTS

Children's mean age was 9.8 years (standard deviation, SD 1.0, range 7-12 years). A 1 SD greater birth length increased the odds of achieving a high MES combined score by 1.42 (95% CI: 0.99, 2.03). A 1 SD increase in linear growth velocity from 6 to 24 months increased the odds of being in the appropriate grade-for-age by 1.66 (95% CI: 1.14, 2.43). Stunting at ages 4 and 6 years was associated with lower odds of achieving a high MES combined score: 0.43 (95% CI: 0.20, 0.93) and 0.31 (95% CI: 0.11, 0.89), respectively. Faster post-natal linear growth was not associated with school achievement.

CONCLUSION

Greater birth length and higher growth velocity from 6 to 24 months were associated with higher school achievement and being in the appropriate grade-for-age, respectively. Children who experienced growth failure were less likely to achieve a high MES score. Interventions aimed at improving school achievement should address maternal and fetal nutrition and health, and monitor post-natal growth.

Stunting and academic trajectory in urban settings of Burkina Faso

BACKGROUND

Impaired growth in childhood can lead to poor cognitive development and low school performance. However, literature on the effects of stunting on school trajectory is very limited. The primary objective of this research was to estimate the age at which children start school according to levels of height-for-age z-score (stunting). A second objective was to estimate the gain in terms of age at school entry associated with an improvement in height-for-age z-score. A third objective was to explore the relationship between stunting, grade repetition, and school dropout.

METHODS

We used longitudinal data from the Ouagadougou (Burkina Faso) Health and Demographic Surveillance System. Data from a 2010 health survey of children under 5 years of age were merged with subsequent longitudinal schooling data. The study included 767 children globally who participated in the health and education surveys. Education data allowed us to apprehend academic trajectory measured by age at school entry, repetition, and dropout. The health survey gathered anthropometric information that was used to measure stunting. The adjusted age at school entry was estimated using a Poisson model. The gain represents the difference in adjusted age at school entry for different values of height-for-age. The relationship between stunting and grade repetition and dropout was studied using a discrete-time survival model.

RESULTS

Results showed that children entered school on average at 5.7 years old, and the incidence of grade repetition and dropout was 17.7 and 6.6 per 100 persons-years, respectively. The adjusted age at school entry of severely stunted children was 6.2 years [95% confidence intervals (CI): 6.1; 6.3] compared to 5.1 years [95% CI: 5.0; 5.3] for children who had normal growth. The difference (gain) in adjusted age at school entry between severely and non-stunted children was thus 1.06 [95% CI: 0.87; 1.25] years. If a child's growth changed from severe stunting to normal growth, their risk of repeating a grade decreased by 5.0 [95% CI: 0.0; 9.0] per 100 persons-years. We did not observe a relationship between height-for-age and dropout.

CONCLUSION

The results show that schooling is affected in several ways for children who are stunted. The age at school entry of stunted children is more likely to be delayed. Also, being stunted is associated with higher incidence of grade repetition. However, the relationship between stunting and dropout was inconclusive.

Early-life air pollution and green space exposures as determinants of stunting among children under age five in Sub-Saharan Africa

BACKGROUND

Childhood malnutrition is a major public health issue in Sub-Saharan Africa (SSA) and 61.4 million children under the age of five years in the region are stunted. Although insight from existing studies suggests plausible pathways between ambient air pollution exposure and stunting, there are limited studies on the effect of different ambient air pollutants on stunting among children.

OBJECTIVE

Explore the effect of early-life environmental exposures on stunting among children under the age of five years.

METHODS

In this study, we used pooled health and population data from 33 countries in SSA between 2006 and 2019 and environmental data from the Atmospheric Composition Analysis Group and NASA's GIOVANNI platform. We estimated the association between early-life environmental exposures and stunting in three exposure periods - in-utero (during pregnancy), post-utero (after pregnancy to current age) and cumulative (from pregnancy to current age), using Bayesian hierarchical modelling. We also visualise the likelihood of stunting among children based on their region of residence using Bayesian hierarchical modelling.

RESULTS

The findings show that 33.6% of sampled children were stunted. In-utero PM2.5 was associated with a higher likelihood of stunting (OR = 1.038, CrI = 1.002-1.075). Early-life exposures to nitrogen dioxide and sulphate were robustly associated with stunting among children. The findings also show spatial variation in a high and low likelihood of stunting based on a region of residence.

IMPACT STATEMENT

This study explores the effect of early-life environmental exposures on child growth or stunting among sub-Saharan African children. The study focuses on three exposure windows - pregnancy, after birth and cumulative exposure during pregnancy and after birth. The study also employs spatial analysis to assess the spatial burden of stunted growth in relation to environmental exposures and socioeconomic factors. The findings suggest major air pollutants are associated with stunted growth among children in sub-Saharan Africa.

Linear growth beyond 24 months and child neurodevelopment in low- and middle-income countries: a systematic review and meta-analysis

AIM

To synthesize available evidence on the association between change in linear growth (height for age z score, HAZ) beyond the first two years of life with later child neurodevelopment outcomes in Low- and middle-income countries (LMICs).

METHODS

We searched PubMed, Web of Science, and EMBASE for cohort studies on the association between change in HAZ after age two and neurodevelopment outcomes in middle or late childhood. Data extraction was done independently by two reviewers.

RESULTS

A total of 21 studies, that included 64,562 children from 13 LMICs were identified. Each unit increase in change in HAZ above two years is associated with a + 0.01 increase (N = 8 studies, 27,393 children) in the cognitive scores at 3.5 to 12 years of age and a + 0.05-standard deviation (SD) increase (95% CI 0.02 to 0.08, N = 3 studies, 17,830 children) in the language score at 5 to 15 years of age. No significant association of change in HAZ with motor (standardized mean difference (SMD) 0.04; 95% CI: -0.10, 0.18, N = 1 study, 966 children) or socio-emotional scores (SMD 0.00; 95% CI: -0.02, 0.01, N = 4 studies, 14,616 participants) was observed.

CONCLUSION

Changes in HAZ after the first two years of life appear to have a small or no association with child neurodevelopment outcomes in LMICs.

Impact of COVID-19 on Outpatient Malnutrition Centers in Urban and Rural Burkina Faso

Although the numbers of SARS-CoV-2 infections and related deaths are relatively low in sub-Saharan Africa, the pandemic might lead to a high indirect death toll there. We determined the impact of the COVID-19 pandemic on the management of malnourished children in urban and rural areas. We analyzed data from two Centers for Rehabilitation, Education & Nutrition (CRENs), one in the capital and one in a rural center, both run by the Camillian Fathers. We compared data from the year before the pandemic (2019) with the first 2 years during the pandemic (2020/2021). In the urban CREN, there was a sharp reduction in new patients enrolled, from 340 in the pre-pandemic year to 189 during the first pandemic year and 202 in the second year. The follow-up was significantly shorter during the first pandemic year, with a rebound in the second year (pre: 57 days versus 42 and 63 days for the first and second years, respectively). In the rural CREN, the situation was different: The numbers of patients did not show any significant variation between the pre-pandemic year (191) and the first and second pandemic years (223 and 179, respectively). Different perceptions of the pandemic in urban (high, more testing, more COVID) and rural (low, less information and testing) areas may partly explain this difference. The discrepancy between the decreasing numbers of malnourished children in specialized care during the pandemic-especially in the urban area-is contrary to the lockdown-induced increase in food insecurity and warrants attention to avoid an increase in the silent epidemic of malnourished children in Africa.

Effects of exclusive breastfeeding on educational attainment and longitudinal trajectories of grade progression among children in a 13-year follow-up study in Malawi

The benefits of exclusive breastfeeding (EBF) for infant health and survival are well documented. However, its impact on educational outcomes has been contested and poorly researched in Africa. It has been hypothesised that positive associations reported in high-income countries can be attributed to residual confounding by socioeconomic status (SES). Our study investigated whether EBF duration in infancy is associated with educational attainment and age-for-grade attainment trajectories at school-age in rural Malawi. Longitudinal data on 1021 children at the Karonga demographic surveillance site in Malawi were analysed. Breastfeeding data were collected 3 months after birth and again at age one. The school grade of each child was recorded each year from age 6 until age 13. We calculated age-for-grade based on whether a child was at, over, or under the official expected age for a grade. Generalised estimating equations estimated the average effect of breastfeeding on age-for-grade. Latent class growth analysis identified age-for-grade trajectories, and multinomial logistic regression examined their associations with EBF. Maternal-child characteristics, SES, and HIV status were controlled. Overall, 35.9% of the children were exclusively breastfed for 6 months. Over-age for grade steadily increased from 9.6% at age 8 to 41.9% at age 13. There was some evidence that EBF for 6 months was associated with lower odds of being over-age for grade than EBF for less than 3 months (aOR = 0.82, 95%CI = 0.64-1.06). In subgroup analyses, children exclusively breastfed for 6 months in infancy were less likely to be over-age for grades between ages 6-9 (aOR = 0.64, 95%CI = 0.43-0.94). Latent class growth analysis also provided some evidence that EBF reduced the odds of falling behind in the early school grades (aOR = 0.66, 95%CI = 0.41-1.08) but not later. Our study adds to the growing evidence that EBF for 6 months has benefits beyond infant health and survival, supporting the WHO's recommendation on EBF.

Dietary intake and stunting in children aged 6-23 months in rural Sumba, Indonesia

Background Linear growth retardation in the first two years of life leads to numerous harmful consequences. Lack of diversity in the diet and inadequate amounts of complementary food have been associated with stunted growth in children. Objective To assess the dietary intake and investigate for associations with stunting among children aged 6-23 months. Methods This case-control study compared the dietary intake of children aged 6-23 months with and without stunting in the South and West Wewewa subdistricts of Southwest Sumba, East Nusa Tenggara, Indonesia. Complementary food types, dietary diversity, and nutritional intake were assessed and compared between groups. Nutrient intake sufficiency and stunting were analyzed by logistic regression. Results A total of 200 participants were equally allocated into groups with and without stunting. Only 6% of stunted children received adequate complementary food diversity compared to 14% of non-stunted children (P=0.05). The stunted group had significantly lower consumption of flesh foods (beef, fish, poultry, organ meat, and other kinds of meat) compared to the non-stunted group (7% vs. 16% of subjects, respectively; P<0.05). The median total protein intake was also significantly lower in stunted children compared to non-stunted children [7.72 (IQR 6.46, 11.31) g vs. 10.02 (IQR 6.53, 13.95) g, respectively; P<0.05] although no association was found between protein intake sufficiency and stunting in the multivariate analysis. Only maternal unemployment was positively associated with stunting (OR 2.32; 95%CI 1.26 to 4.26). Conclusion Overall, most subjects did not receive sufficient amounts of nutrients. Although dietary diversity was not found to be significantly different between those with and without stunting, a significantly lower proportion of stunted children consumed flesh food. The stunted group also received significantly lower protein from their diet although no association was found between nutrient intake sufficiency and stunting. Further studies are needed to longitudinally assess the effects of macronutrient and micronutrient intake sufficiency on linear growth in children.

Stunting, age at school entry and academic performance in developing countries: A systematic review and meta-analysis

AIM

To review evidence of the effects of stunting, or height-for-age, on schooling level and schooling trajectories, defined as the combination of school entry age, grade repetition, and dropouts.

METHODS

We conducted a systematic review of studies (last update March 20, 2021) that assessed the association between stunting, or height-for-age, and at least one component of school trajectory using five databases (PubMed, Embase, Education Resources Information Center (ERIC), Web of Science and PsycINFO). Two independent reviewers performed study selection and data extraction. Pooled effects were calculated using the generic inverse variance weighting random effect model. The risk of bias was assessed using the ROBINS-I tool.

PROSPERO ID

CRD42020198346.

RESULTS

We screened 3944 articles and 16 were eligible for the qualitative and quantitative synthesis. Meta-analysis showed that an increase in height-for-age leads to an increase in early enrollment [OR=1.34 (95% CI, 1.07-1.67)], a reduction in late enrollment [OR=0.63 (95% CI, 0.51-0.78)], an increase in schooling level [MD=0.24 (95% CI, 0.14-0.34)], and a reduction of school overage [OR=0.79 (95% CI, 0.70-0.90)]. Stunted children were more likely to repeat a grade than non-stunted [OR=1.59 (95% CI, 1.18-2.14).

CONCLUSION

This review suggests that stunting in childhood might negatively affect school trajectories. Future research should evaluate the effect of stunting on school trajectories and the modification effect of socioeconomic status.

Malnutrition in early life and its neurodevelopmental and cognitive consequences: a scoping review

The negative impact of stunting and severe underweight on cognitive neurodevelopment of children is well documented; however, the effect of overweight/obesity is still unclear. The 2018 Global Nutrition Report reported that stunting and overweight concurrently affect 189 million children worldwide. As existing reviews discuss undernutrition and overweight/obesity separately, this scoping review aims to document the impact of mild/moderate and severe underweight, stunting, and overweight/obesity among children aged 0-60 months on their cognitive neurodevelopmental trajectories. Twenty-six articles were analysed to extract significant information from literature retrieved from PubMed and Cochrane databases published from 1 January 2009 to 31 October 2019. Length gain is associated with cognitive neurodevelopment in normo-nourished and stunted children aged under 24 months. Among stunted children, it seems that cognitive and neurodevelopmental deficits can potentially be recovered before 8 years of age, particularly in those whose nutritional status has improved. The impact of overweight/obesity on cognitive neurodevelopment appears to be limited to attention, gross motor skills and executive control. Parental education level, birth weight/length, breastfeeding duration, and sanitation level are some identifiable factors that modify the impact of undernutrition and overweight/obesity on cognitive and neurodevelopment. In conclusion, underweight, stunting and overweight/obesity have a significant impact on cognitive neurodevelopment. Multidimensional approaches with various stakeholders should address all issues simultaneously, such as improving sanitation levels, assuring parental job security and adequate social welfare, and providing access to adequate nutrients for catch-up growth among underweight or stunted children and to affordable healthy foods for those who are overweight/obese and from low socio-economic status.

Impact of supplementation with milk-cereal mix during 6-12 months of age on growth at 12 months: a 3-arm randomized controlled trial in Delhi, India

BACKGROUND

A large proportion of infants in low- and middle-income countries are stunted. These infants are often fed complementary foods that are low-quality, primarily in terms of protein and micronutrients.

OBJECTIVES

We aimed to test 2 milk-cereal mixes supplemented with modest and high amounts of protein during 6-12 mo of age, compared with no supplementation, for their effect on length-for-age z score (LAZ) at 12 mo of age.

METHODS

Eligible infants (6 mo plus ≤29 d) were randomly assigned to either of the 2 interventions (modest- and high-protein) or a no supplement group. The milk-cereal mixes provided ∼125 kcal, 30%-45% energy from fats, and 80%-100% RDA of multiple micronutrients (MMN). The modest-protein group received 2.5 g protein [protein energy ratio (PER): 8%; 0.75 g from milk source] and the high-protein group received 5.6 g protein (PER: 18%, 1.68 g from milk source). One packet was given daily for 180 d. Counseling on continued breastfeeding and optimal infant-care practices was provided to all.

RESULTS

We enrolled 1548 infants (high-protein: n = 512; modest-protein: n = 519; and no supplement: n = 517). Compared with the no supplement group, there was an improvement in LAZ [adjusted mean difference (MD): 0.08; 95% CI: 0.01, 0.15], weight-for-age z score (MD: 0.12; 95% CI: 0.06, 0.19), weight-for-length z score (MD: 0.11; 95% CI: 0.02, 0.19), and midupper arm circumference z score (MD: 0.10; 95% CI: 0.02, 0.18) in the high-protein group at 12 mo of age. No significant differences for these anthropometric indicators were noted between the modest-protein and no supplement groups or between the high- and modest-protein groups.

CONCLUSIONS

Cereal mixes with higher amounts of milk-based protein and MMN may lead to improvement in linear growth and other anthropometric indexes in infants, compared with no supplementation.This trial was registered at ctri.nic.in as CTRI/2018/04/012932.

Household and schooling rather than diet offset the adverse associations of height with school competence and emotional disturbance among Taiwanese girls

OBJECTIVE

Short stature may reflect health in early life and be an enduring disability. How birth weight, gender, household, elementary schooling and diet play a role in associations between stature and overall school competence (OSC) have been assessed.

DESIGN

The 2001-2002 Nutrition and Health Survey in Taiwan (NAHSIT) for elementary schoolchildren (n 2274, 52·1 % boys) was linked to birth records. It provided sociodemographic, dietary quality, body compositional and school performance (as Scale for Assessing Emotional Disturbance, SAED; OSC as an SAED subscale) data. Lower birth weight was ≤15th percentile: 2850 g for boys and 2700 g for girls, and stature as z-scores for Taiwanese. Multivariable linear regression was used for relationships between OSC and stature. Trends in OSC by stature and school grade were assessed.

SETTING

The 2001-2002 NAHSIT for elementary schoolchildren.

PARTICIPANTS

Totally, 2274 schoolchildren aged 6-13 years.

RESULTS

Compared to normal height (-2< height for age z-score (HAZ) <2), shorter girls (HAZ ≤ -2) had a lower OSC (8·87 v. 10·5, P < 0·05) and taller girls (HAZ ≥ 2) had a better OSC (12·3 v. 10·5, P < 0·001). Maternal education and household income each contributed more than 5 % of OSC variance. OSC and HAZ among girls were positively associated and emotional disturbance negatively associated. Shortness-associated lower OSC underwent remediation with advancing school grade. Stature and OSC were not evidently related in boys.

CONCLUSIONS

Shorter stature can compromise OSC among school girls. The major determinants in shorter girls are less household income and limited parental education.

Nutrition, growth, and other factors associated with early cognitive and motor development in Sub-Saharan Africa: a scoping review

BACKGROUND

Food insecurity, poverty and exposure to infectious disease are well-established drivers of malnutrition in children in Sub-Saharan Africa. Early development of cognitive and motor skills - the foundations for learning - may also be compromised by the same or additional factors that restrict physical growth. However, little is known about factors associated with early child development in this region, which limits the scope to intervene effectively. To address this knowledge gap, we compared studies that have examined factors associated with early cognitive and/or motor development within this population.

METHODS

Predetermined criteria were used to examine four publication databases (PsycInfo, Embase, Web of Science and Medline) and identify studies considering the determinants of cognitive and motor development in children aged 0-8 years in Sub-Saharan Africa.

RESULTS

In total, 51 quantitative studies met the inclusion criteria, reporting on 30% of countries across the region. Within these papers, factors associated with early child development were grouped into five themes: Nutrition, Growth and Anthropometry, Maternal Health, Malaria and HIV, and Household. Food security and dietary diversity were associated with positive developmental outcomes, whereas exposure to HIV, malaria, poor maternal mental health, poor sanitation, maternal alcohol abuse and stunting were indicators of poor cognitive and motor development.

DISCUSSION

In this synthesis of research findings obtained across Sub-Saharan Africa, factors that restrict physical growth are also shown to hinder the development of early cognitive and motor skills, although additional factors also influence early developmental outcomes. The study also reviews the methodological limitations of conducting research using Western methods in sub-Saharan Africa.

Linear Growth between Early and Late Childhood and Cognitive Outcomes at 6-9 Years of Age

OBJECTIVES

To assess the extent to which linear growth beyond the early years of life determines later cognitive development.

STUDY DESIGN

We revisited children from New Delhi, India, who had participated in a randomized controlled trial 6 years before and assessed neurodevelopment using standardized and validated psychometric tools (Wechsler Intelligence Scale for Children, 4th edition; Crichton Vocabulary Scales; and Neuropsychological test battery). The associations of change in height for age z scores between early (12-36 months) and late (6-9 years) childhood with cognitive outcomes at 6-9 years of age were explored using linear regression models, after adjustment for appropriate confounders.

RESULTS

Out of the 1000 North Indian children who were enrolled in the original study, 791 consented to participate in this follow-up. Height for age z scores in the first 2 years of life was significantly associated with both the Wechsler Intelligence Scale for Children-Crichton Vocabulary Scales (standardized β coefficient [β], 0.15; 95% CI, 0.08-0.23), and the Neuropsychological test battery-II z-score (β, 0.09; 95% CI, 0.03-0.18) at 6-9 years of age. There were no significant associations between change in height for age z scores between early and later childhood and Wechsler Intelligence Scale for Children-Crichton Vocabulary Scales (β, -0.03; 95% CI, -0.11 to 0.04) or Neuropsychological test battery-II z-scores (β, -0.04; 95% CI, -0.12 to 0.06).

CONCLUSIONS

Linear growth between early and late childhood is not associated with later cognitive outcomes. Our findings support the current practice of investing public health efforts to accelerate linear growth in the first 2-3 years of life.