Stunting is a complex problem which requires a multi-sectoral strategy. I would recommend that you first review with other stakeholders in the country to determine what the national strategy for stunting reduction is or if an analysis has been conducted from existing datasets to determine what the likely major contributing variables to stunting are. Based on these inputs you can then determine your comparative advantage for stunting reduction programming. For example, the National Nutrition Survey in 2013 would provide available data to determine some of the influencing variables to stunting in children.

The Global Nutrition Targets 2025 Stunting Policy Brief provides a good summary of the causal factors for stunting and examples of multi-sectoral approaches to stunting reduction. There are many good resources available at the global and regional level to assist in your review.

http://apps.who.int/iris/bitstream/10665/149019/1/WHO_NMH_NHD_14.3_eng.pdf

Dear Shafiqullah,

Your question is very broad and difficult to answer, as stunting is multifactorial and mechanisms underlying it are not clear. Presumably it is due to a combination of inadequate food intake, more specifically to a low intake of animal source foods, environmental enteric dysfunction (EED), chronic infection or inflammation, with a possible role for food contaminant (aflatoxin, possibly bacterial toxins) and indoor air pollution. The contribution of each of these possible causes is not clear. Presumably; it is not the same everywhere and the most effective intervention will depend on the main mechanism involved in each setting. This is not easy to determine, and even in research settings, it is often not clear which effect is the most important.

This comment may not be very helpful when designing programmes. Where do we go from there ? A few general remarks:

- It always helps to implement general nutrition activities which may have a positive effect on growth. First, of course, promotion of exclusive breast feeding, right from birth, and then exclusively up to the age of 6 mo and continued up to 2 years of age at least as recommended by WHO. Promotion of adequate practice of complementary feeding also will help, with special attention to the consumption of animal source foods, or of nutrient dense food supplements. See WHO guiding principles for complementary feeding at: http://www.who.int/nutrition/publications/guiding_principles_compfeeding_breastfed.pdf
- In the same way, water and sanitation programmes may have a positive effect. The expected impact of these programmes on stunting levels is not clear, but they are likely to have an effect on morbidity and mortality, which is always welcome.
- The risk of death in stunted children is higher when stunting is associated with wasting. So treatment of associated wasting (SAM or MAM treatment, if needed with food supplements in food insecure households) will have an effect on mortality, even if the effect on stunting prevention is not clear.

At this stage, knowing more about your settings and what are in your perception the predominant health and nutrition problems would help.

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