In 2017, an estimated 1 in every 4 (23%) children aged < 5 years were stunted worldwide. With slow progress in stunting reduction in many regions and the realization that a large proportion of stunting is not due to insufficient diet or diarrhea alone, it remains that other factors must explain continued growth faltering. Environmental enteric dysfunction (EED), a subclinical state of intestinal inflammation, can occur in infants across the developing world and is proposed as an immediate causal factor connecting poor sanitation and stunting. A result of chronic pathogen exposure, EED presents multiple causal pathways, and as such the scope and sensitivity of traditional water, sanitation, and hygiene (WASH) interventions have possibly been unsubstantial. Although the definite pathogenesis of EED and the mechanism by which stunting occurs are yet to be defined, this paper reviews the existing literature surrounding the proposed pathology and transmission of EED in infants and considerations for nutrition and WASH interventions to improve linear growth worldwide.

Cranfield Water Science Institute Cranfield University Bedfordshire United Kingdom

People in Need Prague Czech Republic

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United Nations’ Children’s Fund, World Health Organization, World Bank. Joint Child Malnutrition Estimates—Levels and Trends. Geneva, Switzerland: World Health Organization, 2017. Available at: http://www.who.int/nutgrowthdb/estimates2016/en/. Accessed December 15, 2017.

WHO Multicentre Growth Reference Study Group . WHO Child Growth Standards: Length/Height-for-Age, Weight-for-Age, Weight-for-Length, Weight-for-Height and Body Mass Index-for-Age: Methods and Development. Geneva, Switzerland: World Health Organization, 2006.

Stevens G, Finucane M, Paciorek C, et al. Trends in mild, moderate, and severe stunting and underweight, and progress towards MDG 1 in 141 developing countries: a systematic analysis of population representative data. Lancet. 2012;380:824–834. PubMed PMC

United Nations’ Children’s Fund. Malnutrition: current status and progress. 2017. Available at: https://data.unicef.org/topic/nutrition/malnutrition/#. Accessed December 15, 2017.

Black R, Victora C, Walker S, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382:427–451. PubMed

Martorell R, Horta B, Adair L, et al. Weight gain in the first two years of life is an important predictor of schooling outcomes in pooled analyses from five birth cohorts from low- and middle-income countries. J Nutr. 2010;140:348–354. PubMed PMC

World Bank. Repositioning nutrition as to development: a strategy for large-scale action. Vol 13 Washington, DC: World Bank, 2006.

Grantham-McGregor S, Cheung Y, Cueto S, et al. Developmental potential in the first 5 years for children in developing countries. Lancet. 2007;369:60–70. PubMed PMC

Martorell R, Zongrone A.. Intergenerational influences on child growth and undernutrition. Paediatr Perinat Epidemiol. 2012;26:302–314. PubMed

Ramakrishnan U, Martorell R, Schroeder DG, et al. Role of intergenerational effects on linear growth. J Nutr. 1999;129:544S–549S. PubMed

Hochberg Z, Feil R, Constancia M, et al. Child health, developmental plasticity, and epigenetic programming. Endocr Rev. 2011;32:159–224. PubMed PMC

Burdge GC, Lillycrop KA.. Nutrition, epigenetics, and developmental plasticity: implications for understanding human disease. Annu Rev Nutr. 2010;30:315–339. PubMed

Prendergast A, Humphrey J.. The stunting syndrome in developing countries. Paediatr Int Child Health. 2014;34:250–265. PubMed PMC

Lampl M, Veldhuis J, Johnson M.. Saltation and stasis: a model of human growth. Science. 1992;258:801–803. PubMed

Pongcharoen T, Ramakrishnan U, Digirolamo A, et al. Influence of prenatal and postnatal growth on intellectual functioning in school-aged children. Arch Pediatr Adolesc Med. 2012;166:411–416. PubMed

Victora C, de Onis M, Hallal P, et al. Worldwide timing of growth faltering: revisiting implications for interventions. Pediatrics. 2010;125:e473–e480. PubMed

Dewey K, Adu-Afarwuah S.. Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Matern Child Nutr. 2008;4:24–85. PubMed PMC

Action Against Hunger, United Nations’ Children’s Fund. WASH’Nutrition: A Practical Guidebook on Increasing Nutritional Impact through Integration of WASH and Nutrition Programs. Paris: Action Against Hunger, 2017.

Action Against Hunger. BabyWASH and the 1,000 Days.2017. Available at: https://www.actionagainsthunger.org/publication/2017/10/babywash-and-1000-days. Accessed December 12, 2018.

Blössner M, de Onis M.. Malnutrition: Quantifying the Health Impact at National and Local Levels. Geneva, Switzerland: World Health Organization; 2005.

United Nations’ Children’s Fund. Strategy for Improved Nutrition of Children and Women in Developing Countries. Vol 8 New York: UNICEF, 1990. PubMed

United Nations’ Children’s Fund. UNICEF’s Approach to Scaling up Nutrition for Mothers and Children. New York: UNICEF, 2015. Available at: https://www.unicef.org/nutrition/files/Unicef_Nutrition_Strategy.pdf. Accessed June 22, 2018.

Ahmed T, Auble D, Berkley J, et al. An evolving perspective about the origins of childhood undernutrition and nutritional interventions that includes the gut microbiome. Ann NY Acad Sci. 2014;1332:22–38. PubMed PMC

Piper J, Chandna J, Allen E, et al. Water, sanitation and hygiene (WASH) interventions: effects on child development in low- and middle-income countries. Cochrane Database Syst Rev. 2017;2017:1–40.

Bhutta Z, Ahmed T, Black R, et al. What works? Interventions for maternal and child undernutrition and survival. Lancet. 2008;371:417–440. PubMed

Action Against Hunger. Water, Sanitation and Hygiene Policy. 2011. Available at: https://www.actionagainsthunger.org/publication/2011/06/water-sanitation-and-hygiene-policy. Accessed December 12, 2018.

Dangour A, Watson L, Cumming O, et al. Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children. Cochrane Database Syst Rev. 2013;8:1–101. PubMed PMC

Matare C, Mbuya M, Pelto G, et al. Assessing maternal capabilities in the SHINE Trial: highlighting a hidden link in the causal pathway to child health. Clin Infect Dis. 2015;61:S745–S751. PubMed PMC

Bhutta Z, Das J, Rizvi A, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet. 2013;382:452–477. PubMed

Merchant A, Jones C, Kiure A, et al. Water and sanitation associated with improved child growth. Eur J Clin Nutr. 2003;57:1562–1568. PubMed

Checkley W, Gilman R, Black R, et al. Effect of water and sanitation on childhood health in a poor Peruvian peri-urban community. Lancet. 2004;363:112–118. PubMed

Rah J, Cronin A, Badgaiyan B, et al. Household sanitation and personal hygiene practices are associated with child stunting in rural India: a cross-sectional analysis of surveys. BMJ Open. 2015;5:e005180–e005180. PubMed PMC

Ngure F, Reid B, Humphrey J, et al. Water, sanitation, and hygiene (WASH), environmental enteropathy, nutrition, and early child development: making the links. Ann N Y Acad Sci. 2014;1308:118–128. PubMed

Fenn B, Bulti A, Nduna T, et al. An evaluation of an operations research project to reduce childhood stunting in a food-insecure area in Ethiopia. Public Health Nutr. 2012;15:1746–1754. PubMed

Checkley W, Buckley G, Gilman R, et al. Multi-country analysis of the effects of diarrhoea on childhood stunting. Int J Epidemiol. 2008;37:816–830. PubMed PMC

Black R, Brown K, Becker S.. Effects of diarrhea associated with specific enteropathogens on the growth of children in rural Bangladesh. Pediatrics. 1984;73:799–805. PubMed

Richard S, Black R, Gilman R, et al. Diarrhea in early childhood: short-term association with weight and long-term association with length. Am J Epidemiol. 2013;178:1129–1138. PubMed PMC

Fischer Walker C, Perin J, Aryee M, et al. Diarrhea incidence in low- and middle-income countries in 1990 and 2010: a systematic review. BMC Public Health. 2012;12: 220. PubMed PMC

Black R, Allen L, Bhutta Z, et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371:243–260. PubMed

Guerrant R, Schorling J, McAuliffe J, et al. Diarrhea as a cause and an effect of malnutrition: diarrhea prevents catch-up growth and malnutrition increases diarrhea frequency and duration. Am J Trop Med Hyg. 1992;47:28–35. PubMed

Briend A. Is diarrhoea a major cause of malnutrition among the under-fives in developing countries? A review of available evidence. Eur J Clin Nutr. 1990;44:611–628. PubMed

Luby S, Agboatwalla M, Painter J, et al. Combining drinking water treatment and hand washing for diarrhoea prevention, a cluster randomised controlled trial. Trop Med Int Heal. 2006;11:479–489. PubMed

Bowen A, Agboatwalla M, Luby S, et al. Association between intensive handwashing promotion and child development in Karachi, Pakistan: a cluster randomized controlled trial. Arch Pediatr Adolesc Med. 2012;166:1037–1044. PubMed PMC

Langford R, Lunn P, Panter-Brick C.. Hand-washing, subclinical infections, and growth: a longitudinal evaluation of an intervention in Nepali slums. Am J Hum Biol. 2011;23:621–629. PubMed

Arnold B, Null C, Luby S, et al. Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale. BMJ Open. 2013;3:1–17. PubMed PMC

Humphrey J, Jones A, Manges A, et al. The sanitation hygiene infant nutrition efficacy (SHINE) trial: rationale, design, and methods. Clin Infect Dis. 2015;61:S685–S702. PubMed PMC

Brown J, Cumming O, Bartram J, et al. A controlled, before-and-after trial of an urban sanitation intervention to reduce enteric infections in children: research protocol for the Maputo Sanitation (MapSan) study, Mozambique. BMJ Open. 2015;5:1–11. PubMed PMC

Null C, Stewart CP, Pickering AJ, et al. Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster-randomised controlled trial. Lancet Glob Health. 2018;6:e302–e315. PubMed PMC

Luby S, Rahman M, Arnold B, et al. Effect of water quality, sanitation, handwashing and nutritional interventions on diarrhoea and child linear growth in rural Bangladesh: a cluster randomized trial. Lancet Glob Health. 2018;6:Pe302–e315. PubMed PMC

Freeman M, Stocks M, Cumming O, et al. Systematic review: hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Trop Med Int Health. 2014;19:906–916. PubMed

Freeman M, Garn J, Sclar G, et al. The impact of sanitation on infectious disease and nutritional status: a systematic review and meta-analysis. Int J Hyg Environ Health. 2017;220:928–949. PubMed

USAID. Toward a Hygienic Environment for Infants and Young Children: A Review of the Literature. Washington, DC: USAID Water, Sanitation, and Hygiene Partnerships and Sustainability (WASHPaLS) Project, 2018.

Korpe P, Petri W.. Environmental enteropathy: critical implications of a poorly understood condition. Trends Mol Med. 2012;18:328–336. PubMed PMC

Humphrey J. Child undernutrition, tropical enteropathy, toilets, and handwashing. Lancet. 2009;374:1032–1035. PubMed

Mondal D, Minak J, Alam M, et al. Contribution of enteric infection, altered intestinal barrier function, and maternal malnutrition to infant malnutrition in Bangladesh. Clin Infect Dis. 2012;54:185–192. PubMed PMC

Kotloff K, Nataro J, Blackwelder W, et al. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study. Lancet. 2013;382:209–222. PubMed

Schenk E, Samloff I, Klipstein F.. Morphology of small bowel biopsies. Am J Clin Nutr. 1968;21:944–961. PubMed

Ramakrishna B, Venkataraman S, Mukhopadhya A.. Tropical malabsorption. Postgrad Med J. 2006;82:779–787. PubMed PMC

Keusch G, Rosenberg I, Denno D, et al. Implications of acquired environmental enteric dysfunction for growth and stunting in infants and children living in low-and middle-income countries. Food Nutr Bull. 2013;34:357–364. PubMed PMC

Kelly P, Menzies I, Crane R, et al. Responses of small intestinal architecture and function over time to environmental factors in a tropical population. Am J Trop Med Hyg. 2004;70:412–419. PubMed

Lindenbaum J, Harmon J, Gerson C.. Subclinical malabsorption in developing countries. Am J Clin Nutr. 1972;25:1056–1061. PubMed

Veitch A, Kelly P, Zulu I, et al. Tropical enteropathy: a T-cell-mediated crypt hyperplastic enteropathy. Eur J Gastroenterol Hepatol. 2001;13:1175–1181. PubMed

Baker S. Subclinical intestinal malabsorption in developing countries. Bull World Health Organ. 1976;54:485–494. PubMed PMC

Campbell D, McPhail G, Lunn P, et al. Intestinal inflammation measured by fecal neopterin in Gambian children with enteropathy: association with growth failure, Giardia lamblia, and intestinal permeability. J Pediatr Gastroenterol Nutr. 2004;39:153–157. PubMed

Campbell D, Elia M, Lunn P.. Growth faltering in rural Gambian infants is associated with impaired small intestinal barrier function, leading to endotoxemia and systemic inflammation. J Nutr. 2003;133:1332–1338. PubMed

Lunn P, Northrop-Clewes C, Downes R.. Intestinal permeability, mucosal injury, and growth faltering in Gambian infants. Lancet. 1991;338:907–910. PubMed

Owino V, Ahmed T, Freemark M, et al. Environmental enteric dysfunction and growth failure/stunting in global child health. Pediatrics. 2016;138:e20160641–e20160641. PubMed

Ordiz M, Shaikh N, Trehan I, et al. Environmental enteric dysfunction is associated with poor linear growth and can be identified by host fecal mRNAs. J Pediatr Gastroenterol Nutr. 2016;63:453–459. PubMed PMC

Kosek M, et al. Causal pathways from enteropathogens to environmental enteropathy: findings from the MAL-ED birth cohort study. EBio Med. 2017;18:109–117. PubMed PMC

Millward D. Nutrition, infection and stunting: the roles of deficiencies of individual nutrients and foods, and of inflammation, as determinants of reduced linear growth of children. Nutr Res Rev. 2017;30:50–72. PubMed

Watanabe K, Petri W.. Environmental enteropathy: elusive but significant subclinical abnormalities in developing countries. EBio Med. 2016;10:25–32. PubMed PMC

Donowitz J, Petri W.. Pediatric small intestine bacterial overgrowth in low-income countries. Trends Molec Med. 2015;21:6–15. PubMed PMC

Donowitz J, Haque R, Kirkpatrick B, et al. Small intestine bacterial overgrowth and environmental enteropathy in Bangladeshi children. MBio. 2016;7:1–7. PubMed PMC

Khin-Maung U, Bolin T, Duncombe V, et al. Epidemiology of small bowel bacterial overgrowth and rice carbohydrate malabsorption in Burmese (Myanmar) village children. Am J Trop Med Hyg. 1992;47:298–304. PubMed

Subramanian S, Huq S, Yatsunenko T, et al. Persistent gut microbiota immaturity in malnourished Bangladeshi children. Nature. 2014;510:417–421. PubMed PMC

Blanton L, Charbonneau M, Salih T, et al. Gut bacteria that prevent growth impairments transmitted by microbiota from malnourished children. Science. 2016;351:6275. PubMed PMC

Ejemot-Nwadiaro R, Ehiri J, Meremikwu M, et al. Hand washing for preventing diarrhoea. Evid-Based Child Health. 2009;4:893–939.

Cumming O, Cairncross S.. Can water, sanitation and hygiene help eliminate stunting? Current evidence and policy implications. Mater Child Nutr. 2016;12(suppl 1):91–105. PubMed PMC

Crane R, Berkley J.. Progress on growth faltering. Lancet Glob Health. 2017;5:e125–e126. PubMed PMC

Nabwera H, Fulford A, Moore S, et al. Growth faltering in rural Gambian children after four decades of interventions: a retrospective cohort study. Lancet Glob Heal. 2017;5:e208–e216. PubMed PMC

Kosek M, Haque R, Lima A, et al. Fecal markers of intestinal inflammation and permeability associated with the subsequent acquisition of linear growth deficits in infants. Am J Trop Med Hyg. 2013;88:390–396. PubMed PMC

Levine M, Robins-Browne R.. Factors that explain excretion of enteric pathogens by persons without diarrhea. Clin Infect Dis. 2012;55:S303–S311. PubMed PMC

Steiner T, Lima A, Nataro J, et al. Enteroaggregative Escherichia coli produce intestinal inflammation and growth impairment and cause interleukin-8 release from intestinal epithelial cells. J Infect Dis. 1998;177:88–96. PubMed

Lin A, Arnold B, Afreen S, et al. Household environmental conditions are associated with enteropathy and impaired growth in rural bangladesh. Am J Trop Med Hyg. 2013;89:130–137. PubMed PMC

Miller M, Acosta A, Chavez C, et al. The MAL-ED study: a multinational and multidisciplinary approach to understand the relationship between enteric pathogens, malnutrition, gut physiology, physical growth, cognitive development, and immune responses in infants and children up to 2 years of. Clin Infect Dis. 2014;59:S193–S206. PubMed

Guerrant D, Moore S, Lima A, et al. Association of early childhood diarrhea and cryptosporidiosis with impaired physical fitness and cognitive function four-seven years later in a poor urban community in northeast Brazil. Am J Trop Med Hyg. 1999;61:707–713. PubMed

Harper KM, Mutasa M, Prendergast AJ, et al. Environmental enteric dysfunction pathways and child stunting: a systematic review. PLoS Neglected Trop Dis. 2018;12:e0006205. PubMed PMC

World Health Organization. Global Nutrition Targets 2025: Stunting Policy Brief: What’s at Stake. Geneva, Switzerland: WHO, 2014.

McKay S, Gaudier E, Campbell D, et al. Environmental enteropathy: new targets for nutritional interventions. Int Health. 2010;2:172–180. PubMed

Alemayehu M, Tinsae F, Haileslassie K, et al. Undernutrition status and associated factors in under-5 children, in Tigray, Northern Ethiopia. Nutrition. 2015;31:964–970. PubMed

Fekadu Y, Mesfin A, Haile D, et al. Factors associated with nutritional status of infants and young children in Somali Region, Ethiopia: a cross- sectional study. BMC Public Health. 2015;15:846. PubMed PMC

Crane RJR, Jones KDJK, Berkley JA.. Environmental enteric dysfunction: an overview. Food Nutr Bull. 2015;36:S76–S87. PubMed PMC

Charbonneau M, O’Donnell D, Blanton L, et al. Sialylated milk oligosaccharides promote microbiota-dependent growth in models of infant undernutrition. Cell. 2016;164:859–871. PubMed PMC

Smith E, Manji K, McDonald C, et al. Early breastfeeding initiation, prelacteal feeding, and infant feeding are associated with biomarkers of environmental enteric dysfunction. FASEB J. 2017;31:959.13

Campbell R, Schulze K, Shaikh S, et al. Biomarkers of environmental enteric dysfunction among children in rural Bangladesh. J Pediatr Gastroenterol Nutr. 2017;65:40–46. PubMed PMC

Taniuchi M, Sobuz S, Begum S, et al. Etiology of diarrhea in Bangladeshi infants in the first year of life analyzed using molecular methods. J Infec Dis. 2013;208:1794–1802. PubMed PMC

Gilmartin A, Petri WJ.. Exploring the role of environmental enteropathy in malnutrition, infant development and oral vaccine response. Philos Transac R Soc London Ser B Biol Sci. 2015;370:pii:20140143. PubMed PMC

Van Der Merwe L, Moore S, Fulford A, et al. Long-chain PUFA supplementation in rural African infants: a randomized controlled trial of effects on gut integrity, growth, and cognitive development. Am J Clin Nutr. 2013;97:45–57. PubMed PMC

Prendergast A, Kelly P.. Review: enteropathies in the developing world: neglected effects on global health. Am J Trop Med Hyg. 2012;86:756–763. PubMed PMC

Wagner E, Lanoix J.. Excreta Disposal for Rural Areas and Small Communities. Vol 39 Geneva, Switzerland: World Health Organization, 1958. PubMed

Morita T, Perin J, Oldja L, et al. Mouthing of soil contaminated objects is associated with environmental enteropathy in young children. Trop Med Int Health. 2017;22:670–678. PubMed

Ngure F, Humphrey J, Mbuya M, et al. Formative research on hygiene behaviors and geophagy among infants and young children and implications of exposure to fecal bacteria. Am J Trop Med Hyg. 2013;89:709–716. PubMed PMC

Curtis V, Cairncross S, Yonli R.. Review: domestic hygiene and diarrhoea—pinpointing the problem. Trop Med Int Health. 2000;5:22–32. PubMed

Mbuya M, Tavengwa N, Stoltzfus R, et al. Design of an intervention to minimize ingestion of fecal microbes by young children in rural Zimbabwe. Clin Infect Dis. 2015;61(suppl. 7):S703–S709. PubMed PMC

Simango C. Prevalence of Clostridium difficile in the environment in a rural community in Zimbabwe. Trans R Soc Trop Med Hyg. 2006;100:1146–1150. PubMed

Pickering A, Julian T, Marks S, et al. Fecal contamination and diarrheal pathogens on surfaces and in soils among Tanzanian households with and without improved sanitation. Environ Sci Technol. 2012;46:5736–5743. PubMed

Black R, Lopez De Roma G, Brown K, et al. Incidence and etiology of infantile diarrhea and major routes of transmission in Huascar, Peru. Am J Epidemiol. 1989;129:785–799. PubMed

Penakalapati G, Swarthout J, Delahoy M, et al. Exposure to animal feces and human health: a systematic review and proposed research priorities. Environ Sci Technol. 2017;51:11537–11552. PubMed PMC

Spears D, Ghosh A, Cumming O.. Open defecation and childhood stunting in India: an ecological analysis of new data from 112 districts. PLoS One. 2013;8:e73784 PubMed PMC

Dufour A, Bartram J, Gannon V.. Animal Waste, Water Quality and Human Health. Geneva, Switzerland: WHO, 2012.

Berrilli F, D’Alfonso R, Giangaspero A, et al. Giardia duodenalis genotypes and Cryptosporidium species in humans and domestic animals in Côte d’Ivoire: occurrence and evidence for environmental contamination. Transac R Soc Trop Med Hyg. 2012;106:191–195. PubMed

Zambrano L, Levy K, Menezes N, et al. Human diarrhea infections associated with domestic animal husbandry: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg. 2014;108:313–325. PubMed PMC

Wang H, Naghavi M, Allen C, et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1459–1544. PubMed PMC

Headey D, Hirvonen K.. Is exposure to poultry harmful to child nutrition? An observational analysis for rural Ethiopia. PLoS One. 2016;11:1–16. PubMed PMC

Bukenya G, Nwokolo N.. Compound hygiene, presence of standpipe and the risk of childhood diarrhoea in an urban settlement of Papua New Guinea. Int J Epidemiol. 1991;20:534–539. PubMed

George C, Oldja L, Biswas S, et al. Fecal markers of environmental enteropathy are associated with animal exposure and caregiver hygiene in Bangladesh. Am J Trop Med Hyg. 2015;93:269–275. PubMed PMC

George C, Oldja L, Biswas S, et al. Geophagy is associated with environmental enteropathy and stunting in children in rural Bangladesh. Am J Trop Med Hyg. 2015;92:1117–1124. PubMed PMC

Torondel B, Gyekye-Aboagye Y, Routray P, et al. Laboratory development and field testing of sentinel toys to assess environmental faecal exposure of young children in rural India. Trans R Soc Trop Med Hyg. 2015;109:386–392. PubMed

Pickering A, Djebbari H, Lopez C, et al. Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial. Lancet Glob Heal. 2015;3:e701–e711. PubMed

Oberhelman R, Gilman R, Sheen P, et al. An intervention-control study of corralling of free-ranging chickens to control Campylobacter infections among children in a Peruvian periurban shantytown. Am J Trop Med Hyg. 2006;74:1054–1059. PubMed

Harvey S, Winch P, Leontsini E, et al. Domestic poultry-raising practices in a Peruvian shantytown: implications for control of Campylobacter jejuni–associated diarrhea. Acta Trop. 2003;86:41–54. PubMed

Ashraf S, Hussain F, Leontsini E, et al. Continued environmental fecal contamination following implementation of sanitation hardware. Health Sci Bull. 2013;11:9–14.

Mbuya M, Humphrey J.. Preventing environmental enteric dysfunction through improved water, sanitation and hygiene: an opportunity for stunting reduction in developing countries. Mater Child Nutr. 2016;12:106–120. PubMed PMC

USAID, Save the Children. Water, Hygiene and Sanitation (WASH) in Rural Households in Amhara, Oromia, SNNP and Tigray: A Report on the Findings and Recommendations of a Multi-Method Qualitative Research Study for Social and Behavior Change Communication Programming in Ethiopia. Washington, DC: USAID, 2014.

Ruel M. The Natural History of Growth Failure: Importance of Intrauterine and Postnatal Periods. In Martorell R., Haschke F., eds. Nutrition and Growth. Nestle Nutrition Workshop Series Pediatric Program. Vol.47. Philadelphia, PA: Lippincott Williams & Wilkins, 2001: 123–158.

Vujcic J, Ram P, Hussain F, et al. Toys and toilets: cross-sectional study using children’s toys to evaluate environmental faecal contamination in rural Bangladeshi households with different sanitation facilities and practices. Trop Med Int Health. 2014;19:528–536. PubMed

Hampshire K, Casiday R, Kilpatrick K, et al. The social context of childcare practices and child malnutrition in Niger’s recent food crisis. Disasters. 2009;33:132–151. PubMed

Kes A, Swaminathan H.. Gender and Time Poverty in Sub-Saharan Africa. Washington DC: World Bank, 2006.

Bartram J, Cairncross S.. Hygiene, sanitation, and water: forgotten foundations of health. PLoS Med. 2010;7:e1000367. PubMed PMC

Danaei G, Andrews K, Sudfeld C, et al. Risk factors for childhood stunting in 137 developing countries: a comparative risk assessment analysis at global, regional, and country levels. PLoS Med. 2016;13:1–18. PubMed PMC

Woodruff B, Wirth J, Bailes A, et al. Determinants of stunting reduction in Ethiopia 2000–2011. Matern Child Nutr. 2017;13:e12307. PubMed PMC

Mansfield D, Morris A.. “All for health and health for all”: a study of basic health care in Peru. Br Med J (Clin Res Ed). 1981;282:1684–1686. PubMed PMC

Chaparro M, Estrada L.. Mapping the nutrition transition in Peru: evidence for decentralized nutrition policies. Rev Panam Salud Publica. 2012;32:241–244. PubMed

De Onis M, Blössner M, Borghi E.. Prevalence and trends of stunting among pre-school children, 1990–2020. Public Health Nutr. 2012;15:142–148. PubMed

United Nations. Open Working Group Proposal for Sustainable Development Goals. Geneva, Switzerland: United Nations, 2014.

World Health Organization, United Nations’ Children’s Fund, USAID. Improving Nutrition Outcomes with Better Water, Sanitation and Hygiene: Practical Solutions for Policies and Programmes. Geneva, Switzerland: WHO, 2015.