Skip to main content

Factors associated with stunting: gut inflammation and child and maternal-related contributors among under-five children in Hawassa City, Sidama Region, Ethiopia



Under-nutrition remains a major global public health challenge, particularly among children under the age of five. Among the manifestations of under-nutrition, stunting accounts for the larger proportion, which is associated with multiple factors. In Ethiopia, however, the link between intestinal inflammation and childhood stunting was not well investigated. Therefore, the present study aimed to determine the association between gut inflammation and childhood stunting.


A community-based cross-sectional study was conducted and a total of 82 children were included in the study. Anthropometric data were collected by measuring weight in underwear and without shoes with an electronic scale to the nearest 0.1 kg and their height in the Frankfort plane with a telescopic height instrument. Environmental risk factors for enteric bacterial exposure, access to improved sources of drinking water, and the presence of facilities for hygiene and sanitation conditions were assessed using a questionnaire. Gut inflammation was tested through fecal leukocyte count and each sample was stained with methylene blue. Stool samples were inoculated on MacConkey agar, Salmonella-Shigella agar, and Xylose Lysine Deoxycholate agar after enrichment with Selenite cystine broth and incubated at 37 °C for 18–24 h. Binary and multiple logistic regressions and Chi-square models were used to analyze the data.


Data from the current study revealed that gut inflammation was (AOR: 5.28, 95% CI: 1.32–22.25) associated with stunting. On the other hand, children with reported diarrhea within the last week were 6 times more likely for the probability of being stunted (AOR: 6.21, 95% CI: 2.68–26.83). The findings of this study also demonstrated that children from a household with a family size of more than 5 members were three times more likely to be stunted than their counterparts (AOR: 3.21, 95% CI: 1.20 -10.13). Facts of the current study demonstrated that breastfeeding for 24 months and below was negatively associated (AOR: 0.3; 95% CI: -0.46-0.89) with gut inflammation. Detection of E.coli and Shigella species in the stool samples of children and Menaheria residents were positively associated with gut inflammation (AOR: 5.4, 95% CI: 1.32–22.25; AOR: 5, 95% CI: 1.47–24.21), respectively.


Therefore, there was a strong correlation between stunting and gastrointestinal inflammation. Moreover, stunting was associated with diarrhea, breastfeeding duration, residence, and family size. Similarly, intestinal inflammation was linked to residence, breastfeeding duration, and the prevalence of bacterial infections such as E. coli and Shigella species.

Peer Review reports


Under-nutrition remains a major global public health challenge, particularly among children under the age of five[1]. It continues to be a major cause of morbidity and mortality, especially in developing countries [2]. Stunting is the most prevalent [3] form of under-nutrition that affected about 149 million under-five children at the global level[4]. Stunting accounts for 14–17% of mortality in under-five children worldwide. It leads to long-term cognitive declines, less time and less performance at school, reduced adult operating performance, and a greater risk of delay in descendants [5]. Childhood nutritional stunting might lead to an increased risk of infections and metabolic disorders, lower fat oxidation, higher risk of creating diabetes, adulthood obesity, and hypertension [6].

Many research findings demonstrated that factors that contribute to stunting are multifaceted [7]. It was linked to biological, behavioral, and environmental variables [8, 9]. According to previous study reports, the prevalence of stunting in the East African region is influenced by factors such as fertility rate, child nutrition, and feeding patterns [10, 11]. Among the environmental factors contributing to stunting, poor drinking water supply, sanitation, and hygiene (WaSH) situation are becoming more significant as it is one of the causes of gut inflammation [12, 13]. A healthy gut as a biological component is essential to achieving normal growth in children. Intestinal health is central to optimal growth and development because it maintains nutrient retention while preventing the body from excessive microbial introduction, illness, and systemic inflammation [14].

Infectious or non-infectious inflammation in maternal during pregnancy and neonates has an essential influence on young children’s growth as well as overall health. A growing literature has arisen with strong evidence that inflammation is negatively and causally associated with height for age among under-five children [15, 16]. Some other studies also have argued for an inverse association between inflammation and cognitive maturity rather than physical growth in children [17, 18]. Gut inflammation, one of the implications of environmental enteropathy, is affecting children’s nutritional status through malabsorption of essential nutrients, and activation of the immune system at expense of cellular proteins and carbohydrates [19]. The health of the gut mucosa is dependent on the composition and metabolic activity of the microbial communities that live there [20]. Preventing the entry of enteric pathogens and other pathogenic microbes through improved WaSH services could prevent the majority of gut disorders in developing countries [12].

Although the association between gut inflammation and childhood stunting is reported elsewhere in previous studies [21, 22], the findings lack consistency because of differences in study designs and biomarkers used to test gut inflammation [14, 23, 24]. However, in Ethiopia, studies have indicated that WaSH status is associated with childhood stunting but have not addressed the concurrent link with gut inflammation. Therefore, the aim of the present study was to determine the association between gut inflammation and childhood stunting in Hawassa City, Sidama Regional State, Ethiopia.

Materials and methods

Study area and period:

This study was performed in Hawassa City, the capital city of the Southern Nation, Nationalities and Peoples Region (SNNPR), and Sidama National Regional State. Hawassa is located at 70’ 03” latitude, 80’29” east longitude, at 7° 3’ 0” N latitude, 38° 28’ 0” E longitude. The City is 270 km South of Addis Ababa, the capital city of Ethiopia. Hawassa is bordered by the Wondo Genet District in the East, the South Dore Bafeno District in the South, the Oromia Region in the North, and the Hawassa Lake and Oromia Region in the West. The metropolis is divided into 8 sub-cities and 32 kebeles. According to the housing and population census, the projected population of Hawassa metropolis administration in 2011 E.C. was 329, 734, out of which 169, 677 were males and 160, 057 were females [25]. However, the actual total number of under-five children in the city in 2021 was 27,651, based on the statistical data of Hawassa City’s health bureau. The study was conducted from July 2021 to August 2021.

Source population, study population, and study design:

The source population for this study was all children aged under five years, and living in Hawassa City. Children aged 6–59 months and stunted ones were eligible for this study. The data were collected using a community-based cross-sectional study design.

Sample size determination:

The sample size was determined using G-power by considering the Chi-square test, α value of 0.05, β value of 0.20, estimated effect size of 0.3, and degree of freedom to be 1 [26]. We assumed a medium effect size based on the close and substantial correlation between environmental enteric dysfunction or gut inflammation and growth faltering in children in developing countries [13, 27]. Thus, the total sample size was calculated and determined to be 88. However, data from 82 child-mother pairs were used for the analysis.

Sampling technique:

Primary sampling unit was the sub-city in Hawassa City, and then the kebeles and the households in the kebeles were the secondary and tertiary sampling units respectively. Eventually, a child-mother pair was selected as a quaternary sampling unit among the source population through simple random sampling. After having the total number of under five children in the city, different numbers of under-five children were selected for each sub-cities based on the city’s demographic data in 2021 through probability proportional to size technique. A household was eligible to participate in the study if it had under-five children and was willing to participate.

Inclusion and exclusion criteria:

Children with age 6–59 months, beginning of solid food intake, and stunted growth were used as inclusion criteria, and those fulfilling these criteria were eligible for the study. Children with any of the exclusion criteria below were not eligible for the study: not exclusively breastfeeding, any chronic illness and any malnutrition case other than stunting.

Data collection tools and procedures:

For anthropometric data collection from children, permission was obtained from the Parents/guardians. The kebeles’ health extension workers participated in the data collection. Data were collected from children aged 24–59 months by measuring their weight in underwear and without shoes with an electronic scale (Type SECA 861 or SECA 813, Hamburg, Germany) to the nearest 0.1 kg and their height in the Frankfort plane with a telescopic height instrument (Type SECA 225 or SECA 214) to the nearest 0.1 cm. Data from children aged 6–23 months, on the other hand, were collected by measuring the child’s weight and that of the mother/guardians, then subtracting the weight of the mother/guardians from the sum weight of the child and the mother/guardians. The height was measured using an accurately graduated length board and recorded to the nearest millimeter. The age of the children was obtained from a parental recall using an events calendar. The height and the weight of the children were measured twice, and the average was taken. The measuring instruments were calibrated at least twice a day in each case. Nutritional status indices were generated by using WHO Anthro software for the children. According to the World Health Organization (WHO), wasting, stunting, and being underweight are defined as Z-scores of less than − 2 standard deviations of weight for height, height for age, and weight for age, respectively[28]. To assess the environmental risk factors for enteric bacterial exposure of the children, the children’s household environment was determined by the data collectors following the guidelines [29] for access to improved sources of drinking water, the presence of facilities for hygiene, and sanitation conditions.

Gut inflammation test:

This was tested through fecal leukocytes count. Fresh stool samples that were collected by using sterile cups were examined for the presence of fecal leukocytes on smears made onto glass slides within 20–30 min after the stools were collected as described in clinical diagnosis guidelines[30, 31]. The stools for microscopic examination were chosen from an area with blood or mucus if present. Each sample was stained with methylene blue (Himedia, Mumbai, India) and examined by an experienced laboratory technician who was blinded to the source of the sample. Microscopic examination of the preparations was done by examining each for 10 min using an optical light microscope. The numbers of leukocytes per field (Lpf) (Oil immersion field, magnification, 1000x) were determined in at least 20 fields. The average results were categorized as follows: 3 to 5 Lpf, 6 to 10 Lpf, 11 to 15 Lpf, or \(\ge\) 16 Lpf. Based on previous studies, we chose a cutoff point of 10 Lpf to decide the presence of a gut inflammation related to an enteric infectious bacteria [32].

Bacterial culture as a conformation test:

Stool samples were collected using clean, dry, and leak-proof stool cups and immediately placed into the Cary-Blair transport medium (Oxoid Ltd., Basingstoke, UK). Samples were transported to Hawassa University’s Food Microbiology Laboratory in cold boxes with ice packs within 2 h of collection for further processing. Stool samples were directly inoculated onto MacConkey agar, Salmonella-Shigella agar, and Xylose Lysine Deoxycholate agar after enrichment with Selenite cystine broth and incubated at 37 °C for 18–24 h. After incubation, bacterial isolates were identified to the genus level by the colony morphology and biochemical characteristics of the isolates[33].

Data analysis

Before the data processing, filled questionnaire was checked for completeness and consistency. Then, the data were coded, entered, and cleaned using SPSS version 200 (SPSS, Inc., Chicago, IL, USA). Data were analyzed by using both descriptive as well as the inferential statistics. Assumptions for the statistical models used for data analysis were checked and fulfilled. Eventually, the data were analyzed by using Chi-square, and bivariate and multivariate logistic regression to identify significant associations at p < 0.25 and p < 0.05 respectively.


Characteristics of the study subjects

Socio-demographic characteristics of the study subjects showed that the majority (54.9%) of them were within the age of 13–35 months followed by 36–59 months (32.9%). On the other hand, 53.7% of them were male and 95.1% of their family were married but the other 4.9% were divorced. The nutritional status of the children showed that 41.5% of them were stunted. Clinical characteristics of the children showed that 23.2% had diarrhea within the last one week. Data on the immunization status of children showed that 94% of them were immunized. On the other hand, 36.6% of the children enrolled in the current study were exposed to antimicrobial agents within the last 3 months. The macroscopic examination of the stool samples showed that 28% had mucus, 3.7% had blood and 57.3% had formed stool samples (Table 1).

Table 1 Socio-demographic and clinical characteristics of children aged 6–59 months at Hawassa City, Sidama Region, Ethiopia, 2022

The association between gut inflammation and stunting

A Pearson’s correlation coefficient was computed to assess the relationship between gut inflammation and height for age (HAZ) among under-five children. According to the results of the analysis, gut inflammation was negatively correlated (r = − 0.323, n = 82, p = 0.003) with HAZ. Overall, there was a weak and negative correlation between gut inflammation and the children’s HAZ. Increases in gut inflammation were correlated with decreases in HAZ as demonstrated in the scatter plot (Fig. 1).

Fig. 1
figure 1

Correlation between log-transformed WBC count and HAZ among under-five children at Hawassa City, Sidama Region, Ethiopia

Multivariate regression analysis of the current data demonstrated that children who had gut inflammation were 5.28 times more likely to be stunted than their counterparts (AOR: 5.28, 95% CI: 1.61–20.21). On the other hand, children with reported diarrhea within the last one week before the stool sample collection was 6.21 times increased probability of being stunted (AOR: 6.21, 95% CI: 2.68–26.83). Surprisingly, children who breastfed for more than 24 months were more likely to be stunted as compared with those who breastfed for less or equal to 24 months (AOR: 1.23, 95% CI: 1.09–11.90). Children belonging to a household with a family size of 5 and more were 3.21 times more likely to develop stunted than their counterparts (AOR: 3.21, 95% CI: 1.20 -10.13). Children who lived in the Haik Dar sub-city of Hawassa city had a 1.61 times greater chance of being stunted than Tulla sub-city (AOR: 1.61, 95% CI: 1.12–17.34). When compared to the reference age group (6–12 months), stunting was associated with children’s ages 13–35 months, but this link was not statistically significant (Table 2).

Table 2 Determinants of stunting among under-five children at Hawassa City, Sidama Region, Ethiopia, 2022

Factors associated with gut inflammation among children

The current study revealed that breastfeeding for 24 months and below was negatively associated (AOR: 0.3, 95% CI: -0.46-0.89) with gut inflammation in the children. However, the prevalence of enteric bacteria (E.coli and Shigella) in the stool and living in the Menaheria sub-city were positively associated (AOR: 5.4, 95% CI: 1.32–22.25; AOR: 5.0, 95% CI: 1.47–24.20) with gut inflammation respectively. The rest three variables: drinking water supply (AOR: 3.3, 95% CI: 0.7-15.88), reported diarrhea in the last week (AOR: 1.39, 95% CI: 0.82–2.83), and the presence of mucus in the stool (AOR: 0.5, 95% CI: 0.13–1.92) were not statistically significantly associated with gut inflammation (Table 3).

Table 3 Factors associated with gut inflammation among under-five children at Hawassa City, Sidama region, Ethiopia, 2022


The purpose of the current study was to determine whether gut inflammation is linked with childhood stunting and other factors associated with gut inflammation. Our findings revealed that gut inflammation is associated with childhood stunting among the sampled population. This is supported by previous research reports that gut inflammation is an indicator of gut damage that affects the body’s nutrient acquisition [34,35,36], thereby contributing to stunting. Similar to the current report, another cohort follow-up study pointed out that childhood growth faltering is strongly associated with systemic inflammation, and caused by gut damage [37]. On the contrary to prospective study among Bolivian infants reported no association between inflammation and stunting[38]. This would probably be due to the infancy age of the study population as the age of children is positively related to stunting[39].

The current study demonstrated that some risk factors such as the presence of diarrhea in the past week, large family size, residence, and breastfeeding duration of more than 24 months showed a statistically significant association with childhood stunting in addition to gut inflammation. Many previous reports in Ethiopia also documented that diarrheal frequency, as well as the duration as the predictor of childhood stunting [40,41,42], which might be a result of repeated infections and leads to essential micronutrient loss, reduced appetite, and an increase in the demand for metabolites of biosynthesis.

Similar to our results, a family size of 5 or more has been determined to be a risk factor for stunting in rural areas of Ethiopia and elsewhere. The possible explanation for this would be the negative association between family size and the households’ food security and less attention for under-five children in the household. Prominent explorations have addressed the positive importance of breastfeeding for optimum growth in children. Those studies stressed only the nutritional value of breast milk for children during their infancy age, but not a change in the composition of breast milk through time. However, our study observed that the extension of the duration of breastfeeding above 24 months decreased the children’s height for age. Inconsistent with our findings, a study from Pakistan implied that children’s nutritional status changes from stunting to severe stunting as the duration of breastfeeding increases after the second year of life [43]. The contributing linkage of longer breastfeeding duration with stunting would likely be a result of the fatty composition of breast milk that is associated with gut inflammation [44, 45], and low appetite for complementary foods that promote linear growth in children.

Data of the current study demonstrated that gut inflammation is significantly associated with the prevalence of enteric bacteria in stool, duration of breastfeeding up to 24 months, and the residence of the children. Many studies have found a link between intestinal inflammation and bacterial infections. A longitudinal study conducted on a birth cohort came up with a direct relationship between gut inflammation and exposure to pathogens’ invasion in early life. The study has also indicated a negative association between gut inflammation and length for age Z-scores[36]. An observational study carried out in the different environments of the same town in India showed that the odds of gut inflammation increase with the prevalence of intestinal pathogens associated with poor WaSH situations [46]. However, we did not see a significant association between WaSH conditions and enteric bacterial pathogens’ prevalence in the present study. The inconsistency between the findings might be explained by the larger sample size, diversity of the groups of gut pathogens identified, and methodological difference in the case of the Indian report. Another study in rural Ethiopia tested that improved drinking water supply decreased the chance of getting gut inflammation among under-five children [47], which is unlike our findings that did not show a significant association. The disparity could be due to a difference in the settings (rural/urban) of the study population.

Based on the findings of this study, the duration of breastfeeding up to 24 months was found to be protective against gut inflammation. This is in agreement with various investigations conducted in middle and low-income countries that established the role of breastfeeding in keeping up the gut health in children [48,49,50]. The fact would probably be related to the healthy proportional composition of breast milk during the first 2 years, and then after that tends to have more fat components than the other macronutrients. According to Imhann F et al., a diet with a high content of fat and sugar increased the concentration of fecal calprotectin in the stool as a biomarker of gut inflammation. The study has also suggested that high fat and sugar in a diet aggravate gut inflammation via the promotion of the growth of pro-inflammatory enteric bacteria[51, 52]. Our findings also revealed that the living of the children in the Menaheria sub-city was positively related to gut inflammation. This could be linked with the contribution of a living environment to the exposure of biological or chemical factors triggering gut inflammation. Likewise, studies carried out under different environmental settings have documented that a certain surrounding has either a protective or predisposing effect on gut inflammation [53, 54].


Data from the current study showed that gut inflammation is significantly associated with stunting among children. Besides gut inflammation, family size, diarrhea in the last week, the living residence, and breastfeeding duration for longer than 24 months were predictors of stunting in children. Gut inflammation was also associated with the prevalence of E.coli and Shigella species in the stool, breastfeeding duration, and the living residence. Accordingly, we strongly recommend that the government’s public health policy should give priority to the awareness creation at both the households and community level about family planning, breastfeeding duration, and environmental hygiene.

Data Availability

All data generated or analyzed during this study are included in this published article.


  1. IFPRI. Global Nutrition Report 2015.Glob Nutr Rep. 2015;201.

  2. Antehunegn G, Id T, Yeshaw Y, Worku MG, Tadesse Z, Id T et al. Pooled prevalence and associated factors of chronic undernutrition among under-five children in East Africa: A multilevel analysis. 2021;1–17. Available from:

  3. UNICEF, World Health Organization, The World Bank. UNICEF-WHO- World Bank. Joint Child Malnutrition Estimates: Levels & trends in child malnutrition. Africa (Lond) [Internet]. 2012;35. Available from:

  4. United Nations-World Health Organization-The World Bank Group. UNICEF-WHO-The World Bank. : Joint child malnutrition estimates - Levels and trends.Report. 2019;p.1–15.

  5. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, et al. Maternal and child undernutrition: consequences for adult health and human capital. Lancet. 2008;371(9609):340–57.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Soliman A, De Sanctis V, Alaaraj N, Ahmed S, Alyafei F, Hamed N, et al. Early and long-term consequences of nutritional stunting: from childhood to adulthood. Acta Biomed. 2021;92(1):1–12.

    Google Scholar 

  7. Stewart CP, Iannotti L, Dewey KG, Michaelsen KF, Onyango AW. Contextualising complementary feeding in a broader framework for stunting prevention. Matern Child Nutr. 2013;9(S2):27–45.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Habimana S, Biracyaza E. Risk factors of stunting among children under 5 years of Age in the eastern and western provinces of Rwanda: analysis of Rwanda demographic and Health Survey 2014/2015. Pediatr Heal Med Ther. 2019;10:115–30.

    Google Scholar 

  9. Waller A, Lakhanpaul M, Godfrey S, Parikh P. Multiple and complex links between babyWASH and stunting: an evidence synthesis. J Water Sanit Hyg Dev. 2020;10(4):786–805.

    Article  Google Scholar 

  10. Tamirat KS, Tesema GA, Tessema ZT. Determinants of maternal high-risk fertility behaviors and its correlation with child stunting and anemia in the East Africa region: A pooled analysis of nine East African countries. PLoS One [Internet]. 2021;16(6 June 2021):1–15. Available from:

  11. Gelli A, Margolies A, Santacroce M, Roschnik N, Twalibu A, Katundu M, et al. Using a community-based early Childhood Development Center as a platform to promote production and consumption diversity increases children’s Dietary Intake and reduces stunting in Malawi: a cluster-randomized trial. J Nutr. 2018;148(10):1587–97.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Mbuya MNN, Humphrey JH. Preventing environmental enteric dysfunction through improved water, sanitation and hygiene: an opportunity for stunting reduction in developing countries. Matern Child Nutr. 2016;12:106–20.

    Article  PubMed  Google Scholar 

  13. Budge S, Parker AH, Hutchings PT, Garbutt C. Environmental enteric dysfunction and child stunting. Nutr Rev. 2019;77(4):240–53.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Ordiz MI, Davitt C, Stephenson K, Agapova S, Divala O, Shaikh N, et al. EB 2017 article: interpretation of the lactulose:mannitol test in rural malawian children at risk for perturbations in intestinal permeability. Exp Biol Med. 2018;243(8):677–83.

    Article  CAS  Google Scholar 

  15. Sinharoy SS, Reese HE, Praharaj I, Chang HH, Clasen T. Effects of a combined water and sanitation intervention on biomarkers of child environmental enteric dysfunction and associations with height-for-age Z-score: A matched Cohort study in rural Odisha, India. PLoS Negl Trop Dis [Internet]. 2021;15(3):1–13. Available from:

  16. DeBoer MD, Scharf RJ, Leite AM, Férrer A, Havt A, Pinkerton R, et al. Systemic inflammation, growth factors, and linear growth in the setting of infection and malnutrition. Nutrition. 2017;33:248–53.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Donowitz JR, Cook H, Alam M, Tofail F, Kabir M, Colgate ER, et al. Role of maternal health and infant inflammation in nutritional and neurodevelopmental outcomes of two-year-old bangladeshi children. PLoS Negl Trop Dis. 2018;12(5):1–20.

    Article  Google Scholar 

  18. Vohr BR, Davis EP, Wanke CA, Krebs NF, Neurodevelopment. The impact of nutrition and inflammation during preconception and pregnancy in low-resource settings. Pediatrics. 2017;139(April):38–49.

    Article  Google Scholar 

  19. Amadi B, Zyambo K, Chandwe K, Besa E, Mulenga C, Mwakamui S, et al. Adaptation of the small intestine to microbial enteropathogens in zambian children with stunting. Nat Microbiol. 2021;6(4):445–54.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Fahim SM, Das S, Gazi MA, Mahfuz M, Ahmed T. Association of intestinal pathogens with faecal markers of environmental enteric dysfunction among slum-dwelling children in the first 2 years of life in Bangladesh. Trop Med Int Heal. 2018;23(11):1242–50.

    Article  CAS  Google Scholar 

  21. Semba RD, Shardell M, Trehan I, Moaddel R, Maleta KM, Ordiz MI et al. Metabolic alterations in children with environmental enteric dysfunction. Sci Rep [Internet]. 2016;6:1–9. Available from:

  22. Lin A, Ali S, Arnold BF, Ziaur Rahman M, Alauddin M, Grembi J, et al. Effects of water, sanitation, handwashing, and nutritional interventions on environmental enteric dysfunction in young children: a Cluster-randomized, controlled Trial in Rural Bangladesh. Clin Infect Dis. 2020;70(5):738–47.

    PubMed  Google Scholar 

  23. Harper KM, Mutasa M, Prendergast AJ, Humphrey J, Manges AR. Environmental enteric dysfunction pathways and child stunting: a systematic review. PLoS Negl Trop Dis. 2018;12(1):1–23.

    Article  Google Scholar 

  24. Yoseph A, Beyene H. The high prevalence of intestinal parasitic infections is associated with stunting among children aged 6–59 months in Boricha Woreda, Southern Ethiopia: a cross-sectional study. BMC Public Health. 2020;20(1):1–13.

    Article  Google Scholar 

  25. Alemayehu FR, Mariam RG, Loha E, Anato A, Desta DT. Maternal Socio demographic characteristics are Associated with Child Stunting in Alamura Subcity of Hawassa, Ethiopia. Public Heal Res. 2020;10(1):12–20.

    Google Scholar 

  26. Serdar CC, Cihan M, Yücel D, Serdar MA. Sample size, power and effect size revisited: simplified and practical approachin pre-clinical, clinical and laboratory studies. Biochem Med. 2021;31(1):1–27.

    Article  Google Scholar 

  27. Prendergast AJ, Rukobo S, Chasekwa B, Mutasa K, Ntozini R, Mbuya MNN et al. Stunting is characterized by chronic inflammation in zimbabwean infants. PLoS One. 2014;9(2).

  28. Herforth A, Arimond M, Álvarez-Sánchez C, Coates J, Christianson K, Muehlhoff E. A Global Review of Food-Based Dietary Guidelines. Adv Nutr. 2019;10(4):590–605.

    Article  PubMed  PubMed Central  Google Scholar 

  29. General Secretariat Malteser International. WASH Guidelines for Field Practitioners. Malterser Int. 2014;1–130.

  30. Silletti RP, Lee G, Ailey E. Role of stool screening tests in diagnosis of inflammatory bacterial enteritis and in selection of specimens likely to yield invasive enteric pathogens. J Clin Microbiol. 1996;34(5):1161–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Jiang ZD, Smith MA, Kelsey KE, Cortez CP, DuPont HL, Mathewson JJ. Effect of Storage Time and temperature on fecal leukocytes and Occult Blood in the evaluation of Travelers’ Diarrhea. J Travel Med. 1994;1(4):184–6.

    Article  CAS  PubMed  Google Scholar 

  32. Mercado EH, Ochoa TJ, Ecker L, Cabello M, Durand D, Barletta F, et al. Fecal leukocytes in children infected with diarrheagenic escherichia coli. J Clin Microbiol. 2011;49(4):1376–81.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Getie M, Abebe W, Tessema B. Prevalence of enteric bacteria and their antimicrobial susceptibility patterns among food handlers in Gondar town, Northwest Ethiopia. Antimicrob Resist Infect Control. 2019;8(1):4–9.

    Article  Google Scholar 

  34. Perin J, Burrowes V, Almeida M, Ahmed S, Haque R, Parvin T, et al. A retrospective case-control study of the relationship between the gut microbiota, enteropathy, and child growth. Am J Trop Med Hyg. 2020;103(1):520–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Lauer JM, Duggan CP, Ausman LM, Griffiths JK, Webb P, Bashaasha B, et al. Unsafe drinking water is associated with environmental enteric dysfunction and poor growth outcomes in young children in rural southwestern Uganda. Am J Trop Med Hyg. 2018;99(6):1606–12.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Id NTI, Syed S, Kabir F, Jamil Z, Akhund T, Id PD, et al. Pathobiome driven gut inflammation in pakistani children with Environmental. Enteric Dysfunct. 2019;189:1–15.

    Google Scholar 

  37. Zambruni M, Ochoa TJ, Somasunderam A, Cabada MM, Morales ML, Mitreva M, et al. Stunting is preceded by intestinal mucosal damage and microbiome changes and is associated with systemic inflammation in a cohort of peruvian infants. Am J Trop Med Hyg. 2019;101(5):1009–17.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Burke RM, Suchdev PS, Rebolledo PA, De Aceituno AMF, Revollo R, Iñiguez V, et al. Predictors of inflammation in a cohort of bolivian infants and toddlers. Am J Trop Med Hyg. 2016;95(4):954–63.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Gebre A, Surender Reddy P, Mulugeta A, Sedik Y, Kahssay M. Prevalence of Malnutrition and Associated Factors among Under-Five Children in Pastoral Communities of Afar Regional State, Northeast Ethiopia: A Community-Based Cross-Sectional Study. J Nutr Metab. 2019;2019.

  40. Tadesse SE, Mekonnen TC, Id MA. Priorities for intervention of childhood stunting in northeastern Ethiopia: A matched case-control study. 2020;82:1–13. Available from:

  41. Wondemagegn AT. Predictors of Chronic Undernutrition (Stunting) among Under Five Children in Rural East Wollega, Oromiya Region, West Ethiopia: A Community Based Unmatched Case - Control Study. J Nutr Heal Food Eng. 2017;7(2).

  42. Asfaw M, Wondaferash M, Taha M, Dube L. Prevalence of undernutrition and associated factors among children aged between six to fifty nine months in Bule Hora district, South Ethiopia. BMC Public Health. 2015;15(1):1–9.

    Article  Google Scholar 

  43. Shaka MF, Woldie YB, Lola HM, Olkamo KY, Anbasse AT. Determinants of undernutrition among children under-five years old in southern Ethiopia: does pregnancy intention matter? A community-based unmatched case-control study. BMC Pediatr. 2020;20(1):1–10.

    Article  Google Scholar 

  44. Berhe K, Seid O, Gebremariam Y, Berhe A, Etsay N. Risk factors of stunting (chronic undernutrition) of children aged 6 to 24 months in Mekelle City, Tigray Region, North Ethiopia: an unmatched case-control study. PLoS ONE. 2019;14(6):1–11.

    Article  Google Scholar 

  45. Syeda B, Agho K, Wilson L, Maheshwari GK, Raza MQ. Relationship between breastfeeding duration and undernutrition conditions among children aged 0–3 Years in Pakistan. Int J Pediatr Adolesc Med [Internet]. 2021;8(1):10–7. Available from:

  46. Praharaj I, Revathy R, Bandyopadhyay R, Benny B, Ko MA, Liu J et al. Enteropathogens and Gut In fl ammation in Asymptomatic Infants and Children in Different Environments in Southern India. 2018;98(2):576–80.

  47. Chen D, McKune SL, Singh N, Yousuf Hassen J, Gebreyes W, Manary MJ, et al. Campylobacter colonization, Environmental Enteric Dysfunction, Stunting, and Associated Risk factors among Young Children in Rural Ethiopia: a cross-sectional study from the Campylobacter Genomics and Environmental Enteric Dysfunction (CAGED) project. Front Public Heal. 2021;8(December 2018):1–13.

    Google Scholar 

  48. Xu L, Claggett PLYKB, Leong RW, Ananthakrishnan AN. Systematic review with meta-analysis: breastfeeding and the risk of Crohn ’ s disease and ulcerative colitis. 2017;(June):780–9.

  49. Brahm P. Benefits of breastfeeding and risks associated with not breastfeeding Beneficios de la lactancia materna y riesgos de no amamantar. 2020;88(1):15–21.

  50. Walker WA, Iyengar RS. Breast milk, microbiota, and intestinal immune homeostasis. 2015;77(1).

  51. Bolte LA, Vila AV, Imhann F, Collij V, Gacesa R, Peters V et al. term dietary patterns are associated with pro- ­ inflammatory and anti- ­ inflammatory features of the gut microbiome. 2021;1–12.

  52. Costa PN, Soares AM, Filho JQ, Junior FS, Ambikapathi R, Mcquade ETR et al. Dietary intake from complementary feeding is associated with intestinal barrier function and environmental enteropathy in Brazilian children from the MAL-ED cohort study. 2020;1003–12.

  53. Gio-Batta M, Sjöberg F, Jonsson K, Barman M, Lundell AC, Adlerberth I et al. Fecal short chain fatty acids in children living on farms and a link between valeric acid and protection from eczema. Sci Rep [Internet]. 2020;10(1):1–11. Available from:

  54. Benchimol EI, Kaplan GG, Otley AR, Nguyen GC, Underwood FE, Guttmann A, et al. Rural and Urban Residence during Early Life is Associated with a lower risk of inflammatory bowel disease: a Population-Based inception and birth cohort study. Am J Gastroenterol. 2017;112(9):1412–22.

    Article  PubMed  PubMed Central  Google Scholar 

Download references


We thank Hawassa University for writing official letters required at various governmental institutions, and Wolaita Sodo University and Ethiopian ministry of education for their financing this study.


The Ethiopian ministry of education and Wolaita Sodo University have jointly funded this research.

Author information

Authors and Affiliations



The entire essay was revised by Professor Baye Gelaw for grammar and scientific expiations. The paper was written by Mr. Berhanu Kibemo while Dr. Dejene Hailu handled the statistical analysis.

Corresponding author

Correspondence to Berhanu Kibemo Lefebo.

Ethics declarations

Ethical consideration

This study was conducted according to the guidelines laid out in the Declaration of Helsinki, and all procedures involving human subjects were approved by the Institutional Review Board of Hawassa University (Ref. No.: IRB/086/13). Verbal informed consent was obtained from all parents of children included in the study. Verbal consent was witnessed and formally recorded. Eventually, the procedure of verbal informed consent was approved by IRB at Hawassa University.

Consent for publication

Not applicable.

Conflict of interest

All authors have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lefebo, B.K., Kassa, D.H. & Tarekegn, B.G. Factors associated with stunting: gut inflammation and child and maternal-related contributors among under-five children in Hawassa City, Sidama Region, Ethiopia. BMC Nutr 9, 54 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • Bacterial pathogens
  • Children
  • Fecal leukocytes
  • Gut inflammation
  • Stunting
  • Undernutrition