In many countries, only a minority of children grow up healthy. 1 The 2018 World Nutrition Report indicates that stunting affects 150.8 million children under five years of age, which represents 22.2% of the world's children. 2,3 The vast majority of stunted children come from developing countries (148.0 of 150.8 million). 3 These countries also have more out-of-school children or people with low academic achievement than the global average. The United Nations Educational, Scientific and Cultural Organization (UNESCO) Institute for Statistics reports that, in 2018, 17.7% of children of primary school age were out of school in the least developed countries, compared with only 8.2% globally. 4 In the same year, only 54.0% reached the last grade of primary education in developing countries compared with 81.7% globally. 4

IntroductionAlthough many studies have examined the associations between growth problems in infancy and age at school entry, grade repetition, school dropout and schooling level in developing country, no synthesis of the evidence has been conducted. We 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 school dropouts.MethodsWe conducted a systematic review of studies (last update March 20, 2021) estimating that estimate the association between stunting, or height-for-age, and at least one component of the school trajectory, or schooling level, using five databases (PubMed, Embase, Education Resources Information Center (ERIC), Web of Science and PsycINFO). Study selection and data extraction were performed by two independent reviewers. Pooled effects were calculated using the generic inverse variance weighting random effect model. The studies’ risk of bias was assessed using the ROBINS-I tool for non-randomized studies.ResultsWe screened 3944 records by titles and abstracts and retained 16 for inclusion in the qualitative and meta-analysis. 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)]. The odds of grade repetition increased by 59% (OR = 1.59; 95% CI: 1.18; 2.14) for stunted children compared to those with no stunting.ConclusionsThis review suggests that stunting in childhood might lead to a delay in school enrollment, grade repetition, school dropout, and low schooling levels in developing countries. Future research should evaluate the effect of stunting on academic trajectories in the same population and explore the potential modification effect of socioeconomic status. The current findings suggest that policy makers need to work more to prevent stunting and to include health issues in educational policies.Systematic review registration: PROSPERO CRD42020198346