Effects of Cooking with Liquefied Petroleum Gas or Biomass on Stunting in Infants

William Checkley, Lisa M. Thompson, Sheela S. Sinharoy, Shakir Hossen, Lawrence H. Moulton, Howard H. Chang, Lance Waller, Kyle Steenland, Ghislaine Rosa, Alexie Mukeshimana, Florien Ndagijimana, John P. McCracken, Anaité Díaz-Artiga, Kalpana Balakrishnan, Sarada S. Garg, Gurusamy Thangavel, Vigneswari Aravindalochanan, Stella M. Hartinger, Marilú Chiang, Miles A. KirbyAris T. Papageorghiou, Usha Ramakrishnan, Kendra N. Williams, Laura Nicolaou, Michael Johnson, Ajay Pillarisetti, Joshua Rosenthal, Lindsay J. Underhill, Jiantong Wang, Shirin Jabbarzadeh, Yunyun Chen, Victor G. Dávila-Román, Luke P. Naeher, Eric D. McCollum, Jennifer L. Peel, Thomas F. Clasen

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Household air pollution is associated with stunted growth in infants. Whether the replacement of biomass fuel (e.g., wood, dung, or agricultural crop waste) with liquefied petroleum gas (LPG) for cooking can reduce the risk of stunting is unknown. METHODS We conducted a randomized trial involving 3200 pregnant women 18 to 34 years of age in four low-and middle-income countries. Women at 9 to less than 20 weeks gestation were randomly assigned to use a free LPG cookstove with continuous free fuel delivery for 18 months (intervention group) or to continue using a biomass cookstove (control group). The length of each infant was measured at 12 months of age, and personal exposures to fine particulate matter (particles with an aerodynamic diameter of 2.5 ?m) were monitored starting at pregnancy and continuing until the infants were 1 year of age. The primary outcome for which data are presented in the current report stunting (defined as a length-for-Age z score that was more than two standard deviations below the median of a growth standard) at 12 months of age was one of four primary outcomes of the trial. Intention-To-Treat analyses were performed to estimate the relative risk of stunting. RESULTS Adherence to the intervention was high, and the intervention resulted in lower prenatal and postnatal 24-hour personal exposures to fine particulate matter than the control (mean prenatal exposure, 35.0 ?g per cubic meter vs. 103.3 ?g per cubic meter; mean postnatal exposure, 37.9 ?g per cubic meter vs. 109.2 ?g per cubic meter). Among 3061 live births, 1171 (76.2%) of the 1536 infants born to women in the intervention group and 1186 (77.8%) of the 1525 infants born to women in the control group had a valid length measurement at 12 months of age. Stunting occurred in 321 of the 1171 infants included in the analysis (27.4%) of the infants born to women in the intervention group and in 299 of the 1186 infants included in the analysis (25.2%) of those born to women in the control group (relative risk, 1.10; 98.75% confidence interval, 0.94 to 1.29; P = 0.12). CONCLUSIONS An intervention strategy starting in pregnancy and aimed at mitigating household air pollution by replacing biomass fuel with LPG for cooking did not reduce the risk of stunting in infants. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).

Original languageEnglish
Pages (from-to)44-54
Number of pages11
JournalNew England Journal of Medicine
Issue number1
StatePublished - Jan 4 2024


  • Environmental Health Hazards
  • Growth and Development
  • Obstetrics/Gynecology
  • Obstetrics/Gynecology General
  • Pediatrics
  • Pediatrics General
  • Public Health
  • Public Health General


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