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Do firstborn children have a height advantage? Empirical findings have found mostly that, yes, second or higher-order children often lag behind firstborns in height outcomes, especially in developing countries. However, empirical investigations of birth-order effects on child height overlook the potential impact that birth spacing can have. We provide an explanation for the negative birth-order effect on stunting outcomes for young Indian children and show it is driven by short preceding-birth spacing. We find that firstborn children are taller than children of higher birth order: The height-for-age gap for third (or higher)-order children is twice the gap for children second in birth order. However, this pattern is observed when spacing between later-born children and their immediate elder siblings is fewer than 3 y. Interestingly, the firstborn height advantage disappears when later-born children are born at least 3 y after their elder siblings. Thus, our findings indicate that spacing length between children explains differences in height, over birth order. Although India's family planning policy has resulted in a substantial reduction in total fertility, its achievement in spacing subsequent births has been less impressive. In showing that spacing can alleviate or aggravate birth-order effects on attained height, our study fills an evidence gap: Reducing fertility alone may not be sufficient in overcoming negative birth-order effects. To reduce the detrimental effects of birth order on child stunting, policy responses-and therefore research priorities-require a stronger focus on increasing the time period between births., Competing Interests: The authors declare no competing interest., (Copyright © 2021 the Author(s). Published by PNAS.)

Childhood stunting remains a public health concern in India. In Karnataka, the districts vary substantially in stunting prevalence. Using the NFHS-4 and AidData GEO datasets, we tested the hypothesis that 'wet' and 'dry' districts in Karnataka show different contributions to stunting. We found that for 30 environmental and health factors, Bengaluru appears to be distinct from the other districts. Using a mixed linear model approach, we found that for the entire state, and in both wet and dry districts, preceding birth interval, altitude-adjusted haemoglobin level and child age showed significant correlations with height for age (HFA). The wet districts showed an additional association between maternal age and child HFA. However, interaction effects also differed among the three conditions. Our results suggest that subtle variations should not be ignored when considering factors impacting child health outcomes. [ABSTRACT FROM AUTHOR]