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“How to Combat The Stunting in Our Children”

Dr. Nenden Nursyamsi Agustina, SpA

Child Health Department - Margono Soekarjo Hospital – Jenderal Soedirman University

Update of Maternal Problem and First-thousand Daiy Life of Pediatrics and Its Developmental (UMBILICAL 2017)
Curriculum Vitae:
Nama : dr. Nenden Nursyamsi Agustina, SpA
Status Marital : Menikah, 1 orang anak
Pekerjaan : - Dosen FK UNSOED
- Dokter Pendidik Klinik di RSUD Prof. Margono Soekarjo
Tempat Praktek : - RSUD Prof. Margono Soekarjo
- RSU Wiradadi Husada
- RS Hermina Purwokerto
Bien Trop Petits
K- Drama
Courtesy: Jawa Pos
Disparities in children’s height

Normal or short stature...?

What do we need in Growth Measurement
• Normal growth falls between the 3rd and 97th percentile of all
children  the shorterst an tallest 3rd fall outside bounds of “
normal” stature
Normal Growth
Growth that follows established patterns based on studies of several different populations
and that follows the trajectories of standard growth charts

 No matter with standard growth charhts, the most importance is how to interpret
 The assesment of growth must be longitudinal and cross sectional
World Health Organization Department of Nutrition for Health and Development WHO child growth standards growth velocity based on weight, l
ength and head circumference: methods and development. (World Health Organization, 2009)
Growth Failure, Short Stature and Stunting

• Growth failure: decline in rate of linear growt

h cross channels
• Short stature: height more than 2.0 SD bello
w the mean for age and gender
• Stunting: HAZ<-2 SD (moderate) and<-3 SD
(severe) from the median of the 2006 WHO
Child Growth Standards (UNICEF 2013) in
children aged 0 -56 months.
Secular Trend
• Child height and weight have increased
dramatically over the past 40–60 years in Japa
n and South Korea
• The secular height trend represents increased
growth in the long bones during infancy

Cole TJ, Mori H. Fifty years of child height and weight in Japan and South Korea: Contrasting secular trend patterns analyzed
by SITAR. Am J Hum Biol. 2017
Genetic and environmental influences on height
Heritability was lowest at age increased with a
ge in early and middle childhood and was ge-
nerally greater in late childhood and adoles-
The greatest heritability estimates were found
for boys at ages 14 and 16 (0.83 and 0.82)

Jelecovic A, Sund R, Hur YM, Yokoyama Y, Hjelmborg JB. Genetic and environmental influences on height from infancy to
early adulthood: An individual-based pooled analysis of 45 twin cohorts. Eports. 2016.
Consequences of Stunting

 Stunted children are more likely to start school later and drop out, and a
re less able to learn due to compromised brain and mental developmen
t at a young age.
 Compromised growth has been linked to lower economic productivity
and incomes
 Malnutrition can reduce a child’s earning potential by as much as 10%

Kar, B., Rao, S., Chandramouli, B. “Cognitive development in children with chronic protein energy malnutrition.” Behavioral and Brain Functions.
2008;4(1): 31.
Branca, F., Ferrari, M. INRAN (National Institute for Food Nutrition Research), “Impact of Micronutrient Deficiencies on Growth: The Stunting
Syndrome.” 2002;46(suppl 1):8–17
Growth  Development
Bigger Brains: Complex Brains for a Complex World

Stiles J, Jernigan TL. The Basics of Brain Development. Neuropsychol Rev. 2010
Effects of undernutrition on brain development

Cordero M.E., D’Acuña E., Benveniste S., Prado R., Nuñez J. A. & Colombo M. (1993) Dendritic development in neocortex of infants with early
postnatal life undernutrition. Pediatric Neurology
Anthropometric indicators vs cognitive performance
OR* for children being in a given intelligence quotient (IQ) category by
nutritional status

Sandjaja, Poh BK, Rojroonwasinku; N, Le Nyugen BK, Budiman B, Ng LO, et al. Relationship between anthropometric
indicators and cognitive performance in Southeast Asian school-aged children. Br J Nutr. 2013
Gut-Brain Axis

Sherman MP, Zaghoiani H, Niklas V. Gut Microbiota, the immune system, and diet influence the neonatal gut-brain axis. 2015
Actions to overcome stunting
1. Improve the identification, measurement & understanding of stunting a
nd scale up coverage of stunting-prevention activities
2. Strengthen interventions to improve maternal nutrition and health, begin
ning with adolescent girls
3. Implement interventions for improved exclusive breastfeeding and com-
plementary feeding practices
4. Strengthen community-based interventions: water,sanitation & hygiene
5. Immunization
6. Stimulation

WHA Global Nutrition Targets 2025: Stunting Policy Brief


Instrumen Sederhana

1. Buku KMS
2. Buku KPSP
3. Aplikasi2 tumbuh kembang di Appstore
The Issue of Breastfeeding
“Brain Development Inside “
Jamaica Project

Development quotient: practical reasoning, eye & hand coordination, hearing

and speech, and performance
Grantham-McGregor SM, Walker SP, Chang SM, Powell CA. Effects of early childhood supplementation with and without stimulation on later development
in stunted Jamaican children. Am J Clin Nutr. 1997 Aug;66(2):247-53.
Building Human Capacity

Interventions in early chilhood are more cost effective than at others age

Grantham-McGregor SM, Powell C, Walker S, Chang S, Fletcher P. The long-term follow-up of severely malnourished children who participated in an inter
vention program. Child Dev 1994; 65: 428-39.
Teach like Finland
“Finland shocked the world”
 Programme for International Student Assessment (PISA 2001)  the highest
score in critical-thinking skills in math, science and reading
 More time for play  Kids have more time to be kids
Take home message
Every child with short stature should be evaluated
Stunting during early childhood demonstrates marker of
chronic undernutrition
Regular anthropometric measurement is highly recommended
in daily practice
Optimizing the first 1000 days life
Thank You