FOTO

Prof. DR. Dr. Hardiono D. Pusponegoro, SpA(K )

Department of Child Health
Division Neurology/ Faculty of Medicine
Universitas Indonesia - Jakarta
Education
• Medical doctor : Faculty of Medicine, Universitas Indonesia, 1976
• Pediatrician : Departement of Child Health, Universitas Indonesia, 1984
• Consultant : Pediatric Neurology, Departement of Child Health
Faculty of Medicine , Universitas Indonesia
• Doctoral : Departement of Child Health, Universitas Indonesia, 2013
• Professor : Professor in Department of Child Health, Universitas Indonesia, 2016
Position
Professor in Neurologic Division
Departement of Child Health, Faculty of Medicine,
Universitas Indonesia / dr. Cipto Mangunkusumo Hospital
Organization
Chief of KAMAS (Koperasi Anak Mandiri Sejahtera) in Indonesian Pediatric Society
 Stunting
• affects cognitive development

• Hardiono Pusponegoro
Department of Child Health
Faculty of Medicine, University of Indonesia
Cipto Mangunkusumo Hospital
Jakarta
What is stunting?

Height for Age

Z score < -2 SD
• Casale D, Desmond C. Recovery from stunting and
cognitive outcomes in young children: evidence from the
South African Birth to Twenty Cohort Study. J Dev Orig
Health Dis. 2016;7:163-171.
• de Onis M, Branca F. Childhood stunting: a global
perspective. Matern Child Nutr. 2016;12 Suppl 1:12-26.
 Stunting Syndrome

Stunting Syndrome
Constitutional multiple pathological
changes marked by linear
Shot stature growth retardation,
increase morbidity and
Stunting mortality, and reduce
physical, neuro-
developmental and
economic capacity.

Prendergast AJ, Humphrey JH. The stunting syndrome in developing countries. Paediatr Int Child Health. 2014;34:250-265.
Etiology of stunting Major Other
Intraut • Nutrition • Sanitation
erine
20% • Infection especially • Clean water
diarrhoea • Mother’s eduĐatioŶ
6-18
months • Poverty
80% • Intrauterine • etc

• Black RE, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet.
2013;382:427-451.
• Torlesse H, et al. Determinants of stunting in Indonesian children: evidence from a cross-sectional survey indicate a
prominent role for the water, sanitation and hygiene sector in stunting reduction. BMC Public Health. 2016;16:669.
• Millward DJ. Nutrition, infection and stunting: the roles of deficiencies of individual nutrients and foods, and of
inflammation, as determinants of reduced linear growth of children. Nutr Res Rev. 2017;30:50-72.
• Shekar M, et al. Reaching the global target to reduce stunting: an investment framework. Health Policy Plan. 2017
• Akombi BJ, et al. Stunting and severe stunting among children under-5 years in Nigeria: A multilevel analysis. BMC Pediatr.
2017;17:15.
 Intra uterine stunting syndrome
Small for gestational
age

LBW Asymmetrical

Intra uterine growth

restriction
20-30%
Symmetrical
(intrauterine stunting)

• Committee WHOE. The use and interpretation of anthropometry. Geneva CH. WHO 1995, technical report 854. 1995
• Christian P, Lee SE, Donahue Angel M, Adair LS, Arifeen SE, Ashorn P et al. Risk of childhood undernutrition related to small-for-
gestational age and preterm birth in low- and middle-income countries. Int J Epidemiol. 2013;42:1340-1355.
• Victora CG, Villar J, Barros FC et al. Anthropometric Characterization of Impaired Fetal Growth: Risk Factors for and Prognosis of
Newborns With Stunting or Wasting. JAMA Pediatr. 2015;169:e151431.
• Mandy GT. Infant with fetal (intrauterine) growth restriction. In: Weisman LE, Kim MS, editors. UpToDate. Waltham, MA: UpToDate;
2017.
• Divon MY, Ferber A. Fetal growth restriction: Diagnosis. In: Levine D, Barrs VA, editors. UpToDate. Waltahm, MA: UpToDate; 2017.
 Risk of stunting after born
compared to Term AGA

OR 4.51

OR 2.43
OR 1.93

Christian P, Lee SE, Donahue

Angel M, Adair LS, Arifeen SE,
Ashorn P et al. Risk of childhood
undernutrition related to small-
for-gestational age and preterm
birth in low- and middle-income
countries. Int J Epidemiol.
2013;42:1340-1355.
Interesting studies Hormonal
factors
• Symmetrical IUGR
• Lo ǁ ŵother’s IgF-1
• Lo ǁ ĐhildreŶ’s IgF-1
• Ikeda N, Shoji H, Suganuma H et al. Effects of insulin-like growth factor-I during early postnatal period in intrauterine growth-
restricted rats. Pediatr Int. 2015

• Some IUGR children has mother with low IgF-1

• Those children who have low IgF-1 cannot catch-up
• Michaelsen KF. Effect of protein intake from 6 to 24 months on insulin-like growth factor 1 (IGF-1) levels, body
composition, linear growth velocity, and linear growth acceleration: what are the implications for stunting and
wasting? Food Nutr Bull. 2013;34:268-271.
• Millward DJ. Nutrition, infection and stunting: the roles of deficiencies of individual nutrients and foods, and of
inflammation, as determinants of reduced linear growth of children. Nutr Res Rev. 2017;30:50-72.
Interesting studies
Biochemistry
Stunting is related with less 9 essential amino acids, not only micronutrient

tryptophan, isoleucine, leucine, valine, methionine, threonine, histidine,

phenyl-alanine, lysine

• Semba RD, Shardell M, Sakr Ashour FA et al. Child Stunting is Associated with Low Circulating Essential Amino Acids.
EBioMedicine. 2016;6:246-252.
• Semba RD, Trehan I, Gonzalez-Freire M et al. Perspective: The Potential Role of Essential Amino Acids and the Mechanistic
Target of Rapamycin Complex 1 (mTORC1) Pathway in the Pathogenesis of Child Stunting. Adv Nutr. 2016;7:853-865.
• Uauy R, Suri DJ, Ghosh S, Kurpad A, Rosenberg IH. Low Circulating Amino Acids and Protein Quality: An Interesting Piece in
the Puzzle of Early Childhood Stunting. EBioMedicine. 2016;8:28-29.
Effects of stunting
 Pathology of CNS in stunting
Less
Less myelination Brain atrophy
synaptogenesis
• Engle PL, Fernández PD. • Cordero ME, et al. Dendritic • Kumar N, et al. MRI in
INCAP studies of development in neocortex Children with Microcephaly
malnutrition and cognitive of infants with early and Severe Acute
behavior. Food Nutr Bull. postnatal life Malnutrition. Int. J. Med.
2010;31:83-94. undernutrition. Pediatr Paed. Oncol. 2016;2:15-19.
Neurol. 1993;9:457-464.
• Benítez-Bribiesca L, et al.
Dendritic spine pathology in
infants with severe pcm.
Pediatrics. 1999;104:e21.
 Functional Development of stunting
Low academic
performance Behavior problems

• Anxiety
• Chang SM, Walker SP, Grantham-McGregor S, Powell CA. J Child
• Depressive
Psychol Psychiatry. 2002;43:775-783.
• Casale D, Desmond C, Richter L. Child Care Health Dev.
• Low self-esteem
2014;40:900-910. • Hyperactive
• Walker SP, Chang SM, Powell CA, Grantham-McGregor SM.
Lancet. 2005;366:1804-1807.
• Chang SM, Walker SP, Grantham-McGregor S, Powell CA. Early
childhood stunting and later behaviour and school
achievement. J Child Psychol Psychiatry. 2002;43:775-783. • Walker SP, Chang SM, Powell CA, Simonoff E,
Grantham-McGregor SM. J Nutr. 2007;137:2464-
2469.
 Stunting is passed
between generation

Martorell R, Zongrone A.
Intergenerational influences on child
growth and undernutrition. Paediatr
Perinat Epidemiol. 2012;26 Suppl 1:302-
314.

www.concernusa.org
We are in a serious trouble
 Stunting
165 millions children worldwide
It OK to be thin
It is still OK to be short
..................

Cognitive problems
Is not OK
Crookston BT, Dearden KA, Alder SC et al. Impact of early
and concurrent stunting on cognition. Matern Child Nutr.
2011;7:397-409.
Casale D, Desmond C. Recovery from stunting and cognitive
outcomes in young children: evidence from the South
African Birth to Twenty Cohort Study. J Dev Orig Health Dis.
20151-9.
© Roger Parkes/Alamy
 INDONESIA
37,2% stunted
RisetKesehatan Dasar 2013. Badan Penelitian
dan Pengembangan Kesehatan Kementrian
Kesehatan Republik Indonesia; 2013
 Stunting prevalence, Indonesia
50%

45%

40%
46,90%
35%

30%
36,80% 35,60% 37,20% 36,40%
25%

20%

15%

10%
108 from 132 countries
5%

0%

1995 2007 2010 2013 2016

• Kementerian Kesehatan RI. Analisis Lanskap Kajian Negara Indonesia. Jakarta: Kementerian Kesehatan RI;
2010
• Departemen Kesehatan RI. RisetKesehatan Dasar 2013. Badan Penelitian dan Pengembangan Kesehatan
Kementrian Kesehatan Republik Indonesia; 2013
• International Food Policy Research. From promise to impact. Ending malnutrition by 2030. Washington:
International Food Policy Research Institute; 2016
Is it real stunting?
 WHO Growth Chart WHO Growth Chart

Indonesian Indonesian

Hermanussen M. Synthetic Growth Reference Chart. Am. J. Hum. Biol. 2015

Hermanussen, M. Synthetic Growth Chart, 2017
We almost have Indonesian
Growth Chart
• 34,800 children (17,229 boys and 17,571
girls) from 0 up to 18 years.
• Mean difference of -1.47 SDS for boys
and -1.43 SDS for girls compared to CDC
growth chart

• Batubara J, Alisjahbana A, JGMGerver-Jansen, Alisyahbana B,

Sadjimin T, Tasli Y, Juhariah J, Tririni A, Padmasiwi WI, Listiaty
T, Delemarre-van de Waal HA, Gerver WJ. Growth diagrams of
Indonesian children The nationwide survey of 2005. Paed
Indonesiana 46, 2006
Is catch-up possible?
 Catch-up

Weight Height Cognitive

Our study
Bayley Infant Neurodevelopmental Scale
in wasting, stunting and constitutional short stature, 0-2 yrs

Wasting + Constitutional Wasting without

Stunting short stature stunting
• n=21 • n=1 • n=15

Planned sample size @ 20 subjects

Handryastuti S, Soebadi A, Raffli M, Nurdadi S, Chandra A, Angge F, Widjaja IR, Pusponegoro HD. Cognitive
evaluation of children with constitutional short stature wasting, and stunting. Research in progress.
 Our study
Bayley Scales of Infant Development 3rd ed.
1. Cognitive
2. Language
3. Motor
4. Social emotional
5. Adaptive behavior
Preliminary Constitutional
Resultsshort stature
(1 subject)

50.00

p=0.590
 p=0.849 p=0.874

50.00 50.00

p=0.547 p=0.704

50.00
50.00
 Interpretation
All functions (especially cognitive function) are < 50 percentile even
though it is not significant. Sample size is still too small

There is still hope if we do intervention of stunting and wasting

before 2 years
 Time of catch-up and cognitive function
Worst
5 yrs Same as persistent
stunting

Catch-up
Cognitive = normal

2 yrs

Casale D, Desmond C. Recovery from stunting and cognitive outcomes in young Cognitive < normal
children. J Dev Orig Health Dis. 2016;7:163-171.
Crookston BT, Penny ME, Alder SC, Dickerson TT, Merrill RM, Stanford JB et al.
Children who recover from early stunting and children who are not stunted
demonstrate similar levels of cognition. J Nutr. 2010;140:1996-2001.
Effect of stimulation on stunting
intervention
 Effect of stimulation
103 stunted v.s. 64 non-stunted children

worse compared
No stimulation
to non-stunting

IQ increase,
Stimulation better verbal
and reading

Walker SP, Chang SM, Powell CA. Effects of early childhood psychosocial stimulation and nutritional
supplementation on cognition and education in growth-stunted Jamaican children: prospective cohort
study. Lancet. 2005;366:1804-1807.
 Supplementation v.s. stimulation
Jamaica, 129 stunted children age 9-24 months, cohort 16 yrs
• Stimulation had better overall scores (F = 2.047, P = 0.049).
• less anxiety
• less depression
• higher self esteem
• fewer attention problems
Walker SP, Chang SM, Powell CA, Simonoff E, Grantham-McGregor SM. Effects of psychosocial stimulation and dietary
supplementation in early childhood on psychosocial functioning in late adolescence: follow-up of randomised
controlled trial. BMJ. 2006;333:472.

• Supplementation only had no significant effect

(F = 1.505, P = 0.17).
Walker SP, Chang SM, Younger N, Grantham-McGregor SM. The effect of psychosocial stimulation on cognition and
behaviour at 6 years in a cohort of term, low-birthweight Jamaican children. Dev Med Child Neurol. 2010;52:e148-54.
Supplementation v.s. stimulation Jamaica, 105
children, cohort 2 yrs
• No significant benefits from supplementation
• Received stimulation
• less involvement in fights (OR 0.36)
• less serious violent behavior (OR 0.33)
• higher adult IQ (coefficient
• higher educational attainment (achievement, grade level attained, and
secondary examinations)
• fewer symptoms of depression and social inhibition.

Walker SP, Chang SM, Vera-Hernández M, Grantham-McGregor S. Early childhood stimulation

benefits adult competence and reduces violent behavior. Pediatrics. 2011;127:849-857.
 Intervention and stimulation at home
Multilevel analyses showed significant benefits for
cognitive development
(3.09 points; 95% confidence interval: 1.31 to 4.87 points; effect size:
0.3 SDs).

Chang SM, Grantham-McGregor SM, Powell CA, Vera-Hernández M, Lopez-Boo F, Baker-Henningham H et al.
Integrating a Parenting Intervention With Routine Primary Health Care: A Cluster Randomized Trial. Pediatrics.
2015;136:272-280.
What should be done
in Indonesia?
Comprehensive
Government

Management • Policy
• Surveillance

IDAI
Parents
• Growth chart
• Knowledge • Comprehensive
program in
stunting

DoĐtor’s
behavior
Food producers
• Proper monitor of
growth and
development
Supplemen-
tation
 Government
• Policy on Growth and
Development
• Routine surveillance:
• Simple questionnaire
send by mobile
phone
 IDAI and professionals
• Apps: Prima
• Growth chart
• Every country should have their own growth chart
• Every professionals should use growth chart
• Comprehensive program on Nutrition and Neuro-Developmental

Professionals:
• Fill the growth chart
• Do developmental screening
• Do intervention: supplementation and stimulation at proper time
IDAI

IDAI apps
Comprehensive Nutritional-Developmental
Program for professionals and parents

Available
• Boston online training Comprehensive
• Nestle Nutrition Institute program
• Various small program
 Supplementation
• Macronutrient, especially
protein & amino acids
• Micronutrient
• Failed?: GiziKita, Taburia
• KAMAS: Local source as
supplementation
• Ikan gabus
• Daun keladi
 Food producer
• Work together with government and IDAI
• CSR
• Technology support

• No profit oriented, no company interest

 Target in 3 years
1. Good surveillance program, internet-based, via mobile phone
2. Indonesian Growth Chart
3. Comprehensive Nutritional Program and Infection prevention
4. Comprehensive Developmental Stimulation-Intervention
5. Iŵproǀ eŵeŶt iŶ professioŶal’s ďehaǀ ior iŶ usiŶg groǁ t h Đhart aŶd
knowledge in nutrition – stimulation management
6. Nutritional supplementation, comprehensively made by
government, professionals, and food-nutrition producer
Thank you