Stunting

24/08/2017
Outlines
• Malnutrition problems in the under fives
in Indonesia
Practical tips to diagnose and manage stunting
• Impact of stunting individually and
in the infancy and toddlerhood
globally
Damayanti Rusli Sjarif • How to diagnose stunting
Div Pediatric Nutrition and Metabolic • How to manage stunting
Diseases Dept of Pediatrics FKUI/RSCM
Jakarta - INDONESIA
DR SJARIF 3017 DR SJARIF 3017
Malnutrition in Indonesian’s
underfives children
Underweight Stunted Wasted Overweight

(WAZ) (HAZ) (WHZ) (WHZ)
Prevalence of malnutrition in underfive children in Indonesia

DR SJARIF 3017 ( National Basic Health Research Data 2007, 2010, 2013 )
DR SJARIF 3017
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• In Indonesia, 37% of children aged less than five years were

stunted in 2013
• the prevalence exceeded 40 % in 15 out of 33 provinces;
• 18 % of children were severely stunted.
Mean developmental quotient (DQ) scores of five groups of children

over two years. The groups are non-stunted children, and stunted
Stunting syndrome children who received both stimulation and supplementation,

supplementation alone, stimulation alone, and no intervention (control)
[Grantham-McGregor SM, Schofield W, Powell C 1987)
( Branca & Ferrari, 2002)

DR SJARIF 3017 DRS 2017
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DR SJARIF 3017
What is stunting ? Short stature ≈ stunting ?

Short stature Stunting
(Clinical-Individual) (Public Health-Community)
• defined as a child • Stunted growth or stunting
or nutritional stunting, is a
≤ -2SD below the mean reduced growth rate in human
height for children of development
• is referred to as HAZ ≤ - 2SD
that gender and of the new WHO Growth
chronological age. Standard,
• it reflects a process of
failure to reach linear growth
potential as due to suboptimal
health or nutrition conditions.
J Clin Endocrinol Metab. WHO CONCEPTUAL FRAMEWORK 2013

2008 Nov. 93(11):4210-7
STUNTED
SEVERELY STUNTED
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Differential diagnosis of short stature
STUNTING
Source:
DR SJARIF 3017 Mark A. Sperling, MD DR SJARIF 3017
How to differentiate stunting to other

causes of short stature 0-24 month
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Plot in the growth chart
Determine Growth Velocity Simple algorithm to differentiate stunting to other causes of short
length velocity <5th = growth deceleration stature 0-24 month I (DR Sjarif 2017)
interval eveluation 2,3,4 or 6 months
Length velocity < p5 (WHO 2006)
(-) Normal variants (+) pathological
Median Parental Height Dysmorphic Proportionate Disproportionate
Bone Age if > 1 years old

Algoritm II
≈ MPH & BA= CA < MPH & HA=BA<CA
Familial Short Constitutional Delay of

Stature Growth
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Dysmorphic or Dysproportionate Simple algorithm to differentiate stunting to other causes of

short stature 0-24 month II (DR Sjarif 2017)
Proportionate
US:UL= (1,7-1,5):1
Prenatal Postnatal
Surgical limb
lengthening TERAPI SULIH ENZIM WA<HA<CA OR HA<WA<CA OR
IUGR
techniques WHZ ≤ +1 WHZ > +1
may increase SGA
height 6-12 inches STUNTING Endocrinopathy (?)
DR SJARIF 3017
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Simple Algorithm to diffentiate stunting with other

causes of short stature (Sjarif 2017)
• Length velocity < p5 classified as growth deceleration,
evaluate with interval 2,3,4 and 6 months
Growth
velocity • WHO 2006 Growth Chart
• US/LS newborn = 1,7:1

• US/LS 1 year=1,6:1
Proportionate • US/LS 2 year=1,5:1
• STUNTING
• Weight for Age < Height for Age < Chronological Age
Postnatal • OR
• Weight for Height (WHZ < Zscore+1)
Effects of growth during early childhood on adolescent height

Sterling et al.Am J Phys Anthropol. 2012 Jul; 148(3): 451–461.
• Each SD decrease in LAZ at birth was

associated with
How to manage stunting in – a decrease in adolescent HAZ of 0.7 SD in
both boys and girls (all p<0.001) and
infancy and toddlerhood ? – 9.7 greater odds of stunting (95% CI 3.3 to
28.6).
• Each SD decrease in LAZ in the first 30
months of life was associated with
– a decrease in adolescent HAZ of 0.4 SD in
boys and 0.6 SD in girls (all p<0.001) and with
– 5.8 greater odds of stunting (95% CI 2.6 to
13.5).
DR SJARIF 3017 Damayanti R.Sjarif 2016
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Nutrient deficiencies that maybe reduced linear growth

Principles of stunting management Golden MH, Acta Paediatr Scand Suppl 1991:374: 95
Growth deceleration
Pediatric nutrition care Looking for etiology

5 steps
Malnutrition
Chronic infectioue diseases
Organic diseases
endocrinopathies
Psychososial
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Protein intake and bone growth

• Low protein intake impairs both the
production and action of IGF-I (Insulin-
like growth factor-I).
• IGF-I is an essential factor for bone
longitudinal growth, as it stimulates
proliferation and differentiation of
chondrocytes in the epiphyseal plate,
and also for bone formation
Bonjour et al Can J Appl Physiol. 2001

Uauy, Linear Growth Retardation and Nutrition)
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Kualitas dan kuantitas asupan protein Limiting amino acids

penting untuk mencegah stunting animal protein versus plant protein
• Penelitian Allen dkk. 1992 menunjukkan

bahwa
– Anak yang mendapat protein 15% dari total
asupan kalori, mempunyai TB yang > daripada
yang mendapat protein 7,5% dari total asupan
kalori
– Sumber protein utama pada diet prot 15%
adalah protein hewani (susu, telur, ayam) yang
mengandung asam amino esensial yang
menunjukkan bahwa kualitas protein juga kritis
untuk pertubuhan linear
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How about Indonesia ? Quality of protein ?

• The study of 300 toddler in Jakarta • The study of 5703 house holds in urban area
Jakarta, Bandung ,Surabaya and Jogjakarta
showed that 76,7% of them consumed showed that animal protein consumption only
low quantities protein (<15% of total 5,74% (economical vegetarian)
energy) (Rae 1999)
• The study of Riskesdas 2010 showed that
among Indonesian children age 6-23 months,
(Sjarif et al 2015) – only 38,25% who consumed meat and eggs, and
– only 37,2% who consumed milk or its product
(Kekalih, 2015)
Milk consumption and stunting

prevalence in ASEAN countries
60
50
40
Stunting prevalence,
30 2011-2013 (%)
20
Milk consumption per
10 capita, 2007
(kg/capita/year)
0
Wharton Research Scholars Journal 2014

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ASUPAN PROTEIN STUNTING VS NON STUNTING BATITA DI JAKARTA

2017 (Sjarif et al 2017)
Variabel Stunting (N=103) Normal (N=102) p-value

Rerata Usia (dalam bulan) 24 (12-35) 23 (12-35) 0,550
Jenis Kelamin 0,446
Perempuan 57 (55,3%) 51 (50,0%)
Laki-laki 46 (44,7%) 51 (50,0%)
Rerata BB 9,07 ± 1,23 10,69 ± 1,76 <0,001a
Rerata TB 78,05 ± 4,86 83,35 ± 5,69 <0,001a
Rerata BMI 14,87 ± 1,13 15,34 ± 1,51 0,012 a
Rerata WHZ -1,17 ± 0,88 -0,57 ± 1,13 <0,001 a
Rerata WAZ -2,27 ± 0,71 -0.88 ± 0.89 <0,001 a
Rerata HAZ -2,72 ± 0,56 -0,91 ± 0,87 <0,001 a
Asupan Protein Total 26,11 ± 9,55 31,13 ± 14,76 0,004 a
Asupan Protein Hewani
a
Non Susu 17,08 ± 8,40 19,78 ± 10,79 0,047 a
T-test
Asupan Protein Nabati
b Mann Whitney test
1,5 (0-22,5) 1,55 (0-39,26) 0,534
Asupan Protein Susu 13,8 (0-109,6) 18,6 (0-103,4) 0,041b
What is the nutritional risk factors of

stunting in daily practices ?
Adapted from ACC/SCN (2000)
In many pathologic types of short stature, weight is affected first, then

height velocity, and finally brain growth (documented by head
circumference).(Genet Med. 2009 Jun; 11(6): 465–470.)
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Rekomendasi WHO (MAKANAN PENDAMPING ASI)

(2003)
• Inisiasi menyusu dini (< 1 jam
setelah bayi lahir)
• ASI eksklusif selama 6 bulan
• Makanan pendamping ASI
diberikan paling lambat pada
usia 6 bulan sambil
melanjutkan pemberian ASI
• Berikan Makanan Pendamping
ASI:
– Tepat waktu
– Kandungan nutrisi cukup
baik makro maupun mikro
dan seimbang
– Aman
– Diberikan dengan cara
yang benar
?
Pada saat 6 bulan, kandungan zat gizi ASI tidak cukup untuk
menunjang pertumbuhan bayi, oleh sebab itu harus dilengkapi
oleh MPASI
Damayanti Rusli Sjarif 2009

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PemenuhanPemenuhan
kebutuhan zat gizi
kebutuhan oleh
zat gizi olehMP-ASI pada usia
6-9 bulan danpada
MP-ASI 9-12
usia bulan (%AKG)
9-12 bulan (%AKG)(Dewey, 2001)
• Persentase AKG zat gizi yang harus dipenuhi MPASI untuk bayi
6-8 bulan
• Persentase AKG zat gizi yang harus dipenuhi MPASI untuk bayi
9- 11 bulan DR SJARIF 3017 DR SJARIF 3017
MPASI pertama yang populer di Kandungan zat gizi tipe 2 pada MPASI
pertama terkait pertumbuhan linier
sosial media INDONESIA
Energy Protein Amino Acids Score Zn mg/100 g
Pure buah atau sayur kcal/100 g g/100g
brocolli 34 3,10 72 (low leu, meth 0,4
& cys)
pisang 89 1,09 62 (low metionin & 0,15
cystine)
pear 42 0,00 56 (low lys, phe, 0.10
tyr, meth,
cys,hys)
alpukat 160 2,00 129 0,64
wortel 35 0,93 81 (low meth & 0,24
cystin)
Kacang 30 3,03 67 (low meth & 0,47
hijau cys)
DR SJARIF 3017
MP ASI 29% RDA 21% RDA >100
DR SJARIF 3017
79% RDA
(2,31 g) (2,4 mg)
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Alternatif sumber protein untuk batita

Source: Nutrient data for this listing was provided by USDA SR-21
Jumlah (g) Kuantitas Kualitas Keterangan

Protein Protein (AAS)
Daging ayam 28 g 8 gram 136 (>100) lengkap,
(dada ) kualitas tinggi
Telur ayam 50 g 7,5 gram 132 (>100) lengkap,
kualitas tinggi
Daging sapi 28 g 7 gram 136 (>100) lengkap,
cincang kualitas tinggi
ikan kembung 28 g 7 gram 148 (>100) lengkap,
(mackerel) kualitas tinggi
kalengan
Susu sapi cair 250 ml 8 gram 136 (>100) lengkap,
UHT kualitas tinggi
Tempe 28 g 5 gram 79 (limiting (< 100), tdk
amino acids lengkap,memer
methionine lukan makanan
+cystine) pelengkap
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How much proteins are needed for growth and

development ???
Energi dan protein yang dibutuhkan untuk

mencapai pelbagai kecepatan tumbuh kejar7
Protein* Energi† Protein/ene
(g/kg/hari) (kcal/kg/hari) rgi (%)
1 g/kg/hari 1.02 89 4.6
2 g/kg/hari 1.22 93 5.2
5 g/kg/hari 1.82 105 6.9
10 g/kg/hari 2.82 126 8.9
20 g/kg/hari 4.82 167 11.5
*Deposit jaringan 14% disesuaikan untuk efisiensi penggunaan 70% ditambah kadar rumatan
yang aman (0,82g/kg/hari) †Energi rumatan pada 85 kkal/kg + biaya energi keseluruhan pada
4,1 kkal/kg/hari. 9,7% deposit jaringan disesuaikan untuk efisiensi penggunaan 70% ditambah
kadar rumatan yang aman (0.82 g/kg/hari)
DAMAYANTI RUSLI SJARIF 2017 DR SJARIF 3017
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Effect of early protein intake on linear growth

velocity and development of adiposity
• Based on the current evidence, there is no proof
of harmful effects of a „normal“ protein intake
during the complementary feeding period, i.e., a
diet based on a family diet with a PE% of 12–15. Application the knowledge
• Until we know more about the mechanisms
through which protein intake modulates growth,it
is difficult to give more precise advice.
• In the meantime it seems, however, prudent to
avoid diets with a very high protein intake.
K. Fleischer Michaelsen · C.Hoppe · C.Mølgaard
Monatsschr Kinderheilkd 2003 · [Suppl 1] 151:S78–S83
Pediatric Nutrition Care

Case Study A girl, corr age 6 mo, 3,44 kgs, 58,7 cms
Assessment
• Baby girl 7 months •
– Determined Gestational age (to estimate corected age)
(corrected age = 6 – Determined WA HA , and stature
months), referred due – Determined nutritional status
• Requirements
to failure to thrive – Ideal Body weight X RDA (120 kcal/kgs)
– weight 3,440 g, length • Route
58,7 cms, HC 37,5 cm – Suck and swallows ability and gastrointestinal maturity
• Type of food
• Born prematurely 36 – Breastmilk (MOM or donor) (± HMF) or premature formula (<32
weeks or < 1500 g)
weeks – Standard formula or standard enriched formula for ≥ 32 weeks or ≥
– weight 1,638 g, length 1500 g
46 cms, HC 30 cm • Monitoring
– Acceptability, tolerance and efficiency : increased weight 15 g/day
copy right damayanti rusli sjarif 2017 copy right damayanti rusli sjarif 2017
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• Assesssment
– Difficulties to drink milk, crying every nights, sandifer signs,
family history of atopy (+)
– Occult blood test (+) → susp cow milk allergy
– LAZ ≈ <-3 & WHZ ≈ <-3
– Short stature and malnourished
– Causes if short stature ?
• Growth velocity 0-6 mo → 12,7 cm < 13,9 cm→ pathological short
stature
• History of SGA
• Proportionate
• No dysmorphism
– Stunting
– HA ≈ 2-3 mo < CA ≈ 6 mo
– WA ≈ 1-2 mo
Length Velocity 0-6 mo Pediatric Nutrition Care

• Requirement
– HA ≈ 2-3 mo
– IBW ≈ 5,5 kgs
– 5,5 x 120 kcal x 50-75% = 330-495 kcal
• Route
– Enteral (nasogastric tube)
• Type of nutrition
– Amino acid based formula : 10 x 2 scoops (60 mL),
60 mL/hour
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• Monitoring
– Akseptabilitas
• Intake 26 out of 27 scoops/ day, sometime mother
missed 1 times
– Toleransi
– Efisiensi
• 2 mo post therapy weight = 4810 g, length 63 cm
• LAZ = -2,82, 2 months before -3,54
• Length velocity : 63-58,7 cm = 4,3 cm in 2 mo ≈ p75
• WHZ = -5,32, 2 months before -3.67
Expected Weight gain Energi dan protein yang dibutuhkan untuk

(Nelson’s pediatrics) mencapai pelbagai kecepatan tumbuh kejar7
• Weight gain before 40 weeks Protein* Energi† Protein/ene

– birth weight < 1500 g: 13,5-16 g/kg/d (g/kg/hari) (kcal/kg/hari) rgi (%)
– birth weight > 1500 g: 10-13 g/kg/d 1 g/kg/hari 1.02 89 4.6
• Weight pattern – after 40 weeks 2 g/kg/hari 1.22 93 5.2
trimester 1 : 25-30 g/d = 200 g/w = 750-900 g /mo
trimester 2 : 20 g/d = 150 g/w = 600 g/mo 5 g/kg/hari 1.82 105 6.9
trimester 3 : 15 g/d = 100 g/w = 400 g/mo
trimester 4 : 10 g/d = 50-75 g/w = 200-300 g/mo 10 g/kg/hari 2.82 126 8.9
20 g/kg/hari 4.82 167 11.5
*Deposit jaringan 14% disesuaikan untuk efisiensi penggunaan 70% ditambah kadar rumatan
yang aman (0,82g/kg/hari) †Energi rumatan pada 85 kkal/kg + biaya energi keseluruhan pada
4,1 kkal/kg/hari. 9,7% deposit jaringan disesuaikan untuk efisiensi penggunaan 70% ditambah
copy right damayanti rusli sjarif 2017 kadar rumatan yang aman (0.82 g/kg/hari)
DAMAYANTI RUSLI SJARIF 2017
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Analysis Take home message

• Catch Up rates • Stunting adalah short stature (perawakan pendek) yang diakibat
oleh kondisi kesehatan yang suboptimal terutama kuantitas dan
– 4810-3440/60 =22,8 g/day > expected 15 g/day kualitas asupan makanan yang salah
– 6,6 g/kg/day < expected ? • Stunting akan berdampak pada kecerdasan anak serta risiko
timbulnya penyakit degeneratif (obesitas, DM, penyakit jantung
• Intake koroner, dll) dikemudian hari
– Neocate LCP, PER 12,4% expected weight gain 20g/kg/day • Stunting dapat dicegah dengan memperhatikan kuantitas dan
kualitas protein yang dikonsumsi balita
• Bayi direkomendasikan mengonsumsi protein 1,5 g/kg BB/hari
sedangkan batita dianjurkan mengonsumsi 1,1g/kgBB/hari,
protein yang berkualitas tinggi (mengandung asam amino esensial
lengkap) i, yang didapat dari sumber hewani yaitu daging
(sapi,ayam,ikan), telur atau susu. dengan PER 12-15%
• Meskipun demikian, Early protein hypothesis mensinyalir bahwa
konsumsi protein yang berlebihan pada 1000 HPK dapat
meningkatkan angka obesitas dan resistensi insulin dikemudian
hari → asupan protein tidak melebihi safe upper level
20

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24/08/2017

DR SJARIF 3017 DR SJARIF 3017

Underweight Stunted Wasted Overweight

Prevalence of malnutrition in underfive children in Indonesia

• In Indonesia, 37% of children aged less than five years were

Mean developmental quotient (DQ) scores of five groups of children

Stunting syndrome children who received both stimulation and supplementation,

( Branca & Ferrari, 2002)

What is stunting ? Short stature ≈ stunting ?

J Clin Endocrinol Metab. WHO CONCEPTUAL FRAMEWORK 2013

Differential diagnosis of short stature

How to differentiate stunting to other

DR SJARIF 3017 DR SJARIF 3017

Plot in the growth chart

DR SJARIF 3017 DR SJARIF 3017

Length velocity < p5 (WHO 2006)

(-) Normal variants (+) pathological

Median Parental Height Dysmorphic Proportionate Disproportionate

Bone Age if > 1 years old

Familial Short Constitutional Delay of

DR SJARIF 3017 DR SJARIF 3017

DR SJARIF 3017 DR SJARIF 3017

Dysmorphic or Dysproportionate Simple algorithm to differentiate stunting to other causes of

Simple Algorithm to diffentiate stunting with other

• US/LS newborn = 1,7:1

DR SJARIF 3017 DR SJARIF 3017

Effects of growth during early childhood on adolescent height

• Each SD decrease in LAZ at birth was

Nutrient deficiencies that maybe reduced linear growth

Pediatric nutrition care Looking for etiology

DR SJARIF 3017 DR SJARIF 3017

Protein intake and bone growth

Bonjour et al Can J Appl Physiol. 2001

DR SJARIF 3017 DR SJARIF 3017

DR SJARIF 3017 DR SJARIF 3017

Kualitas dan kuantitas asupan protein Limiting amino acids

• Penelitian Allen dkk. 1992 menunjukkan

DR SJARIF 3017 DR SJARIF 3017

How about Indonesia ? Quality of protein ?

DR SJARIF 3017 DR SJARIF 3017

Milk consumption and stunting

Wharton Research Scholars Journal 2014

ASUPAN PROTEIN STUNTING VS NON STUNTING BATITA DI JAKARTA

Variabel Stunting (N=103) Normal (N=102) p-value

What is the nutritional risk factors of

In many pathologic types of short stature, weight is affected first, then

Rekomendasi WHO (MAKANAN PENDAMPING ASI)

Damayanti Rusli Sjarif 2009

Alternatif sumber protein untuk batita

Jumlah (g) Kuantitas Kualitas Keterangan

DR SJARIF 3017 DR SJARIF 3017

How much proteins are needed for growth and

DR SJARIF 3017 DR SJARIF 3017

Energi dan protein yang dibutuhkan untuk

Effect of early protein intake on linear growth

DR SJARIF 3017 DR SJARIF 3017

Pediatric Nutrition Care

Pediatric Nutrition Care

DR SJARIF 3017 DR SJARIF 3017

Length Velocity 0-6 mo Pediatric Nutrition Care

DR SJARIF 3017 DR SJARIF 3017

Pediatric Nutrition Care

DR SJARIF 3017 DR SJARIF 3017

Expected Weight gain Energi dan protein yang dibutuhkan untuk