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ELECTRONIC ARTICLE Increasing Prevalence of Overweight Among US Low-income Preschool Children: The Centers for Disease Control and Prevention Pediatric Nutrition Surveillance, 1983 to 1995

Objective. To determine whether the prevalence of overweight in preschool children has increased among the US low-income population. Design. Analysis using weight-for-height percentiles of surveillance data adjusted for age, sex, and race or ethnicity. Setting. Data from 18 states and the District of Columbia were examined.a Subjects. Low-income children <5 years of age who were included in the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Results. The prevalence of overweight increased from 18.6% in 1983 to 21.6% in 1995 based on the 85th percentile cutoff point for weight-for-height, and from 8.5% to 10.2% for the same period based on the 95th percentile cutoff point. Analyses by single age, sex, and race or ethnic group (non-Hispanic white, nonHispanic black, and Hispanic) all showed increases in the prevalence of overweight, although changes are greatest for older preschool children. Conclusion. Overweight is an increasing public health problem among preschool children in the US lowincome population. Additional research is needed to explore the cause of the trend observed and to find effective strategies for overweight prevention beginning in the preschool years. Key Words:  overweight  obesity  prevalence  preschool children  weight-for-height Childhood obesity is an increasing problem in developed countries and an increasing public health concern.1Researchers have found an association between obesity in childhood and higher levels of blood pressure,6diabetes,9,10 respiratory disease,11 adult obesity,12 and orthopedic13,14 and psychosocial disorders.15 Determining the factors that contribute to excess weight gain in children is of great interest, as is the question of whether the prevalence of obesity or overweight in children is increasing. Among US children 6 to 11 years of age, Troiano et al2reported an ∼7 percentage point increase from 1963 to 1991 in the prevalence of overweight, based on a body mass index (weight/height2) above the 85th percentile, and a 5 percentage point increase in the prevalence based on a body mass index above the 95th percentile. Gortmaker et al3 reported a 9.5 percentage point increase from 1963 to 1980 in the prevalence of obesity for children age 6 to 11 years of age based on triceps skinfold measurements above the 85th percentile and a 5.8 percentage point increase in the prevalence of obesity above the 95th percentile of the triceps skinfold measurements. This report3 also noted that weight-for-height among children 6 and 7 years old increased during the same period. More recently, Ogden et al16 reported a greater increase for girls (2.8 percentage points at 2 to 3 years and 5.0 at 4 to 5 years) than for boys (1 percentage point decrease at 2 to 3 years and only a 0.6 percentage point increase at 4 to 5 years, but no statistical significance in the change of prevalence both at 2 to 3 years and at 4 to 5 years of age) in the prevalence of overweight based on the 95th percentile of weight-for-height data from the National Health and Nutrition Examination Survey I (NHANES I, 1971 to 1974) to NHANES III (1988 to 1994). In this study, we try to determine whether the prevalence of overweight in preschool children among the US low-income population has increased also and to extend our analyses to include infants and toddlers (0 to 23 months of age). Previous SectionNext Section

Since 1973, the Centers for Disease Control and Prevention (CDC) has assisted states in monitoring key growth and hematologic indicators of nutritional status of low-income US children who participate in publicly funded health and nutrition programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Early Periodic Screening, Diagnosis and Treatment Program; and clinics funded through Maternal and Child Health Program block grants.17,18 Data for the majority of the infants and children monitored by the Pediatric Nutrition Surveillance System (PedNSS) come from clinic

service records of WIC. The WIC program, which was initiated in 1972, is administered by the Food and Nutrition Service of the US Department of Agriculture.19,20 The PedNSS has expanded from five participating states in 1973 to 38 states, the District of Columbia, Puerto Rico, and 7 Indian Reservations in 1995. This surveillance system provides a rich source of data for studying the nutritional characteristics of low-income children on a state-by-state basis.17,18 In the PedNSS system, height or length is measured to the nearest 0.1 cm or 1/8 inch. According to the protocols, a measuring board is used to measure the child's recumbent length if the child is <24 months of age; otherwise, a standing height is measured for children >24 months. Weight was measured to the nearest 0.1 kg or ¼ pound using a pediatric scale or other beam balance scale.21,22 All the records are entered onto a standardized paper form or onto an automated computer system in the clinics. Once the records are computerized at the state level, they are transferred to the CDC for inclusion in the PedNSS database. To study the trend in prevalence of overweight from 1983 through 1995, we selected all children 0 to 59 months old from the 18 statesa(plus the District of Columbia) who participated consistently in the PedNSS during this period. Among the 18 states and the District of Columbia, we checked the data quality by using the anthropometric data quality assurance indexes22,23 across states and years within each state to verify whether the data are comparable. Because a nearly constant variance in height- and weight-based z score distributions is indicative of data quality,23 the SD units of weight-for-height z score were used to check the data quality across states and years. We found the that the SD units of thez score distribution were within the normal range (0.85 to 1.10)23 and were stable. Also, we tracked the height-for-age z score across years for each state included in this analysis to examine whether an increasing bias of measuring children too short could affect the overall overweight trend. We found that there was no change in the mean height-for-age z score across years for all the states in the dataset. Furthermore, the records of the children with missing ages were automatically excluded before they were transferred to the PedNSS database. The percents of missing height/length and weight were 1.5% and 1.1%, respectively. The percent of records with biologically implausible values of weight-for-height (z score below −4 or above +5)23 was 0.5%. To examine whether the criteria for enrollment in these publicly funded health and nutrition programs remained approximately the same from 1983 to 1995 in the selected 18 states and the District of Columbia, a survey was conducted in those states regarding any certification criterion or priority changes for overweight in the programs during the 13 years. Because the PedNSS, which receives data from publicly funded health and nutrition programs, has multiple records on children per calendar year and a disproportionate number of first visit records for young infants, one record per child per visit year was randomly selected to avoid double counting of children who visit the program more than once in a calendar year. Repeat visits were identified using the unique WIC identification number, which is maintained for WIC administration. The final sample for this study was 15 029 147 preschooler clinic records. To examine trends more generally for children <5 years old, we age-adjusted the prevalence estimates for each year, assuming a uniform age distribution. To do this, we weighted the data so that the prevalence of each single month of age was weighted equally. The results were also adjusted for race or ethnicity and for sex, assuming that the ethnic mix for all 13 years combined applies for each calendar year, and assuming that there should be 50% boys and 50% girls. We examined trends by the urban/rural classification of the county in which the clinical measurements were taken using the Census Bureau definition of urban and rural. To examine how the CDC PedNSS low-income preschooler population differs from the US general population at the same ages, we compared the demographic and anthropometric characteristics of the PedNSS data with NHANES II and III data. In recent years, several studies have shown that the current NCHS/CDC growth reference sections based on the Fels sample (<2 years of age) and the part based on the national representative NHANES I sample (≥2 years of age) are not comparable. When the two curves are compared, there is a clear disjunction of heightfor-age and weight-for-height at 24 months of age.24,25 These disjunctions make it difficult to compare the growth status of children <2 years of age with that of children >2 years of age. Because of the disjunction, we also performed the trend analysis separately for these two age groups. There is no generally accepted definition of obesity or overweight for children and adolescents.26,27 Various criteria for overweight and obesity have been used to estimate prevalence and trends among children and adolescents.3,28,29 For this study, we used weight-for-height status above the 85th and 95th percentiles of the NCHS/CDC weight-for-height reference to estimate the prevalence of overweight or obesity in our study population. We calculated weight-for-height percentiles and z scores by using the NCHS/CDC age- and sex-

specific growth reference.30,31 Any weight-for-height z scores below −4 or above +5 were excluded, because these extreme values were most likely attributable to errors in measurement or data entry.23 Previous SectionNext Section

From the survey among the states and district in this study, we confirmed that each of them maintained the same overweight certification criteria for preschoolers during the 13-year period, except for one state, which changed the criteria from ≥95th percentile to ≥90th percentile of weight-for-height after 1990. Exclusion of this state did not change our results. Among the preschoolers, there were no priority changes or restrictions for younger children (birth to 2 years), and only two states put the older children (age 3 to 4 years) on a waiting list or restricted program entry for a short time (1 to 3 months) in the early 1990s. However, the short time restriction did not affect the overall trend observed. The PedNSS data showed a higher proportion of young infants and more black and Hispanic children compared with NHANES II and III data (Table1). Also, the children in the PedNSS have a lower mean birth weight and a higher percentage of low birth weight, lower mean height-for-age, lower mean weight-for-age, and higher weight-for-height z scores compared with NHANES II and III data. View this table:  In this window  In a new window Table 1. Comparison of Demographic and Anthropometric Characteristics (%) of NHANES II and III Data With the CDC PedNSS Data The PedNSS data also showed an increasing proportion of older children from 1983 to 1995, as well as an increased proportion of Hispanic children and urban children (Table 1). The standardized adjustments in the prevalence of overweight we described in ―Methods‖ account for these changes in demographic characteristics. The prevalence of overweight for the children 0 to 59 months old in the period increased from 18.6% in 1983 to 21.6% in 1995, based on the weight-for-height 85th percentile cutoff point, representing an absolute increase of 3.0 percentage points and a relative increase of 16.1%. Based on the weight-for-height 95th percentile cutoff point, the prevalence increased from 8.5% in 1983 to 10.2% in 1995, representing an absolute increase of 1.7 percentage points and a relative increase of 20% (Table 2). As shown in Fig 1, during the 13-year period, there was a consistent increase in the prevalence of overweight using both the 85th and 95th percentile cutoff points. View this table:  In this window  In a new window Table 2. Prevalence of Overweight (%) Among Children 0–59 Months by Age Group, at 85th and 95th Percentile Cutoff Points—the CDC PedNSS, 1983 and 1995

View larger version:  In this page  In a new window  Download as PowerPoint Slide Fig. 1. Prevalence of overweight (weight-for-height above 85th or 95th percentile) among US low-income children 0 to 59 months of age, adjusted by race or ethnicity, sex ratio, and age in month; the CDC Pediatric Nutrition Surveillance, 1983–1995.

non-Hispanic blacks had the largest absolute increase in prevalence of overweight. However. 2. Figure 2 (A and B) shows the age-specific trends in the prevalence of overweight based on the 95th percentile cutoff point.When we examine trends by single year of age.05). When we compare the prevalence of overweight by sex. For children >2 years of age. View larger version:  In this page  In a new window  Download as PowerPoint Slide Fig. the increase in the prevalence of overweight is greatest for 48. at 85th and 95th Percentile Cutoff Points—the CDC PedNSS.05). View larger version:  In this page  In a new window  Download as PowerPoint Slide . The prevalence of overweight for Hispanics is significantly higher than for non-Hispanic blacks.7 percentage point increase for boys and a 1. in both absolute and relative terms. adjusted by race or ethnicity. and age in month. 1983 and 1995 The non-Hispanic white. with an increase observed for each year of age (Table 2). at both the 85th and the 95th percentile cutoff points (Table 3).4 percentage points for girls using the 85th percentile. and for nonHispanic blacks is significantly higher than for non-Hispanic whites (P < .8percentage point for girls (Table3). 1983–1995. The trend is similar at the 85th percentile cutoff point (results available on request). Prevalence of Overweight (%) Among Children 0–59 Months by Age Group.9 percentage points for boys and 3. Age-specific prevalence of overweight (weight-for-height above 95th percentile) among US low-income children 0 to 23 months months of age (A) and 24 to 59 months of age (B). sex ratio. and Hispanic subgroups all demonstrated an increasing trend in the prevalence of overweight from 1983 through 1995 (Fig 3 for the children >2 years of age using the 95th percentile). and Race or Ethnicity. Sex. the CDC Pediatric Nutrition Surveillance. View this table:  In this window  In a new window Table 3. Among children >24 months of age. we see a similar trend in the prevalence of overweight from 1983 through 1995. non-Hispanic whites had the largest absolute increase in prevalence of overweight. Using the 95th percentile. there is a 1. The prevalence of overweight for girls is significantly higher than for boys (P< . there is an absolute increase of 2. boys and girls show a parallel increase in the prevalence of overweight at both the 85th and 95th percentile cutoff 59-month-old children. Among those children <2 years old. non-Hispanic black.

90th. the increasing trend in rural is not consistent during the 13-year period. The 5th. 0. healthy children at least <5 years old from different ethnic backgrounds and different continents is reasonably similar. Because the data come from multiple clinics and the techniques of measurement are not tightly controlled.0 percentage point decrease at 2 to 3 years and only a 0. We observed an increase in the prevalence of overweight among both urban and rural children. 3.38 On the other hand. both urban and rural clinics showed an increasing trend in the prevalence of overweight from 1983 to 1995 (Table 3). To decide whether the increase in the prevalence of overweight among US low-income preschool children was related to an increase in a subpopulation of children who were heavier or to a general shift of the entire weight distribution. 1983–1995. Prevalence by race or ethnicity of overweight (weight-for-height above 95th percentile) among US lowincome children 24 to 59 months of age.2. and age in month. Children 48 to 59 months of age have the highest relative increase in the prevalence of overweight compared with other age groups. there is a downward trend between 1989 and 1991. the increase in the prevalence of overweight observed among US low-income preschool children reflects a general upward shift in the weight distribution over the 13-year period rather than simply an increase in the size of the upper tail.07. Among children >24 months of age.7 for rural (Table 3). 75th. and racial/ethnic group.33. and 95th percentiles increase by 0. our checks on data quality for the states in this analysis showed reasonably good data quality. sex. using the 85th percentile. Also. However. 0. Hispanic children have a higher prevalence than other race or ethnic groups. There is an increasing trend in the relative increases with age.6 percentage point increase at 4 to 5 years. Thus. adjusted by sex ratio. The prevalence of overweight is higher for girls compared with boys. Additional research is needed to understand fully the difference in behaviors in different geographic settings for other socioeconomic strata. the CDC Pediatric Nutrition Surveillance. It is not clear whether this inconsistency reflects true difference in trends for the WIC population or results from methodologic differences. respectively.6 percentage points for rural children. we observed a parallel increase in the prevalence of overweight between boys and girls among the low-income preschoolers. but no statistical significance in the change of prevalence at both 2 to 3 years and 4 to 5 years of age).2.33 and adults. we used the weight-for-height zscore to compare the height-standardized weight distribution for the preschool children using records from 1983 and 1995. .14.12. Using the 95th percentile.36 and between school children and adolescents32. Also. there is an absolute increase of 3. Our study has potential limitations commonly found in surveillance systems that use routine clinical data.3 percentage points for urban children and of 1.11 z score. 0. 50th. Also.0 percentage points at 4 to 5 years) than for boys (1. Previous SectionNext Section DISCUSSION We found that from 1983 through 1995. 0. When we compare the prevalence of overweight by clinic settings.37 may also be observed in preschool children.08. This evidence suggests that the entire population in the United States is getting heavier.32. Additional research is needed to understand fully the difference in gender behaviors for different socioeconomic strata. because there is no change in the mean height-for-age z score across the 13-year period for all the states included in this analysis. Trowbridge et al41 have suggested that high weight-for-height in Hispanics is associated with lower body fat. These data suggest that underlying causes of the differences in overweight prevalence by gender.15.34 Our analysis has demonstrated that these trends are observed even before the age of 24 months. 25th. However.0 percentage point increase for urban and a 0. environmental. The increasing prevalence of overweight was also observed for each age. This same trend has been documented in the US population in preschool children. although trends were more marked and consistent in the urban areas. The increase in the prevalence of overweight is the result of a general upward shift of the weight-for-height distribution in the population.08. 0. the quality of anthropometric measurements cannot be guaranteed.32. and between racial/ethnic groups observed among adults. 10th.8 percentage points at 2 to 3 years and 5.32. whereas data from NHANES III16 showed a greater increase for girls (2. The growth in height and weight of well-fed. it is unlikely that a bias in height measurement could affect the observed overweight trend.34. there was a consistent increase in the prevalence of overweight among low-income preschool children in the United States.Fig.16 school children. The higher prevalence of overweight among Hispanic preschool children may be related partially to dietary. there is a 2. or genetic factors. 0.32adolescents. the weight-for-height distribution of the two periods had a similar variance and shape. from 1983 to 1995. This confirms the result from the NHANES study for preschoolers16 that the prevalence of overweight increase with age.

dan berbagai aspek mengenai pelayanan kesehatan (akses. Our analysis cannot delineate fully the reasons for this increase in overweight. especially the 18 states and the District of Columbia. this study shows a consistent increase over the past 13 years in the prevalence of overweight among preschool children from low-income families. perilaku kesehatan (perilaku hidup bersih dan gaya hidup). BADAN LITBANG DEPKES GELAR RISET KESEHATAN DASAR Hingga saat ini belum tersedia data berbasis komunitas yang memadai untuk perencanaan pembangunan kesehatan sampai tingkat kabupaten. angka kesakitan. 2. Additional research needs to determine the underlying changes in the care of preschool children. Additional research is needed to explore the cause of the trend observed and to find effective strategies for overweight prevention beginning in the preschool years. The genetic component of obesity cannot account for the trends observed. We also thank Ellen Borland and Jimmy Simmons for providing data management support.16 However. Rencananya pengambilan data akan dilakukan mulai bulan Juni 2007 di seluruh kabupaten/kota di Indonesia (461 kabupaten/kota). Previous SectionNext Section ACKNOWLEDGMENTS We thank all state nutrition programs participating in the CDC PedNSS. mutu layanan. Selain itu. dietary intake. This supports the conclusion that the overweight trends observed from the study reflects an actual increase in overweight. physical activity. Data kesehatan dasar dari Riskesdas diperlukan untuk mendukung salah satu strategi utama (grand strategy) Depkes yaitu meningkatkan sistem surveilans. Riskesdas adalah kegiatan riset yang diarahkan untuk mengetahui gambaran kesehatan dasar penduduk termasuk biomedis yang dilaksanakan dengan cara survei rumah tangga di seluruh wilayah kabupaten secara serentak dan periodik. biologi. because the PedNSS system does not currently collect data on health behavior. could changes in factors affecting birth weight have shifted the birth weight distribution toward higher weights without a proportionate increase in height? Have feeding patterns of young children changed toward fattier. or other potential contributing factors. and Bettylou Sherry. baik untuk Tim Kesehatan Masyarakat maupun Tim Biomedis. PhD. for reviewing the document. our study differs from the NHANES III study16 in that we observed a parallel increase in the prevalence of overweight for preschool girls and boys. higher calorie foods? Have activity levels of children decreased as TV watching rises? Overall. Triono Soendoro. This finding extends previous analyses to infants and toddlers from the NHANES III for preschoolers of mixed socioeconomic backgrounds. monitoring dan informasi kesehatan dengan salah satu produknya adalah berfugsinya sistem informasi kesehatan yang berdasarkan data (evidence based) bukan saja berskala nasional. The increasing trend in the prevalence of overweight suggests a general shift in behaviors of the population. berbagai survei/riset/studi di bidang kesehatan selama ini masih dilakukan secara terpisah dan sporadis. WHO Global Database on Child Growth and Malnutrition Department of Nutrition for Health and Development . Demikian disampaikan Kepala Badan Litbangkes dr. Badan Penelitian dan Pengembangan Kesehatan (Litbangkes) Depkes untuk pertama kalinya melakukan suatu pendekatan penelitian baru yaitu Riset Kesehatan Dasar (Riskesdas). However. Ph. For example. 3. pembiayaan kesehatan).Another potential limitation is that changes in program enrollment practice at the state level could have caused changes in the prevalence of overweight. tetapi juga harus menggambarkan indikator kesehatan minimal sampai tingkat kabupaten. dan sosial). Adapun data kesehatan dasar yang diperlukan meliputi semua indikator kesehatan yang utama tentang kasus kesehatan (angka kematian. Jakarta. Sementara tahun 2006 ini telah dilakukan penyusunan kuesioner dan modul serta pelatihan dan uji coba di Kabupaten Sukabumi dan Bogor pada bulan November 2006.D kepada pers dalam acara sosialisasi Riskesdas 2007 di kantor Depkes Pusat. that provided the data for this study. 20 Desember 2006. our survey among the states showed no systematic changes in the certification criteria or priorities served by states for preschoolers during this period. Demi memenuhi kebutuhan data dasar kesehatan tersebut dan mengintegrasikan berbagai hasil riset serta mendorong kegiatan riset agar lebih terarah. kesehatan lingkungan (lingkungan fisik. whereas Ogden et al16 observed an increase in overweight only for preschool girls. dan angka kecacatan).

His name is "Today". 1948 AGE GROUPS N <-3 SD (Months) WEIGHT/AGE (%) <-2 SD 1 Mean zscore SD zscore <-3 SD HEIGHT/AGE (%) <-2 SD 1 Mean zscore SD zscore <-3 SD <-2 SD 1 WEIGHT/HEIGHT (%) >+1 SD 1 >+2 SD 1 >+3 SD Mean zscore OTAL (0-60) 0-5 6-11 12-23 24-35 36-47 48-60 AGE GROUPS N <-3 SD WEIGHT/AGE (%) <-2 SD 1 Mean zscore SD zscore <-3 SD HEIGHT/AGE (%) <-2 SD 1 Mean zscore SD zscore <-3 SD <-2 SD 1 WEIGHT/HEIGHT (%) >+1 SD 1 >+2 SD 1 >+3 SD (Months) Mean zscore ale (0-60) 0-5 6-11 12-23 24-35 36-47 48-60 AGE GROUPS N <-3 SD WEIGHT/AGE (%) <-2 SD 1 Mean zscore SD zscore <-3 SD HEIGHT/AGE (%) <-2 SD 1 Mean zscore SD zscore <-3 SD <-2 SD 1 WEIGHT/HEIGHT (%) >+1 SD 1 >+2 SD 1 >+3 SD (Months) Mean zscore male (0-60) 0-5 6-11 12-23 24-35 36-47 48-60 . Right now is the time his bones are being formed." Gabriela Mistral. his blood is being made and his senses are being developed. To him we cannot answer "Tomorrow". neglecting the foundation of life. but our worst crime is abandoning the children."We are guilty of many errors and many faults. The child cannot. Many of the things we need can wait.

4.Differential improvement among countries in child stunting is associated with
long-term development and specific interventions.
Abstract Stunting represents growth failure resulting from poor nutrition and health during the pre- and postnatal periods. Initiatives since 1980 have steadily reduced malnutrition and consequent retardation of child growth, but 1 of 3 preschool children worldwide remains stunted. Countries have varied substantially in progress achieved in reducing stunting. This study aimed to understand which underlying (i.e., proximal) and basic (i.e., distal) national factors have been most important in explaining this variation among countries, and the relation between the 2 sets of factors. Eighty-five developing countries with at least 2 surveys for stunting >4 y apart were included from the WHO Global Database on Child Growth. The analytic data set with independent variables from several sources was constructed to match closely by year for each country to initial and final stunting data. Full-information maximum likelihood estimated multiple linear regression models while accounting for missing data in independent variables. The final model explained 65.5% of the variance of change in stunting, and included both underlying and basic variables: initial and change in immunization rate, initial and change in safe water rate, initial female literacy rate, initial government consumption, initial income distribution, and the initial proportion of the economy devoted to agriculture. Although factors that were important for reducing stunting in the past may not necessarily be the ones that are important in the future, these results suggest that it possible for substantial progress to be made in reducing the current high prevalence of stunting by investing in both long-term development and in specific interventions.

5. I. I. Meshram, A. Laxmaiah, Ch. Gal Reddy, M. Ravindranath, K. Venkaiah, G. N. V. Brahmam Division of Community Studies, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, -500007, India
Correspondence: Indrapal Ishwarji Meshram, Scientist ‘C’, Division of Community Studies, National Institute of Nutrition, Indian Council of Medical Research, Jamai-Osmania (PO), Tarnaka, Hyderabad-500007, India. Tel: 91-040270197255. Fax: 040-27019141. E-mail: Background: Under-nutrition continues to be a major public health problem, especially among young children in India. The present study was undertaken to assess the nutritional status of under-3 year-old children and factors associated with under-nutrition. Method: A community-based cross-sectional survey was carried out in 40 Anganwadi centre villages of Medak district of Andhra Pradesh, India. A total of 805 children were selected for nutritional assessment in terms of underweight, stunting and wasting using the new WHO growth standards. Wealth index was calculated using principal components analysis. A conceptual hierarchical framework was used as a basis for controlling for the explanatory factors in multivariate analysis. Results: Prevalence of under-weight, stunting and wasting was 39%, 30% and 22%, respectively. The risk of underweight and stunting was 1.80- and 3.02-times higher among 12–23 months and 3.13- and 5.50-times higher among 24–36 months children as compared to children under 12 months, respectively. The risk of under-weight was 2.74and 1.73-times higher among children belonging to the lowest and middle household wealth index, respectively. Conclusions: Under-nutrition is a significant public health problem among under 3 year-old children. The prevalence of under-nutrition was significantly higher among boys and those belonging to the lowest and middle wealth index. Thus, implementation of appropriate nutritional intervention strategies and improvement in household socioeconomic condition may help in improving nutritional status.

6. Peran status kelahiran terhadap stunting pada bayi : sebuah studi prospektif
Departemen Gizi Kesehatan Masyarakat, Fakultas Kesehatan Masyarakat Universitas Indonesia ABSTRAK
Di Indonesia, prevalensi stunting pada bayi dan anak masih cukup tinggi sebagai akibat asupan gizi yang tidak adekuat. Stunting merupakan masalah kesehatan masyarakat karena berhubungan dengan meningkatnya risiko terjadinya kesakitan, kematian, perkembangan motorik terlambat, dan terhambatnya pertumbuhan mental. Tujuan penelitian ini adalah untuk menilai peran status kelahiran terhadap stunting pada bayi. Studi prospektif kohor yang

mengikutsertakan 720 bayi diikuti selama 12 bulan di Kecamatan Sliyeg dan Gabus Wetan, Kabupaten Indramayu. Hasil penelitian menunjukkan, pada umur 3 bulan dan 6 bulan, pada bayi laki-laki terdapat perbedaan panjang badan yang bermakna antara kelompok normal dan prematur, intra uterine growth retardation - low Ponderal index (IUGR LPI) serta intra uterine growth retardation - adequate Ponderal index (IUGR API). Untuk bayi perempuan terdapat perbedaan panjang badan yang bermakna antara kelompok normal dan prematur; selain itu juga terdapat perbedaan panjang badan yang bermakna antara kelompok IUGR API dan IUGR LPI. Pada umur 12 bulan, pada bayi laki-laki terdapat perbedaan panjang badan yang bermakna antara kelompok normal dan prematur, IUGR API serta IUGR LPI, sedangkan untuk bayi perempuan terdapat perbedaan panjang badan yang bermakna antara kelompok normal dan prematur serta IUGR API. Hasil penelitian juga menunjukkan bahwa risiko relatif growth faltering lebih besar pada bayi yang telah mengalami growth faltering sebelumnya. Semua kelompok status kelahiran berkontribusi terhadap terjadinya stunting pada umur 12 bulan; kontribusi terbesar dari kelompok IUGR API dan terkecil kelompok normal. Kata kunci: Stunting, berat lahir, panjang badan, lama gestasi, bayi

The role of birth status on stunting in infants : a prospective study
In Indonesia, many infants and young children have an inadequate nutritonal status reflected by high prevalence of stunting. Stunting indicates a public health problem because of its association with an increased risk of morbidity, mortality, and delayed motor development. A cohort prospective studi was conducted to evaluate the role of birth status on stunting in infants. Seven hundred and twenty newborn were able to be measured at birth in two Subdistricts Sliyeg and Gabus Wetan, Indramayu Regency. This study showed, that at 3 and 6 months of age, there was a significant difference for boys between the mean of length of the normal group and the preterm, intra uterine growth retardation - low Ponderal index (IUGR LPI), and intra uterine growth retardation - adequate Ponderal index (IUGR API) groups. In girls there was a significant difference between the length of the normal group and preterm, and the IUGR group. At 12 months of age there was a significant difference for boys between the normal and the preterm, IUGR API and the IUGR LPI groups. For the girls there was a significant difference between the normal group and the preterm and between the normal group and the IUGR API. The relative risk for growth faltering was greater in those infants who have had falter previously and there was no catch up growth of the low birth weight group. All groups of birth status contributed on stunting at 12 months of age, the greatest with the IUGR API group, and normal group the lowest. Key words: Stunting, birth weight, length, gestation, infants

Kusharisupeni Status kelahiran dan stunting pada bayi

PENDAHULUAN Seperti di negara-negara berkembang lain, pendek [stunting = retardasi pertumbuhan linier dengan defisit dalam panjang badan sebesar -2Z atau lebih menurut baku rujukan pertumbuhan World Health Organization/National Center for Health Statistics (WHO/NCHS)] di Indonesia merupakan hal yang umum terjadi. Prevalensi stunting pada bayi dan anak-anak masih cukup tinggi sebagai akibat asupan gizi yang tidak adekuat.(1) Stunting disebabkan oleh kumulasi episode stres yang sudah berlangsung lama (misalnya infeksi dan asupan makanan yang buruk), yang kemudian tidak terimbangi oleh catch up growth (kejar tumbuh). Hal ini mengakibatkan menurunnya pertumbuhan apabila dibandingkan

dengan anak-anak yang tumbuh dalam lingkungan yang mendukung. Stunting merupakan masalah kesehatan masyarakat karena berhubungan dengan meningkatnya risiko terjadinya kesakitan dan kematian, perkembangan motorik terlambat, dan terhambatnya pertumbuhan mental.(2) Oleh karena itu, stunting merupakan indikator sensitif untuk sosioekonomi yang buruk dan prediktor untuk morbiditas serta mortalitas jangka panjang. Sementara berkembang konsensus tentang sebab-sebab dan konsekuensi stunting. Perdebatan terus berlanjut tentang apakah faktor genetik atau lingkungan yang lebih berpengaruh terhadap pertumbuhan, dan kriteria yang harus dipergunakan untuk mendefinisikan stunting pada kelompok populasi yang berbeda. Sebuah studi yang dilakukan di Indonesia pada anak-anak pra-sekolah menunjukkan status sosioekonomi berpengaruh terhadap pertumbuhan anak.(3) Penemuan ini mendukung perlunya satu standar pertumbuhan untuk semua kelompok ras dan etnis.(4) Di pihak lain ada pendapat yang menyatakan bahwa gen mempunyai peran terhadap variasi ukuran tubuh antar individu dalam suatu kelompok etnis, dan gen ini mempunyai pengaruh yang kuat pada pertumbuhan dalam beberapa tahun pertama kehidupan.(5) Berdasarkan berat lahir dan lama gestasi, bayi lahir dapat dikategorikan ke dalam: i) normal, ii) prematur, dan iii) intra uterine growth retardation (IUGR) yang terdiri dari dua kelompok yaitu adequate Ponderal index (API) dan low Ponderal index (LPI). Perkembangan bayi IUGR, bayi berat lahir rendah (BBLR) dengan masa kehamilan genap bulan (37 minggu), yaitu IUGR API dan IUGR LPI berhubungan dengan karakteristik lahir.(6) BBLR adalah bayi yang lahir dengan berat kurang dari 2500 g.(7) Perbedaan pertumbuhan kedua kelompok ini tergantung pada waktu terjadinya kurang gizi dalam kehamilan. Pada kelompok API, kurang gizi terjadi sejak permulaan kehamilan, sedangkan pada kelompok LPI hanya pada trimester ketiga kehamilan. Oleh karena itu baik berat maupun panjang badan lahir kelompok API terkena dampaknya (kurus dan pendek), sedangkan dampak pada kelompok LPI terlihat hanya pada berat lahir (kurus) dan kurang terlihat pada panjang badan lahir. Berbeda dengan bayi prematur, yang juga termasuk BBLR tetapi dengan umur kehamilan <37

minggu, berat dan panjang badannya selain tergantung pada status gizi ibu, juga pada umur kehamilan. Seperti juga stunting, prevalensi BBLR di Indonesia masih cukup tinggi. Angka nasional menunjukkan sebesar 14%, sedangkan hasil-hasil peneliti lain di berbagai daerah menunjukkan nilai lebih tinggi.(8) Hanya memfokuskan BBLR sebagai hal yang patologik, menyebabkan penelitianpenelitian di Indonesia kurang mampu menunjukkan prognosis dalam pertumbuhan linier dan implikasi kesehatan. Stunting harus merupakan perhatian, sebab hal ini dapat dicegah. Penelitian ini bertujuan untuk menilai peran status kelahiran terhadap stunting pada bayi. METODE Waktu dan lokasi penelitian Penelitian dilakukan pada tahun 1995-1997 sebagai bagian dari sistem pengumpulan data longitudinal yang disebut dengan Sample Registration System (SRS) dan dilakukan Center for Child Survival, Universitas Indonesia (CCSUI). Penelitian dilakukan di 22 desa Kecamatan Sliyeg dan Gabus Wetan, Kabupaten Indramayu dengan populasi yang menunjukkan fertilitas dan morbiditas tinggi, pendidikan rendah serta umumnya bekerja sebagai buruh kasar tani. 75
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Desain dan sampel penelitian Desain penelitian yang digunakan adalah studi prospektif kohor, dan besar sampel ditetapkan dari perhitungan Fliess,(9) dengan power sebesar 0,80 untuk studi longitudinal. Dari perhitungan itu didapat jumlah sampel minimal untuk bayi kelompok normal 221, untuk kelompok prematur 50, kelompok IUGR API 81 dan IUGR LPI 92. Kriteria inklusi adalah bayi lahir di daerah penelitian antara April 1995Februari 1997, genap/tidak genap bulan (>= 37 minggu/ <37 minggu), kelahiran tunggal, ibu tidak menderita diabetes atau pra diabetes, bayi tidak menderita kelainan congenital, selama penelitian bayi tetap tinggal di daerah penelitian dan tidak menderita penyakit berat. Beberapa kriteria eksklusi ditentukan untuk analisis data antropometri yaitu: panjang badan untuk umur skor Z<-1,5 dan >+3, dan berat badan untuk umur skor Z<-5 dan >+5, dengan alasan sedikit sekali harapan bayi dapat hidup hingga berakhirnya penelitian. Pengumpulan data Pada awalnya dilakukan registrasi ibu hamil oleh 10 orang petugas lapangan yang mencatat usia kehamilan dan perkiraan tanggal kelahiran dihitung sejak hari pertama haid terakhir ibu menurut rumus Naeggle. Petugas juga melakukan pengukuran berat dan panjang badan bayi yang dilakukan saat lahir, umur 3, 6, 9, dan 12 bulan pada hari tanggal lahir (maksimal ditambah 3 hari sesudah tanggal lahir). Pengukuran berat badan dilakukan menggunakan timbangan berat badan baby scale (Tanita) yang telah dikalibrasi sebelum digunakan dengan ketelitian

sebesar 0,1 kg. Panjang badan diukur dalam keadaan berbaring menggunakan alat ukur dari kayu yang dianjurkan Badan kesehatan Sedunia dengan ketelitian 0,1 cm. Setiap kunjungan pengukuran selalu disertai dengan wawancara tentang air susu ibu (ASI), makanan pendamping ASI (MPASI) dan penyakit yang diderita bayi. Kualitas data Umur kehamilan (gestasi) sangat menentukan apakah bayi lahir genap atau kurang bulan, maka umur kehamilan dikonfirmasi dengan palpasi uterus yang dilakukan oleh bidan dan dokter tim peneliti. Timbangan bayi sebelum dipakai telah ditera oleh Bidang Metrologi Departemen Perdagangan D.K.I. dan setiap 10 kali penimbangan ditera ulang dengan memakai anak timbangan yang telah distandarisasi. Papan pengukur panjang badan diperiksa kestabilannya setiap kali akan dipakai. Dan dilakukan standarisasi antar dan intra pengukur menurut WHO pada awal dan pertengahan penelitian.(10) Pengolahan data Data dimasukkan dan dikelola dengan program Fox Pro. Selanjutnya analisis dilakukan dengan program EPI INFO dan SPSS versi 7.5. Indeks Ponderal Rohrer (BB/PB x 100) dipakai untuk mengelompokkan IUGR ke dalam kategori IUGR API atau IUGR LPI dan memberikan evaluasi yang baik tentang status gizi. Untuk menghitung cut off point IUGR LPI dan IUGR API, dilakukan tahapan berikut: (i) menghitung korelasi antara indeks Ponderal Rohrer dan panjang badan pada umur-umur tertentu, (ii) mengelompokkan bayi lahir IUGR terhadap umur dengan korelasi yang tertinggi, dan (iii) cut off point dari indeks Ponderal ditentukan berdasarkan sensitivitas, spesifisitas dan nilai prediksi yang tinggi. Dalam studi ini gagal tumbuh (growth faltering) dihitung menurut Fronggillo.(11) Growth faltering ini perlu diketahui oleh karena berdampak terhadap pertumbuhan linier dengan demikian juga berdampak pada kejadian stunting. Seperti juga growth faltering maka catch up growth mempunyai dampak terhadap pertumbuhan linier, selanjutnya pada kejadian stunting. Catch up growth diketahui melalui perbandingan pertumbuhan linier kelompok BBLR dengan kelompok normal. Skor Z dihitung dan cut off point untuk stunting ditentukan pada skor -2Z. Analisis data Uji analysis of variance (Anova) dan Tuckey digunakan untuk membandingkan pertumbuhan antara kelompok normal (genap bulan dengan berat lahir >= 2500 gram), prematur (bayi dengan umur kehamilan < 37 minggu dengan berat lahir < 2500 gram), IUGR API (bayi genap bulan dengan berat lahir < 2500 gram dengan indeks Ponderal yang adekuat) dan IUGR LPI (bayi genap bulan dengan beat lahir < 2500 gram dengan indeks Ponderal rendah); analisis multivariat digunakan untuk mengetahui faktor penentu pertumbuhan linier.

kelompok normal dan IUGR API (p<0.1 kg) dan IUGR API (-0.55 cm dengan rata-rata berat lahir 2.7%) termasuk status kelahiran normal. Rata-rata penyimpangan pertumbuhan linier faltering (cm) berdasarkan status kelahiran dan interval pengamatan umur (bulan) * IUGR LPI = intra uterine growth retardation .low Ponderal index ** IUGR API = intra uterine growth retardation adequate Ponderal index Tabel 1.23 No. Untuk bayi laki-laki.05). Tabel 2. Rata-rata berat lahir IUGR LPI 2.69 cm dengan rata-rata berat lahir 3 kg).low Ponderal index ** IUGR API = intra uterine growth retardation adequate Ponderal index 77 J Kedokter Trisakti Vol. prematur dan IUGR berurutan 3 kg. 54 (26. 2. diikuti oleh IUGR LPI (laki-laki 46. IUGR LPI (17 bayi) dan prematur (12 bayi). Risiko falter pada interval umur lebih tua lebih besar apabila bayi pernah falter sebelumnya. 65 laki-laki dan 76 perempuan.74 cm dengan berat lahir 2. Gagal tumbuh (growth faltering) dan pencapaian berat badan normal (catch up growth) Pada interval observasi pertama (umur 0-2 bulan). Pada interval observasi ke-2 (umur 2-4 bulan).76 Kusharisupeni Status kelahiran dan stunting pada bayi HASIL Kohor sebanyak 720 bayi diikuti sejak lahir hingga umur 12 bulan.5%) lahir IUGR LPI dan 87 (42.6%) lahir IUGR API.05).3%) bayi dalam penelitian ini termasuk dalam BBLR. Panjang badan terpanjang didapatkan pada kelompok normal diikuti oleh IUGR LPI. Rata-rata panjang badan (cm) bayi laki-laki menurut status kelahiran dan umur (bulan) * IUGR LPI = intra uterine growth retardation .05). gagal tumbuh yang terbesar dialami oleh kelompok IUGR API (-0.1 kg (n=87).96 cm) dan yang terkecil kelompok normal (-0.05). Dengan menggunakan indeks Ponderal dari Rohrer diperoleh cut off point untuk kelompok IUGR sebesar 2. Sesudah umur 6 bulan jumlah bayi semakin . dan antara kelompok normal dan IUGR LPI (p<0.1 kg dan 2. 27 laki-laki dan 36 perempuan. Berdasarkan berat lahir dan lama kehamilan maka 516 (71. Uji Anova dan Tuckey menunjukkan perbedaan yang bermakna antara panjang badan bayi laki-laki kelompok normal dan prematur (p<0.9 cm) serta prematur (laki-laki 43.3 berkurang baik laki-laki maupun perempuan.9 cm dan perempuan 43. 6.31 kg (n=54) dan IUGR API 2.low Ponderal index ** IUGR API = intra uterine growth retardation adequate Ponderal index Untuk bayi perempuan. dengan rata-rata berat lahir 2. Jadi.4 cm).05). kelompok normal (113 bayi) masih mencapai panjang badan yang tertinggi. Untuk bayi perempuan terdapat perbedaan yang bermakna antara kelompok normal dan prematur (p<0. Pada interval observasi terakhir (umur 4-6 bulan) faltering yang terbesar dialami oleh kelompok IUGR API (-0.05).74 cm.74 cm) dan yang terkecil dialami oleh kelompok normal (-0. Selain itu juga terdapat perbedaan yang bermakna antara kelompok IUGR LPI dan IUGR API (p<0.45 termasuk kelompok IUGR LPI dan <2. kelompok normal dan IUGR API (p=<0.67 cm). diikuti oleh IUGR API (dengan jumlah sampel terkecil = 5 bayi). Risiko relatif growth faltering pada interval umur 2-4 bulan* dan 4-6 bulan** * pada interval umur 0–2 bulan bayi termasuk kelompok yang mengalami growth faltering ** pada interval umur 2–4 bulan bayi termasuk kelompok yang mengalami growth faltering @ tidak dihitung karena sampel terlalu kecil # intra uterine growth retardation . Panjang lahir untuk kelompok normal terpanjang untuk laki-laki besarnya 48. urutan di atas berbeda. IUGR API (lakilaki 44. Pada umur 12 bulan.05).31 kg). diikuti oleh IUGR LPI (9 bayi). faltering yang terbesar dialami oleh kelompok prematur (-0. umur 3. dan 12 bulan baik untuk bayi laki-laki maupun perempuan dapat dilihat pada Tabel 1 dan Tabel 2.4 cm dan perempuan 43.4 cm dan perempuan sebesar 47. 63 bayi (8.45 kelompok lahir IUGR API. terdapat perbedaan panjang badan yang bermakna antara kelompok normal dan prematur (p<0. Dari masing-masing kelompok berurutan 246 laki-laki dan 270 perempuan.05) dan antara kelompok normal dan IUGR API (p<0.3 cm dan perempuan 45. Rata-rata panjang badan (cm) bayi perempuan menurut kelompok lahir dan umur (bulan) * IUGR LPI = intra uterine growth retardation . Hasil uji Anova (uji Tuckey) menunjukkan untuk bayi laki-laki terdapat perbedaan panjang badan yang bermakna antara kelompok normal dan prematur (p<0. Dua ratus empat (28. prematur (10 bayi) dan IUGR API. Tabel 4.05). Risiko falter IUGRAPI dan prematur tidak dihitung karena sampel terlalu kecil. Dengan demikian >= 2. kelompok lahir normal (94 bayi) mencapai panjang badan yang tertinggi. (Tabel 3) Risiko relatif untuk faltering lebih besar pada bayi-bayi yang telah mengalami falter sebelumnya (Tabel 4).7%) prematur dan 141 (19.2 kg.05). falter merupakan prediktor untuk terjadinya falter berikutnya. Hal yang sama terjadi pada bayi perempuan. 9.1 kg) dan yang terkecil pada kelompok IUGR LPI (-0.8 cm.45. IUGR API dan prematur.05) dan kelompok normal dan IUGR API (p<0.low Ponderal index Tabel 3. Berat dan panjang lahir Rata-rata berat lahir untuk status kelahiran normal.0 cm).9%) lahir prematur.6%) IUGR. 63 (30. kelompok normal dan IUGR LPI (p<0. Panjang badan bayi pada saat lahir.

dan terkecil kelompok normal. proporsi IUGR lebih besar dibandingkan prematur. Bayi dengan growth faltering pada umur dini menunjukkan risiko untuk mengalami growth faltering pada periode umur berikutnya. Studi ini konsisten dengan penelitian yang dilakukan di Filipina. penyakit dan defisiensi nutrient.9%).2%). pada kelompok BBLR. PEMBAHASAN Penelitian ini mendukung pernyataan bahwa ukuran tubuh pada saat lahir mampu memprediksi pertumbuhan janin. Derajat growth faltering pada kelompok IUGR API lebih besar daripada kelompok IUGR LPI. Berat lahir kelompok normal. yang dibentuk oleh growth faltering dan catch up growth yang tidak memadai merupakan suatu keadaan yang patologis. (Tabel 5) Hasil analisis regresi ganda menerangkan bahwa prediktor terbesar untuk stunting pada umur 6 sampai 12 bulan adalah kelompok IUGR. dan meningkat sesudahnya hingga umur 12 bulan. Oleh karena lingkungan yang relatif sama. Dengan demikian catch up growth pada kelompok BBLR tidak memadai. Hasil ini tidak berbeda dengan studi di Meksiko yang menunjukkan bahwa growth faltering pada usia 6 bulan dipengaruhi oleh infeksi dan asupan nutrien. Dengan demikian growth faltering merupakan prediktor untuk faltering berikutnya. baik perempuan maupun laki-laki. Jumlah bayi stunting tinggi saat lahir. panjang badan yang jauh di bawah rata-rata prematur pada umumnya. UCAPAN TERIMA KASIH .1 kg berada pada persentil ke-30 standar WHO/NCHS. Karenanya. menurun pada umur 4-6 bulan. pada umur 3 bulan dan 6 bulan kelompok prematur (30.6%). ditambah dengan keterpaparan terhadap infeksi. Temuan lain dari penelitian ini adalah rata-rata panjang badan kelompok prematur berada di persentil ke-10 atau kurang dari hasil temuan Alisyahbana. Persentase bayi stunting laki-laki menurut status kelahiran dan umur (bulan) * IUGR LPI = intra uterine growth retardation . diasumsikan bahwa pola dan kualitas makanan yang dikonsumsi juga sama. Artinya ibu dengan gizi kurang sejak trimester awal sampai akhir kehamilan akan melahirkan BBLR.(13) Tabel 5. diikuti oleh IUGR API (60%). Lambatnya pertumbuhan kelompok prematur disebabkan karena adanya retardasi pertumbuhan linier selain singkatnya umur kehamilan. berarti berat lahir kelompok normal masih termasuk dalam batas-batas normal. prematur (53.(12) Artinya. maka dampak pada kelompok normal paling berat. Panjang lahir kelompok normal baik bayi perempuan maupun laki-laki berada pada persentil ke-20 standar WHO. jumlah IUGR API lebih besar daripada IUGR LPI.4% dan 51. risiko terjadinya stunting pada bayi dipengaruhi oleh status kelahirannya terutama panjang dan berat badan saat dilahirkan. Semua kelompok lahir berkontribusi terhadap stunting dengan kontribusi terbesar dari kelompok lahir IUGR dan terkecil dari kelompok lahir normal. Hal di atas menjelaskan bahwa terdapat 2 pola retardasi pertumbuhan intra uterin yang berbeda pada bayi umur kehamilan genap bulan (IUGR). dan pada dari kelompok IUGR. Lebih besarnya proporsi IUGR daripada prematur.low Ponderal index ** IUGR API = intra uterine growth retardation adequate Ponderal index 80 Kusharisupeni Status kelahiran dan stunting pada bayi Rendahnya pola asupan makanan.8%) dan kelompok normal (14. meskipun kelompok normal sendiri tidak bertumbuh optimal. 3. mendukung kenyataan bahwa IUGR berkontribusi terhadap siklus intergenerasi yang disebabkan oleh kemiskinan. serta kelompok IUGR LPI dan IUGR API.(14) KESIMPULAN DAN SARAN Growth faltering telah dimulai sejak umur dini (2 bulan) tetapi tidak diikuti oleh catch up growth yang memadai. (Gambar 1 dan Gambar 2) Stunting Jumlah bayi pendek (stunting) laki-laki terbanyak pada saat lahir ada pada kelompok IUGR API (91. Stunting. Seperti di negara-negara berkembang lain. Pertumbuhan linier (cm) tiap-tiap kelompok lahir (perempuan) umur 0-12 bulan dibanding dengan rujukan pertumbuhan WHO/NCHS (P50) Gambar 1. Pada umur 6 bulan. Pertumbuhan linier (cm) tiap-tiap kelompok lahir (laki-laki) umur 0-12 bulan dibanding dengan rujukan pertumbuhan WHO/NCHS (P50) 79 J Kedokter Trisakti Vol. terdapat perbedaan panjang badan yang bermakna antara kelompok IUGR dan prematur.23 No. disebabkan karena sudah mengalami retardasi pertumbuhan saat dalam kandungan. Kelompok lahir normal (kelompok dengan berat lahir >= 2500 gram) merupakan prediktor terbaik untuk panjang badan baik pada umur 6 bulan maupun umur 12 bulan. stunting mencerminkan ketidakmampuan untuk mencapai pertumbuhan optimal yang disebabkan oleh status kesehatan dan atau status gizi yang suboptimal. tidak cukupnya asupan nutrien untuk bayi normal menyebabkan bertambahnya jumlah bayi dengan growth faltering. yang nantinya akan menjadi stunting. Semua kelompok lahir berkontribusi terhadap stunting hingga umur 12 bulan dengan kontribusi terbesar dari kelompok IUGR dan terkecil dari kelompok normal. Growth faltering pada setiap kelompok status kelahiran terjadi pada umur dini (umur 2 bulan).3 Catch up growth (kejar tumbuh) Pada umur 12 bulan kelompok BBLR (prematur. IUGR API dan IUGR LPI) tidak mencapai panjang badan yang dicapai oleh kelompok normal.78 Kusharisupeni Status kelahiran dan stunting pada bayi Gambar 2.2% berurutan) dan pada umur 12 bulan ada pada IUGR LPI (70.

300. Am J Human Biology 1994. defisit protein rumah tangga (BBIU : OR = 1. Johnston LB.2% berstatus gizi kurus. Eur J Clin Nutr 1994.4% wasting. CI = 0. New York: John Wiley and Sons. keluarga miskin (BBIU : OR = 1.314.027. 6: 265-71. CI = 1. BBIPB : OR = 1.199. CI = 0. 49: 740-4.906-1. 11. Am J Clin Nutr 1996. 2. CI = 2. indeks PBIU sebesar 1. Sampel adalah semua RT yang memiliki bayi (0-12 bulan) dan mempunyai data berat lahir yang terdapat pada data Riskesdas 2007 yakni sebanyak 7. banyak bayi dan anak balita mempunyai status gizi yang tidak adekuat yang direfleksikan dengan tingginya angka prevalensi underweight dan stunting (pendek). Gross R. CI = 0. 86: 108-12.048. WHO Technical Report Series 854. Fronggillo EA. 13. Growth faltering is prevented by breast-feeding in underprivilaged infants from Mexico city.004 . the situation of children and woman in Indonesia. Wolke D.260). Terima kasih kami sampaikan juga kepada pewawancara/pengukur dan supervisor lapangan. Geneva. 63: 966-77. BBIPB : OR = 1.415. CI = 0. 50: 179-90.143). defisit energi rumah tangga (BBIU : OR = 1. Baltimore: Child Health Research Project.149. Perinatal mortality and morbidity in rural West Java.970-1. Droomers M. Reily S.007-1. Sastroamidjojo S. Geneva: Unicef. 32. 1981. 14. terdapat 12. PBIU : OR = 1.866-1. ibu bekerja (BBIU : OR = 1. Special report: reducing perinatal and neonatal mortality.000 bayi setiap tahunnya. 14.520.228.418). berdasarkan data Depkes tahun 2004 dilaporkan bahwa angka BBLR diperkirakan mencapai 350. Schurch B. Eur J Clin.927-1. 2000. CI = 0.743. tidak memperoleh ASI (BBIU : OR = 1. menderita pneumonia (BBIU : OR = 1. Eur J Clin Nutr 1995.4% terkategori stunting. Nutr 1994. 2000. Pediatrics 1986. defisit protein MP-ASI (PBIU : OR = 1. J Nutr 2000. Fleis JL.824-1. 1999. CI = 1. CI = 0. High socioeconomic class preschool children from Jakarta.598. Schultink W.949-1.946-1. CI = 0. Unicef. Geneva: WHO. Fourth report on the world nutrition situation: nutrition throughout the life cycle. CI = 1.117. Clark AJL. 2: 491-501. Becker JA.462-2.327).061. Lopez-Alarcon M.7% untuk indeks BBIPB. Alisyahbana A. PBIU : OR = 1. 48: S1-S216. PBIU : OR = 1. Genetics factors contributing to birth weight. Di Indonesia.053. CI = 0. Adapun faktor risiko status gizi bayi adalah BBLR (BBIU: OR = 2.314.205.920-1. korelasi pearson) serta analisis odds ratio (OR)Hasil penelitian menunjukkan bahwa terdapat 378 bayi (4. Part II: The result of a longitudinal survey on pregnant woman. CI = 0. serta menurunnya kemampuan fisik anak dan gangguan pertumbuhan yang biasanya tidak dapat diperbaiki (irreversible).936. 4. PBIU : OR = 1. Setiap tahun diperkirakan 15. Philippines.286. Determining growth faltering with a tracking score. CI = 0. keterlambatan perkembangan motorik dan mental.003-1.194. Psychosocial adversity and growth during infancy.194).263.079.883-1. PBIU . BBIPB : OR = 1. ACC/SCN. 3. BBIPB : OR = 1. 7. CI = 0.992-2.734).147. CI = 0. kepada pak Yusron dan pak Eddy untuk manajemen data. Challenges for a new generation.8%) BBLR dan 7552 (95. 10.2%) bayi dengan berat lahir normal. Analisis hubungan menunjukkan bahwa status gizi bayi dipengaruhi oleh berat badan lahir secara bermakna (p<0. Suroto AE. Risk factors for wasting and stunting among children in Metro Cebu.104. 6.908-1.415-2. 7. menderita ISPA (PBIU : OR = 1. Causes and mechanism of linear growth retardation. BBIPB : OR = 1.Penyandang dana untuk studi ini adalah USAID melalui Center for Child Survival Universitas Indonesia.218-3. tidak diimunisasi BCG (BBIU : OR = 1. Postnatal growth of intrauterine growth retarded infant.975-1.100-1.580 . Ricci JA.876-1. Villar J. 1995. CI = 0. CI = 1.930 sampel.195 .028. Indonesia are taller and heavier than NCHS reference population.119. Dampak Berat Badan Lahir terhadap Status Gizi Bayi Latar Belakang : Kurang gizi merupakan sebuah issu global yang sangat serius dibicarakan. Waterlow JC. 48: S113-30.920-1. Metode: Penelitian ini untuk mengungkap sejauh mana dampak berat badan lahir terhadap status gizi anak balita dan lebih khusus lagi pada bayi dengan menggunakan rancangan analisis cross sectional. PBIU : OR = 1. Pengolahan data dengan menggunakan SPSS dengan uji statistik (chi-square. Arch Dis Child 2002. BBIPB .022 . Disamping itu.690-1. ibu berpendidikan rendah (BBIU : OR = 1. Savage OM. Statistical methods for rates and proportion. CI = 0. 12. CI = 0.009. 8. WHO Expert Committee: Physical status: the use and interpretation of anthropometry. OR = 1. CI = 0.4% dan hanya 0. 5.5% anak lahir BBLR dan 95% diantaranya lahir di Negara berkembang.195).05) sebesar 5% untuk indeks BBIU.003. CI = 1. CI = 0.238.818 .969-1.283. Pediatrica Indonesiana 1994. 130: 54652. Gangguan gizi pada anak bayi dan balita akan membawa dampak terhadap peningkatan risiko kesakitan dan kematian. Skuse D.195).017-1.040.884-1. Child Health Research Project.689). CI = 0. menderita diare (BBIU : OR = 1.570. ACC/SCN in collaboration with IFPRI. PBIU : OR = 1.293). 2nd ed. 9. Daftar Pustaka 1.148. Berdasarkan status gizi. Villalpando S.167).

Untuk mencegah anemi pada saat bayi umur 1 tahun dan mencegah dampak berkelanjutan pada tumbuh-kembang. and the Department of Nutrition. Baltimore. in Indonesia. Kesimpulan : Berat badan lahir mempengaruhi status gizi (p<0. and 8. nonuse of adequately iodized salt is associated with a higher prevalence of child malnutrition and mortality in neonates. CA (SYH) Background: Salt iodization is the main strategy for reducing iodine deficiency disorders worldwide. sanitasi lingkungan yang buruk dan penggunaan bahan beracun/berbahaya. MS. JAWA BARAT ABSTRAK LATAR BELAKANG. Stronger efforts are needed to expand salt iodization in Indonesia. measured by rapid test kits. Among families who used adequately iodized salt.5% compared with 13. was assessed between January 1999 and September 2003 in 145 522 and 445 546 families in urban slums and rural areas.2% compared with 6. among families who did not use adequately iodized salt. ibu bekerja. underweight. Conclusion: In Indonesia.168). keluarga rniskin. 8.1%.3%. respectively (P < 0. Child malnutrition and mortality among families not utilizing adequately iodized salt in Indonesia1. respectively. and children aged <5 y. Sonja Y Hess.2% of families from urban slums and rural areas. infants.0001 for all). maka perlu suplementasi besi paling tidak pada saat bayi berusia 6 bulan. in urban slums.3% compared with 4. Saskia de Pee. tidak memperoleh ASI dan imunisasi BCG. and wasted. Saran: Kebijakan secara makro yakni pengentasan kemiskinan melalui perbaikan kesejahteraan rakyat untuk meningkatkan status gizi dan kesehatan masyarakat. Italy (SdP.050. CI = 0. 5. Masalah kurang gizi pada bayi secara umum berhubungan dengan pemberian MP-ASI. Diet tradisional bayi tidak menjamin kecukupan kebutuhan nutrient mikro termasuk besi dan seng. penanggulangan malnutrisi khususnya pada anak bayi lebih difokuskan terhadap perbaikan gizi dan kesehatan ibu baik pra-konsepsi maupun setelah hamil (fetal programming) untuk mengurangi kejadian BBLR yang sangat mempengaruhi kejadian malnutrisi di usia tumbuh kembang anak. Rome. Families not using adequately iodized salt were more likely to have children who were stunted. PENGARUH SUPLEMENTASI SENG DAN BESI TERHADAP PERTUMBUHAN. Kekurangan seng dilaporkan mempunyai .9% compared with 9. Objective: The objective was to determine whether families who do not use iodized salt have a higher prevalence of child malnutrition and mortality and to identify factors associated with not using iodized salt. Results: Adequately iodized salt was used by 66. respectively.944-1. the respective values were 4. and children aged <5 y was 3. Characteristics of families not using iodized salt need to be known to expand coverage.2. PERKEMBANGAN PSIKOMORIK DAN KOGNITIF BAYI: UJI LAPANGAN DI INDRAMAYU. University of California. penyakit infeksi (diare.2%. Kai Sun.5% compared with 7.: OR = 1.3% (P < 0. and 6.0001 for all) in rural areas. mortality in neonates.6% and 67.3 Richard D Semba. and MWB). stunting dan wasting pada bayi (OR> 1). 9.1% compared with 11. pneumonia dan ISPA).005) dan merupakan faktor risiko undernutrition. Hasil juga menunjukkan bahwa yang menjadi faktor risiko terhadap status gizi bayi (OR >1) yakni berat badan lahir. Mayang Sari and Martin W Bloem 1 From the Johns Hopkins School of Medicine. low maternal education was the strongest factor associated with not using adequately iodized salt. Disamping itu. infants. defisit energi-protein rurmah tangga.2%. MD (RDS and KS).1%. defisit protein MP-ASI. 7. penggunaan bahan beracun berbahaya dan sanitasi lingkung yang buruk. serta ibu merokok saat ada anggota rumah tangga. Davis. ibu berpendidikan rendah. Design: Use of adequately iodized salt (≥30 ppm). In multivariate analyses that controlled for potential confounders. World Food Programme.

Gadjah Mada University. TUJUAN: Menilai pengaruh suplementasi kombinasi seng & besi terhadap pertumbuhan. 12 minggu dan 24 minggu.2. but knowledge of their potential interactions when given together is insufficient. Anemi. kematian. Pemantauan perkembangan psikomotorik bayi setiap bulan untuk melihat pencapaian tahapan milestones motorik pada umur tertentu. maka perlu dilihat ada atau tidaknya nilai tambah suplementasi kombinasi seng-besi untuk meningkatkan tumbuhkembang bayi. Uji kandungan nutrient mikro terutama besi dan seng pada controlair minum dan sample nakanan bayi juga dilakukan.3 Torbjörn Lind. the Department of Nutrition. HS. and the International Centre For Diarrhoeal Disease Research. Setelah rekrutmen. yaitu: kelompok penerima 10 mgseng sulfat atau 10 mg fero sylfat atau kombinasi seng dan besi atau placebo. Sweden (TL. 10. Bangladesh. yaitu awal penelitian. melalui tiga kali pengukuran. tidak menderita kurang gizi dan masih mendapatkan ASI. Bo Lönnerdal. perkembangan psikomotorik bayi anemi dan bayi defisiensi seng dibandingkan suplementasi seng atau besi tersendiri. Perkembangan kognitif dan psikomotorik bayi diuji dengan Beyley Scale for Infant Development II setelah suplementasi berakhir. tidak cacat fisik / punya kelainan bawaan. Davis (BL). Hans Stenlund. Bangladesh (E-CE and L-AP). Sebelum suplementasi. E-CE.dampak pada tumbuh-kembang bayi. . kepatuhan minum suplementasi juga dievaluasi. Rosadi Seswandhana. MEODE: Randomized Block Clinical Trial di lapangan dengan pendekatan tersamar ganda pada 800 bayi. Suplementasi kombinasi seng-besi mempunyai nilai tambah dalam peningkatan pertumbuhan linier terutama bayi laki-laki stunting. diberikan 5 hari dalam seminggu. Abstrak Doktor Universitas Diponegoo. Background: Combined supplementation with iron and zinc during infancy may be effective in preventing deficiencies of these micronutrients. Perkembangan kognitif suplementasi seng maupun besi lebih tinggi dibandingkan placebo. Yogyakarta. Centre for Health and Population Research. Setiap bayi mendapatkan satu dosis sirup suplementasi. tidak sakit berat. Epidemiology. Kesakitan. Kriteria inklusi sample adalah: bayi waktu rekrutmen berusia 4-7 bulan. Kadar Hb diukur pada 199 bayi dari darah kapiler tumit & pengukuran akhir pada keseluruhan bayi di akhir penelitian. Di Negara berkembang kekuranaganmutrien mikro biasanya tidak berdiri sendiri. bayi secara random dikelompokkan dalam 4 suplementasi. sample mendapatkan vitamin A sebanyak 100. Panjang Badan. dan Lingkar Lengan Atas. 2009 48 KESIMPULAN: Pengaruh suplementasi seng (dan kombinasi) pada pertumbuhan terutama pada bayi stunting dan pengaruh suplementasi besi (dan kombinasi) pada penurunan anemi serta perkembangan bayi. Dhaka. Pengaruh suplementasi dilihat pada pertumbuhan dengan pengukuran antopometri: Berat Badan.A community-based randomized controlled trial of iron and zinc supplementation in Indonesian infants: interactions between iron and zinc1. Suplementasi kombinasi seng-besi terbukti tidak harmful dan dapat dipakai sebagai alternative untuk mengatasi masalah anemi dan defisiensi seng yang banyak terjadi pada bayi. Indonesia (DI and RS). Faculty of Medicine. Community Health and Nutrition Research Laboratories. Umeå University. untuk mengukur Indeks Perkembangan Mental atau kognitif dan Indek Perkembangan Psikomotor. Umeå. Uji lingkungan anak dilakukan pada 344 bayi dengan HOME dan asupan makanan dievaluasi dari 356 (sub-sampel) dengan metode ingatan 24 jam Quality control dan quality assurance kepatuhan minum suplementasi dilakukan pengukuran kadar seng dan besi air seni pada 119 sub-sempel penelitian. Eva-Charlotte Ekström and Lars-Åke Persson 1 From the Department of Public Health and Clinical Medicine. University of California. Djauhar Ismail. and L-AP).000 Unit Internasional dan data dasar demografi segera dikumpulkan. perkembangan kognitif dan psikomotorik bayi serta mengkaji fisibilitas suplementasi kombinasi seng-besi. Suplementasi seng dan besi tersendiri telah dilakukan dan dilaporkan mempunyai pengaruh positif pada tumbuhkembang bayi usia lebih tua.

height-for-age. 39. Malnutrition and Morbidity Are Higher in Children Who Are Missed by Periodic Vitamin A Capsule Distribution for Child Survival in Rural Indonesia1. Results: Baseline prevalences of anemia. 6. 10 mg Fe + 10 mg Zn (Fe+Zn group).0001). . the Fe group had higher hemoglobin (119. Periodic high-dose vitamin A supplementation is one of the most cost-effective interventions to reduce child mortality (2) and has prevented an estimated 1 million child deaths from 1998 to 2001 (3). Venous blood samples were collected at the start and end of the study.3 µg/L.4 compared with 115. current diarrhea.5%. and weight-for-height Z scores . 1. Nutr.05) and serum ferritin (46. we compared nutritional status and other health indicators of children aged 12–59 mo in rural Indonesia who did and did not receive a vitamin A capsule within the last 6 mo. In 2004. 7. P < 0.4 vs. the proportion with weight-for-age.05) values than did the Fe+Zn group. or placebo from 6 to 12 mo of age. 54. 10 mg Zn (Zn group).8%. the proportion with anemia. and low serum zinc (< 10. A total of 241. 8%. respectively. but at different levels. 0.034 children (72. Design: Indonesian infants (n = 680) were randomly assigned to daily supplementation with 10 mg Fe (Fe group).0%. Although a lack of access to other public health interventions and demographic factors may also contribute to the rate of malnutrition in children missed by the vitamin A capsule program.22 were 37. 11. There was a dose effect on serum ferritin in the Fe and Fe+Zn groups.087 of 335. Children who did not receive vitamin A were also less likely to have received childhood immunizations and belonged to families with higher infant and under-5-y child mortality than children who receive vitamin A. 42. with evidence of an interaction between iron and zinc when the combined supplement was given. the Copenhagen Consensus identified vitamin A supplementation among the best .3 g/L.05) than did the placebo group. Conclusion: Supplementation with iron and zinc was less efficacious than were single supplements in improving iron and zinc status.2 vs. Introduction Each year.5 compared with 32. 8. and 78%. P < 0. 45. 2007.0001).9 vs.06 µmol/L.7 µmol/L) were 41%. Five hundred forty-nine infants completed the supplementation and had both baseline and follow-up blood samples available for analysis.2 Abstract Universal periodic high-dose vitamin A capsule distribution is a cost-effective intervention to increase child survival in developing countries.0%) received a vitamin A capsule between 1999 and 2003.7 vs.7% (P .2 vs. respectively. After supplementation.4% (P . most of whom reside in developing countries (1). 4. In children who did and did not receive a vitamin A capsule. Similarly. and current fever was 49. it is likely that increased coverage of vitamin A supplementation would help to maximize the benefits for child survival. It is unclear whether children who are missed by the program are at higher risk for malnutrition and infectious disease morbidity. Based on data from the Nutritional Surveillance System. and 1.10 million children die.58 compared with 9. whereas no dose effect was found in the Fe+Zn group beyond 7 mg Zn/d.4 vs. J.6%. iron deficiency anemia (anemia and low serum ferritin). 0. indicating an effect of zinc on iron absorption.0 vs.Objective: The goal was to compare the effect in infants of combined supplementation with iron and zinc and of supplementation with single micronutrients on iron and zinc status. 137: 1328– 1333. 6. There was a significant dose effect on serum zinc in the Zn group. and 6. diarrhea during the last wk. The Zn group had higher serum zinc (11. P < 0.4%.

E-mail: rdsemba@jhmi. West Java. and Helen Keller International (HKI) in 1995 (15). and 4) to come from families with higher rates of infant and under-5-y child mortality than children who received vitamin A. From 1973 to 1975. and anemia. Semba from Research to Prevent Blindness. the government of Indonesia conducted a pilot program of dispensing high-dose vitamin A capsules every 6 mo to every preschool child in 20 selected subdistricts in the island of Java (10). and blindness (7–9). Vitamin A deficiency has long been recognized as a highly prevalent nutritional deficiency in women and children in Indonesia and a major cause of morbidity. wasted. Banten. no conflicts of interest. fever. To gain further insight into this issue. G. * To whom correspondence should be addressed. and underweight. D. To address these hypotheses. M. may not be reaching the children who need them the most (6).edu. 1999 and September 27. by on November 5. It has been suggested that vitamin A supplementation in developing countries may miss the children who are at highest risk (13). 3) to have lower childhood immunization coverage. Indonesia has one of the strongest vitamin A capsule distribution programs for child survival and the intended coverage is for all infants 6–12 mo and all preschool children 12–59 mo of age. The subjects included in this analysis were surveyed between January 1. 60 mg retinol equivalents. 2008 who are reached and not reached by the national vitamin A capsule distribution program in rural Indonesia. 2) to be at higher risk of diarrhea disease. . 2 Author disclosures: S. Initial review completed 9 January 2007. mortality. Government of Indonesia.nutrition. Manuscript received 20 December 2006. Berger. D. such as vitamin A supplementation. The effectiveness of vitamin A capsule distribution programs for child survival is likely related to the extent of programmatic coverage (6). An estimated 140 million preschool children have vitamin A deficiency and the majority of these affected children live in south and southeast Asia and sub-Saharan Africa (5). The subvillage level health post (posyandu) is the main site for distribution of vitamin A capsules to children. The vitamin A capsule distribution program in Indonesia was more widely expanded in the 1980s (11). de Pee. Downloaded from jn. we sought to characterize the demographic and health characteristics of preschool children 1 Supported by a Lew R. Halati.strategies to improve global welfare (4). Subjects and Methods The study subjects consisted of children from families that participated in the major Nutritional Surveillance System (NSS)7 in Indonesia that was established by the Ministry of Health. no conflicts of interest. Lombok. The NSS was conducted in the provinces of Lampung. to children aged 12–59 mo and onehalf the dose for infants 6–12 mo (12).00 ª 2007 American Society for Nutrition. Recently. 1328 0022-3166/07 $8. Semba. no conflicts of interest. Revision accepted 24 February 2007. no conflicts of interest. Wasserman Merit Award to R. W. it has been suggested that child survival interventions. and South Sulawesi. but little has been done to characterize nutritional status and infectious disease morbidity in children who are missed by vitamin A supplementation (14). East Java. Central Java. We hypothesized that children who missed vitamin A supplementation were more likely: 1) to be stunted. S. we examined the characteristics of children who did and did not receive vitamin A capsules in rural families in Indonesia. The program consists of biannual distribution of oral vitamin A. It is not well known whether this important child survival program is missing children who may actually be at greater risk of morbidity and mortality. no conflicts of interest. Bloem. S.

HKI provided training to new field teams. The field teams were instructed to explain the purpose of the NSS and data collection to each child‘s mother or caretaker. A quality control team from HKI revisited 10% of households without prior warning within 2 d of data collection by the field teams and recollected data on selected indicators. Data analyses were restricted to children who were 12– 59 mo of age at the start of the most recent vitamin A capsule distribution round.000 randomly selected rural households every quarter. The mother of the child or other adult member of the household was asked to provide information on the household‘s composition.2003.22 SD for WHZ. Data collected by these quality control teams were later compared with the data collected by the field teams to check the accuracy of the data collection. The NSS was based upon stratified multistage cluster sampling of households in ecological zones of provinces of the country and in slum areas of large cities (15). In each zone. because these were the children who were eligible for receiving 60 mg retinol equivalent (200. or stunted (18).125 mm were considered at high risk of malnutrition (19). environmental sanitation. For each child over age 6 mo. New households were selected every round. a monitoring team from HKI visited all field sites to check and calibrate the equipment and supervise data collection.12 mo of age. on children aged 0–59 mo.5 y of age. The NSS was based upon UNICEF‘s conceptual framework on the causes of malnutrition (16) with the underlying principle to monitor public health problems and guide policy decisions (17). WAZ. father. The NSS in Indonesia involved the collection of data from .000 IU) every 6 mo in the Indonesian vitamin A capsule program. A structured. Hemoglobin was measured using a HemoCue instrument (HemoCue AB). underweight. Birth dates of the children were estimated using a calendar of local and national events and converted to the Gregorian calendar. During each round. including history of diarrhea in the previous week and current diarrhea. date of birth. and sex. Axillary temperature was recorded.40. underweight. coded questionnaire was used to record data. Children who had a mid-upper arm circumference (MUAC) . Severe wasting. Participation was voluntary and all subjects were free to withdraw at any stage of the interview. which uses the reference population of the U.1 cm. and height-for-age (HAZ) (stunting) were calculated using EpiInfo software (CDC). Morbidity histories were obtained for each child. along with other socioeconomic. Data were collected on the history of any infant dying in the household . parental education. and any child deaths . and. including anthropometric measurements. National Center for Health Statistics. villages were selected by probability-proportional-tosize sampling.12 mo of age at the time of the last vitamin A capsule distribution round in the local area were not included in this analysis. and stunting were defined by respective Z scores less than . because supplementation of children in this age . .S.1 mo of age. including anthropometric measurements. or HAZ were considered wasted. or guardian was asked whether the child received a vitamin A capsule within the last 6 mo. Z scores of weight-for-height (WHZ) (wasting). and weekly household expenditures. Data were collected by 2person field teams. The protocol was approved by the Medical Ethical Committee of the Ministry of Health. data collection and phlebotomy proceeded only after written informed consent. the father and/or household head. Government of Indonesia. weightfor-age (WAZ) (underweight). The field teams measured and recorded the weight of each child aged 0–59 mo to a precision of 0. Children who were 6 to . the mother.1 kg and the length/height to a precision of 0. Children with Z scores less than . field supervisors. The study protocol complied with the principles enunciated in the Helsinki Declaration (20).23 SD. and assistant field officers and refresher training prior to each new round of data collection. if present. and health indicators.

MUAC.125 mm. 0. 0.151. The youngest child within 12–59 mo of age was selected to represent each family for families with more than 1 child. P .95.65.3% and Central Java the highest at 80. HAZ.48.22. odds ration.12. East Java. The geometric mean distance and time to walk from the house to the posyandu were significantly higher for children who did not receive a vitamin A capsule compared with children who received a vitamin A capsule. 2008 A program. Logistic regression models were used to examine the relation between the child receiving a vitamin A capsule and possible risk factors. and West Java showed coverage rates of 57. WHZ. male. The frequency . 1. and have anemia compared with children who received a vitamin A capsule. and WHZ . weight-forheight Z score. Children who did not receive a vitamin A capsule were significantly more likely to be younger. Demographic characteristics are shown for children who did not vs. respectively. as measured by time. 7–9 y of maternal education (odds ratio [O.range with a different dose and type of capsule had just been implemented at the beginning of the NSS data collection. Continuous variables were compared using Student‘s t test and variable transformations were used when needed to normalize the data. WAZ.0001) compared with 0–6 y of maternal education were associated with an increased likelihood of the child receiving a vitamin A capsule. Categorical variables were compared using chisquare tests.0%) of whom received a vitamin A capsule within the last 6 mo. Population-based weighting was used to account for differences in population size of the various provinces.05.] 1. P . current diarrhea. oral poliovirus. the number of children . Variation in coverage rates was found in the provinces. Malnutrition in children missed by vitamin A distribution 1329 Downloaded from jn.0001) and 101 y of maternal education (O. 95% [CI] 1. Increased distance to the posyandu. 0.91. 95% [CI] 1. HKI. OPV. 0. O. weight-for-age Z score. NSS.02–2.R. 66. Helen Keller International.087 (72.07. Parental education. Banten. 77.87–1.R. 1.45–0. 68. and have fathers who were less educated.034 children. and WHZ . Lampung.R. Similarly. Multivariate logistic regression models were used to examine the relation between separate outcomes of stunting and history of diarrhea in the last week and not receiving a vitamin A capsule and other factors. a history of diarrhea over the last week.69. HAZ. height-for-age Z score.23. according to WHO criteria (21). mid-upper arm circumference. Results There were 335..R. 95% [CI] 1. P . and 78. 95% [CI] 2.62–1. have a MUAC .7.R. The level of significance in this study was P .0001) and 101 y of paternal education (O.nutrition.5. with South Sulawesi demonstrating the poorest coverage at 54.8. have mothers who were younger and less educated. Health characteristics for children who did and did not receive vitamin A capsules are shown in Table 2. current fever. Children who did not receive a vitamin A capsule were significantly more likely to have WAZ.5. Anemia was defined as hemoglobin . WAZ.0001) compared with 0–6 y of paternal education were also associated with an increased probability of the child receiving a vitamin A capsule. those who did receive a vitamin A capsule (Table 1). Nutrition Surveillance System. P . was also associated with decreased odds of receiving a vitamin A capsule (Table 1). Adjusting for other factors. 2. 0. 7–9 y of paternal education (O.6%. 241. HAZ.11 g/dL.6 y in the household. Lombok.7%. An increase in the number of children under 6 y of age in the household was association with decreased odds of being reached by the vitamin 7 Abbreviations used: by on November 5. diphtheria-pertussistetanus. and distance to the posyandu were strong predictors of failure to be reached by the vitamin A program. aged 12–59 mo.

8 1.2 2.1 mo of age.00 7–9 16.7 2.0 19.84) 1 All variables were adjusted for time (year in which the interview was conducted).1 0.1 29. TABLE 1 Demographic and health characteristics of children.28 (1.25–1. aged 12–59 mo.24 (1.01– 1.3 19.95) .79–0.63) 4 0.2 0.5 1.0001 0.6%).32.3 0.1 1.82) 3 2.04) Maternal age.66 (0.12–1.3 28.79) (6.88 (0.5 58.99. 1).distribution of hemoglobin levels in children who did and did not receive a vitamin A capsule shows that the distribution of hemoglobin in children who did not receive a capsule was shifted to lower values compared with children who did receive a capsule (P . y 0–6 64.3 20. the proportion of infants who died .80 (0.66–0. Childhood immunization coverage was compared for children who did and did not receive a vitamin A capsule (Table 3).48–0.9 19.79 (0.23 0.4 1.81) .0001 0.0001 1.125 mm 3.0001 1.69) $10 12.98 (1.86) MUAC .0 4.0001 0. % Female 48.25) 2001 24.77–0.4 0.22 45. they utilize other health services (7.91 (1.22 7.60 (0. 5.77) 51 0.9 26.7 51.79) 2003 13.5 10.02 (1. min3 6.01 0.12 mo of age. of 1.0001 1.27) 36–47. by vitamin A capsule receipt1 Characteristic Did not receive vitamin A Received vitamin A P OR (95% [CI]) WAZ score .00 2000 26.30) 331 23.0001 0.14–1.7 38.95) Children in household .7%).17) Maternal education.5 1.02–2.79) .41) (4.14 (1.00 24–27.0001) (Fig.7 1.R.68–0.12–1.0 1.92) Year of interview 1999 14.93–2.93 (0. n 1 73.70–1.62–1. aged 12–59 mo.48 (1. 6.45–1.07 (2. In children who did not attend the posyandu.8 27.79–0. or that the health post was too far (7.16 (1.0 29.16–1. TABLE 2 Health characteristics of children. Children who did not receive a vitamin A capsule were significantly less likely to receive diphtheria-pertussis-tetanus (DPT) immunizations 1.78 (0.6 1.8 11. and the under-5-y mortality rate were significantly higher than in households in which the child received a vitamin A capsule (Fig.70) HAZ score .94) Diarrhea last wk 8.4%).4 0.3 1. 2.70 (0.5 25.0001 1.0001 0. and 3.0001 1.19) 48–59 12.9 0.15 (1. 2 Odds of receiving a vitamin A capsule compared with a reference group that has an O.9 42.4 6. or guardian for not going to the posyandu were that the health post was not active (26.2 0. In the households in which the child did not receive a vitamin A capsule.22 (1.2 1.5 23.002 1.4 0.9 1.2 0.84) Anemic 54.7 0. and 3.0 0.2 20. they thought the child was already too old (11.78–0.9 24.03) 1 All variables were adjusted for time (year in which the interview was conducted). the 5 main reasons given by the mother.00 7–9 15. mo 12–23. y #23 26.71 (0.1 1.22 42.8 49.04–1.6 0.23 15.81 (0. A history of child mortality was compared in households in which the children did or did not receive a vitamin A capsule.81) Diarrhea today 6.3 11.00.22–1.5 0.3 0.0 20.19–1.77 (0.76–0.0 0.56–0.5 23.66 (0.12) Paternal education.7 0. they thought immunizations were already complete (9.6 39. 0.4 6.1 19.36 5.68 (0.9 1.0%).19 (1.4 0. by vitamin A capsule receipt1 Characteristic Did not receive vitamin A Received vitamin A P OR2 (95% CI) Child age.0001 0.57–0.6 1.3 19.0001 1.74–0. father.23 8.4 0.78 (0.4 0.6 0. the proportion of infants who died .00 24–35.07 (1.74) Fever today 1.78–0.5%).81 (0. y 0–6 72.72) WHZ score .83–0.5 0.7 0. .8 23.0001 0.0001 0.21) 28–32.6 y old.5 37.9 6.0001 0.51) $10 19.69–0.2 0.00 2 23. 2).75 (1. 2.71–0.78 (0.7 49. oral poliovirus (OPV) immunizations 1. 3 Geometric mean (95% [CI]).09) Gender.04) Time to walk to posyandu.9 25.5 0. and measles immunization.18) 2002 21.1 1.90–0.2 0.87–1.7 78.65 (1.

1 55.85 (1. maternal education.00 Doesn't know 2.0001 5.3 11. and wasted children who had Z scores . no record 36.9 1.2 1. with record 34.3 0. 1330 Berger et al.88 (5. the lack of receipt of a vitamin A capsule was associated with a significantly increased risk of stunting (Table 4). no record 34. more likely to be anemic.92 (1. the more severely underweight.2 33.1 3.75–1.8 1.79) Not received 36.26–2.81–2.35 (3.FIGURE 1 Frequency distribution of hemoglobin levels in children who did not (n ¼ 18.9 1.0001 6. and wasting.2 0.1 31.8 34. the lack of receipt of a vitamin A capsule was associated with a significantly increased risk of a history of diarrhea in the previous week (Table 4). this is the first study to characterize nutritional status and morbidity in children who are and are not reached by vitamin A capsule distribution. TABLE 3 Relation of vitamin A capsule receipt with childhood vaccinations1 Characteristic Did not receive vitamin A.4 56.79 (5. with record 32.00 Doesn't know 3. stunted.7 3.2 3.4 1. A strength of this study is that it is a population-based sample with a large sample size. maternal education.27–3.98–3.23 were less likely to receive vitamin A.5 1.75) OPV vaccine dose 2 Received.9 1.5 0.51) Received.8 2.% P OR2 (95% [CI]) DPT vaccine dose 1 Received. no record 37.73 (2. To our knowledge.75–6.02) DPT vaccine dose 3 Received.00 Doesn't know 3.9 0.0001 7. 2008 Multivariate logistic regression models were used to examine the relation between history of diarrhea in the previous week and not receiving a vitamin A capsule and other factors. with record 29.31 (5.0 1. with record 31.9 31.78) Not received by on November 5. Moreover.00 Doesn't know 3.45–2.02) Received.0001 by Mantel-Haenszel chisquare).56) Not received 27.6 55.67) Received.6 1.nutrition.0001 5.93–3. distance to the posyandu. The findings show that this important child survival intervention may be missing children who are at the highest risk of dying.35–6.86 (6.3 53. After adjusting for child age. with record 33.00 Doesn't know 2.225) and did (n ¼ 46. no record 31.8 1.2 57.12) Not received 32.9 32.68 (3.19–5. distance to the posyandu.4 13.69–7.38–3. and the time of the interview.05 (2.67–2.6 33. and the year in which the interview was conducted.859) receive a vitamin A capsule (P . Multivariate logistic regression models were also used to examine the relation between stunting (HAZ .95) Measles vaccine .30) OPV vaccine dose 3 Received.00 (2.0 8. Downloaded from jn. with record 30. stunting.92) Received. Discussion This study shows that children aged 12–59 mo who were not reached by universal vitamin A capsule distribution within the last 6 mo in rural Indonesia were at greater risk of underweight.66 (1.32 (7.2 2.1 0.58–3.51 (6.2 1. After adjusting for child age.43) Received.2 2.00 Doesn't know 2. % Received vitamin A. no record 31.17 (2. no record 32.58–1. 0.66–5.07) Not received 34.8 2. A history of diarrhea in the previous week was selected as the outcome.47 (3.03) Received.13–7.3 3.54) DPT vaccine dose 2 Received.6 0.1 1.4 1. and had higher rates of diarrhea and fever than children who received vitamin A.59 (2.2 57.8 2.7 7.0001 6.0001 5. Stunting is recognized as the best indicator of long-term malnutrition compared with other health indicators.43) Not received 30.40 (2. 22) and not receiving a vitamin A capsule and other factors.05–2.75) OPV vaccine dose 1 Received. such as wasting or underweight.3 1. because this is a health indicator strongly associated with vitamin A deficiency (22).6 3.9 10.3 6.

mo 0.58 0.38 (1.52 1.31–1. In our study.07 2.0% and the government‘s target rate was 80%.20–5. In addition. vitamin A supplementation programs in developing countries should reach 85% of preschool children twice per year (29).9 1.46) 1 All variables were adjusted for time (year in which the interview was conducted). a study of over 13.974 0.000 children showed that those who were not reached by vitamin A capsule distribution in 1993 and 1998 had mothers with lower education level and lower socioeconomic status compared with those who received vitamin A (13).011 0.1 2.006 1. y 0–6. An estimated 75% of children in sub-Saharan Africa and 46% of children in South Asia receive at least 1 dose of vitamin A annually (29). Many programs have fallen short of this goal. FIGURE 2 History of infant dying .19 1.46–1. children who were not participating in the vitamin A capsule program were more likely to be . which in turn may lead to greater susceptibility to diarrheal diseases.17–1.01 0. and wasted are at a higher risk of diarrheal morbidity and mortality (23) and diarrheal disease increases the risk of vitamin A deficiency (24). children who were missed by the vitamin A .010–1. The overall rate of vitamin A coverage in these children was 72. children who are underweight.00.71 (2.3 by on November 5. the relation between malnutrition and diarrheal diseases is often mutually reinforcing.44) Received.0001 by chi-square test).97– 1. In a sample of 677 children aged 1–5 y in Central Java.23 1. infant dying .29 0.9 1. The coverage rate of the program in Indonesia was less than the 84% coverage in Bangladesh (28) but higher than the 34% coverage in Cambodia (28) during approximately the same time period.0001 Child age.17 0.113 1 Both regression models were adjusted for time (year in which interview was conducted).52 0. y 0–6.9 1.972–0. min 1.12 mo of age. stunted. TABLE 4 Multivariate logistic regression models of relation between children’s vitamin A capsule receipt and other factors and stunting and history of diarrhea in previous week1 Variable OR 95% [CI] P History of diarrhea in previous week Lack of vitamin A capsule receipt 1.00 – – Loge time to walk to posyandu. as the 28% of children who were not reached by Indonesia‘s vitamin A program demonstrated higher rates of child morbidity than children who were reached by the program.Received. Two previous studies characterized children who are missed by vitamin A capsule programs. no record 31.0001 7–9.0001 Maternal education.973 0. Indonesia. Interventions such as vitamin A supplementation are considered a means of interrupting this cycle.0001 7–9.1 mo of age.12 0.48 1.9 2.17–1.nutrition.77) Not received 37. 0. mo 1.779) receive a vitamin A capsule (*P .0001 101 1.5 32.00– 1.09–1.36 mo of age and from families with more than 1 preschool child (14).0001 5.6 1.4 1. Ideally. and under-5-y child mortality in families in which the child did (n ¼ 163. stunted and wasted children are at a higher risk of vitamin A deficiency (25–27). The investigators concluded that the vitamin A program in the Philippines was missing some of the most vulnerable children.050 Stunting Lack of vitamin A capsule receipt 1.65–2.3 0.00 Doesn't know 3. 2008 In developing countries. Malnutrition in children missed by vitamin A distribution 1331 Downloaded from jn.828) and did not (n ¼ 56.00 0.03–2.9 52. Our findings challenge the assumption that targeting only 80% of children is a sufficient intervention strategy.32 (5. of 1.21 0.0001 Child age.13 1.44–1.00 – – Loge time to walk to posyandu.010 1.0 1. min 0. with record 27.0001 Maternal education.99 0.0001 101 1. 2 Odds of receiving a vitamin A capsule compared with a reference group that has an O.R. In the Philippines.

These findings suggest that children missed by vitamin A supplementation are more stunted. Universal periodic high-dose vitamin A supplementation is known as an effective intervention to increase child survival in developing countries. These findings suggest that demographic factors that impact a child‘s participation in vitamin A supplementation programs may also impact participation in other public health interventions. It has been argued that vitamin A supplementation should be targeted to highrisk children. it cannot be determined from these cross-sectional data whether the children had higher risk of diarrhea because they did not receive a vitamin A capsule or that children who did not receive a vitamin A capsule came from households where diarrheal morbidity was generally higher. blindness. Given that children who are missed by the vitamin A programs are at higher risk of malnutrition and morbidity. Distance and nonfunctioning of the posyandus appeared to be important barriers to the utilization of these rural health posts. but. Literature Cited . The relation between vitamin A supplementation and stunting has not been consistent between studies (31). This study also suggests that the parents did not take their children to the posyandu because they thought immunizations were complete or that the child was too old. In September 2000. It is evident that strategies need to be developed to reach children who are missed by basic primary preventive care programs in developing countries. although the strength of the correlation was not as great as that of maternal education. and measles immunization. The lack of receipt of a vitamin A capsule was associated with an increased risk of stunting and an increased risk of a history of diarrhea in the previous week. Further work is also needed to determine whether the parents have adequate knowledge of the purpose and benefits of the vitamin A capsule program and how public health promotion campaigns could be used to increase attendance at the posyandu. Formal parental education was 1 of the most significant determinants of receipt of vitamin A capsules. by about one-quarter (32). primarily from diarrheal disease. measlesrelated pneumonia. Greater research in this area would therefore be beneficial for informing strategies for health programming. similar to the association between vitamin A capsule receipt and diarrhea. 189 countries endorsed the goals set forth by the United Nations millennium declaration to reduce under-5-y child mortality by two-thirds between 1990 and 2015 (2). Vitamin A deficiency increases the risk of measles morbidity. Paternal education significantly influenced the likelihood of the child receiving a vitamin A capsule.capsule distribution program were less likely to have received DPT. the extent of mortality reduction by periodic vitamin A supplementation is unclear. OPV. including the severity of diarrheal disease. analyses have shown that universal supplementation is most cost effective (33). Because these health posts provide basic primary care. causality cannot be determined. and the lack of immunization places these children at an even higher risk of infectious disease morbidity and mortality from vaccinepreventable diseases. Periodic high-dose vitamin A supplementation has been shown to reduce preschool child mortality. it seems that children who are missing vitamin A supplementation may also be missed by other critical child survival interventions. and mortality (30). Although vitamin A supplementation is associated with a reduction in diarrhea morbidity. Little research has been done on the impact of paternal education on child health. Further work is needed to expand coverage of existing programs to reach children who are at higher risk of dying. however. The leading cause for not taking a child to the posyandu was that the posyandu was not active.

National vitamin A supplementation campaign activities: August 2001. 1980. Bloem MW. New York: Cambridge University Press. On keratomalacia in Java and Sumatra (in particular upon the Karo-Plateau) and in Holland.Wu LSF. 24. Tabatabai H. 2005. Black RE. Brown KH. Bishai D. editors. Reducing child mortality: can public health deliver? Lancet. 4. Hennart P. J Health Popul Nutr. 1990. Assessing and communicating impact of nutrition and health programs. LeClerq SC. Socioeconomic differentials in supplementation of vitamin A: evidence from the Philippines. Brasseur D. Donnen P. Egger RJ. High prevalence of low hemoglobin concentration among Indonesian infants aged 3–5 months is related to maternal anemia. Ending vitamin A deficiency: a challenge to the world. 2004. In: Semba RD. 8. Katz J. Am J Clin Nutr. 2001.132:2215–21. Tarwotjo I. de Pee S. 1993. 17. 1995. Wolfson L.1. Sastroamidjojo S. arm circumference. 2. Geneva: WHO. 7. 2002. 2001. 2004. Mild vitamin A deficiency and risk of respiratory tract diseases and diarrhea in preschool and school children in northeastern Thailand. de Pee S. Biesalski HK. Gwatkin D. Habicht JP. Bahwere P. Smets R. Bull World Health Organ. Sommer A. 16.20:1–11. Katz J. 2003. Bull World Health Organ. Indonesia Crisis Bulletin. Yip R. 2001. 1981–1992.307:710–3. New York: UNICEF. Speek AJ. Tonglet R. 1968. Increased risk of xerophthalmia following diarrhea and respiratory disease. Helen Keller International.nutrition. Sommer A.79:373–4. Mededeel Dienst Volksgezond Nederl Indie¨. WHO. 483–506. 15. 2003. de Haas JH. 25. 2005. Pangaribuan R. Kosen S. editors.131:332–9. Socioeconomic and familial characteristics influence caretakers‘ adherence to the periodic vitamin A capsule supplementation program in Central Java. 18. Thapa . J Nutr. Erhardt JG. Indonesia [dissertation]. 1987. p. Scherbaum V. East Java.West KP Jr. 21. Geneva: WHO.9:371–84. Causes of blindness in and around Surabaja.45:977–80. Saowakontha S.331:1177. 14. Int Ophthalmol. Combating nutritional blindness in children: a case study of technical assistance in Indonesia. J Trop Pediatr. Hutubessy R. 6. BMJ. Oomen HAPC. Wedel M. Habicht JP.3:1–4. Muhilal. Totowa (NJ): Humana Press. Assessment and control of vitamin A deficiency: the Annecy Accords. Schrijver J.50:143–7. Serum albumin concentrations. Pergamon Policy Studies on SocioEconomic Development. Bryce J. Fritz C. Downloaded from jn. 1968. Susatio B. Indonesia. Cost effectiveness analysis of strategies for child health in developing countries.19:39–42. Pariyo G. 2002. Kiess L. Lomborg B. global solutions. Where and why are 10 million children dying every year? Lancet. el Arifeen S. Nutrition and health in developing countries.133:S328–32. 9.132 Suppl 9:S2845–50. Evans DB. by on November 5. Valverde V. Khatry SK.362:159–64. Nutritional surveillance. Nutrition and health in developing countries.23:156–64. 22. 2001. Lanata CF. 1332 Berger et al. Global crises. and oedema and subsequent risk of dying in children in central Africa. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. Bryce J. 1931. J Nutr. ten Doesschate J. 19. UNICEF. 12. Aikins M. Diarrhea and malnutrition. J Nutr. Dramaix M. In: Semba RD. Jakarta (Indonesia): University of Jakarta. p. de Onis M. 1984. Bloem MW. Mason JB. Choi Y. Sari M. 71–91. Bloem MW. 2003. 1953. Child growth and development. 20. BMJ. Totowa (NJ): Humana Press. Semba RD. Bloem MW. Edejer TTT. Bloem MW.361:2226–34. Natadisastra G. Morris SS. Infant malnutrition in Indonesia. 2008 11. 3. Davidson FR. 13. The decline of admissions for xerophthalmia at Cicendo Eye Hospital. Multi-Country Evaluation of IMCI Study Group. Black R. 10. World Medical Association. 5. Am J Epidemiol. Mudjene O. Schreurs WH. Hill K. New York: Pergamon Press. Pradhan EK. Nutritional anemia: report of a WHO Scientific Group. 2001. 23.

org by on November 5. Pokhrel RP. Ramakrishnan U. 1995. Interpretation Both maternal and paternal education are strong determinants of child stunting in families in Indonesia and Bangladesh. Costales MO. Increased risk of respiratory disease and diarrhea in children with preexisting mild vitamin A deficiency. Jalil MA. 26. 0·956. 2004.MD. 31. while that in Bangladesh was 50·7%. Ross A. 13. McCabe G.49: 243–55. State of the world‘s children 2005.nutrition. Using cost-effectiveness analysis to evaluate targeting strategies: the case of vitamin A supplementation. Available from: web. Leemhuis de Regt E. Health Policy Plan. and mortality. Beaton GH. UNICEF. 2004. greater paternal formal education led to a decrease of 3% in the odds of child stunting (0·970. 30. Findings The prevalence of stunting in families in Indonesia was 33·2%. 29. Loevinsohn BP. 2008 12.12:29–37. Aronson K. 1986. Cohen N. Our aim was to determine the effect of length of maternal and paternal education on stunting in children under the age of 5 years. greater maternal formal education led to a decrease of between 4·4% and 5% in the odds of child stunting (odds ratio per year 0·950. 27. 1993. and use of iodised salt (all p<0·0001).32: 73–8. 95% CI 0·946–0·954 in rural settings. [cited 2006 April 16]. greater maternal formal education led to a 4·6% decrease in the odds of child stunting (0·954. better sanitation. McCabe G. Sommer A.113:425–9. 28.worldbank. World Bank. Multimicronutrient interventions but not vitamin A or iron interventions alone improve child growth: results of 3 meta-analyses. Sprague J. Effectiveness of Vitamin A supplementation in the control of young child morbidity and mortality in developing countries.134: 2592–602.pagePK: 642298.Effect of parental f/ormal education on risk of child stunting in Indonesia and Bangladesh: a cross-sectional study Background Child stunting is associated with poor child development and increased mortality. while greater paternal formal education led to a decrease of between 2·9% and 5·4% in the odds of child stunting (0·971. November 2004. J Trop Pediatr. Malnutrition in children missed by vitamin A distribution 1333 Downloaded from jn. Martorell R. In Indonesia. 0·941–0·951 in urban settings). complete childhood immunisations. Mitra M. Martorell R. 2004. 1997. In Bangladesh. childhood illness. 0·951–0·957). In Indonesia. . Epidemiology of xerophthalmia in Nepal: a pattern of household poverty. 33. 0·967–0·974). ACC/SCN Stateofthe-Art Nutrition Policy Discussion Paper No. Bloem MW. including vitamin A capsule receipt. 0·969– 0·974 in rural settings. Rahman H. 32. J Nutr. Am J Clin Nutr. Methods Data for indicators of child growth and of parental education and socioeconomic status were gathered from 590 570 families in Indonesia and 395 122 families in Bangladesh as part of major nutritional surveillance programmes. New York: UNICEF. 0·946. Blinding malnutrition in rural EXTERNAL/TOPICS/EXTHEALTHNUTRITIONAN DPOPULATION/ EXTPHAAG/0. Vitamin A. 1984.contentMDK:20800011. Sutter RW. Katz J. New York: United Nations. Aburto N. Measles blindness. Public health at a glance. Surv Ophthalmol. Semba RD. Arch Ophthalmol.40:1090–5. Tarwotjo I.menuPK:1314 810. high levels of maternal and paternal education were both associated with protective caregiving behaviours. Edmonston B. 0·950–0·961 in urban settings).

15. respectively. and income (poorest and middle-class family). Methods The health and nutritional status of children aged less than five years was assessed in North Maluku province of Indonesia in 2004 using a cross-sectional multi-stage survey conducted on 750 households from each of the four island groups in North Maluku province. Abstract Risk factors for stunting among under-fives in Libya . After controlling for potential confounders. A total of 2168 children aged 0-59 months were used in the analysis. and of severe underweight and severe stunting was 5. The risk factors for severe stunting in children aged 0-23 months were income (poorest family).05.4%.020) and severe stunting (OR 1.2) and 14. 2000–2003. father's occupation (not working). 95% CI 1. and 9.9) for children aged 0-59 months. Understanding of the risk factors for stunting and severe stunting among children aged less than five years in North Maluku province is important to guide Indonesian government public health planners to develop nutrition programs and interventions in a post conflict area. 95% CI 1.7-17.0) for children aged 0-23 months and 38. p<0. multivariate analysis revealed that the risk factors for stunted children were child's age in months.001) and stunting (OR 1.08 to 1.06. Conclusions: Paternal smoking is associated with an increased risk of child malnutrition in families living in rural Indonesia.001).10) p = 0.Paternal smoking and increased risk of child malnutrition among families in rural Indonesia Abstract Objective: To determine whether paternal smoking is associated with an increased risk of child malnutrition among families in rural Indonesia.2%. p = 0. p<0. The prevalence of underweight and stunting was 29. male sex and child's age in months.16. Conclusion Programmes aimed at improving stunting in North Maluku province of Indonesia should focus on children under two years of age. male sex and number of family meals per day (≤2 times). Methods: The relation between paternal smoking and child malnutrition was examined in a population-based sample of 438 336 households in the Indonesia Nutrition and Health Surveillance System. defined by respective Z scores <−3.11. for children aged 0–59 months of age.12.0) and 18. 95% CI 1. The purpose of the current study was to assess the prevalence of and the risk factors associated with stunting and severe stunting among children aged less than five years in North Maluku province of Indonesia.9-41.13. paternal smoking was associated with an increased risk of underweight (odds ratio (OR) 1.001) and severe underweight (OR 1.09 to 1.4% (95%CI: 35.7%. child's age in months and male sex for children aged 0-59 months. 14.1-20.1%.Prevalence and risk factors for stunting and severe stunting among underfives in North Maluku province of Indonesia Abstract Background Adequate nutrition is needed to ensure optimum growth and development of infants and young children.1% (95%CI: 11. respectively.03. child age.01 to 1. maternal age. male sex and child's age in months and for children aged 0-59 months were income (poorest family).4% and 31. Results: The prevalence of paternal smoking was 73.0-32.01 to 1.4% (95%CI: 16. for children aged 0-23 months.13. 95% confidence interval (CI) 1. Main outcome measures were child underweight (weight-for-age Z score <−2) and stunting (height-for-age Z score <−2) and severe underweight and severe stunting. of male sex and from families of low socioeconomic status. maternal education. weekly per capita household expenditure and province. After adjusting for child gender. Results Prevalence of stunting and severe stunting were 29% (95%CI: 26.

Factors at one level influence other levels. undernutrition remains an important public health problem(3. 2?29) and low birth weight (OR51?8. throwing garbage in the street (OR513?81. Stunting (i. These effects occur even in mild-to-moderate cases(3). Logistic regression was used to determine individual risk factors in bivariate and multivariate analyses. poor housing environment. 30?95). This framework.11. 2?16. risk factors were young age (1 –2 years: OR5 2?32. 3?22. 95% CI 1?67. which was developed in 1990 as a part of UNICEF‘s nutritional strategy(8).5 years in developing countries. 95% CI 1?22. At risk-groups include those with young age (1–3 years). In multivariate analysis. It is more difficult to treat than acute forms of undernutrition such as wasting. Such determinants usually occupy different positions in the dependence chain and they cannot adequately be modelled by including them all in a linear regression analysis(10. demography. resident of Al-Akhdar region. 95% CI 1?08. diarrhoea and low birth weight. poor psychosocial stimulation.e. Keywords Libya Children Under-fives Stunting Risk factors Nutritional status is a sensitive indicator of the quality of life in a given population(1. 95% CI 2? r The Authors 2008 are multifactorial with roots in many sectors of development such as education. Our aim was to ascertain major predictors of stunting in children . 95% CI 1?05. 95% CI 1?20. 2?40). 95% CI 2?31.12). Population and methods: A nationally representative. Identification of the causes in a particular setting implies the investigation of complex interactions between these multiple interrelated social. having a less educated father (illiterate: OR52?10. Protective factors were older age of father (OR50?53. 95% CI 1?09. It classifies the causes of undernutrition into three categories that account for the complexity of the nutritional status of children: (i) basic causes at the societal level.7). 3?77. Libya is classified as a low-prevalence area of wasting (3?3%) and stunting (15?1%) using the National Center for Health Statistics/Centers for Disease Control and Prevention/ . Undernutrition profoundly affects human function. boys. preparatory school: OR51?71.4).9). Results: Anthropometric measurements were available for 4498 children. Reduction of undernutrition prevalence by 50% between 1990 and 2015 is among the most important targets of the first Millennium Development Goal. filtered water (OR58?45. being a boy (OR51?28. 95% CI 0?32. 95% CI 1?17.Objective: Stunting is a chronic condition reflecting poor nutrition and health. provides a holistic and pragmatic approach. One example of such a model is the UNICEF conceptual framework. 2?65). economic and environmental determinants. while transgenerational effects refer to a similar vicious spiral that extends to forthcoming offspring and induces permanent effects on mental. More than half of deaths of children in these countries are related to undernutrition(5). Nevertheless. low height-for-age) is a chronic condition that reflects poor linear growth accumulated during preand/ or postnatal periods because of poor nutrition and/or health. 95% CI 0?54. These variables only explained 20% of cases of stunting. progress remains slow. two-stage stratified cluster sample survey enrolled 4549 under-fives from 6707 households. Conclusion: Various multilevel actions are needed to improve nutritional status of under-fives in Libya. father‘s low educational level. cross-sectional. Individual effects include the well-known undernutrition–infection vicious cycle. Despite global improvement in the health of children aged . 2?21). Causes of stunting *Corresponding author: Email tajoury@pediatrician. They can be better understood within an integrated conceptual framework that considers these factors and their interactions(8. 95% CI 1?11. diarrhoea (OR51?58.6. 95% CI 1?07. resident of Al-Akhdar (OR51?67. obesity (particularly the abdominal type) and chronic diseases makes it an important health hazard even for countries in transition. agriculture and rural development(8. and (iii) immediate causes. Undernutrition also affects society at large because it leads to reduced productivity and limited ability to escape the consequences of poverty(3. Its relationship to micronutrient deficiencies. poor psychosocial stimulation (no family visits or trips: OR51?52.11). 4?16). 2?58). Among the 929 stunted children (20?7 %). 495 were boys (53?3%) and 434 were girls (46?5 %). 2–3 years: OR51?64. 81?72). Reduction of the prevalence of undernutrition in under-fives is a top priority to reduce child mortality and morbidity. with both individual and transgenerational effects. 1?55). 0?90). father rarely/never plays with child: OR52?24. and most international goals set for improving child nutrition and health were not met by 2000.5 years old in Libya. social and physical well-being. (ii) underlying causes at the household/family level.2). 0?90) and water storage (OR50?70. 95% CI 1?17.

0?5 were also selected. In the second stage.26 as outliers. were selected randomly. Switzerland) and SPSS version 13 (SPSS Inc. methods and nutritional status of under-fives in Libya from the LMCHS are described in more detail elsewhere(13. The Libyan Maternal and Child Health Survey (LMCHS). two mountainous (Al-Akhdar and Al-Gharbi) and two predominantly desert areas (Sirt and Sabha). Sirt.15. Population and methods Design The design. In the first stage. In bivariate analysis. IL.15). Tripoli and Al-Zaouia). birth.14). being a boy. in rural areas and in underprivileged groups(13. two-stage stratified probability cluster sample of 6707 households that was undertaken during the summer of 1995. Weight. including 102 units from rural areas. Data and outcome measures Data were collected in interviews with mothers during household visits using the three different standard PAPCHILD questionnaires with a few modifications to conform to local patterns of disease and determinants(17). low paternal and/or maternal education and limited psychosocial stimulation (absent or rare interaction between the child and father.5 years in this population. and a locally validated socioeconomic classification that incorporates parental occupation and education(18). etc. These regions were three costal (Benghazi. In the final stage. Each region was divided into urban and rural zones. Improvement in nutritional status needs effective planning that accounts for the underlying risk factors. USA) statistical software package. Basic determinants included age 1–3 years. As such. Al-Zaouia or Al-Gharbi regions.0?02). belonging to less privileged groups.0?05. nutrition. is the first nationally representative maternal and child health survey ever undertaken in Libya(13. Other basic attributes of the children participating in the survey are shown in Table 2. All children younger than 60 months at the time of the survey were eligible for recruitment. with the second year having the highest risk even in comparison with the first year (OR51?31. nationally representative. large family size (having $4 siblings in the family). Stunting was defined as a length/height more than two standard deviations below the median height/length-for-age of the WHO Child Growth Standards from the WHO Multicentre Growth Reference Study(16). absence . Stunting in Libya is more prevalent in certain geographic regions. each sampling unit was divided into five segments of equal sizes. These variables were organized according to the conceptual framework developed by UNICEF(8). The reproductive health questionnaire contained items on the mother‘s health and reproductive history.WHO reference growth curves(13. determining for each of the variables the odds ratio. The LMCHS is a cross-sectional. Statistical analysis with logistic regression was performed by SPSS. undertaken as part of the Pan Arab Project for Child Development (PAPCHILD). There is a paucity of studies that would permit a fuller contextual assessment of the patterns and determinants of undernutrition in Libya. sanitation facilities and garbage collection. identifying at-risk subgroups and permitting targeted interventions. Analysis of national cross-sectional surveys can provide clues to fill this gap. a total of 307 sampling units. 95% CI 1?04. Statistical analysis Data were analysed using WHO Anthro 2005 software (WHO. The level of significance was set at P. Each independent variable was individually evaluated in bivariate analyses for possible correlation with stunting. some other potentially confounding variables as 1142 A El Taguri et al. 95% confidence interval and statistical significance of the association with stunting. length/height and age data were used to calculate Z scores of height-for-age in comparison with the newly published WHO growth curve. various significant factors increasing (Table 3) or decreasing (Table 4) the risk of stunting were found. indicated by P. 1?64. Results Anthropometric measurements were available for 4498 children.17). The third questionnaire gathered data on household characteristics and the surrounding environment such as the availability of safe water supply. Socio-economic classification was based on the combination of an asset index of households with its area characteristics. there were 495 boys (22?2%) and 434 girls (19?4 %). Geneva. The child questionnaire contained items related to child health and its determinants such as vaccination.17). living in rural areas and being a resident of Al-Akhdar. Rates are as high as 28% in Al-Akhdar region when the newly published growth charts from the WHO Multiple Centre Growth Reference Study(16) are used. All households in one randomly selected segment were included in the sample. The WHO Anthro 2005 program considers Z-score values for length/height-for-age . The present study is a secondary analysis of the raw data from the LMCHS. Among the 929 stunted children (20?7 %). P. The aim was to ascertain predictors of childhood stunting in children aged . Only statistically significant risk factors are presented here. Chicago. in addition to the variables that were identified as significant in the bivariate analyses. The independent variables that were chosen for their possible association with stunting are shown in Table 1. These were all put together in a single logistic regression model to determine their net effects on stunting. Underlying determinants found included family and caregiver conditions such as consanguinity. the country would be reclassified as an intermediate-level country(15).. The country was divided into seven administrative regions.

gender. 2?70 0?004 Primary 184/839 1?91 1?31. 1?63 0?03 Family goes on no trips or visits 144/482 1?77 1?42. age. history of prematurity. abortion and previous sibling deaths Father’s attributes Educational state. 2?24 0?04 Family does not watch television 94/323 1?75 1?35. 2?47 0?000 2–.1 year 172/780 1?50 1?17. if weaning started at 6–8 months of age and if breast-feeding continued for . currently working for cash. preserved baby foods or family foods Health Diarrhoea. otitis. stillbirth. state of the area around dwelling (flooded or stagnant water) III Immediate determinants Diet Feeding history of the child*: onset. Meanwhile. type and location of toilet facilities. 2?89 0?000 Read and/or write 106/504 1?81 1?22. animal and pasteurized bottle milk. age at first marriage. blood relation with husband. 1995 Risk factor n/N OR 95% CI P I Basic determinants Living in a rural area 316/1363 1?24 1?07. accidents or other illnesses.of external social contact. source. 2?05 0?000 II Underlying determinants Family and caregiver conditions Consanguinity (ref: No relation) 452/2381 1?00 – Husband is a paternal cousin 328/1461 1?24 1?05. Table 2 Basic attributes of under-fives involved in the Libyan Maternal and Child Health Survey. 1?45 0?006 Age (ref: 4–. Onset of weaning at 4–6 months of age rather than 6–8 months and a large birth weight decreased the risk for stunting. Delivery in a private health establishment decreased the risk. storage and treatment of drinking water. juice. 1?51 0?03 Underprivileged 188/750 1?61 1?27. mother’s age and age at birth. 1?45 0?01 Husband is a maternal cousin 122/523 1?30 1?03.3 years 204/968 1?42 1?12. 1?40 0?01 Socio-economic class (ref: Privileged) 150/870 1?00 – Intermediate 591/2877 1?24 1?02. extended family. earning regular wages Health services Immunizations. location and disposal of garbage. change of residence. 2?15 0?01 Al-Gharbi 122/488 1?92 1?42. Other underlying determinants included poor utilization of health services (absence or poor follow-up during pregnancy. use of Caesarean section Household environment Area of residence and household characteristics: dwelling type and ownership. 2?26 0?000 . multiple wives. type. duration and practices of breast-feeding. 1?92 0?001 1–.3 968 21?5 3–. giving rice. 1?80 0?004 Region (ref: Benghazi) 89/604 1?00 – Al-Akhdar 154/552 2?24 1?67. place and complications of delivery. 2?78 0?001 Preparatory 128/666 1?62 1?10. collection. 3?00 0?000 Sirt 157/631 1?92 1?44.1 780 17?3 1–. herbal drinks. type of weaning. living arrangements. whereas if weaning started between 4 and 6 months of age. the model was significantly associated with stunting. keeping animals. watching and reading of media.5 years) 138/871 1?00 – . 1995 Variable n % Age of child (years) . residence in the last 3 months. breast-feeding was considered appropriate. weight at birth *Optimal breast-feeding was considered if breast-feeding started early. conjunctivitis. measles infection. but it explained only 20% of the variance as indicated by its R2 value (Table 5).5 871 19?4 Gender Boys 2231 49?6 Girls 2267 50?4 Socio-economic class Privileged 870 19?3 Intermediate 2877 64?0 Underprivileged 750 16?7 Area Urban 3135 69?7 Rural 1363 30?3 Region Al-Akhdar 553 12?3 Benghazi 604 13?4 Sirt 631 14?0 Tripoli 1513 33?6 Al-Zaouia 407 9?1 Al-Gharbi 487 10?8 Sabha 303 6?7 Degree of stunting Mild 1167 25?9 Moderate 591 13?1 Severe 324 7?2 Stunting risk factors in Libya 1143 Table 3 Bivariate analysis of factors associated with increased risk for stunting in under-fives in Libya: secondary analysis of data from the Libyan Maternal and Child Health Survey. being a first or a single child decreased the risk for stunting. urbanization. age of introduction of powdered. socio-economic conditions II Underlying determinants Family and caregiver conditions Main caregiver.2 895 19?9 2–. number of rooms and bedrooms. introduction of solid foods. poor family social life Reproductive history of mother Age at menarche. infant formula-feeding and bottle-feeding. check-ups during pregnancy. single mother. cough. Many immediate factors related to feeding practices and health status such as low birth weight and diarrhoea were found also to increase the risk of stunting. incomplete immunization). The logistic regression model for multivariate analysis included the factors reported above in addition to some other potentially confounding variables such as father‘s age. 2?56 0?000 Al-Zaouia 86/407 1?55 1?12. working for cash before or after marriage. 2?39 0?02 Secondary 112/614 1?51 1?02.4 983 21?9 4–. educational state of mother. number of children.12 months. listening. inadequate sanitation and garbage collection were among the underlying determinants that increased the risk of stunting.2 years 242/896 1?96 1?55. type of previous residence. Table 1 Variables assessed for their possible association with stunting I Basic determinants Region of residence. birth order of the child. Overall. kitchen location and fuel used. father‘s education and using water from wells without pumps. Housing environment such as type of dwelling. 2?61 0?000 Boys 495/2230 1?21 1?05. 2?20 0?000 Educational status of mother (ref: University) 39/301 1?00 – Illiterate 345/1507 2?02 1?41. fever. lack of safe water supply. absence of media contact). playing with the child. birth order.

2?34 0?000 Secondary 210/944 1?72 1?29. recall bias. 1?89 0?006 Traditional 198/797 1?82 1?38. 1?55 0?009 Household environment Dwelling type (ref: Apartment) 88/578 1?00 – Popular 252/1216 1?45 1?11. 1?63 0?000 Thrown in street 14/44 2?18 1?15.Family does not listen to radio 461/2100 1?17 1?01. Discussion Libya is a country with an intermediate level of income. number of stunted children in the category.12 months) 73/470 0?69 0?53. much work remains to be done(15). A number of programmes were implemented to improve the nutritional status of the population in the second half of the last century. 7?21 0?03 Source of drinking water (ref: Pipe system) 521/2522 1?00 – Wells without pump 88/318 1?46 1?12. with a per capita gross domestic product of $US 6418 in 1995(19). 0?92 0?009 Inappropriate 458/2342 0?77 0?65. 1126?81 0?000 Kitchen location (ref: Inside dwelling) 873/4296 1?00 – Outside dwelling 49/185 1?41 1?01.4 months 449/2257 0?84 0?71. N. 0?96 0?02 More than 6 h 211/1120 0?74 0?60. 1?35 0?04 Number of siblings (ref: 2–4) 302/1494 1?00 – . We did not find any evidence of significant collinearity in our model. N. certain inherent limitations may arise in the study such as the difficulty to examine temporal relationships. A nutritional surveillance system was introduced in maternal and child health centres.5 391/1743 1?18 1?00. 3?42 0?001 Sometimes 291/1277 1?22 1?04. 1?70 0?002 III Immediate determinants Dietary intake Table 4 Bivariate analysis of factors associated with decreased risk for stunting in under-fives in Libya: secondary analysis of data from the Libyan Maternal and Child Health Survey. 1?90 0?005 Rainwater catchment 23/70 1?84 1?11.20). Large amounts of resources were spent on food subsidy programmes and also on food distribution activities for women and children(15). 0?99 0?04 4–6 months 98/547 0?74 0?57. 0?89 0?000 Given infant powdered milk 438/2268 0?85 0?74. 3?04 0?03 Others 27/28 149?48 19?83. 7?93 0?000 Open air 17/53 2?09 1?16. 2?96 0?02 Other 49/155 1?69 1?17. Table 3 Continued Risk factor n/N OR 95% CI P Garbage disposal method (ref: Plastic bags) 288/1609 1?00 – Container without lid 434/1871 1?38 1?17. 0?89 0?005 Breast-feeding practices (ref: Optimal) 300/1248 1?00 – Appropriate 50/299 0?63 0?46. 4?14 0?02 Others 9/15 7?26 2?58. 43?45 0?02 Incomplete immunization 175/717 1?28 1?06. 0?89 0?01 Health services Place of delivery (ref: Public health establishment) 815/4022 1?00 – Private establishment 12/122 0?42 0?23. 0?93 0?005 Ever fed from infant bottle 604/3152 0?74 0?64. There have been marked improvements over the past few decades in the nutritional status of children(15. 0?77 0?005 III Immediate determinants Dietary intake Time after birth breast-feeding started (ref: . 3?06 0?02 Water storage (ref: No water storage) 231/1068 1?00 – Tin container 25/76 1?80 1?09. 0?97 0?03 Given pasteurized bottled milk 404/2195 0?77 0?66. 1?96 0?001 Weight at birth (ref: Normal) 758/3750 1?00 – Low birth weight 88/289 1?74 1?34. 0?87 0?002 Number of children (ref: 2–4) 316/1610 1?00 – Single child 35/267 0?61 0?42. 0?95 0?02 Feeding practices (ref: Optimal) 103/426 1?00 – Acceptable 60/339 0?68 0?47. 1?43 0?013 Educational status of father (ref: University) 79/550 1?00 Illiterate 122/487 2?00 1?46. The result was a many-fold rise in the price of most food items. 2?17 0?000 Others 4/6 7?87 1?43. 2?73 0?000 Read and/or write 89/455 1?47 1?05. number of stunted children in the category. 1?53 0?005 Place of delivery (ref: Public health establishment) 815/4022 1?00 – Home 79/267 1?65 1?26. However. 0?92 0?006 Age when animal milk was given (ref: Not given) 806/3815 1?00 – Delayed introduction (. total number of children in the category. 0?92 0?004 Given preserved baby food 269/1480 0?80 0?68. 1144 A El Taguri et al. 0?87 0?000 Health conditions of the child Weight at birth (ref: Normal) 758/3750 1?00 – Large-for-age at birth 44/329 0?62 0?44. 0?98 0?03 Given juices 700/3547 0?77 0?65. 0?88 0?007 Acceptable 93/507 0?71 0?55. 19?82 0?003 Type of toilet facilities (ref: Flush toilet with sewer) 438/2372 1?00 – Latrine with container 165/612 1?63 1?32. 2?28 0?000 Health services Mother had no check-ups during pregnancy 209/868 1?29 1?08. 3?76 0?02 Sudden weaning 399/1899 1?29 1?08. differences in seasonal distribution of risk factors. 1?86 0?03 Preparatory 207/910 1?76 1?33. 20?44 0?000 Garbage container located outside dwelling 276/1182 1?38 1?13. 1?97 0?04 No kitchen 7/17 2?80 1?09.1 h) 220/919 1?00 – Between 1 and 3 h 315/1585 0?79 0?65. total number of children in the category. However. 2?41 0?000 Modern 342/1789 1?31 1?01. 2?04 0?02 Primary 174/921 1?39 1?04. Stunting risk factors in Libya 1145 This is the first time that data have been exploited to formulate a hypothesis on possible factors determining the problem of undernutrition among under-fives in Libya. 2?00 0?000 Pit 17/35 4?06 2?08. 0?85 0?004 n. 1?69 0?04 Hut and house made from fur 22/91 1?79 1?06. 2?26 0?000 n. One of the important aspects of this survey is that it was performed during the peak of political and economic difficulties that faced the country in the 1990s following UN sanctions and the counteracting measures that were taken. 1?54 0?004 Health conditions of the child Diarrhoea 94/339 1?53 1?19. 1995 Risk factor n/N OR 95% CI P II Underlying determinants Family and caregiver conditions Birth order (ref: 2nd–4th child) 302/1494 1?00 – First child 88/608 0?67 0?52. 0?91 0?002 Age when powdered milk was given (ref: Not given) 309/1354 1?00 – . absence of data on maternal . 1?40 0?05 Father plays with child (ref: Almost every day) 585/3011 1?00 – Rarely/never 31/90 2?20 1?41. 2?44 0?005 Water treatment (ref: No treatment) 885/4305 1?00 – Treatment by filtering 7/11 6?01 1?82.

but it disappeared in multivariate analysis indicating that it was a confounding variable.nutrition and food practices of the family. absence of data on parasitic infections. Such factors include parental education. 1995 Risk factor OR 95% CI P I Basic determinants Resident of Al-Akhdar (ref: Benghazi) 1?67 1?08. 2?40 0?005 1146 A El Taguri et al. should have followed the horizontal expansion which occurred in the country during the 1970s. The paths indicated by the arrows in the UNICEF framework are meant to suggest distal v. to promote.30–50 years) 0?53 0?32. 3?77 0?01 Preparatory 1?71 1?11. The complex interrelated factors associated with stunting that we found in the current study are represented according to the UNICEF conceptual framework (Fig. Educated families live in smaller households. On other occasions. Further studies are needed to verify the exact role of these factors in this population. such models should be interpreted only from an exploratory point of view(11).28). The results of our study show the importance of the UNICEF model incorporating parental and socioeconomic characteristics in understanding the prevalence of stunting in Libya. 4?16 0?01 Father’s age . The two regions with the highest risk for stunting were the two mountainous areas. Gender is an important aspect of equity. 2?29 0?02 Low birth weight 1?68 1?17. dietary habits. There is no evidence of gender bias in stunting in Libya based on the current study. 81?72 0?004 III Immediate determinants Health conditions of the child Diarrhoea 1?58 1?09. exposure to unsanitary conditions increasing the risk of infections that suppress appetite and directly affect nutrient metabolism. and the possibility that respondents would answer in more socially desirable ways. 0?90 0?006 Water treatment by filtering (ref: No treatment) 8?45 2?31. In spite of equity-driven health and education service expansion in Libya during the 1970s. and return of the mother to work(11. 1?55 0?02 II Underlying determinants Family and care giver conditions Father’s educational status (ref: University) Illiterate 2?10 1?17. In the current study. . In the current study.22. Models constitute a platform for better comprehension of potential dynamics and possible sites of intervention(21). the Pan Arab Project for Family Health and Multiple Indicator Cluster Surveys do not evaluate measures taken by different authorities to combat undernutrition. paternal education and age were significant factors associated with stunting in the final model. People living in urban areas are provided with better access to health services. living practices.50 years at birth (ref: . 2?58 0?02 Age (ref: 4–. 2?16 0?02 Father rarely/never plays with child (ref: Almost every day) 2?24 1?20. Educated mothers are known to be older at their first birth and are more knowledgeable about care practices. 2?65 0?02 Family goes on no trips or visits 1?52 1?07. and are more adept at keeping their environment clean(11. 1). These factors determine the ability of the family to combine their knowledge. These findings may also reflect the absence of vertical expansion that Table 5 Multivariate analysis of risk factors associated with stunting in under-fives in Libya: secondary analysis of data from the Libyan Maternal and Child Health Survey.5 years) 1–. environmental conditions such as cold climate.27). stunting was related to living in rural areas as well as in certain geographical regions. proximal relationships. Possible explanations could include access to food. hygienic measures such as water supply. stunting was associated with age period of 1–3 years. Equal degree of undernutrition between under-five boys and girls by the year 2020 is accepted as a mean for evaluating gender equity in different societies(11. they are better able to use health-care facilities. Studies have shown conflicting results on the impact of consanguineous marriages on child health(29).12. The effects of income are known to be mediated through other underlying determinants (4. 0?90 0?02 Household environment Water storage in tanks (ref: No water storage) 0?70 0?54.11. 3?22 0?0001 2–.12). in better houses.25).23. In the current study.22–24). and do not necessarily mean that distal factors cannot have direct effects on stunting.12. Standard national cross-sectional studies such as PAPCHILD. However.12). Parental consanguinity was a significant factor associated with stunting in bivariate analysis in the current study.26). Other factors increasing the risk of stunting in this age period include loss of passive immunity. Higher education could reflect higher income and more paternal interest in child nutrition. absence of comprehensive data on mental health of the family including different psychosocial stimulation and/or interaction between family members.2 years 2?32 1?67. psychosocial stimulation and household environment(4. A strong inverse association between child height and altitude has been noticed previously. On occasions. being from the less privileged groups was a risk factor initially but disappeared in subsequent multivariate analysis.3 years 1?64 1?22. the anthropometric status of children worsens considerably only when they are weaned and particularly if low-quality solid foods are introduced. More educated fathers are more likely to have educated wives. resources and patterns of behaviour. 30?95 0?001 Garbage is thrown in the street (ref: Plastic bags) 13?81 2?33. education and other social support systems which are either not available or not easily accessible to residents in rural areas.12. and parasitic infections(7. children may be born undernourished due to growth retardation in utero and their growth may improve exponentially over time(11. 2?21 0?001 Boys 1?28 1?05. recover or maintain health status and to cope with a difficult environment(4. Stunting is known to be more prevalent in rural areas(22).23).

In the current study. the fact that storing water in tanks protects against infections in comparison to publicly supplied piped water calls for better quality control of this system. when a child is severely stunted. food hygiene is frequently poor. In the current study.12). The prevalence of diarrhoea from our data was found to be 17?3% (779/4498). In fact. Early introduction of complementary foods is a known predictor of undernutrition(23). In some regions of Libya and in spite of major drinking water projects. which increases the risk of pathogen contamination and exposure to illnesses. for example. Moreover. thereby predisposing children to repeated bouts of infection. These factors are known to influence stunting both directly and indirectly. In addition. Previous studies reported a similar observation where. breast-feeding was considered optimal if it started early.Indicators for health services utilization such as incomplete immunization. The current survey was conducted during the summer. including shelter. Examples include boiling of water from superficial wells and the use of desalinated or filtered water from near-by factories. and should not be an argument for advertising of these substitutes(11). optimal breast-feeding was not as protective as appropriate breast-feeding. many people have to use variable methods to obtain a continuous water supply or more palatable water. In other cases. sanitation and environmental safety. after which supplementary foods should be introduced appropriately into the child‘s diet(24). or lacking in some micronutrients. Sirt. methods of water storage and treatment * Type of toilet facilities Garbage container location and method of disposal such as throwing in the street* Less privileged sections of the community Inhabitants of rural areas Inhabitants of certain geographical regions such as Al-Akhdar*. Diarrhoea is a known risk factor for stunting(11. Environmental factors refer to the availability of safe water. An initial period of exclusive breast-feeding is essential to lower the risk of stunting. longer breast-feeding was associated with both higher stunting and severe stunting risk(24). and Al-Gharbi Boys* I.30). Al-Zaouia. Immediate determinants When water is not readily available. Targeting health education messages to mothers with children younger than 3 years old may be an important option to consider.31). poor check-up during pregnancy and non-supervised deliveries were all risk factors for stunting. Health knowledge and access to health care could also explain regional differences in undernutrition(11. Having piped water in the home also reflects higher income levels and/or that the environmental sanitation in these homes is better. most of the positive effect of income on child height could be mediated by the quality of family housing(7.33). but there is a debate as to the most suitable age that supplements should be first given(32). In the current study. As children get older. Environmental factors such as poor housing and exposure to untreated water are known to be associated with stunting(30. Breast milk contains the mix of nutrients that is best suited to the infant‘s metabolism. they may become more immune to infections due to a gradual increase in the colonization of various bacteria and viruses in the gut. there was a protective effect of bottle feeding and early introduction of breast milk substitutes such as powder milk or pasteurized bottled milk. if it was continued for . household quality was an important risk factor in the multivariate model. However. Diarrhoea could be related to food preparation and feeding practices and to increased exposure to pathogens as children become increasingly mobile throughout the first three years of life. as in Libya. which might compromise growth. It was considered appropriate if weaning started earlier (between 4 and 6 months). Dietary intake Breast-feeding practices Complementary feeding and weaning practices Health Weight at birth* Diarrhoea* Fig. Such water may be either contaminated. mothers may respond by a decision to continue breast-feeding(24. This should be viewed as failure of optimal complementary feeding and the inability of the household to provide supplemental foods. 1 Explanatory model and possible interactions of different risk factors associated with stunting among under-five children in Libya based on the UNICEF conceptual framework(8) of the determinants of nutritional status (*bold italic font indicates those factors that persisted in the multivariate model) Stunting risk factors in Libya 1147 STUNTING Family and caregiver conditions Consanguinity Family size Parental education* Father’s age* Psychosocial stimulation* Health services Follow-up during pregnancy and delivery Immunization Household environment Dwelling type Kitchen location Source of drinking water.23. Underlying determinants III.12 months and if weaning started at 6–8 months. The use of bottle feeding predisposes to infections and may be associated with diluted non-nutritive formula preparation(24). none of the dietary intake factors in the current study persisted .23). Basic determinants II.

703– en/ (accessed April 2008). As in other datamapper/index. In the current study. This is achieved for a household when secure access to food is coupled with a sanitary environment. The current study provides relevant information for determining courses of action to be taken at the meso and micro level to improve the nutrition and health of children in Libya. diarrhoea and low birth weight.B. 1677–1691. Baltimore. 7. 7–15. Libyan J Med AOP: 071006. World Health Organization (2005) Libyan Arab Jamahiriya. Foraita R. de Onis M. 12. 20. were responsible for study design and coordinated the supply of the data. Castillo R. particularly on regional differences. PhD Thesis. was responsible for data analysis and interpretation. contributed to drafting the paper. 9. The Libyan Maternal and Child Health Survey.E. 335–351. 2nd ed. Nutrition Policy Discussion Paper no. Drachler Mde L & Giugliani ER (2004) Determinants of growth retardation in Southern Brazil. Switzerland. 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UNICEF (1990) Strategy for Improved Nutrition of Children and Women in Developing Countries. 14. performed statistical analysis and drafted the paper. Perez-Cuevas R. and their effects started even before birth(35). Lancet 1. and I. less educated fathers. P. 409–415.php (accessed April 2008).in the multivariate model. Sert. Policy frameworks must be established that incorporate short-. Klasen S & Pigeot I (2003) Undernutrition in Benin – an analysis based on graphical models. Abdel Monem A. 5. is required to design relevant and effective intervention programmes. http://www. Selwyn BJ & Shah SM (2005) Prevalence and correlates of stunting among primary school children 1148 A El Taguri et al. 459–466. 13. Corresponding intervention strategies should be comprehensive. Khuwaja S. Monteiro C. 7. Geneva: ACC/SCN. Econ Hum Biol 2.T.M. http://www. World Economic Outlook. difficult to manage. 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Goldstein H & Tanner JM (1980) Ecological considerations in the creation and the use of child growth standards. Pan Arab Project for Child Development (2006) Arab Maternal and Child Health Survey. Particular attention should be given to the particularly brief window of intervention from the mother‘s pregnancy through the child‘s first two years of life. 11. Sandoval A. Low birth weight is a known correlate of stunting(12. 21. WHO Multicentre Growth Reference Study (2006) Enrolment and baseline characteristics in the WHO Multicentre Growth Reference Study. Santos JI. the broader concept of nutritional security should be implemented. Nutr Rev 52. Acknowledgements There are no conflicts of Interest and no sources of funding. supervised data analyses and contributed to interpretation of To fight undernutrition sustainably. A. adequate health services and knowledgeable care. the risk factors of stunting that we found were diverse. 4. Behrman JR & Skoufias E (2004) Correlates and determinants of child anthropometrics in Latin America: background and overview of the symposium. O. changes in many of the underlying factors are necessary(11). In spite of the existence of food security programmes in Libya. Oxford: Blackwell Science. Principal Report. culturally sensitive and addressed at various levels. The General People‘s Committee for Health and Social Affaires (1996) The Pan Arab Project for Child Development. The known effect of low birth weight on child health makes it the most relevant single factor for children‘s survival(34).M. University of Zurich. MD: The Johns Hopkins Press. 1182–1190. in rural areas of southern Pakistan. 582–585. it had a potent effect on stunting that persisted in the single multivariate analysis.who. Bull World Health Organ 71. Am J Public Health 96. Authors’ contributions: A.and long-term strategies to solve nutritional problems in Libya. Mahmud SM. 10.G. 72–77. 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BMC Pediatr 7. Econ Hum Biol 2. Measures of household demographic and socioeconomic characteristics. 30. risk factors. New York: Raven Press. WHO Working Group (1986) Use and interpretation of anthropometric indicators of nutritional status. Stunting risk factors in Libya 1149 16. 25. household socioeconomic characteristics emerged with behavioral and biological variables as important determinants of malnutrition. Ann Nutr Metab 46. Br J Nutr 94. Nestle´ NutritionWorkshop Series. father‘s education and presence of a television and/or radio. Mohamed AG. The preyalence of wasting in children the same age ranged from 1. Himes JH & de Onis M (2002) Prevalence of nutritional wasting in populations: building explanatory models using secondary data. 23. Astrom AN. 4). a recent comparative analysis of Demographic and Health Survey data from 19 developing countries (8 from Sub-Saharan Africa. Mahfouz A & Zeid HA (2001) Malnutrition among pre-school children in Alexandria. 109–126 [JC Waterlow. Am J Clin Nuir l996.Risk factors for wasting and stunting among children in Metro Cebu. Eur J Clin Nutr 62. 260–270. 275–280. Wamani H. Fernandez ID.3% in Trinidad and Tobago to 69. by urban or analyzed cross-sectionally in six child age-residence strata by using logistic regression. Maunder E. Stunting signifies the accumulated consequences of . Suppl. 28. 4–13. 33. editor]. 609–618. nutritional disorders. In Linear Growth Retardation in Less Developed Countries. 24. They also indicate that the principal risk factors for stunting and wasting in infants < 6 mo of age were either maternal behaviors or child biological characteristics under maternal control. Philippines. 29. Dev Med Child Neurol 45. For example. Yan H & Yamamoto S (2008) High altitude and early childhood growth retardation: new evidence from Tibet. Bentley ME & Ahmed S (1966) Is prolonged breastfeeding associated with malnutrition? Evidence from nineteen demographic and health surveys. Niteroi. Nofal L. These figures provide important evidence of a global nutrition problem that must be addressed. El-Sayed N. Branca F & Ferrari M (2002) Impact of micronutrient deficiencies on growth: the stunting syndrome. Bull World Health Organ 64. breast-feeding status and birth weight. 17. Steyn NP. Tumwine JK & Tylleskar T (2007) Boys are more stunted than girls in sub-Saharan Africa: a meta-analysis of 16 demographic and health surveys. 3 from the Near East/North Africa. Peterson S. Dang S. and 6 from Latin America/Caribbean) indicated that the prevalence of stunting in children 1 y of age ranged from 5.4% in Guatemala (2). Nutrition 21. 2 from Asia. Implications of the results for interventions are discussed. 35.2% in Colombia to 19. 26. Labadarios D. respectively.63:96675. 929–941. McDonald J & Shlomowitz R (2004) Infant feeding practices and chronic child malnutrition in the Indian states of Karnataka and Uttar Pradesh. Brazil. and child biological variables were developing countries indicate that. However. Bull World Health Organ 80. 14.4% in Sri Lanka. 31. Reilly JJ & Wells JC (2005) Duration of exclusive breastfeeding: introduction of complementary feeding may be necessary before 6 months of age. 342–348. stunting (a deficit in length relative to age) and wasting (a deficit in weight relative to length) affect > 40% and > 10%. and wasting among children aged 5 and under in western Kenya. of children < 5 y (1). Caulfield LE. maternal characteristics and behavior. stunting. 27. 34. they mask the marked variation in proportions of stunted and wasted children that exist from country to country. Biological and epidemiologic evidence indicates clearly that stunting and wasting represent different processes of malnutrition (3. 693–703. eg. After 6 mo of age. Nel J & Lombard C (2005) Secondary anthropometric data analysis of the National Food Consumption Survey in South Africa: the double burden.22. eg. vol. Our results support biological and epidemiologic cvidence that wasting and stunting represent different processes of malnutrition. Ann Hum Biol 29. 139–158. Rappaport R (1987) Endocrine control of growth. 1. Bittles AH (2003) Consanguineous marriage and childhood health. Philippines ABSTRACT Risk factors for wasting and stunting were examined in a longitudinal study of 18 544 children younger than 30 mo in Metro Cebu. Household socioeconomic status influenced the risk of stunting earlier in rural than in urban barangays. stunting. wasting INTRODUCTION Statistics on the prevalence of protein-energy malnutrition in rural residence. 32. Brennan L. and among children at different ages. on average. Egypt. 8–17. 571–576. malnutrition. KEY WORDS Anthropometry. Marins VM & Almeida RM (2002) Undernutrition prevalence and social determinants in children aged 0 –59 months. J Trop Pediatr 50. Int J Epidemiol 25. 282–291. 869–872. Bloss E. pp. J Health Popul Nutr 19. Wainaina F & Bailey RC (2004) Prevalence and predictors of underweight.

One documented at different ages and in different environmental and sociocultural settings. They include both an increased risk of morbidity from infectious diseases (5-7) and of mortality (8. Received June. particularly during episodes of the Maryland Department of Health and Mental Hygiene. 1996. neonatal. These women experience an increased risk of mortality during childbirth (16) and of poor pregnancy outcomes such as low birth weight and elevated perinatal. The prevalence of stunting gradually increases in children from birth to ―ı‗2 y of age when it tends to level off (3). 2011 RISK FACTORS FOR WASTING AND STUNTING 967 in children represents only one stage in an intergenerational continuum of impaired function that affects not only currently malnourished children. Under conditions of marginally adequate food intake. and environmental ecosystems warrant a populalionspecific approach when studying risk factors for malnutrition. The analyses . cultural beliefs. 500 North Calvert Street. the Bureau for Science and Technology and USAID/ Manila through the Child Survival Project. by guest on December 29. Philippines. being small is of lesser concern than is the process of becoming small. and the Department of Population Dynamics.slowed skeletal growth often associated with long-term dietary I From inadequacy. 9). acute infectious illness. Wasting can result from either weight loss or failure to gain weight. Baltimore. Small achieved body size often indicates that conditions have detrimentally affected human environmental factors. Baltimore. Then. as stunted children mature. MD 21202. Research is needed on risk factors for stunting and wasting development (11). we also expect risk factors for malnutrition to vary among functional consequence of stunting includes reduced learning ability in school (14). or both. and the Institute for International Programs at The Johns Hopkins University. 1995. Thus. its onset can occur rapidly. diminished functional capacity The purpose of this study was to examine risk factors for wasting and stunting in children < 30 mo of age in Metro Cebu. and populations. Differences in population characteristics such as patterns of dietary intake and morbidity.ajcn. 18). However. and their subsequent offspring (19). The application of such study results will help to improve the outcome of interventions designed to improve nutritional status. the functional consequences continue. Accepted for publication February 1. The ramifications of wasting are well-documented. 2 Supported in part by the United States Agency for International Dcvelopment (USAID). Developmental impairment is the most extensive public health problem among children in many developing countries (12) and its effects can be permanent (13). Many stunted children will never achieve their full growth potential and will mature into stunted adolescents and adults (10). We know that inadequate food intake and high morbidity within the social and economic context of poverty increases children‘ s risk of growth faltering. and to recommend interventions. However. In 1985. Wasting indicates that a child has an unusually low body tissue and fat mass for an individual of his or her length. access to health care. an estimated 500 million women of reproductive age in developing countries were stunted as a result of childhood proteinenergy malnutrition (15). Maryland Department of Health and Mental Hygiene. Stunting also poses a considerable nutrition Downloaded from www. The Johns Hopkins University School of Hygiene and Public Health. in addition to other problem. Both wasting and stunting are associated with poor health outcomes in infants and young children. the health consequences of which are less well understood. impairs the fulfillment of individual genetic potential throughout life (20). because malnutrition is etiologically heterogenous among populations (2 1). infant mortality (17. Malnutrition. Wasting peaks in prevalence between 12 and 24 mo of age when dietary insufficiency and diarheal diseases are most frequent (3). 3 Address reprint requests to JA Ricci. repeated infections. Baltimore. child caregiving behavior (including feeding practices). but also adolescents and adults (particularly women) who were malnourished as children.

current weight. field personnel obtained detailed information on the demographic. and economic status of study households. Maternal information included a reproductive history. Households were enrolled in the study and participated as long as a child younger than 30 mo was resident. Data were collected on each child during an initial (baseline) visit and then at ―6-mo intervals until the child exited the study. prenatal care sought for the study child. At baseline. they quit. of Metro Cebu. these are classified officially as rural barangays (23). and distance to nearest health facility. Ltd. The research design called for periodic crosssectional surveys of all households in a fixed sample of urban and rural barangays. Children were measured while wearing only either because they reached 30 mo of age or because the study ended. Mothers were asked whether children had had an episode .5 y. Children‘s recent history of illness was obtained by interview with a validated morbidity instrument and protocol (25. and recent history of illness. and children. Older children at study entry and new births during the last 6 mo of the study contributed only one record. all field personnel were trained to measure weights and lengths and were retrained in anthropometry twice during the study‘s 2. they refused to light clothes at home and in the presence of and with permission from their mothers. water and sanitation facilities. Recumbent length was measured on all children. anthropometric. During the followup surveys. behavioral. The study examined a total of 18 544 children younger than 30 mo from 7 urban and 26 rural barangays. regardless of experience. encompasses Cebu City and its entire metropolitan area.5 million people resided in > 200 of residence. Eighty-two percent of the children exited the study Field staff were all college graduates with experience in data collection. immunization history. Baltimore.identified demographic. they were not contacted. and biological correlates of wasting and stunting in children in three age groups residing in urban and rural sectors participate. knowledge and use of oral rehydration solution. The study was conducted between July 1988 and December 1990. located on Cebu Island. ownership of radio and television. The evaluation included an assessment of the reach and effectiveness of health services and an evaluation of their effect on the Approximately 70% of study children were visited on more than one occasion. mothers. Metro Cebu. field personnel measured children‘s weights and lengths and interviewed mothers to update their predominantly urban barangays (local political administrative units). socioeconomic. At the time of this study. Some agricultural and fishing areas are also located in Metro Cebu. health. A Salter scale (CMS Weighing Equipment. current breast-feeding status. The sampling criteria and methods were described previously (22). current reproductive status and their children‘s recent history of illness. London) and a locally made infantometer were used following standard procedures (24).5 observations during the course of their study participation. with each child contributing an average of 2. one of the Central Visayan islands of the Philippines. However. Household data included the demographic composition and characteristics of the household. including anthropometry. SUBJECTS AND METHODS Data collection The data for this research were collected by the Office of Population Studies of the University of San Cabs as part of a larger longitudinal study to evaluate health services provided by the Philippines Department of Health in Metro Cebu. type and construction morbidity and mortality of children younger than 2 y (22). Migration and death accounted for the study exit of another 12% and 3%. The remaining 3% of chilthen were lost to follow-up (eg. recumbent length. means of transportation. Severely ill children were referred to the nearest health facility. and current contraceptive practice. Metro Cebu‘s population of 1. or they were not available). Information on the child included birth weight. including those > 24 mo of age. 26). The study was conducted under the ethical guidelines of the Committee on Human Research at The Johns Hopkins University School of Hygiene and Public Health. respectively.

age of child. Data were analyzed cross- sectionally within each of the six age-residence strata. type of toilet. First. This variable was selected because its three levels (neither mo. we weighted observations by the socioeconomic variable ―presence of a television and radio‖ in each age-residence stratum in which birth weight or length of previous birth interval was significantly associated with wasting or stunting (P < 0. were retained for inclusion . to analytically avoid the bias. and ill with both respiratory and diarrheal illnesses. basic descriptive statistics were generated: frequency distributions for categorical and ordinal variables and medians. These indexes were then expressed as Z scores relative to the international [National Center for Health radio nor television. maternal occupation. or television with or without radio) were roughly evenly distributed among households in each of the six age-residence strata. behavioral. yeas of maternal formal education. it was ignored as a specific category of illness in the analyses. sex. A child was categorized as stunted if his or her length was less than that of a child (of the same age) with a value 2 SDs below the reference median length-for-age. A child‘s nutritional status was then categorized by his or her length-for-age and weight-forlength z scores (30). Data analysis Data were initially entered and edited on microcomputers at the University of San Cabs with additional data cleaning at Johns Hopkins University. respectively. type of cooking fuel. means. Categorical and continuous variables that were significant (P < 0. To do this.05) according to a chi-square or t statistic. number of prenatal visits. and I 2-30 mo of age. Respiratory illness encompassed symptoms from mild coughing to severe pneumonia. and the data were available for all households. and weight-for-age (27. or measles during the previous 6 by guest on December 29. ill with severe respiratory disease only (defined as cough with difficulty breathing and _ 2 d of fever). Statistics (NCHS)/Centers for Disease Control and Prevention (CDC)/ World Health Organization] reference population to standardize the distribution (29). distance to clinic. In these tabulations no tests of significance were done. length of previous birth interval. years of paternal formal a value 2 SDs below the reference median weight-forlength. A comparison of the household socioeconomic characteristics of children with and without these data indicated that those without were of significantly lower socioeconomic status. it does not differentiate stunted from wasted children (3). Measles was defined as rash with fever on _ 4 d in the past 3 Data were stratified by place of residence (urban or rural) and the child‘s age at the time of interview. However. 28). A child was defined as wasted if his or her weight was less than that of a child (of the same length) with and biological variables were tested in each ageresidence stratum. Computer files were constructed with multiple records for each child and additional variables were derived to describe children‘s health and anthropometnic status. radio only. socioeconomic. we adjusted the socioeconomic distribution of the analytic sample (children with birth weights) to that of the entire sample (children with and without birth weights). maternal age. Diarrhea was defined by the mother‘s account. ill with diarrhea only. Therefore. and SDs for continuous variables. breastfeeding categories. Variables tested for an association with nutritional status included type of flooring material. child health status. type of wall material. and reported number of stools on the worst day was also recorded. Anthropometric measurements were converted to three indexes: length-for-age.of diarrhea or respiratory disease during the 2 wk before the interview. Four health states were defined: well. status at the time of interview. Bivariate associations between stunting and wasting and season of year and demographic. Because of the very low Downloaded from www. and season of year. paternal occupation. as a composite index. Three age intervals were created within each residence stratum based on clear age differences in the percentage of stunting and wasting observed during preliminary analyses: birth to 5 mo. 6-1 1 mo. month of first prenatal visit. water source. Approximately one-third of children in each ageresidence stratum had missing data on birth weight and/or length of previous birth interval. severe respiratory disease. or both if any of these illnesses existed simultaneously with measles. presence of television and radio. children with measles were included in the samples of children with diarrhea.05). birth weight. 2011 968 RICCI AND BECKER incidence of measles in the population. Weight-for-age was not considered beyond the descriptive level because. Children who were simultaneously wasted and stunted were included in both education. number of persons per room. weight-for-length.

As a product of the longitudinal research design. By 6. 12. RESULTS Characteristics of the sample The socioeconomic status of households differed markedly (n = 6072) Categorical variables Television and radio Neither . and the parents‘ amounts of formal education. number of persons per room). Attempts were made to apply generalized estimating equation models to adjust for the dependent observations (32). season of year and socioeconomic variables were added first. The order of between urban and rural barangays (Table 1). with the number of variables However. ownership of a television and radio. 2011 % 31 35 34 13 70 17 42 25 33 68 32 17 38 45 20 15 65 57 14 29 52 48 4599 85 15 4616 51 49 in the models and observations that required weighting. As a final step in refining the models. Results before and after application of the ―adjustment‖ procedure were very similar. Metro Cebu‘ Urban Variable (n 6698) Rural calculated from anthropometnic measurements with an anthropometric program of the CDC (34). interactions were tested between variables found to be significant predictors of wasting or stunting. Rural mothers were more likely to delay their first prenatal visit and have fewer such visits. Maternal reproductive characteristics and prenatal care also differed between urban and rural barangays (Table 1).05 based on the chi-square test of the difference in the -2 log likelihoods of the models with and without the variable present (31). urban and rural households differed little in household size and density (eg. 1 were retained for further testing. one observation was randomly selected for each child in the sample (using the RANUNI function) and the final models were rerun. Thus. the available software could not be used successfully on a data set of this size. on average. to have longer birth intervals. Logistic-regression models were constructed for each ageresidence stratum. Groups of covariates were added sequentially to the models. Urban households had clearly higher socioeconomic status as measured by housing characteristics such as water regression models. adding variables was determined by their conceptual relation to the outcome variables and progressed from distal to proximal. These observations violated the assumption of independence required for statistical tests.ajcn. followed by behavioral variables. the data set contained two or three observations on some children > 12 mo of age. Virtually all women initiated breast-feeding. Data preparation and analysis were performed by using SAS version 6. Variables included in the final logistic models were significant at P < 0. and relative changes in the magnitude and significance of regression coefficients were noted. in this age stratum. cooking fuel. Rural mothers also tended. by guest on December 29. Covariates with a significance level of P < 0. The median duration of breastfeeding in the sample was ı 12 mo. Collinearity diagnostics (condition indexes) were examined for evidence of multicollinearity. Downloaded from www. However. biological variables. 80%. and 18 mo of age. type of floor and wall construction.04 statistical software for personal computers (33). Age and sex-specific Z scores were 58 42 4317 85 15 4121 RISK FACTORS FOR WASTING AND STUNTING 969 TABLE 1 Percentage distributions and means for selected characteristics of study children by place of residence. and lastly.

0 ± 5.05). after 51 24moof age.3 ± 6. In < 1% of the visits the child had both illnesses. and 40%.1 ± 3. The pattern of wasting was different from that of stunting. < 1% of children in urban and rural barangays were wasted. These values compare with 70%. 60%. The apparent improvement in mean length-forage begin59 ning at 24 mo of age can be attributed to the Wood Gas or oil Water source Well Purchased Pipe/pump Type of toilet None Pit Sealed juncture of the 14 length and stature medians at 24 mo of age in the NCHS reference population (35). Stunting oc24 curred early. plateaued at 12%.9 4. roughly 13% of infants were stunted before 6 mo 70%. ı 10% found a child ill with diarrhea.4 ± 3.12 14.8 7. 13 The Female Continuous variables Age of child at study entry (mo) Age of mother at child‘s study entry Formal education of father (y) patterns of stunting and wasting were similar between 71 urban and rural children although a larger percentage of children were stunted in the rural barangays and a larger percent5ı age were wasted in the urban barangays.0 ± 1. age significantly 19 more urban children were wasted (P < 0.9 ± 4. 28 decreased through 12 mo of age.3 ± 6. and 30% of urban children the same age (22). respectively. The difference in 39 prevalence of stunting by place of residence was significant after 6 mo of age (P < 0. During the first 3 mo of life. The prevalence increased between 6 and 17 mo of age.7 6.Radio only Television Wall material Wood Cement All else were longer and leaner than their urban counterparts.9 (y) 27. However.6 ± 3. the situation reversed and urban children were consistently 43 longer and leaner than rural children.3 ± 7.6 7. rural children 9. children‘s mean length was below the NCHS reference median length-for-age from birth through 30 mo of 27 age. Mean weight-for-length exceeded Mother‘s employment Not employed Employed in home ı the NCHS reference median during the first 6 mo of life. before 6 14 mo of age it could be attributed to low lengthfor-age whereas after 6 mo of age it was due to both below average length-for16 age and weight-for-length. These results were similar for urban and rural children. and then dropped to the visits the child had severe respiratory disease. Considering all visits.7 ± 3. 2j ± SD.6% in urban and rural children. Flooring material Bamboo/all else Any wood Any cement Cooking fuel 22 In both strata.4 .2 6. In the urban barangays. Before 6 mo of age. In the rural barangays. more boys than girls were stunted and wasted before 2 y of age. Data on the exclusivity of breastfeeding and other feeding practices were not collected. Anthropometry A cross-sectional view of the children‘s mean anthropometric status at 1 -mo intervals from birth to 30 mo of age is shown in Figures 1-3. sex differences in . and then leveled off and Employed away from home Previous birth interval _ 24 < 24 Number of observations Birth weight _ 2500 g < 2500 g Number of observations Sex of child Male gradually improved.6 5. after 2 y of age the situation reversed.0% and 5.5 ± 1. of rural children were still breastfed. and on ı2% of of age and the prevalence of stunting sharply increased between 6 and 23 mo of age.05). At 18-23 mo of age. Number of observations are indicated where _ 5% of children are missing data. Significantly more rural children 57 < 6 mo of age were wasted but after 12 mo of Formal education of mother (y) Number of prenatal visits Month of first prenatal visit 14.8 8. Children‘s mean weight also fell below 86 the NCHS reference median weight-for-age. After 3 35 mo. respectively.0 9. 40% of urban children and almost one-half of rural children were stunted.8 27. 49 There were sex differences in stunting and wasting (Table 2). However.5 ± 3.

Although the risk associated with low birth weight was greatest in infants < 6 mo of age and gradN .03. Philippines.0. being female.1. n 21 852 observations on 8748 children) and urban ( #{1. in rural (U. rainy season) were significant risk factors for wasting in children only after 12 mo of age. Illness (diarrhea. The difference in factors Downloaded from www.5 0 5 10 15 20 25 30 risk factor for wasting among rural children. in rural (U. n = 24 235 observations on 9790 children) areas. In .0. Protective strata.ı .04. and higher household socioeconomic status (as indicated by the presence of a radio and/or television in the home and the parents‘ amounts of formal education).ajcn. the middle of the rainy season.5 .2 0 10 15 20 25 30 0. Mean weight-for-age Z scores by age of child and place of residence in Metro Cebu.49p}ooled SEM by guest on December 29. It was protective in urban areas but was related to elevated risk of wasting in rural areas.5 0 .5 0 5 10 15 20 25 RISK FACTORS FOR WASTING AND STUNTING 971 N .05). Interestingly. respectively. . Philippines. 2011 0. pooled SEM 0.1. Risk factors for stunting showed more consistency across age groups and residence Age (mo) 30 FIGURE 3.5 . residence strata (P < 0.5 0 . 970 MCCI AND BECKER Age (mo) FIGURE 1. In the urban barangays. season of year (ie. low-birth-weight infants were four times more likely than normal-weight infants (_ 2500 g) to be stunted during the first 6 mo of life. The percentage of wasted children varied throughout the year with a clear apex in July. Variables listed in Tables 3 and 4 were significantly associated during bivariate analyses with stunting and wasting. Low birth weight (< 2500 g) and a short previous birth interval (< 24 mo) were the two most important risk factors for stunting. or both) in the 2-wk period before the study interview was the most consistent Downloaded from www.stunting and wasting followed patterns similar to those in the rural barangays.05. 9p}ooled SEM = 0. in at least one of the six child age- ually lessened with age. Low birth weight and Age (mo) FIGURE 2.5 .1 factors against wasting for older children included higher household socioeconomic status (presence of a television in the home) and maternal employment away from home. pooled SEM = 0. more frequent prenatal care. 2011 .2 associated with stunting and wasting in the six child ageresidence strata indicated that place of residence and child‘s age are important risk factors for both states of malnutrition. No significant changes occurred in either the magnitude or significance of regression coefficients during the model-building process of sequential addition of groups of covariates. n 21 852 observations on 8748 children) and urban ( #{14:9p} ooled SEM = 0. the effect of maternal employment at home depended on the place of residence. severe respiratory infection.ajcn. n = 24 235 observations on 9790 children) areas. none of the variables emerged as a risk factor for wasting in more than one age interval. n 24 235 observations on 9790 children) areas. Philippines. Previous research has shown that weight-forlength responds sensitively to changes in season (36).org by guest on December 29.05. n = 21 852 observations on 8748 children) and urban ( #{14. Two principal seasons occur in the Metro Cebu region: a rainy season from approximately May to October and a dry season from November to April. Mean weight-for-length Z scores by age of child and place of residence in Metro Cebu. Risk factors for wasting exhibited much more child age-residence stratum specificity. low-birth-weight children were almost twice as likely as their counterparts of normal birth weight in both urban and rural areas to be stunted even after 1 2 mo of age. pooled SEM 0. Mean length-for-age Z scores by age ofchild and place ofresidence in Metro Cebu. these odds doubled to almost eight. Risk factors for stunting and wasting Clear differences in risk factors for stunting (Table 3) and wasting (Table 4) emerged from the multiplelogistic-regression analyses. Protective factors against stunting included current breastfeeding (particularly for infants ı 5 mo of age). in rural (U. In rural areas. In urban areas.

. 2011 972 RICCI AND BECKER TABLE 3 Relative odds for risk factors for stunting by place of residence and age of child. birth weight and infants‘ current breast-feeding status had a 3 Categories more pronounced effect on the risk of stunting in urban than in rural barangays.93 0.30 ..66 0.25 1.0.05) unless indicated otherwise.0 7. As the Wasted 0-5 0. or determined by maternal biological characteristics.6 2.81 Cooking fuel (reference = wood) Gas or oil ..4 34. 1 1 . the principal predictors of stunting and wasting were behavioral and biological variables (eg. Socioeconomic factors operate indirectly to affect children‘s nutritional status by determining the quality of the child‘s diet.9 6.97 0.03 _8 0..80 .9 3.73 0.I .13‘ Currently breast-feeding (reference = no) Yes 0..59 .16 1.ajcn.06 . Diarrheal morbidity increased an infant‘s risk of wasting almost four times during the first 6 mo of life in urban barangays.8 6.1 14.95 .0.94 0.80 Type of toilet (reference = none) Pit .. influenced by maternal behavior.72 4.3 10.56 0.67 1 .0.05).2101) (ii 2084) (n 2678) Socioeconomic variables Television and radio (reference = neither) Radio only 0. 2 Variable stunting associated with low birth weight and short previous birth interval persisted through the children‘s first 30 mo of life.1‘ 41.12 11.33 1.7 40. During the first 6 mo of life in urban and rural areas.0. and physical environment.96 ..92 0.4 0.7 -1.Number of prenatal visits (reference = 0-4) 5-7 0.82 6-1 1 24.. Estimates are significant (P < 0..0.Years of father‘s formal education .8 32. by guest on December 29.02 Month of first prenatal visit .. mother‘s previous birth interval and employment Downloaded from www.0 6-Il 4.64.2 1..47 1.other words.0.0. Residence modified the effect of these risk factors on infants‘ risk of malnutrition during the first 6 mo of life.0.0.7 45.6 6.74 0.1. P < 0.70 .l.71 Flooring material (reference = bamboo/all else) Wood .67 Birth weight (reference = _ 2500 g) < 2500 g 7.35.01. presence of a television and/or radio in the home.1. P < 0.05.5 -0. I 7 1.77 Water source (reference = well) Purchased .0. and health status) as important risk factors for wasting and stunting. These are factors under Risk factor and category (17 = 221 1) (n 2230) (n 2885) (ii .22 18-23 39.3 28.3 20.95 Age of mother (y) .0lı Cement 0.76 Previous birth interval (reference _ 24 mo) < 24 mo 1 ..4 12.92ı .0.75 0.74 0.0.46 1.1 0.22 27.. of this variable had no significant effect (P < 0.IS‘ ‘ Boys children matured. An urban infant had twice the risk of stunting during this age interval compared with a rural infant if the child was born of low birth weight (Z 2.01).2 13.0.4 -0.2 34.91 . n values direct maternal control.2 11. Metro Cebu‘ Urban Rural 0-5 mo 6-1 1 mo 12-29 mo 0-5 mo 1 1 mo I 2-29 mo status.0 0.4 1 1 . and the child‘s birth weight. mother‘s previous birth interval and the child‘s birth weight.61 0.77 0.0. household socioeconomic characteristics (eg.9 4.1 17. and health status).7 3.64 .3 .. Anthropometnc status and age (mo) Urban Rural Boys Girls Difference‘ Boys Girls Difference Stunted 0-5 13. I 8 Sex of child (reference = male) Female .82 0.9 7.80 Biological variables Age of child (mo) .6 5..57 . ı p < 0.. Residence modified the effect of some of these factors on . breast-feeding offered greater protection in urban areas than in rural areas by reducing an urban infant‘s risk of stunting by two-thirds compared with the reduction by one-half observed in rural infants < 6 mo of age (Z = 2.86 Television 0. Similarly. father‘s amount of formal education. current breast feeding status.0 3.0ı‘ 24-29 27.1 0. test of null hypothesis of no difference between sexes: 2 p < 0.1 ..1 3.6 9.1 1.6 34.3 For variables (eg.95 0.9 9. Collinearity diagnostics did not indicate multicollineanity among model covariates.3ı 24-29 8..70 Number of persons per room .77 0.4 2.93 Behavioral variables Years of mother‘s formal education 0. and toilet facilities) emerged in conjunction with behavioral and biological minus girls.68 2.05) after adjustment for dependent observations.54 .7 4. TABLE 2 DISCUSSION The patterns of stunting and wasting observed in Cebuano children reflected their differential exposure to risk factors associated with age and residence.02 18-23 15. The risk of are number of children. current breastfeeding status.70 0.7 48.47 1 .9 -0.02 1 . Low Prevalence (percentage) of stunting and wasting among boys and girls in Metro Cebu by age and place of residence .0 1 . distal variables (eg.59 0. season of year and indicators of household socioeconomic status) that were significant in the initial model remained significant after the addition of behavioral and biological variables more proximal to the outcome.90 I Relative odds estimates are shown for final models.92 Pipe/pump 0.72 12-17 35.66 0. 2. water source.3 not included in final model.82 12-17 13.0.7 3.5 -0.60 0.83 Sealed 0.2 12.97‘ .14 3.

org by guest on December 29._8 0. = 3881) Season (reference = dry) Rainy .ajcn.01 for malnutrition.l.20 1.1.05) unless indicated otherwise.58 Wall material (reference = wood) Cement ... in the age group birth to S mo.96 . 2 Results for children aged 0-5 mo are not shown because the model failed to converge..- versity observed in risk factors for wasting is consistent with the fact that a relatively short period of risk exposure can precipitate its onset in children.. respectively.I .69 .. 2011 RISK FACTORS FOR WASTING AND STUNTING 973 TABLE 4 Relative odds for risk factors for wasting by place of residence and age of child.85 .1.97 Sex of child (reference = male) Female .. In Metro Cebu it elevates children‘s risk of stunting at all ages in urban and rural barangays. Household socioeconomic status influenced the risk of stunting earlier in the rural than in the urban barangays.1.40 .05) All else 0.95 1. I 74 2.93 2.95 Number of persons per room . Metro Cebu‘ Urban Rural2 0-5 mo 6-1 1 mo I -29 mo 1 1 mo I 2-29 mo Risk factor and category (n = 4594) (n 4872) (n = 4407) (n = 4527) (.67 2. and also significantly increases a child‘s risk of being wasted after 12 mo of age.0.Age of mother (y) .33 Employed away from home 0.91 Number of prenatal visits (reference = 0-4) 5-7 .1. After 12 mo of age.I ...36 0. statistical power to detect significant associations between children‘s weightforlength and other variables is low. children‘s risk of wasting in rural but not in urban barangays after 12 mo of age.77 0. both biological and behavioral.80 . Conversely.94 . were strongly associated with children‘s nutritional status.. but decreased it in urban barangays.1. I 2 Years of father‘s formal education . birth weight.95 . Birth weight < 2500 g was the most consistent risk factor Currently breast-feeding (reference = no) Yes 0.2.98 . maternal employment. or both) increased Severe respiratory illness only 1.05 . severe respiratory infection. The relatively consistent pattern of risk factors for stunting suggests that continued exposure to adverse conditions over an extended period of time retards children‘s linear growth.43 1.90 Television 0.. 4)..1 Relative odds estimates are shown for final models. the estimates of power to detect the same percentage difference in stunting and wasting (assuming an alpha level of 0. frequency of prenatal care.0.62 Birth weight (reference = _ 2500 g) < 2500 g . The observed diversity in risk factors for wasting may be unrelated to its epidemiology. whereas the power of the test to detect the same difference of 20% in the proportion wasted between two groups would be only 9%.0.47 Water source (reference = well) Purchased . Consequently.. the power of the test to detect a true difference of 20% in the proportion stunted between two groups with approximately equal numbers of children would be 75%.68 1. 4 Categories of this variable had no significant effects (P < 0. The prevalence of wasting is much lower than that of stunting (Table 2).older children‘s risk of malnutrition.0.0.Behavioral variables Years of mother‘s formal education . Estimates are significant (P < 0. maternal employment in the home increased children‘s risk of wasting in rural barangays. This persistent influence of birth weight on children‘s Health status (reference = well) Diarrhea only ... and level of formal education all emerged as important risk factors for malnutrition. length of preceding birth interval.51 .3lı Biological variables Age of child (mo) .0.0.. For the age group 6-I 1 mo. Adverse conditions encompass a wide range of risk factors from measures of household socioeconomic status to mdividual biological endowments. Maternal factors. The patterns of risk factors for stunting and wasting within and across age-residence strata support biological and epidemiologic evidence that stunting and wasting represent two different processes of malnutrition (3. the greater di- Downloaded from www. an artifact of differences between numbers of stunted and wasted children in the sample.89ı 0. and instead.44 0.I .. breast-feeding...0.Mother‘s employment (reference = not employed) Employed in home . Children‘s health status (diarrhea.59 - Pipe/pump 0.79 Both 0. 3 Variable not included in final model.66 0.33 .69 were 95% and 28%. For example.46 .05) after adjustment for dependent observations.1.77 Socioeconomic variables Television and radio (reference = neither) Radioonly .82 Diarrhea in past 2 wk (reference = no) Yes 3..

4) promote breast-feeding. Kenya. Tomkins A. Beaton OH.33: 1836-45. In addition. Use and interpretation of anthropometnic indicators of nutritional status. Efforts to target low-birth-weight infants. Tomkins A. Sommerfelt AE. Administrative Committee on Coordination/Subcommittee on Nutrition.) 13. Lancet 198 1. 1990. supervisors. Adriko BC. for their dedicated work. children born within 24 mo of a sibling are at a disadvantage. Judy Gehret of Johns Hopkins University assisted in data processing. Calloway D. Malnutrition and infection in the classroom. interviewers. 3) encourage family planning to increase birth spacing. 1993. The risk factors associated with malnutrition in this population suggest several potential applications for interventions to improve children‘s nutritional status. Chowdhury AKMA. Migliori GB. In addition. 7. PEW Lecture. 5. Over and above its effect through birth weight. 3. Inc. 10. and Mexico. 2011 974 RICCI AND BECKER links between birth weight and growth through infancy (37) particularly positive effects on children‘s nutritional status in urban barangays. 9. Anthropometry and childhood mortality in northwest and southwest Uganda. No. The association between wasting and stunting: an international perspective. . Stewart MK. New York: Oxford University Press. Ithaca. Am J Clin Nutr l980. Belgium: United Nations Educational. 8. Anthropometnic assessment of energy-protein malnutrition and subsequent risk of mortality among preschool aged children. although our analyses do not show causality. We also thank William and beyond (38). Valverde V. and data-management personnel at the Office of Population Studies (OPS).48(suppl):S45-57. Kevany J. Borghesi A. 2) increase women‘s access to prenatal care. 2. 12. ACC/SCN State-ofthe-Art weight. (Nutrition Policy Discussion Paper no. 14. 4. nutritional status and health care: analyses of their interrelationships. Nutritional status and severity of diarrhoea among preschool children in rural Nigeria. Schroeder DO. 1989. Becker S. Vella V. Am J Clin Nutr 1984:39:8794. Brown KH. The recent United Nations International Conference on Population and Development recognized this and noted that birth intervals and maternal reproductive health are closely linked to child morbidity and mortality (40).org by guest on December 29. This may be because they receive less adequate care from their Flieger and Connie Gultiano (OPS) and Robert Black (Johns Hopkins University) for comments on an earlier draft. 7. J Nutr 1992:122:1105-10. Martorell R. among young The significant associations between children‘s nutritional status and maternal factors indicate that intervention must focus not only on children but also on their mothers. New York: UNICEF. increase birth weight. and 5) reduce children‘s diarrheal and respiratory morbidity. Belizan JM. World development report 1993. Victora CG. Kettle Kahn L. Infants born of low birth weight and within 2 y of an elder sibling should be singled out for intervention. A We thank the administration. Pollitt E. Chen LC. The functional consequences of malnutrition and implications for policy: case studies in Egypt. Malnutrition is a determining factor in diarrheal duration. Demographic and Health Surveys comparative studies. A recent comparative analysis of Demographic and Health Survey data also indicates that short previous birth interval is a significant risk factor for stunting among children in 19 developing countries (2). 12. Kelly A. Scientific and Cultural Organization (UNESCO). Huffman SL. 1994. San Carlos University. but not incidence. mothers or because they experience more competition for household resources such as food or health care (39). Ecol Food Nutr 1983:12:229-34. World Health Organization Working Group. Reversibility of stunting: epidemiological findings in children from developing countries. Children‘s nutritional status. Black RE. Eur J Clin Nutr l994. Calverton. Diarrhoeal diseases. Bull World Health Organ 1986:64:929-41. Ndiku J. 1989. 6. I 1.well-being is consistent with other findings that showed Downloaded from www. World Bank. Geneva: ACC/SCN. Delgado HL. we propose that women and children in this population would benefit from interventions that 1) increase birth children in a longitudinal study in rural Bangladesh. Am J Public Health l993. Appropriate uses of anthropometric indices in children. Report of the 15th session of the ACC/SCN. and promote breast-feeding could have Series.ajcn. Martorell R. Mason J. REFERENCES 1. Leslie et al (41) also suggest that empowering women by improving their health may prove to be one of the best approaches to promoting the health and wellbeing of children in the Third World. NY: Cornell University. Klein RE.1 :860-2.83:16I6-8. Short previous birth interval is also a consistent risk factor for stunting. MD: Macro International.

Administrative Committee on Coordination/Subcommittee on Nutrition. CA: Lifetime Learning Publications.) 23.7: 533-46. Bull World Health Organ 1977. 1978. Inc. Harrison 0G. maternal nutrition and infant mortality. Black RE. 1988. Br Med J 1972. Biometrika 1986. Waterlow JC. Waterlow JC. 32. DC: US Government Printing Office. The children of Santa Maria Cauque: a prospective field study and Statistical Office. Royston E. Scrimshaw NS.48(suppl):S90-l02. Vazquez L. 2011 RISK FACTORS FOR WASTING AND STUNTING 975 30. The CDC anthropometric software package (CASP). United Nations International Conference J Epidemiol 1991 . Nutrition and population links. DHEW publication (PHS) 78 1650. Classification and definition of proteinenergy malnutrition. Liang K-Y. Pediatrics 1989:84:613-22. Version 6.6:1-19. Kleinbaum DO. 1988. Interpretation of Z-score anthropometric indicators derived from the international growth reference. Dibley MJ. Philippines Department of Health. eds. Geneva: ACC/SCN. Becker 5. MA: Auburn House Publishing Company. Eur J Clin Nutr l994. . and economic crises: approaches to policy in the Third World. Gomez F. Peters D. Mortality in second and third degree malnutrition. Leslie J. United Nations.7:30-9. 20. The presentation and use of height and weight data for 18. 22. 165. Delgado H. Staehling N.) 40.Short stature of mothers from an area endemic for undernutrition is associated with obesity. Brown KH. DPIUNIINT-81-04l/6E. Zeger SL.20: 193-8. Galvan RR. Kupper LL. 1986. New York: United Nations. Health Policy Plan 1992. Assessing the nutritional status of young children in household surveys. NC: SAS Institute. Habicht J-P. Klein RE. 1989. Low birth weight and intrauterine growth retardation in Filipino infants. The Philippines: results of a baseline survey. 1992. 4th infants and children-examples from the Human Nutrition Collaborative Research Support Program-Kenya and Egypt studies. 1982. 33. Tanner JM. Baltimore: The Johns Hopkins University Institute for International Programs. 41 . hypertension and stunted children: a populationbased study in the semi-arid region of Alagoas. Republic of the Philippines: Regional Health Office no. Martorell R. 37. In: Bell DE.) 25. Northeast Brazil. Hum Biol l98l. Am J Clin Nutr 1982:36:303-13. SAS Institute. (Nutrition Policy Discussion Paper no. United States Department of Health and Human Services. 19. 7. Chavez R. Reich MR. Investing in women: the focus of the nineties. 38. Am J Clin Nutr 1987:46:749-62. 35. State of the world population 1989. Klein RE. Mata L.73:13-22. Buzina R.1992. Seasonal changes in nutritional status and the prevalence of malnutrition in a longitudinal study of young children in rural Bangladesh. Am J Public Health 1995. 17. Preventing maternal deaths. Preliminary version. Health. Washington. fertility. Downloaded from www. Nutr Rep Int l973. 21 . mt of health and growth. 13. Centers for Disease Control and by guest on December 29. MA: MIT Press. 39. Women‘s nutrition: the key to improving family health in developing countries. Kalter HD. Trowbridge FL. Lycette M. [Series 1 1. Centers for Disease Control. New York: United Nations Population Fund.0. National Center for Health Statistics. nutrition. Department of Health. ACC/SCN Symposium Report. Public activities in Metro Cebu. 1991. United Nations Population Fund. Buvinic M. Lechtig A. Michaman MZ. Keller W. 29. Onset and evaluation of stunting in Belmont.(Document no. Health Policy Plan 1991. Yarbrough C. l986. comparing the nutritional status of groups of children under the age of 10 years. Adair L. Black RE. Evaluation of key child survival ed. 27.85:622-4. Gray RH. 34. Validation of the diagnosis of childhood morbidity using maternal health interviews. Cravioto Munoz J. The validation of interviews for estimating morbidity. Lane JM. Cambridge. 1990. and infant mortality.3:566-9.2:77-83. 1989.ajcn. United Nations Department of Technical Co-operation for Development Health Service. Frenk 5. SAS/STAT user‘s guide. 24. Longitudinal data analysis using generalized linear models. Relationships of birth weight. 17. 16. Maternal stature. Leslie J. 15. Kalter H.55:489-98. Becker S. J Trop Pediatr l956. The new paradigm of public health nutrition. Nieburg P. Vols 1-2. Cairo: United Nations. Geneva: World NCHS growth curves for children birth-18 years.53:303-12. on Population and Development. Annual report 1988. (Occasional paper no. 28. 11. 36. Version 3. Oultiano SA. 1994. 1978. Final document. Armstrong S. How to weigh and measure children. Dover.1 Health Organization. 26. Morgenstern H. Neumann CG. Atlanta: Centers for Disease Control and Prevention. Epidemiologic research. Valverde V. 31. Weathering economic crises: the crucial role of women in health. Cary.

with those in the 1st quartile being defined as of short stature and those in the 4th quartile being defined as of normal stature and serving as a reference for the comparison of variables of interest. Multivariable logistic regression examined the association between pregnancy intention and stunting.02-0. 0.04–1.019) in the offspring. Additionally. calcium and copper in breast milk was measured. Infants fed >3 times/d. 95% confidence interval (CI): 0.5 kg/m(2)) and 20% were night blind. Ethiopia. The results showed that low maternal stature was independently associated with obesity (percentage body fat >or= 30. 95% CI: 0. P = 0. Infants and toddlers with both parents reporting them as unwanted had an increased risk of . may differ among areas and communities. consuming less food or not consuming cow's milk [differences: 0. After excluding strongly self-correlated variables (r >or= 0.72. Among mothers. 95% CI: 1.Abstract The objectives of the study were to investigate whether the health conditions of mothers with short stature differed from those with normal stature. 95% CI: 0.70). particularly stunting. differentiating unwanted and mistimed pregnancies. Infants of mothers with low concentrations of zinc in their breast milk were more stunted. P = 0. frequency of consumption.33. abdominal adiposity (waist:hip ratio >or= 0. women of short stature presented a higher prevalence of chronic degenerative diseases and produced less healthy children than women of normal stature. and anthropometric and demographic data were collected.Factors associated with stunting in infants aged 5-11 months in the DodotaSire District. rural Ethiopia. 0. P = 0. P = 0. Parental pregnancy intention and early childhood stunting: findings from Bolivia Background This study examined the impact of maternally reported pregnancy intention. it examined the influence of paternal pregnancy intention status.007) and high systolic blood pressure ( >or= 140 mmHg. 18. In conclusion. Thus. consuming >600 mL/d or consuming cow's milk in addition to cereals and/or legumes had markedly higher length-for-age Z-scores than their peers fed less frequently. P = 0. Abstract The contribution of various factors to malnutrition. and to establish if these aspects were associated with the health of the offspring. 27% had chronic energy deficiency (body mass index. Source Ethiopian Health and Nutrition Research Institute. Mothers were categorised according to stature. Infants (n = 305) and their mothers were examined physically. 41% underweight and 13% wasted.01) and stunting (height-for-age Z score < . and by providing supplements to infants where appropriate. indicating that vitamin A deficiency was a serious problem.2. <18. and time of introduction of supplementary feeding.045). the remaining variables were analysed by multiple linear regression. 36% were stunted. Overall.72) and unwanted pregnancies (PRadj 1. Ethiopia. Data relating to health and socio-economic. demographic and anthropometric conditions were collected from a probabilistic sample population consisting of 1180 mothers and 1511 children ( < 10 years) living in the semi-arid region of the State of Alagoas.28.17. respectively).32. the quality and quantity of foods consumed by infants is insufficient to prevent stunting. Thus it is necessary to increase the nutrient supply to infants by increasing intake and nutrient concentration of breast milk and of supplementary foods they consume. The highest prevalence of malnutrition was seen in infants aged 9-11 mo. This cross-sectional study aimed to estimate the level of malnutrition and identify factors associated with the high level of stunting in breast-fed infants aged 5-11 mo living in Dodota-Sire District.39. The sample was restricted to lastborn.04-0.56) were at about a 30% greater risk for stunting than children from intended pregnancies. Short maternal stature was associated with low birth weight ( < 3000 g.40. in the semi-arid region of Alagoas. singleton children younger than 36 months who had complete anthropometric information. Approximately 29% of the maternally unwanted children were stunted as compared to 19% among intended and 19% among mistimed children. on the prevalence of early childhood stunting. respectively. 95% confidence interval [CI]: 1. Methods Data were collected from a nationally representative sample of women and men interviewed in the 1998 Bolivia Demographic and Health Survey.74. Addis Ababa. and data collected on the type.85. Following verification that maternal stature fulfilled parametric assumptions.03–1. Brazil.07-0.006). The content of zinc. 19. its associations with the other variables were determined by calculating Pearson correlation coefficients. Children 12–35 months (toddlers) from mistimed pregnancies (adjusted prevalence risk ratio [PRadj] 1. Results Children from unwanted and mistimed pregnancies comprised 33% and 21% of the sample.

including sensory-motor. Human brain development Reproduced with permission of authors and American Psychological Association17 (Thompson RA. health. and social-emotional. both of which are linked to later earnings. cognition. [14] and [15] The first few years of life are particularly important because vital development occurs in all domains. all of which are likely to be affected. Nelson CA. and the second is to ensure that all children complete primary schooling. is related to reduced fertility. the second paper discusses the proximal causes of the loss. and gliogenesis. synaptic pruning. [6] and [7] Thus the failure of children to fulfil their developmental potential and achieve satisfactory educational levels plays an important part in the intergenerational transmission of poverty. nutrition. [13] . national development is likely to be affected. Measurement of paternal pregnancy intention status is valuable in pregnancy intention studies. [11] . and education. [4] . This paper is the first of a three part series reviewing the problem of loss of developmental potential in young children in developing countries. we focus on cognitive development because of the paucity of data from developing countries on other domains of young children's development. and the final paper reviews existing interventions. cognitive. synaptogenesis. Furthermore. poor health and nutrition. The discrepancy between their current developmental levels and what they would have achieved in a more nurturing environment with adequate stimulation and nutrition indicates the degree of loss of potential. death is the tip of the iceberg. such that small perturbations in these processes can have long-term effects on the brain's structural and functional capacity. myelination. We have made a conservative estimate that more than 200 million children under 5 years fail to reach their potential in cognitive development because of poverty. improved parental education. Children's development consists of several interdependent domains. we first examine why early child development is important and then develop a method to estimate the numbers of children who fail to fulfil their developmental potential. However. Children born to parents reporting mistimed or unwanted pregnancies should be monitored for growth stunting. [5] and [9] there is less recognition of their effect on children's development or of the value of early intervention. [3] . No association was found for infants less than 12 months. axonal and dendritic growth. The first UN Millennium Development Goal is to eradicate extreme poverty and hunger. particularly of mothers.16 The brain develops rapidly through neurogenesis. Developmental science and the media: early brain development. Poverty and its attendant problems are major risk factors. 20. [12] .8 Improving early child development is clearly an important step to reaching these goals. Developmental potential in the first 5 years for children in developing countries Introduction A previous Lancet series1 focused attention on the more than 6 million preventable child deaths every year in developing countries. [2] and [3] and improved child survival.being stunted as compared with children both of whose parents intended the pregnancy. Unfortunately. 56: 5–15). In countries with a large proportion of such children. Am Psychol 2001. In later childhood these children will subsequently have poor levels of cognition and education. and appropriate interventions should be developed. Here. [5] . and deficient care. Full-size image (42K) High-quality image (364K) Figure 1. Although policymakers recognise that poverty and malnutrition are related to poor health and increased mortality. Why early child development is important Children's development is affected by psychosocial and biological factors10 and by genetic inheritance. We then estimate the loss of income attributed to poor child development. . cell death. These ontogenetic events happen at different times (figure 1)17 and build on each other. The first paper describes the size of the issue. Conclusions Reducing unintended pregnancies in Bolivia may decrease the prevalence of childhood growth stunting.

28 Early cognitive development predicts schooling Early cognitive and social-emotional development are strong determinants of school progress in developed countries. cognitive ability and achievement at the end of grade one predicted later school progress. and wealth quintile. [18] . and of those enrolled.5 years 18 years grades achieved 1·07 * Adjusted for sex. and poor stimulation and social interaction can affect brain structure and function. variations in the quality of maternal care can produce lasting changes in stress reactivity. [23] and [24] In humans and animals. Change in later school outcomes per SD increase in intelligence quotient (IQ) or developmental quotient (DQ) in early life* N Independent variable Outcome variable Measure of effect Estimate 95% CI Jamaica† 165 IQ on the Stanford Binet test Dropped out before (42) at 7 years grade 11 Reading and arithmetic score at age 17 Philippines 1134 Cognitive Score at 8 years Brazil‖ Ever repeat a grade by age 14 years Odds ratio Mean difference in SD Odds ratio 0·53‡ 0·65§ 0·60¶ 0·32– 0·87 0·53– 0·78 0·49– 0·75 152 DQ on Griffiths test (43) at Grades attained by age Mean difference in 0·71** 0·34– 4.44 Most children who fail to complete are from sub-Saharan Africa and south Asia. Hosmer-Lemeshow goodness-of-fit test p=0·5704. controlling for a wealth index. . Intervention and stunting status were also adjusted for. ** p=0·0002. Only around half of the children enrol in secondary schools. [37] . [38] and [39] ). Further evidence of the importance of early childhood is that interventions at this age [37] and [41] can have sustained cognitive and school achievement benefits (table 1 [35] . iron-deficiency. multiple regression of educational outcome (or logistic regression for dichotomous variables). † Sample consisted of stunted (<−2 SD) children participating in an intervention trial and a non-stunted (>−1 SD) comparison group. Despite the vulnerability of the brain to early insults. and memory function in the offspring. In developing countries. [20] . showed that early cognitive development predicted later school outcomes. [21] . ‡ p=0·0117. Problem of poor development National statistics on young children's cognitive or social-emotional development are not available for most developing countries. [19] . [30] and [31] A search of databases for longitudinal studies in developing countries that linked early child development and later educational progress identified two studies. children in some developing countries have much lower achievement levels than children in developed countries in the same grade. an estimated 99 million children of primary-school age are not enrolled. although school and family characteristics also play a part. only 78% complete primary school. Animal research shows that early undernutrition. In each case. [26] and [27] and generally the earlier the interventions the greater the benefit. ¶ p<0·0001. R2=51·9%. Table 1. [36] .34 Three further studies had appropriate data that we analysed (from the Philippines [35] and [36] and Jamaica37) or requested the investigators to analyse (from Brazil [38] and [39] ). § p<0·0001. Furthermore. Table 1 shows that each SD increase in early intelligence or developmental quotient was associated with substantially improved school outcomes. Hosmer-Lemeshow goodness-of-fit test p=0·5375. Failure to complete primary education (Millennium Development Goal 2) gives some indication of the extent of the issue.Brain development is modified by the quality of the environment. stress. mother's education. and child's sex and age. age. ‖ Boys only. preschool cognitive ability predicted children's enrolment in secondary school32 and achievement scores in adolescence. [18] . remarkable recovery is often possible with interventions. and this gap contributes to the invisibility of the problem of poor development.40 maternal education.33 In South Africa. In Guatemala. [29] . [22] .45 In 12 African countries. environmental toxins. and have lasting cognitive and emotional effects.25 anxiety. R2=54·4%.

which is further exacerbated by inadequate schools and poor family support (due to economic stress. stunting and to a lesser extent poverty are consistently defined across countries.63 but most stunted children remain stunted through to adulthood. and worldwide data are available. Finally. We omit other risk factors that could affect children's development because they fail to fit all the above criteria and there is marked overlap between them and with stunting and poverty.61 Faltering begins in utero or soon after birth.70 . [15] . Hypothesised relations between poverty. [50] . [12] .surveys of grade 6 (end of primary school) children showed that on average 57% had not achieved minimum reading levels (webtable). [55] . Patterns of growth retardation are also similar across countries. is pronounced in the first 12–18 months. Poverty is also associated with poor maternal education. [68] and [69] and inadequate stimulation in the home. Assessment of stunting. [47] . We then show that they are good predictors of poor school achievement and cognition. [53] . poverty. [51] . [56] and [57] Indicators of poor development In the following section we estimate the numbers of children who fail to reach their developmental potential. However. and poor sanitation and hygiene that lead to increased infections and stunting in children. we use these indicators to estimate the number of children involved. [46] . [33] and [71] Deficits in development are often seen in infancy [31] and [72] and increase with age. both are relevant to most developing countries. Poverty is associated with inadequate food. after which it levels off. stunting. [12] and [70] Poor development on enrolment leads to poor school achievement. [71] . [48] . child development. more so in rural areas.65 and surveys in 45 developing countries reported that 37 % of children lived in absolute poverty. adjusted for purchasing power parity by country66 because this information is available for the largest number of countries. This indicator is considered the best available despite excluding important components of poverty.70 All these factors detrimentally affect child development (figure 2).67 and is more conservative than measures based on deprivation65 since it identifies only the very poorest families. a cross sectional study in Ecuador reported that the language deficit in poor children increased from 36 to 72 months of age compared with wealthier children (figure 3). and the developmental deficit increases with the number of risk factors. availability of services. and school achievement Risk factors related to poverty frequently occur together. and child development Growth potential in preschool children is similar across countries. There are multiple approaches to measuring poverty. by using only two risk factors we recognise that our estimate is conservative. [73] and [74] For example.62 and could continue to around 40 months. [49] . and infrastructure. Full-size image (18K) High-quality image (130K) Figure 2. We first identify early childhood growth retardation (length-for-age less than −2 SD according to the National Center for Health Statistics growth reference58 [moderate or severe stunting]) and absolute poverty as possible indicators for poor development. We use the percentage of people having an income of less than US$1 per day. [54] . increased maternal stress and depression. [59] and [60] and stunting in early childhood is caused by poor nutrition and infection rather than by genetic differences. We identified stunting and poverty for indicators because they represent multiple biological and psychosocial risks. Some catch-up might take place. [52] . respectively.64 One assessment used measures of deprivation of basic needs. and little knowledge and appreciation of the benefits of education).

To establish whether stunting and absolute poverty were useful predictors of poor child development in individual studies.99 and in Ghana98 stunted children enrolled in school late but taller children left school early to earn money or help with family farming. based on the assumption that stunting developed in early childhood.Full-size image (22K) High-quality image (146K) Figure 3.100 Jamaica.93 Indonesia.78 and Ghana and Tanzania79). we searched the published papers and identified all observational studies that related stunting and poverty in early childhood to concurrent or later child development or educational outcomes. the average prevalence was 20%.70 As a first step to examining the use of poverty and stunting as indicators. India.75 In 79 countries with information on stunting and education.108 and Bangladesh.102 and Kenya. were less likely to be enrolled in school (Tanzania77). for every 10% increase in the prevalence of poverty there was a decrease of 6·4% (b=−0·64. There are fewer studies with younger children. which indicates a combination of weight-for-height and height-for-age.107 Ethiopia.83 Philippines. Vocabulary scores of Ecuadorian children aged 36 to 72 months by wealth quartiles TVIP=Test de Vacabulario en Imagenes Peabody.101 Chile. 95% CI=−0·81 to −0·46. and the relation between them (adjusted or unadjusted) was examined.90 Guatemala [only in boys]91). We assessed whether measurements of the risk factors and developmental outcome were clearly reported. R2=36·2%. to attain lower achievement levels or grades for their age (Nepal. the average prevalence of stunting was 26·0%.76 and absolute poverty prevalence came from UNICEF. R2=46·3%. more likely to enrol late (eg. In the Philippines.89 Turkey.95 and Chile96).112 growth retardation in infancy predicted age of walking.92 Guatemala.88 Brazil. [85] and [86] Malaysia.94 Ethiopia. We selectively reviewed studies of older children that linked economic status to school achievement or cognition.78 China.106 Weight-for-age.80 Jamaica. has often been used instead of stunting to measure nutrition in young children. p<0·0001) of children entering the final grade of primary school.103 associations between height and child development measures were reported. four published longitudinal studies showed that early . with data from developing countries (defined as the non-industrialised countries in UNICEF classification). and Vietnam. Weight-forage was associated with child development in India.105 but height was not related to motor development in Kenyans at 6 months of age.87 Vietnam. Peru. We did not assess causality. Excluding studies of children hospitalised for severe malnutrition. 95% CI −1·03 to −0·55. and have poorer cognitive ability or achievement scores (Kenya. Age of walking was related to height-for-age in Zanzibarian104 and Nepalese children. In Guatemala. compared with non-stunted children. p<0·0001). Stunted children. [81] and [82] India. associations were recorded with weight-for-height. We also identified all studies that related stunting at school age to cognition or education. For every 10% increase in stunting (less than −2 SD). Only three studies [97] . [98] and [99] reported no significant relation between stunting and poor school progress. [84] . In 64 countries with information on absolute poverty. the proportion of children reaching the final grade of primary school dropped by 7·9% (b=−0·79. choosing examples with international or nationally representative samples. Nepal. we did regression analyses of the relation between the percentage of children completing primary school44 and poverty and stunting. Reproduced with permission from the authors. Stunting and poor development Cross-sectional studies Many cross-sectional studies of high-risk children have noted associations between concurrent stunting and poor school progress or cognitive ability. [109] and [110] Longitudinal studies In Pakistan111 and Guatemala.75 Stunting prevalence was based on the WHO Global Database on Child Growth and Malnutrition.

[95] . In these studies.116 weight-for-age at 1 year of age did not predict scores on a cognitive test at 7 years. [47] .126 . n=603)‡ years. n=368) years. * Males only. grades attained. 71·4% of 3887 children from more affluent families entering fee-paying preparatory schools had mastery of all four school-readiness subjects tested. [51] .125 An association between poverty and child development was recorded at as early as 6 months of age in Egypt. age at enrolment in school.114 and stunting at 72 months was related to cognition between 25–42 years. Stunting at 24 months was related to cognition at 9 years in Peru113 and. we reanalysed the data from Philippines. n=2489) Not stunted 56·4 Mildly stunted 53·8 (−0·21) Ravens Reasoning and Attained 120 Matrices (7 arithmetic (9 grades (18 years.123 There are fewer studies on wealth and development in preschool children.36 Jamaica. We added two other longitudinal studies. ‡ SD scores. from Brazil38 and South Africa. [35] and [36] In Jamaica. [57] .38 Being moderately or severely stunted compared with not stunted (height-for-age greater than −1 SD) was associated with scores for cognition in every study. [56] . stunting between 12 and 36 months was related to later measures of cognition117 or grade attainment. [55] . Representative surveys in 16 Latin American countries124 also reported that family income predicted the probability of completing secondary schooling. with moderate to large effects. [48] .107 In Ecuador.113 and Indonesia 116 (Guatemala had too few well-nourished children to be included). and general knowledge in late adolescence. stunting before 24 months was related to cognition and school achievement at 17–18 years and dropout from school. reaching as high as ten grades in India. n=72) 92·3 89·8 (−0·20) WAIS Reading and ‡118 IQ (17– arithmetic‡ 18 years. Stunting was also associated with attained grades. Rural children were worse off in most studies. [46] . WAIS=Wechsler Adult Intelligence Scale. height at 36 months was related to cognition. literacy. or both.123 In Zambia. numeracy. grade repetition. wealth was related to vocabulary scores of children from 3 to 6 years of age. and achievement. To assess the size of the deficit in later function associated with a loss of 1 SD in height in early childhood. [121] . and in Uganda the difference was ten times. In 3668 Indian children under 6 years. [50] .70 In Jamaica. 37 Peru.stunting predicted later cognition. paternal occupation was associated with developmental milestones. † The sample comprised stunted (<−2 SD) children participating in an intervention trial and a non-stunted (>−1 SD) comparison group. [122] and [123] Gaps in mean attained grades between the richest and poorest children were particularly large in western and central Africa and south Asia. in the Philippines to intelligent quotient (IQ) at 8 and 11 years. The consistent relation between early childhood stunting and poor child development. [54] . WISC=Wechsler Intelligence Scale for Children. and dropout from school. and the effect size varied from 0·4 to 1·05 SD.37 In Guatemala. Poverty and poor development Cross-sectional studies Nationally representative studies from many countries have seen relations between household wealth and school enrolment. [52] . Descriptive summary of follow-up studies showing associations between stunting in early childhood and later scores on cognitive tests and school outcomes Philippines South Africa Indonesia Brazil* Peru Jamaica† Cognitive score (8 years.115 In Indonesia. (17–18 years) n=165) 0·38 0·40 Moderately or 49·6 (−0·54) −0·23 (−0·40) 9·7 (−0·43) 6·5 (−0·7) 79·2 −0·55 −0·60 (−1·00) severely (−1·05) (−0·93) stunted Data are mean (effect size as unadjusted difference from non-stunted children in z scores).117 that had not previously analysed the effect of stunting (table 2). [49] . Table 2. [53] . n=2041) 0·17 0·05 (−0·12) 11·2 10·3 (−0·26) 8·1 7·2 (−0·4) WISC IQ119 (9 years. compared with 42·7% of 22 241 children entering free government primary schools. school progress. early dropout. justifies its use as an indicator of poor development. whereas growth in weight between 1 and 7 years did. poor children were four times more likely to start school late than the richest children.

116 The effect size in all these studies was substantial. * Tertiles. Descriptive summary of follow-up studies showing association between wealth quintiles in early childhood. † SD scores. Sensitivity analysis based on imputing stunting by poverty and imputing poverty by stunting through regression analysis gave similar results to using the regional average (webappendix). Table 3. ranging from 0·70 to 1·24 SD scores between the top and bottom quintiles in children from varied socioeconomic backgrounds. n=1143) Attained grades (18 years of age at assessment. We extrapolated all the stunting and poverty data to the year 2004 (table 4). [76] . We had to use wealth quintiles rather than the cutoff of US$1 per day because of limitations in the data.38 In Guatemala.36 and to cognitive scores at 7 years in South Africa117 and 9 years in Indonesia. and with school grades attained at 18 years in 2222 men on army enlistment. n=2485) Reasoning and arithmetic (9 years of age at assessment. n=371) Ravens progressive matrices†120 (7 years of age at assessment. with median 2000 and inter-quartile range of 3 years.131 socioeconomic status at birth was associated with school attainment and cognition in 1469 adults.128 and 18 months in Bangladesh. Estimate of number of children who are stunted or living in poverty We estimated the prevalence of children under 5 years who are stunted or living in absolute poverty in developing countries. We analysed data from three other longitudinal studies (table 3). and later cognitive and school outcomes Philippines Indonesia South Africa Brazil Guatemala* Cognitive score (8 years of age at assessment. 126 have a known stunting prevalence and 88 have a known proportion living in absolute poverty (table 4). n=2222) Reading and vocabulary (26–41 years of age at assessment) Boys (n=683) Fifth quintile 56·9 (wealthiest) Fourth quintile 52·5 (−0·35) 12·1 11·0 (−0·31) 11·0 (−0·31) 9·5 (−0·74) 0·47 0·13 (−0·34) −0·16 (−0·63) −0·20 (−0·67) 9·3 8·2 (−0·48) 7·4 (−0·84) 6·8 (−1·11) 41·0 (−0·53) 37·6 (−0·45) 43·3 (−0·45) 43·6 (−0·01) 50·9 Girls (n=786) 44·8 Third quintile 51·6 (−0·42) Second quintile 49·4 (−0·60) First quintile 46·4 (−0·84) 8·4 (−1·06) −0·23 (−0·70) 6·5 (−1·24) (poorest) Data are mean (effect size as unadjusted difference from the richest quintile in z scores).12 months in Brazil.130 In Brazil. preschool children's language scores were associated with maternal working but not income.127 10 months in India.76 Of the 156 countries analysed. [132] and [133] .129 Longitudinal studies Several longitudinal studies have assessed the association between wealth at birth and later educational and cognitive attainment. and from 0·45 to 0·53 SD scores in Guatemala where all study children were poor. Socioeconomic status in infancy was associated with children's cognition at 5 years of age in Kenya. Wealth quintiles at birth were related to IQ at 8 years in the Philippines. Thus poverty can be used as an indicator of poor development. parental income at birth was associated with poor performance on a developmental screening test at 12 months in 1400 infants.68 In another Brazilian study. We replaced missing country values of stunting and poverty with the average prevalence of the region for the purpose of estimating the proportion and number of disadvantaged children. Poor children consistently had considerable developmental deficits compared with more affluent children. The most recent stunting data were up to year 2004. The most recent poverty data we obtained was up to year 2003. with median 2000 and inter-quartile range of 4 years. Data for the number of children in 2004 and percent living in poverty were obtained from UNICEF75 and data for stunting obtained from WHO. [75] .

et al. There are 559 million children under 5 years in developing countries. decline in absolute poverty (less than US$1 per day) was stagnant in all developing regions except east Asia and south Asia. did not include the central and eastern Europe region in their analysis. Hence. Prevalence and number (in millions) of disadvantaged children under 5 years by region in 2004 Population Percentage Number Percentage Number Percentage Number †‡§ younger than living in living in stunted stunted. A meta-analysis of the datasets showed that 43% of children below the poverty line were stunted. the decline was levelling off and could be captured accurately by a non-linear regression equation (R2=93%). and then calculated the difference between the expected and observed figures for each country. living in stunted. the total number of disadvantaged children is 227 million. Based on this estimate. In east Asia. An alternative estimate of the prevalence of stunting in children in poverty was obtained by analysis of micro-level data from 13 Multiple Indicator Cluster Surveys134 in developing countries with data for both stunting and a wealth index. We used their equations132 to estimate the expected poverty figures for east Asia and Pacific and south Asia for each country in these regions in the latest years with available poverty data. ‡ We extrapolated poverty figures to 2004 based on findings from Chen and Ravallion132 that. we estimated the prevalence of stunting among children in poverty in countries with both indicators available. .75 † Where data missing. et al. Poverty reduction was stagnant in the 1990s and early 2000s132 in central and eastern Europe. and calculated the numbers of stunted children plus the number of non-stunted children living in poverty. We used the observed poverty figures as the 2004 estimates for other developing countries.3 § Stunting source data taken from WHO Global Database on Child Growth and Malnutrition.133 de Onis.76 ¶ Based on estimate that prevalence of stunting among children in poverty is 50%. 2006. The relation between prevalence of stunting and poverty at the country level is non-linear and can be captured by a regression line of percentage stunted=7·8+4·2×√%poverty (using the 82 countries with available data. We therefore assume that for countries in this region there has been no change in stunting prevalence in the period concerned. We projected stunting figures for every country except those in the central and eastern Europe region to 2004 based on sub-regional linear trends estimated by de Onis. in the 1990s and early 2000s. or 39% of all children under 5 in developing countries. We refer to these children as disadvantaged. the number of children stunted or living in poverty is the sum of the total number of stunted children (156 million) plus 50% of children living in poverty (63 million) making a total of 219 million disadvantaged children. living 5 years* poverty*†‡ poverty poverty or both¶ in poverty or both¶ Sub-Saharan Africa Middle east and north Africa South Asia East Asia and Pacific 117·0 44·1 46% 4% 54·3 1·6 37% 21% 43·7 9·1 61% 22% 70·9 9·9 169·3 145·7 27% 11% 10% 46·3 16·6 5·9 39% 17% 14% 65·6 25·2 7·9 52% 23% 19% 88·8 33·6 10·8 Latin America 56·5 and the Caribbean Central and eastern Europe 26·4 4% 1·0 16% 4·2 18% 4·7 Developing 559·1 22% 125·6 28% 155·7 39% 218·7 countries * Population and poverty source data from UNICEF State of the World's Children. R2=40·9%). To avoid the double-counting of children who are both stunted and living in poverty. 156 million of whom are stunted and 126 million are living in absolute poverty (table 4). regional averages were used for percentage living in poverty and percentage stunted. Extrapolation of this regression line gives an estimate of the prevalence of stunting in people living in poverty to be 50%. in south Asia the decline could be accurately captured by a linear equation (R2=99%). We added this country-level difference to the regional figure in 2004 projected by Chen and Ravallion's equations to obtain the projected poverty level in 2004 for each country.Table 4.

We also need data to establish which cutoff for income and poverty is best for identifying children at high risk. and micronutrient deficiencies. Bangladesh 10. Also. followed by south Asia with 52%. Indonesia 8.135 and the −2 SD curves for length and height-for-age are slightly higher than the −2SD curves of the previous standards in certain age ranges under 60 months. limitations in the data suggest that the estimate is conservative. Internationally comparable and feasible measures of child development would produce the best estimate of disadvantaged children. and children in slightly better off households are probably also at risk. 61% (table 4). Figure 4 shows the numbers of disadvantaged children in millions by region. China 15. However. Sub-Saharan Africa has the highest prevalence of disadvantaged children under 5 years. unstimulating homes. we did not take into account many other risk factors for poor development. (B) living in poverty. it is more conservative than the alternative estimate of 227 million. and (C) disadvantaged (either stunted. Furthermore. Full-size image (58K) High-quality image (485K) Figure 5. Pakistan 8. and Tanzania 4. Figure 5 shows the prevalence by country. The precision of the estimate of disadvantaged children would be improved with internationally comparable data for maternal education and stimulation in the home. living in poverty. These ten countries account for 145 (66%) of the 219 million disadvantaged children in the developing world. less than US$1 per day is an extreme measure of poverty. we use the lower estimate in the rest of the paper. Nigeria 16. or both) in year 2004. This assumption probably underestimates the number of children because poverty is associated with higher fertility levels and larger household size. such as maternal illiteracy. and there is an . Uganda 5. Full-size image (31K) High-quality image (223K) Figure 4. Ethiopia 8. Regional distribution of the number of children under 5 years in millions (A) stunted. The top ten countries with the largest number of disadvantaged children (in millions) are: India 65. Democratic Republic of the Congo 6. We assumed that the percentage of people in absolute poverty was equal to the percentage of children in absolute poverty. Most disadvantaged children (89 million) are in south Asia. Percentage of disadvantaged children under 5 years by country in year 2004 Limitations of the estimate of numbers of disadvantaged children More than 200 million disadvantaged children is an exceedingly large amount. Therefore. WHO recently produced new growth standards.Although the estimate of 219 million is inevitably crude. if we used the new growth standards our estimate of prevalence of stunting and disadvantaged children would be slightly higher.

or both (table 6). controlling for years of schooling and income. Table 5 presents data for school grades attained in 18-year-old Brazilian men.86 Regression analysis with Jamaican data37 corroborate this finding. Brazil. this average matches another more rigorous study. Table 6. the combined reading and math test score of stunted children was 0·72 SD below that of non-stunted children. stratified for income quintiles was 0·91 grades. Some of the disadvantaged children would have IQs of less than −2 SD. This estimate is limited by the scarcity of data for the loss of learning ability of children in poverty. poverty (first vs third quintile of wealth). each year of schooling increases wages by 9·7%. Table 5. in schooling and percentage loss in yearly income in developing countries . the level used to diagnose mild mental retardation (IQ 50–69). Two pathways reduce their productivity: fewer years of schooling. the deficit from being both stunted and in poverty (first income quintile) compared with being non-stunted and in the third income quintile was 2·15 grades. the loss from living in poverty but not being stunted is 5·9% and from being both stunted and in poverty is 30·1% (table 6). HAZ=height-for-age z score. * Data provided by the Pelotas Birth Cohort Study. a deficit in adaptive behaviour is usually needed to make the diagnosis and these data are not available. We are concerned in this series about the loss of potential across the whole range of cognitive ability. Controlling for stunting.38 Stunted children also learn less per year in school. Data from the Philippines has shown that. This reduction was equivalent to 2·0 fewer years of schooling. We estimate from these data that the deficit attributed to being stunted (height-for-age less than −2 z scores compared with non-stunted greater than −1 z scores). on average. and stunting status in early childhood* Income quintile Poorest 20% 2nd quintile 3rd quintile 4th quintile Wealthiest 20% HAZ ≥ −1 n n HAZ < −2 6·96 (2·11) 141 116 5·54 (2·17) 7·10 (2·17) 213 6·44 (2·08) 123 6·56 (1·98) 7·69 (2·05) 8·43 (1·89) 9·40 (1·83) 274 127 325 111 336 59 7·06 (1·92) 7·74 (1·91) 9·27 (2·03) 7·03 (2·05) 6·65 (2·42) 8·69 (2·29) HAZ −1 to −2 6·67 (2·05) n 71 77 38 17 13 Data are mean (SD) unless otherwise stated.136 However. Economic implications of poor child development Disadvantaged children in developing countries who do not reach their developmental potential are less likely to be productive adults. and almost certainly underestimates the true loss.38 by income quintile at birth and stunting status in the first 2 years. Attained grades in 18-year-old Brazilian men. and both. poor children almost certainly learn less per year in school. and the deficit from living in poverty (first vs third quintile of income) stratified for stunting status was 0·71 grades.138 which reported that each year of schooling in Indonesia increased wages by 7–11%. living in poverty. Taking into account the number of children who are stunted. stunted children's combined math and reading test score was 0·78 SD below those of non-stunted children. Both stunting and poverty are associated with reduced years of schooling. [137] and [138] we estimate that the loss in adult income from being stunted but not in poverty is 22·2%. Deficit associated with stunting. by income level. controlling for wealth and grade level. Assuming that every year of schooling increases adult yearly income by 9%. we calculate the average deficit in adult yearly income for all 219 million disadvantaged children to be 19·8%. but we know of no studies that convincingly estimate the deficit. What is the economic cost of one less year of schooling? Studies from 51 countries show that. although most would have learning problems in school and restricted employment opportunities. Furthermore.137 Although some of the studies had methodological weaknesses.urgent need to develop such measures both to more accurately assess the problem and to assess interventions. and less learning per year in school.

There are few national data for children's development but our conservative estimate is that more than 200 million children under 5 years of age in developing countries are not developing to their full potential. both economically and in terms of equity and individual wellbeing. and the availability of effective interventions. Conclusion Many children in developing countries are exposed to multiple risks for poor development including poverty and poor health and nutrition. we can no longer justify inactivity. disadvantaged children are destined not only to be less educated and have poorer cognitive function than their peers but also to be less productive. There is increasing evidence that early interventions can help prevent the loss of potential in affected children and improvements can happen rapidly (see third paper in this series). with the weights inversely proportional to the square of the SE of the quintile-specific difference). ‖ Difference between non-stunted and third quintile vs stunted and first quintile in Brazil (table 5). The problem of poor child development will remain unless a substantial effort is made to mount appropriate integrated programmes.91)−1=−0·222. controlling for stunting (similar method to [‡]). [137] and [138] Implies that a reduction of 1 year of schooling will reduce income by 8·3% (1/1·09−1 = 0·083). We estimate that this loss of human potential is associated with more than a 20% deficit in adult income and will have implications for national development. Philippines86 Sum of and Jamaica37 columns 1 and 2 Clearly. In consideration of the total cost to society of poor early child development. § Deficit associated with poverty. sustaining existing inequities in society with their attendant problems.Deficit in school grades attained Deficit in Total deficit learning in grade ability per equivalents grade in grade equivalents 2·0 ≥0¶ ≥2·0¶ 2·91 0·71¶ 4·15¶ Percentage loss of adult yearly income per grade* 8·3% 8·3% 8·3% Total percentage loss†of adult yearly income (compounded) Number (%) of children younger than 5 years in developing countries 92·9 (16·6%) 62·8 (11·2%) 62·8 (11·2%) Average percentage loss of adult yearly income per disadvantaged child 19·8% Stunted only Poor only 0·91‡ 0·71§ 22·2% 5·9% 30·1% Stunted 2·15‖ and poor Evidence Brazil38 51 Combining See table 4 Weighted countries137 columns 3 and 4 average from plus columns 5 and 6 Indonesian study138 * An increase of one grade of schooling is assumed to increase income by 9%. (1/1·094·15)−1=−0·301. (1/1·090·71)−1=−0·059. we need to take into account that the next generation will be affected. The proximal causes of poor child development are analysed in the second paper in this series. controlling for wealth quintiles. . (The estimate is a weighted average of the differences between stunted *<−2 z+vs non-stunted *>−1 z+ children in the five wealth quintiles. ¶ Indicates that the figure is lower bound and under-estimates true figure because the effect of poverty on learning per year of schooling is unknown. a person with an income of 91·7 due to a loss of 1 year of schooling would have had an income of 100 (91·7×1·09) had that person not lost that year of schooling. † (1/1·092. Sub-Saharan African countries have the highest percentage of disadvantaged children but the largest number live in south Asia. that is. ‡ Deficit associated with stunting. national development will also be substantially affected. These costs have to be weighed against those of interventions. In view of the high cost of poor child development. The children will subsequently do poorly in school and are likely to transfer poverty to the next generation.67 Where large numbers of children are affected.

―educational achievement‖. A multitude of biological and environmental factors were analysed. Undernutrition and prematurity were the two most prevalent etiological diagnoses (21% each). Conflict of interest statement We declare that we have no conflict of interest. Maximum delay was observed in the 0–12 months age group (7.Severity and Timing of Stunting in the First Two Years of Life Affect Performance on Cognitive Tests in Late Childhood1. focusing on the significance of severity.Search strategy and selection criteria The following databases were searched for studies in developing countries reported in English from 1985. ERIC. Microenvironmental factors Introduction . Interactions between stunting and schooling were not significant. JN Medical College. 21. Keywords Global developmental delay . ―grade attained‖. The sample included > 2000 Filipino children administered a cognitive ability test at ages 8 and 11 y. and Cochrane Review. largely because children stunted very earl y also tended to be severely stunted (χ2 P = 0. LILACS. A total of 468 (243 boys and 225 girls) children aged 0–3 years were included. PsychInfo. Results As many as 7. Aligarh. ―grade retention‖. India. and UNESCO's International Bureau of Education. With the use of data from the Cebu Longitudinal Health and Nutrition Study. The timing of stunting was also related to test performance. ―school dropout‖.1% of the children screened positive for global developmental delay. For search 2 we also used stunting or malnutrition or undernutrition. Children stunted between birth and age 2 y had significantly lower test scores than nonstunted children. we assesshere the relationship between stunting in the first 2 y of life and later cognitive development. Developmental screening was performed for each child. Results emphasize the need to prevent early stunting and to provide adequate schooling to disadvantaged children. 22. along with published documents from the World Bank.2 Undernutrition in infancy and early childhood is thought to adversely affect cognitive development. After multivariate adjustment. UNICEF. and for search 3 we used search 1 keywords and poverty or income or economic status. timing and persistence of early stunting. suggesting that adverse effects may decline over time. which was the result of a substantial delay in initial enrollment as well as higher absenteeism and repetition of school years among stunted children. EMBASE. Conclusions Developmental delay can be predicted by specific biological and environmental factors which would help in initiating appropriate interventions. Stunting and maternal illiteracy were the microenvironmental predictors on stepwise binary logistic regression while prematurity and a history of seizures emerged significant biological predictors. The shortfall in test scores among children stunted in the first 2 y was strongly related to reduced schooling. Methods Cross sectional descriptive study was conducted in field practice areas of the Department of Community Medicine. especially when stunting was severe. Deficits in children's scores were smaller at age 11 y than at age 8 y. to February. 2006: BIOSIS via ISI web of science. References in retrieved papers were examined and further information sought from experts in the field. indicating that stunted and nonstunted children benefitted similarly from additional schooling. Stunting status was determined on the basis of anthropometric data collected prospectively between birth and age 2 y. severe stunting at age 2 y remained significantly associated with later deficits in cognitive ability. although evidence of lasting effects is not well established. PubMed.000). Biological . SIGLE. Global Developmental Delay and Its Determinants Among Urban Infants and Toddlers: A Cross Sectional Study Abstract Objective To estimate the prevalence of global developmental delay among children under 3 years of age and study the determinant factors. Keywords used for search 1 were: ―developing countries‖ or ―developing nations‖ or ―third world‖ and ―child development‖ or ―cognitive development‖ or ―language development‖ or ―cognition‖ or ―education‖ or ―school enrolment‖.0%).

In terms of demographic characteristics. Khalique : M. family environments of young children are major predictors of cognitive and socioemotional abilities. Alam : Z.T. the sample size calculated was 157. It was however decided to inflate this estimated sample size to the order of almost trebling to around 500 in order to augment validity. The present study is an attempt to assess the magnitude of global developmental delay among children under 3 years of age and to analyse the impact of important biological and ambient environmental factors on their psychosocial development. the systematic sample was representative of the overall population of children surveyed.1007/s12098-010-0151-9 Sample Size and Sampling Method The estimated sample size was calculated according to the formula: N=4pq/d2 where p is the prevalence of global developmental delay. Among the 1410 households surveyed. namely (i) gross motor.1% [3] and relative precision d as 5% of p. Ansari JN Medical college. A systematic sample consisting of every third child listed was pre-selected for developmental screening [4]. language and concept development.250. Indian J Pediatr (2010) 77:975–980 DOI 10. (iv) personal skills and (v) social skills.000 children aged 0–6 years was used for developmental screening of the children. Khan : N. J N Medical College. a total of 1496 children in this age group were listed. A community based household survey was conducted in the registered areas. Early identification and timely intervention in populations with established risk can go a long way towards improving their functional capacity [2]. AMU. Aligarh. The urban health training center (U. Amir : S. (iii) hearing. (ii) vision and fine motor. Besides biological determinants. Global Developmental Delay was operationally defined as a significant delay. their probable lack of awareness regarding benefits of developmental screening.C) has four registered peri-urban localities with 1410 households and a registered population of 9.More than 200 million children under 5 years of age in developing countries do not reach their developmental potential [1]. India e-mail: sandeepsemail@rediffmail. Taking the prevalence of Global Developmental Delay (GDD) in children under 3 years of age as p=11. The final sample however comprised of 468 children (225 females and 243 males) as 32 kids from the initial cohort did not participate because of parental refusal and. and d is relative error. The screening test comprised of five major developmental areas. S. India. Sachdeva (*) : A. q=1-p. especially infants and toddlers constitute the most disadvantaged group as far as psychosocial development is concerned. A. This is attributable to the greater vulnerability of the developing brain in the early formative years. Aligarh. The age of attainment of skills in each of these developmental areas was compared with the average age of attainment (50th centile) of a milestone and any lag from this reference was deemed as a delayed milestone.H. Material and Methods Study Areas and Subjects This community based cross sectional study was conducted (during the period of August 2007 to June 2008) in the field practice areas of the Department of Community Medicine. below the mean in two . Study Instruments The ICMR Developmental Screening Test questionnaire [5] developed and standardized on more than 13.

If the child was born prematurely. or activities in daily living) [6]. II and III of the modified Prasad’s classification were categorized as upper class and IV and V as lower classes. 12–24 and 24–36 months respectively. There were an aggregate of 13 (of 186).7%) of children were seen in the 0– 12 months age group and the least (120/25. corrected to the nearest month.46%) of the children belonged to Muslim families and rest were from Hindu families.05 were considered to indicate statistical significance All confidence intervals were calculated at 95% level. General Information The exact age of the child was computed from the child’s date of birth. Binary logistic regression was used to do the multivariate analysis. gestation at birth. 1). Height and weight measurements were recorded following standard techniques.08% of the study group. birth asphyxia. Around 10% children were born preterm. mode of delivery. Female children constituted 48. For this study. Biological Factors The impact of the following biological factors was assessed: consanguinity. the age was corrected by subtracting the number of weeks of missed gestation from present (chronological) age.or more domains (gross/fine motor skills. IL). Age and sex specific—2 z-scores were followed to define wasting and stunting.6%) in the 24– 36 months age group (Fig.0 (SPSS. Half (51. caste. dwellings. Eightythree percent children were living in overcrowded dwellings and 76. wasting and pallor. stunting. A precise history of dietary intake of the child was elicited from the mother (recall of food items consumed in last 24 h). 10 (of 162) and 4 (of 120) children with developmental delay in each of the age groups of 0–12. seizures and facial dysmorphism. single parenting and social class. underweight. Nutrition Variables pertinent to nutrition were appropriateness of breast feeding. Sixty 976 Indian J Pediatr (2010) 77:975–980 percent were living in nuclear families. A regional local-events calendar was used to assist the mothers for better recall. All p values were two tailed and values of <0. The social class of the child’s family was determined using the Modified Prasad Scale [7]. Anthropometry was carried out for each child and stigmata of micronutrient deficiencies were sought for. cognition. speech/language. Chicago. the age as told by the mother was used. Microenvironmental Factors The microenvironmental factors assessed were the type of family.2%) as the age . Results The majority (186/39. neonatal jaundice.0% to 6.5% belonged to the lower socio economic class. When data on the exact date of birth was not available. Continuous variables were expressed as mean ± standard deviation (Gaussian distribution) or range and qualitative data was expressed as percentage. children born before 34 weeks gestation fulfilled the criterion for prematurity. Statistical Analysis Analysis was performed using SPSS version 10. multiple gestation. The trend therefore was of a marginal decline in the proportion of this group of children (from 7. parental literacy. personal/social skills. Social classes I. Chi square test and Fisher’s exact test were used for univariate analysis. Indices for wasting and stunting were used to evaluate the nutritional status of the subjects as per the Centre for Disease Control 2000 norms.

too were predictors of poor developmental performance among the children studied. (Table 4). The model for binary logistic regression of important predictor variables obviated the effect of a few factors found significant on univariate analysis except for maternal literacy (Adjusted OR=4.4% of GDD in children under 3 years of age.8) Delayed 9 4 3 7 2 2 (10. The relative distribution of the most probable etiologies to the developmental lapses observed in the study population is illustrated in the pie chart below (Fig.09.5 to 446. 95% CI 1. 95% CI 4.7).1 to 4. pucca dwellings(OR=2. and in children with maternal deprivation and Down’s syndrome.5.4 to 9. More girls were affected in comparison to boys among the 0–12 months age group. 2).7 to 574. facial dysmorphism. maternal deprivation (3% each) and dysmorphic syndromes (9%) contributed to the rest. 95% CI 1.2.95% CI 1.63) were found to be positive deviants towards developmental performance in these children.66) and seizures (Adjusted OR=6.95% CI 1.7. (OR= 2.1% of the children screened positive for global developmental delay in the present study.2) correlated with poor outcome.8) (3. Nutrition related factors. Discussion As many as 7.3) and birth asphyxia(OR=21.2. Undernutrition (PEM) and prematurity could be attributed as the major causes (21% each) whereas in as many as 28% of cases.56) in decreasing order of their relative risks. (Table 3).5) (96.5) (3.2) (96.95% CI 1.6) and pallor (OR=2.67). Workers from India [9] Fig. Investigators from Korea reported a prevalence of 11.9) and literate mother (OR=3. (OR=62. whereas single parenting (OR=2. 95% CI 6.44) and stunting (Adjusted OR=5. Variables pertaining to home environment like social class (OR=3. Undernutrition was a common denominator in almost half of the children with history of premature birth.5) (3. The biological factors of significance that were brought into fore were gestational age (Adjusted OR=3.2 to 4. seizures (OR=45.2) Total 85 101 83 79 57 63 (100) (100) (100) (100) (100) (100) Table 1 Age and sex distribution . Comparable rates were observed by workers from the UAE [8] who observed a prevalence of 8.95%CI 1. sequelae of (meningo) encephalitides. (Table 2) Amongst the biological factors analysed in the univariate analysis. only to exhibit a steep fall to 3. A history of consanguinity among parents and prematurity. Factors as pallor and pucca dwellings significant on univariate analysis did not emerge significant on binary logistic regression analysis.1) (96.48 to progressed from 0–12 months to 12–24 months. varying degrees of hearing loss. a definitive clinical condition could not be discerned.25 to 7.7) were significantly associated with poor developmental performance on univariate analysis. Child with Down’s syndrome phenotype had history of birth asphyxia as well.69).5.62). were associated with developmental lag.6) (8. Birth asphyxia (9%).4) (91.9) (3.3. 95% CI 3. 1 Bar chart representing age and gender distribution of the study population Age group (months) Development 0–12 months 12–24 months 24–36 months Normal Female Male Female Male Female Male 76 97 80 72 55 61 (89. particularly chronic energy deficiency manifesting in the form of decreased height for age.5% in the 24–36 months age group (Table 1). visual impairment (vitamin A deficiency in our case).1% [3] of questionable development in children under 2 years of age.1 to 5.5) (96.3 to 5.

This could explain an otherwise normal developmental outcome in several of the home deliveries with history of ‘delayed cry’ at birth. Investigators have opined that ultimate developmental potential is multifactorial and is a function of a multitude of genetic and environmental factors.3 to 7. Although a history of delayed birth cry was common. Analysts from Canada have also confirmed that etiologic yield in an unselected series of young children with global developmental delay is close to 40% overall and 55% in the absence of any coexisting autistic features [15]. it was noted that development of gross motor milestones was Fig. In another Indian study.1 (1. Besides. this view has been refuted by few other workers [11. 14]. Nearly a third of the children could not be assigned a specific etiology of their delayed development.4 to 9.6) Literate 177 6 6 Father . There is limited information regarding prevalence of neurodevelopmental delay in developing nations. Reduced school performance has been observed in stunted children in Guatemala [22].5% in children under 2 years from deprived urban settlements of Hyderabad city.4) Lower 283 25 3 Family Nuclear 272 19 0. 2 Pie chart showing relative proportions of different etiologies of developmental delay among children in the study population. Chronic undernutrition manifest in the form of stunting was observed in as many as 59% of children.No Variable Development Normal Delayed OR(95% CI) 1 Social class Lower 262 28 3. Randomised clinical trials conducted at several centres including India [18] have proven that room air is as good as 100% oxygen for resuscitation of term asphyxic newborns without causing adverse neurodevelopment at 2 years.6) Joint 163 14 4 Dwellings Katcha 392 27 2. 12]. birth asphyxia was not the most prevalent of the recognizable etiologies as in other studies [10]. The decline in the rate of developmental faltering with age corroborates with the observation made by Persha and Arya et al.of normal and delayed development in the study population Numbers in parentheses indicate percentages Indian J Pediatr (2010) 77:975–980 977 observed the same to be of the order of 2. [10].4 to 1.7 (0.6 (0. This has been confirmed in other studies [13. as for example better child rearing practices on part of the mother. 17].7(1.1 to 5. The prevalence of developmental delay reported by various authors in different studies varies over a wide range. Several other studies have also shown that stunted growth adversely affects a child’s cognitive ability later in childhood [19–21].7) Upper 173 5 2 Caste Upper 152 8 0.3 to1. This could be a result of a lack of uniformity in the instruments employed to assess developmental performance.9) Pucca 43 6 5 Mother Illiterate 258 27 3. The maximum detriment to child development was posed by undernutrition and prematurity as observed in other studies as well [10. a minor proportion was afflicted with easily remediable impairments as deafness. Coexistent etiologies are depicted in similar colours Table 2 Univariate analysis of microenvironmental and co morbidity related determinants of developmental performance S. However. including India.5 (1. This indicates a positive impact of certain factors that accumulate with age. This interplay of nature vs nurture renders identification a difficult task [16].

Pallor is a usual accompaniment of undernutrition and was significant in the univariate analysis. pre-and postpartum.Illiterate 273 23 0.3 (1. Maternal schooling was believed to affect children’s cognitive development by means of environmental organization.1 to 4. parental expectations and practices.5 (1. Either a lack of adequate total calories or a deficiency of protein may impede the development of the neurological system. 28].2) Inappropriate 173 18 9 Weight for age Normal 320 19 1. have not studied the effect of these factors on individual spheres of development. The results of our analysis suggest that both the nutritional and social domains are related to cognitive development.2) No 317 17 8 Breastfeeding Appropriate 262 15 0. It is therefore undesirable to neglect the developmental prognosis of these children.3 to 1. however. Finally. probably on the particular domain of development. Preterm neonates faltered significantly in psychomotor development as found in the present study as well as in other contemporary works [27.6) Stunted 123 16 11 Weight for height Normal 402 30 0. Complications like intraventricular hemorrhage peculiar to the premature state could well be responsible for developmental .2 to 3.9) Underweight 115 14 10 Height for age Normal 312 17 2. Because a majority of the informers had no record of the birth weight. Morris BH et al.7) Absent 273 14 OR Odds ratio 978 Indian J Pediatr (2010) 77:975–980 delayed in significantly high percentage of stunted infants with H/A<−2S. We. has insufficient energy to take advantage of opportunities for social contacts and learning. the biological factors also deserve mention as two of them were independently significant with developmental outcome. 25] but this was not found in our case. Another determinant that emerged significant in the logistic regression was maternal illiteracy which was noted by several other investigators as well.003) [23]. Apart from the above microenvironmental factors.9 to 3. and that their relative importance depends. A highly significant association with the outcome variable in the present study was elicited. prematurity of less than 34 weeks gestation was operationally used as a marker to indicate significantly small size at birth.4 to 1. Several workers have reported an independent association between nutritional anemia and developmental outcome [24.5 (0.6) Literate 162 10 7 Single parenting Yes 118 16 2.2 (1.8 (0.2 to 4.7 (0.3 to 5. provision of materials for child’s cognitive stimulation. the survival of extremely preterm/ELBW neonates is improving. in their prospective longitudinal study also demonstrated a greater length of time required to reach full enteral feeding and mental developmental outcome at 24 months corrected age [29].6%.7 (0.5) Wasted 33 3 12 Pallor Present 162 19 2. which leads to increased social learning opportunities. Another possibility is that the poorly nourished child. Preterm births secondary to congenital infections/malformations may develop CNS complications.2%) compared to normal H/A (5. it may be that adults and older children treat the larger child as a more mature individual. With state of the art intensive care. and variety in daily stimulation [26].D (22. This is because poor linear growth creates an overall comparative disadvantage in an already deprived environment. p value=0.

68 Maternal literacy −8.63 0. thereby making a case for their easy and cost effective prevention.7 (1. and malaria infection as predictors of motor activity in 771 children aged 5-19 mo. gestation and seizures were more significant than the distal factors. in a large European cohort study.4) No 173 10 5 Birth asphyxia Yes 2 3 21.7) Preterm 39 7 4 Multiple gestation Yes 262 23 0. Abstract Motor activity improves cognitive and social-emotional development through a child's exploration of his or her physical and social environment. Its retrospective design is a limitation as well.3) No 433 29 7 Jaundice Yes 11 2 2. hemoglobin (Hb).2 (6.No Variable Development Normal Delayed OR(95% CI) 1 Consanguinity Yes 86 12 2.5 to 2.66 0. Binary logistic regression assessed the predictors of any locomotion.88 1.5(0. However. Children exposed to these factors are at risk of developmental delay. The spectrum of etiology could include Table 3 Univariate analysis of biological determinants of developmental performance S.20 4.7 to 574. Children who did not locomote during .3 to 1.48 2. Children with iron deficiency.E of estimate Odds ratio Significance (p) Stunting −1. iron deficiency.02 Single parenting 12.04 29.5) No 433 30 6 Seizures Yes 2 4 45 (4. stunting. iron deficiency anemia.1 (1.69 0.5) No 349 21 2 Delivery Normal 285 21 1.problems including cerebral palsy among survivors. lengthfor-age Z-score (LAZ).7) No 434 28 Variable Estimated coefficient S.3) Caesarean 150 12 3 Gestation Term 396 26 2. The proximate factors in the child’s mileu such as nutrition.1 (0.65 5.03 Seizures 6.55 0. it was noted that the outcome in children after lengthy febrile convulsions and status epilepticus was better than reported from studies of selected groups and seems determined more by the underlying cause than by the seizures themselves [31].62 0.70 30.90 0.88 0.04 Pallor −2.59 0. It is cost effective to detect early developmental lags (including hearing impairment) in at risk children through simple screening tests.6 (0.7) No 424 31 8 Facial dysmorphism Yes 1 5 62.1 to 4.55 28.5to11. This study assessed anemia.86 0. Trained observers conducted 2.2 to 4-h observations of children's motor activity in and around their homes. Conclusion Developmental performance of children is a function of several biological and social factors. or malaria have lower motor activity scores and spend less time in locomotion. Research is required to investigate the ‘hidden’ etiologies of developmental delay. the study attempts at being a sensitizing exercise for health care providers towards this extremely crucial issue of the lives of our future generation.89 0.68 Gestation 5.84 Pucca dwellings −12. 23.44 0.01 Table 4 Model for logistic regression of significant predictor variables for developmental performance Indian J Pediatr (2010) 77:975–980 979 varied causes like epilepsy or sequelae to encephalitides/birth asphyxia.5 to 446. The study falls short of not being able to study correlates of individual domains of child development.43 0.5 to 134.55 3.6 (3. Recurrent seizures in the neonatal or early childhood period can cause chronic brain hypoxia resulting in poor brain development. A significant independent association with seizures as in our case was observed by Barnard C and coworkers who concluded that 34% of children with refractory epilepsy demonstrated developmental deterioration [30].45 6. However.

Iron deficiency with and without anemia. Media Profil Kesehatan Kota Semarang merupakan salah satu sarana untuk menilai pencapaian kinerja pembangunan kesehatan dalam rangka mewujudkan Kota Semarang Sehat 2010.1. originate through impaired growth and development during fetal life and infancy. Oleh sebab itu dalam pelaksanaan pembangunan kesehatan telah dilakukan perubahan cara pandang (mindset) dari paradigma sakit menuju paradigma sehat sejalan dengan Visi Indonesia Sehat 2010. hypertension and non-insulin dependent diabetes. Malaria infection significantly predicted less TMA and locomotion in crawlers. Improvements in iron status and growth and prevention or effective treatment of malaria may improve children's motor. Instalasi . Profil kesehatan kota Semarang 2009 BAB I PENDAHULUAN 1. However. Profil Kesehatan menyajikan berbagai data dan informasi diantaranya meliputi data kependudukan. Linear regression evaluated the predictors of total motor activity (TMA) and time spent in locomotion for all children who locomoted during the observation combined (movers) and then separately for crawlers and walkers. cognitive. sensitive period of early life results in long-term changes in physiology or metabolism. and malaria infection significantly predicted TMA and locomotion in all movers. maka Visi Pembangunan Kesehatan di Kota Semarang yang merupakan Ibu Kota Provinsi Jawa Tengah adalah Terwujudnya Masyarakat Kota Pantai Metropolitan yang Sehat Didukung dengan Profesionalisme dan Kinerja yang Tinggi. 24. These diseases may be consequences of 'programming'. LAZ. with malaria being important for the younger. and the associated conditions. whereas higher Hb and LAZ significantly predicted more activity and locomotion. masalah kesehatan dan lain -lain. Iron deficiency (77. iron deficiency anemia predicted less activity and locomotion.9%). Dalam rangka memberikan gambaran situasi kesehatan di Kota Semarang Tahun 2009 perlu diterbitkan Buku Profil Kesehatan Kota Semarang Tahun 2009. Latar Belakang Kesehatan merupakan salah komponen utama dalam Index Pembangunan Manusia (IPM) yang dapat mendukung terciptanya SDM yang sehat. and failure of maturation is largely irrecoverable. Seiring dengan visi tersebut. In walkers. malaria infection (33. There are critical windows of time during which maturation must be achieved. pencapaian program – program kesehatan. anemia (58. cerdas. less developmentally advanced children and Hb and LAZ becoming important as children begin to attain walking skills. Pembangunan kesehatan merupakan salah satu hak dasar masyarakat yaitu hak untuk memperoleh pelayanan kesehatan sesuai dapat dipenuhi. Puskesmas. which occurs because the systems and organs of the body mature during periods of rapid growth in fetal life and infancy. terampil dan ahli menuju keberhasilan Pembangunan Kesehatan.Fetal undernutrition and disease in later life Abstract Recent findings suggest that coronary heart disease and stroke.Dinas kesehatan Semarang. the relative importance of these factors is dependent on motor development. 25.9%). Tersusunnya Buku Profil Kesehatan Kota Semarang Tahun 2009 didukung oleh pengelola data dan informasi Dinas Kesehatan Kota Semarang. fasilitas kesehatan.the observation (nonmovers) were excluded from further analyses. Animal studies provide many examples of programming.0%). even after controlling for attained milestone. Hb. and social-emotional development either directly or through improvements in motor activity. and stunting (34. whereby a stimulus or insult at a critical.6%) were prevalent.

Tersedianya alat untuk memacu penyempurnaan sistem pencatatan dan pelaporan kesehatan. Rumah Sakit maupun Unit-Unit Kesehatan lainnya. Diperolehnya Data / informasi tentang status kesehatan masyarakat yang meliputi angka kematian. JAMSOSTEK.2. tepat waktu dan sesuai kebutuhan dalam rangka meningkatkan kemampuan manajemen kesehatan secara berhasilguna dan berdayaguna sebagai upaya menuju Kota Semarang yang Sehat.2.Perbekalan Farmasi.2.2.4. juga lintas sektor terkait (Badan Pusat Statistik.2.6.2. data kependudukan dan sosial ekonomi.2.2. 1.7. perilaku masyarakat yang berkaitan dengan kesehatan masyarakat. yang meliputi cakupan kegiatan dan sumber daya kesehatan. 1.5. 1. Diperolehnya Data / informasi umum dan lingkungan yang meliputi lingkungan fisik dan biologi. 1. akurat.2. POLWILTABES Kota Semarang). Diperolehnya Data / informasi untuk bahan penyusunan perencanaan kegiatan program kesehatan.2. angka kesakitan dan status gizi masyarakat.3.2.1. 1. U mum Tujuan disusunnya Profil Kesehatan Kota Semarang Tahun 2009 adalah tersedianya data / informasi yang elevan. Khusus Secara khusus tujuan penyusunan Profil Kesehatan adalah : 1. ASKES. 1.2.2. Diperolehnya Data / informasi tentang upaya kesehatan. T u j u a n 1. BKKBN. 1. Tersedianya alat untuk pemantauan dan evaluasi tahunan program – program kesehatan. 1.2. Tersedianya wadah integrasi berbagai data yang telah dikumpulkan oleh berbagai sistem pencatatan dan pelaporan yang ada di Puskesmas. .