TINGGI BADAN > PENDEKATAU STUNTING

RABU, 22 JUNI 2016

SHORT STATURE OR STUNTING DR.
TOPIK Dr. AMAN B PULUNGAN, Sp.A(K) Dr.
PEMBICARA
PIMPRIM B YANUARSO, Sp.A(K)
MODERATOR
Tinggi < P3 atau -
2SD
Short stature or
Stunting
Aman Pulungan
 NO 3 GOOD HEALTH AND 4 QUALITY 5 GENDER
POVERTY WELL BEING EDUCATION EQUALITY

6 CLEAN WATER ANO

-V* ii I
DECENT WORK AND Q INDUSTRY INNOVATION >1 fi REDUCED ECONOMIC GROWTH
SANITATION SI AND INFRASTRUCTURE IU INEQUALITIES

9
SUSTAINABLE
ANO COMMUNITIES
CTOS
THE GLOBAL GOALS
Jfe (5 40 RESPONSIBLE l£
CONSUMPTIOI
CONSUMPTION AND
PRODUCTION
For Sustainable Development

<|Q CLIMATE IO ACTION •■7 PARTNERSHIPS I#

M
UTE BELOW
1R llFE PUCE AND JUSTICE STRONG
INSTITUTIONS
FOR THE GOALS
IU ONU
WATER
Pada tahun 2030, mengakhiri semua bentuk malnutrisi, termasuk mencapai, pada
tahun 2025, target yang disepakati secara internasional tentang stunting dan
wasting pada anak di bawah usia 5 tahun, dan mengatasi kebutuhan gizi remaja
perempuan, wanita hamil, dan menyusui dan orang yang lebih tua.
 Growth: Normal and
Abnormal
Short stature or stunting

Pertumbuhan: Normal dan Abnormal

Perawakan pendek atau stunting
Normal Growth
• Pertumbuhan yang mengikuti pola yang ditetapkan berdasarkan studi
dari beberapa populasi yang berbeda dan yang mengikuti lintasan
grafik pertumbuhan standar

• Pertumbuhan normal jatuh antara persentil ke-3 dan ke-97 dari semua
anak -> 3% terpendek dan tertinggi jatuh di luar batas perawakan
"normal"
Normal Distribution/Standard
Deviation Scores/Percentiles
Standard Normal Curve
Sportsmen in 1900 were put in line
according to height:
Short ones on the right
Tall ones on the left

Let us do this with our children

Z-score = (observed - mean of reference) / SD

Short ones one the right

Tall ones on the left

Centiles inform how many percent of the

others are shorter.
Because height is normally distributed
we can convert position (centile) into Z-
or standard deviation scores.
 How does it look next
year?
p50
p60 p40
p 70 p3()

p80 p20

SD
 Some children CHANGE
IN POSITION, because
they grow faster than
others.
Most however do not.
p50
p60 p40 Most children keep their
position.
 Some children CHANGE IN
POSITION, because they
grow faster than others.

Most however do not.

p50 Most children keep their

position
p60 p40
even though the variance
increases as the group drifts
apart.
 Some children CHANGE IN
POSITION, because they
grow faster than others.

Most however do not.

p50 Most children keep their

position
p60 p40
 Some children CHANGE IN
POSITION, because they
grow faster than others.

Most however do not.

Most children keep their
position
p60 p40
 Some children CHANGE IN
POSITION, because they
grow faster than others.

Most however do not.

p50 Most children keep their

position
p60 p40
even though the variance
p70 p30
increases as the group drifts
apart.
p8Q p2 O
Phases of Normal Growth
• Intrauterin
• Pertumbuhan sangat dipengaruhi oleh lingkungan intrauterin
• Insulin, IGF, dan protein pengikatnya memainkan peran penting
dalam pertumbuhan janin
• GH, hormon tiroid tidak terlalu penting
•Kekanak
• Pertumbuhan yang cepat namun melambat selama 2 tahun
pertama kehidupan
• Bayi sering melintasi garis persentil selama 24 bulan pertama
saat mereka tumbuh menuju potensi genetik mereka dan semakin
jauh dari ekses atau kendala lingkungan intrauterin
Phases of Normal Growth (2)
•Masa kanak
• Pertumbuhan dengan kecepatan yang relatif konstan 4,5 hingga 7
cm/tahun (1,8 hingga 2,8 in/tahun)
• Mungkin sedikit melambat sebelum masa remaja

• Pubertas
• Ditandai dengan percepatan pertumbuhan 8 hingga 14 cm/tahun
(3,2 hingga 5,5 in/tahun) karena efek sinergis dari peningkatan
steroid gonad dan sekresi hormon pertumbuhan
Phases of Normal Growth (cont)
(1+2 + 3)

Age (years)
Adapted from Kariberg J. Acta Paediatr Scand Suppl. 1989;350:70-94.
Normal Growth Rates During Childhood

Age (y)
 Best practices for anthropometric measurements

Peralatan standar dan teknik pengukuran sangat penting untuk penilaian

pertumbuhan linier yang akurat, serta untuk pengukuran antropometri
lainnya

Use child and/or infant stadiometer correctly

Data yang diperoleh dari pengukuran harus dicatat dengan cermat

dalam grafik pertumbuhan yang sesuai -> grafik pertumbuhan mana
yang harus digunakan?

Gunakan stadiometer anak dan/atau

bayi dengan benar
Descriptive and normative reference charts

Descriptive national or • Based on representative sample from the population

regional growth reference
chart • Currently used for children > 4 years in most high-income
countries

• NCHS, CDC

• Meant to depict “ideal” growth under favorable

environmental and nutritional conditions

Normative growth standard • WHO-growth chart

WHO Growth Chart

■ Paling sering dipekerjakan

■ Berdasarkan :
■ Anak-anak berusia 0-4 tahun dari 6 negara (Brasil, Ghana, India,
Norwegia, Oman, dan AS)
■ Hidup dalam kondisi lingkungan yang menguntungkan
■ Disusui secara eksklusif atau dominan selama setidaknya 4 m.o
■ Di mana makanan pendamping diperkenalkan oleh 6 m.o
■ yang terus menyusui hingga setidaknya 12 m.o.
In general, a considerably higher proportion of children are classified as stunted with the 2006 WHO
standards compared to the CDC or NCHS growth charts
WHO and CDC Growth Charts for Children Under 2 Years:
Differences

• Grafik pertumbuhan CDC

• "Referensi pertumbuhan" menunjukkan bagaimana penampang
besar bayi AS benar-benar tumbuh antara tahun 1970 dan awal
1990-an
• Data yang digunakan dari bayi yang pemberian makannya
mendekati campuran praktik pemberian makan pada waktu itu
• -50% pernah disusui dan -33% disusui hingga 3 bulan
• Persentase yang lebih besar disusui sekarang
WHO and CDC Growth Charts for Children Under 2 Years:
Differences (cont)

• Grafik pertumbuhan WHO

• Lahir 2 tahun berdasarkan 882 bayi yang disusui secara
eksklusif/dominan selama minimal 4 bulan dan yang melanjutkan
menyusui selama minimal 12 bulan
• Kelompok bayi berasal dari beberapa situs di seluruh dunia tetapi
dari SES tinggi
• Bayi diukur 21 kali dalam 24 bulan
• Bagan menunjukkan bagaimana bayi yang disusui dominan "harus
tumbuh" dalam kondisi ideal dan dianggap sebagai standar
pertumbuhan
SES = status sosial ekonomi.
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2010;59(No. RR-9):1-15.
Comparison of WHO and CDC Growth Charts: Length and
Weight (Boys)
Comparison of WHO and CDC Growth Charts in
Children <24 Months

Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2010;59(No. RR-9):1-15.
Growth Chart
Btrth to 24 months: Boys NAME_ 2 to 20 years: Boys
l *ngth-f or-age and Welght-for-ago percentiles 3ECC«> • Stature-tor-age and Wetght-lor-age percentiles

Target HT

Predicted HT

STiia
Growth Charts: Take-Home Points
• CDC curves overdiagnose failure-to-thrive (underweight) in US infants
• Use of the WHO curves should lead to fewer referrals for further
evaluation of ''underweight" infants
Growth Failure and Short Stature: Definitions
• Definitions
• Short stature: height more than 2.0 SD below the mean for age and
gender; strictly statistical convention
• Growth failure: decline in rate of linear growth (cross channels)
• Slowly growing children are usually short

• There are many non-endocrine and endocrine causes of growth

failure and short stature
Causes of Growth Faltering
• decreased (inadequate)dietary intake
• availability
• protein and energy
• micronutrients
• diseases
• increased nutritional requirements
• metabolic response to disease
• increased nutritional losses
• mal-digestion
• mal-absorption
Stunting
• Stunting is defined as the percentage of children aged 0 to 59
months whose height-for-age is <-2 SD for moderate and <-3
SD deviations for severe stunting from the median of the 2006
WHO Child Growth Standards (UNICEF 2013).

• Stunting during early childhood demonstrates marker of

chronic undernutrition
Stunting (2)
• Poverty and poor living conditions are associated with stunting.
• In 2012, +- 33% of urban residents in the developing world lived in
slums.
• By 2030 slum populations are predicted to reach two billion people
(United Nation 2012).
• Every day, more than 100,000 people move to slums in the developing
world.
• Nearly 1.5 billion people currently live in urban slums without adequate
access to health care, clean water and sanitation (BRC 2012).
• Evidence shows that children living in slums -> more likely to suffer from
undernutrition, including stunting. (Awasthi 2003; Ghosh 2004; Haddad
1999; Hussain 1999; Menon 2001; Pryer 2002; Ruel 1999; Unger 2013)
 Stunting prevalence: increases very rapidly between 12 to 24
months (40% to 54%), continues increasing until 36 months of age
(58%), and then remains fairly stable until five years old (55%)
(Bhutta 2013)

The loss in linear growth is not recovered, and catch-up growth

later on in childhood is minimal. (Victora,2010)
• Long term affect adult size
• intellectual ability
• poor school achievement
• Less economic productivity and reproductive ability
• Increase the risk of metabolic disorders and cardiovascular disease

Black 2008; Dewey 2011; Grantham-McGregor 2007; Victora 2008

• Poverty
• In-utero insults
• Inadequate dietary intake
• High infectious disease
burdens
• Contaminated
environment
Deceleration of linear growth
(growth faltering) and or poor
weight gain
Particularly in the first 2 years of
postnatal life

• Trophic enteropathy (?)

STUNTING IN INDONESIAN
CHILDREN
Stunting in the World
Prevalence: estimated 40 to 26 per cent in 2011. (UNICEF, 2013)

Leal than 10 par cant

10to19per cent 20 to 29

per cent - 30 to 39 per

cent 140 per cent or

more I No available data

Countries with the Largest Number of Stunting
Stunting % of global
prevalence burden
Ranking Country Year 1%) (20111 Number of stunted children (moderate or severe, thousands)
1 India 2005-2006 48 16
2 Nigeria 2008 41 7 11,049
3 Pakistan 201) 44 £ 9,663
4 China 2010 10 5 8,059
5 Indonesia 2010 36 5 7,547
6 Bangladesh 2011 41 4 5,958
1 Ethiopia 2011 44 3 5.291

8 Democratic Republic of 2010 43 3 5.228

the Congo
9 Philippines 2003 32 2 ■ 3,602
United Republic of
10 Tanzania 2010 42 2 ■ 3.475

11 Egvpt 2008 29 2 ■ 2,628

12 Kenya 2008-2009 35 1 ■ 2,403
13 Uganda 2011 33 1 ■ 2,219
U Sudan
2010
35 1 ■ 1,744
 NUTRITIONAL STATUS
Burden of malnutrition (2011) 7.S4I MOG 1 progress On tract
Stunted (unde'-trre«. ootx
Stxntng country rank Shereufworldstintng burden
5 Wetted luneerivet. OCOI 2,820 Underweight lunder-bvet, COOl
2,196
IN)
S Severe^ wetted lunder fives, COOl 1,272 Oreiwe^ht (undeMwes. 0001 2,968

Stunting trends Stunting disparities Underweight trends

Percentage of children <5 years old stunted Percentage of ctiildren «:5 years old stunted, by selected Percentage of children <5 years old underweight
background characteristics

4
30 n

BOS ins
H H 1 II
»«K« Olttff MS 2110
1
INFANT AND YOUNG CHILD FEEDING
IMS 2000 2001 2007 20 IS Other
MICS Otlwr NS Other MS Other NS NS

Exclusive breastfeeding trends Infant feeding practices, by age

Percentage of infants <6 months old exclusively breastfed

in*

1981 IS8I Its; XXD-2003 3037

OHS OHS OHS DH$ DHS

Breewied and^
waa*ed ■ Br9U«tr*d
(not breastfed) B>**itf and pain Mater only
ed and sdidi'sami solid ■ Excluovety
toads Breewied and breastfed
other miRitormuU
The SEANUTS study

• It reveals that Indonesia suffers from double burden of malnutrition

• Growth of Indonesian children was below the WHO standard
• The older the children, the greater the difference
• Major nutritional problem in Indonesia is stunting compared to wasting
and thinness
• Stunting is always related to wealth because protein is relatively
expensive
• There is a need to emphasize on the first 1000-days-of life program
British Journal of Nutrition (2013), 110, SI 1-S20 €> The dohlO.l017/S0007114513002109
Authors 2013

Food consumption and nutritional and biochemical status of 0-5-12-year-

old Indonesian children: the SEANUTS study
Sandjaja Sandjaja1*, Ha.suki Budiman1, Ilcryudarini Harahap , Fitrah Kmawati1, Moesijanti Sockatri',
Yckti Widodo1, Edith Sumedi1, Effendi Kustan1, Gustina Sofia1, Sainstiani N. Syarief1 and Use Khouw2
'SFANVTS Indonesian Team/Fersatuan Ahti Gizi Indonesia, Jaltm /lanjt Jehat III/Fi, Kebayoran Itaru, Jakarta. Indonesia 'Fru-siand<Uim/iitut.
Amersfoort. The Netherlands
(Submitted 11 September 2012 Hnat rvrtsum wetted 9 A/trU 201.1 - Accefited I / AjmJ 201.1)

Key words: Nutritional status: t hi Id growth: Micron utrient deficiencies: l-ood intakes: Indonesian children
 35

30

io>
25

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® 20

15

10
50-59 6 0-69 7 0-79 80-89 90-9-9
Age (years)
Fig. 3. Mrxvn woryht ol boys agod 50 99 yonrs—, WHO , urtxm; - - , rural
Age (years) (A colour vorslon ol this hguo can bo found onlmo at hop //www pumuts
Fig. 1. Moan wa(?*al boys agod 0-5 49 years—.WHO; , urban:rural aimbndgo.org/bfn)
(A colour worsen ol tss hguro can bo lound orlno at httpy/wwwjournals
Cambridge orgbyi)
 Age (years) Age (years)
Fig. 5. Moan bcmf* at boys agod 05 49 ynars—.WHO: . urban; - - , rival Fig. 7. Moan height of boys agod 5 0 9 9 years. —. WHO; . urban; - - . rural
(A colour version ol tvs figure can be found odne at http 7/www journals (A colour version of Ihfc figure can be found ontne at htfp;/www|(Xjrnais
cambndgc orgfbjn) Cambridge orgbjn).
 35

10---■---■-
50-5-9 60-6-9 70-7-9 8-0-69 90-9-9
Age (years) Age (years)
Fig. 2. Moan wcr^il al gals aged 0-5 4-9 years—.WHO, , urban;rural. Fig. 4. Mean weight of girls aged 50-9-9 years. —. WHO; . urban; - - , naal
(A colour version d this figure can be found online at http/Avww journals. (A colour version of tvs figure can be found ontoo at hrtp/rwww journals
Cambridge orgbjn) Cambridge onytajn)
 170 r
120
160

Ago (years)
Age (years) Fig. (. Moon hor^rt of gate agod 50 9 9
Fig. 6. Moan hon7« ol gris agod as 49 years —, WHO; , urtMn; - - , rural yoars—.WHO; . urban;rural
(A odour version ol Itvs tiguc can bo found ootnc at hOpV/www loumals (A colour vemon ol Ihrs Irguro can bo found
Cambridge orgta)n) orAne at Imp/Awnrvir founds cambndgc
orytyi)
RISET KESEHATAN DASAR
RISKESDAS 2013
 1 S
■ Sangatpendek Pendek Gambar 3.14 7
Prevalensi pendek anak umur 5-12 tahun menurut provinsi. Indonesia 2013

National stunting prevalence : 37,2% (18.0% severely stunting and 19.2% stunting) Highest
prevalence in boys is at 13 years of age (40.2%) while in girls is at 11 years of age (35.8%)
14 provinces have severe stunting problem (prevalence : 30-39%) and 15 provinces have
serious stunting problem (prevalence more than 40%)
 70.0
400

•2007 02010 92013

Gambar 3.14 1 •2007 02010 «2013

Kecenderungan prevalent, status gta B8AJ <-2S0 menurut provinsi Indonesia
Gambar 3.14 2
2007 2010. dan 2013
Kecenderungan prevalensi status TBAJ <-2 SD menurut provinsi.
Indonesia 2007.2010. dan 2013

Gambar 3 14 4
□ Pendek-kurus ■ Pendek-Normal □ Pendek-Gemuk
Kecenderungan prevalent gia kurang. pendek. kurus, dan gemuk pada bakta Indonesia
20072010 dan 2013 □ Normal-kurus □ Normal-normal □ Normal-gemuk

Gambar 3.14.5
Kecenderungan prevalensi status guu balita menurut gabungan mdikator
TBAJ dan BB/TB. Indonesia 2007 2010, dan 2013
Assessment of linear growth of children in low-
and middle income countries (LMIC)

Jan M. Wit, John H. Himes , Stef van Buuren, Donna M. Denno, Parminder S. Suchdev
Pattern of Linear Growth in LMICs

The window of opportunity for preventing linear growth faltering ends at 2 years of age

Six discrete phases of growth were distinguished

1. Intrauterine growth failure
2. Precipitate decline in HAZ 0-2 years
3. Partial recovery 2-5 years
4. Parallel growth in later childhood; Apparent growth faltering
5. Delayed pubertal growth spurt, of long duration, associated with recovery of the artificial
loss in phase 4a and further catch-up of almost 1 z-score
6. Attainment of adult height

The best way to analyze growth may be different for the various age periods
Presumed causes of growth faltering in the first two years

Multifactorial and associated with:

• Poverty
• Short birth spacing
• Teenage pregnancy
• In-utero insults
• Lack of exclusive breastfeeding
• Food insecurity
• Poor complementary feeding
practices
• Inadequate psychosocial stimulation
• Large burden of diarrheal disease
• Other infection
• EED(Environmental enteric
dysfunction)
EED : hypothesized as an important underlying cause of stunting
It is characterized by small bowel villous blunting and crypt hyperplasia leads
malabsorption.
Indicator of growth
No gold standard to measure growth thus most suitable indicator has to be
selected

HAZ as a continuous variable HAZ as

categorical variable Conditional HAZ

Change of z-scores of attained height

Height of HAZ slope modeling The z-

score of the change in height

Potential covariates and confounders

Stunting Prevention
• The World Health Assembly has adopted a new target of reducing the number of stunted
children under the age of 5 by 40 per cent by 2025. Focusing on:
• Improving Mother Nutrition
• Exclusive breastfeeding
• Complimentary feeding: timely, safe, appropriate and high-quality
• Prevention and treatment of micronutrient deficiencies (vitamin A, iron, salt iodization, fortification of food)
• The growth of children under five must be routinely monitored in local health centers to
early detect any growth deficiency.
• Access to clean water, sanitation facilities, and clean environment should be improved. ->
more frequent a child experiences diarrhea episodes -> a higher potential of stunting.
Hygiene and sanitation interventions with 99% coverage is reported to reduce diarrhea by
30%, which in turns decrease stunting prevalence by 2.4%.
Stunting Prevention
• The United Nations Secretary-General has included elimination of
stunting as a goal in his Zero Hunger Challenge, launched in June 2012.
• The initiation of the SUN (Scaling up Nutrition) movement in 2010
brought about much-needed change. SUN members come from various
countries, civil society, the United Nations (UN), donor agencies, private
sector, and researchers.
• The SUN movement seeks to build national commitment to accelerate
progress to reduce stunting and other forms of undernutrition, as well as
overweight, determine nutritional status, such as improved feeding and
care practices, clean water, sanitation, health care, social protection and
initiatives to empower women (Indonesia joined SUN on 22 December
2011)
Diagnostic approach in children with short stature

• Anthropometric measurement
• Evaluate further if:
• HAZ < -3SD
• Growth velocity is under 25 th percentile or <5cm/year
• Projected adult height below potential height
• Growth faltering
• Laboratory work for short stature evaluation
:
• Complete blood count
• Thyroid hormone level
• Bone age
• Karyotipe
• Growth hormone and IGF-1 level
Algorithm for diagnostic
approach in short
stature children
Definition IUGR:

• birth weight < -2 SD

and/or

• birth length < -2SD

Catch up growth:

10% do not catch up completely

Conclusion

• Pendek adalah gejala, bukan penyakit

• Setiap anak dengan perawakan pendek harus dievaluasi
• Tidak semua perawakan pendek bersifat stunting, tetapi stunting
merupakan bagian dari perawakan pendek
• Pengukuran antropometri secara teratur sangat dianjurkan dalam
praktik klinis sehari-hari
• Grafik Pertumbuhan Nasional/IDAI??
THANK YOU