RABU, 22 JUNI 2016

TOPIK : SHORT STATURE OR STUNTING

PEMBICARA : DR. Dr. AMAN B PULUNGAN, Sp.A(K)
MODERATOR : Dr. PIMPRIM B YANUARSO, Sp.A(K)
 Tinggi < P3
atau -2SD
Short stature or Stunting
Aman Pulungan
By 2030, end all forms of malnutrition, including achieving, by 2025, the
internationally agreed targets on stunting and wasting in children under 5 years of
age, and address the nutritional needs of adolescent girls, pregnant, and lactating
women and older persons.
 Growth: Normal and
Abnormal
Short stature or stunting
Normal Growth
• Growth that follows established patterns based on studies of several
different populations and that follows the trajectories of standard growth
charts

• Normal growth falls between the 3rd and 97th percentiles of all children 
the shortest and tallest 3% fall outside the bounds of “normal” stature
 Normal Distribution/Standard
Deviation Scores/Percentiles
68% of the population
95% of the population
99% of the population

19.1% 19.1%

15.0% 15.0%
9.2% 9.2%

0.1% 0.5% 4.4% 4.4% 0.5% 0.1%

1.7% 1.7%

-3 -2.5 -2 -1.5 -1 -0.5 0 0.5 1 1.5 2 2.5 3

-2.25 -1.88 1.88 2.25
1.2% 3%

2.3%
Standard Normal Curve

50th Percentile

95th
5th
 Sportsmen in 1900 were put in
line according to height:
Short ones on the right
What are height SD-scores ?
Tall ones on the left

Let us do this with our children

5 4 3 2 1
8 7 6

www.siegburg.de
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?
Some children CHANGE
IN POSITION, because
they grow faster than
others.
Most however do not.
Most children keep their
position.
Some children CHANGE IN
POSITION, because they
grow faster than others.
Most however do not.
Most children keep their
position
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.
Most children keep their
position
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.
Most children keep their
position
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.
Most children keep their
position
even though the variance
increases as the group drifts
apart.
Phases of Normal Growth
• Intrauterine
• Growth strongly influenced by intrauterine environment
• Insulin, IGFs, and their binding proteins play important roles in fetal growth
• GH, thyroid hormone not very important

• Infantile
• Rapid but decelerating growth during first 2 years of life
• Infants often cross percentile lines during the first 24 months as they grow toward
their genetic potential and get further away from the excesses or constraints of the
intrauterine environment
Phases of Normal Growth (2)
• Childhood
• Growth at a relatively constant velocity of 4.5 to 7 cm/year (1.8 to 2.8
in/year)
• Perhaps some slight slowing just prior to adolescence

• Pubertal
• Characterized by a growth spurt of 8 to 14 cm/year (3.2 to 5.5 in/year)
because of the synergistic effects of increasing gonadal steroid and
growth hormone secretion
Phases of Normal Growth (cont)
(1 + 2 + 3)
180 Combined
160 Growth (1 + 2)
140
Length/Height (cm)
120
100
80 Infancy (1)
60 Childhood (2)
40
Puberty (3)
20
0
-1 1 3 5 7 9 11 13 15 17
Age (years)
Adapted from Karlberg J. Acta Paediatr Scand Suppl. 1989;350:70–94.
 Normal Growth Rates During Childhood
Age Growth rate (cm/y)
1-6 months 34-36
6-12 months 14-18
22
1-2 years 11
20
2-3 years 8
18
Height Gain (cm/y)

3-4 years 7
16 4-9 years 5
14 Puberty Girls 6-11/Boys 7-13
12
10
8
6
4

B 2 4 6 8 10 12 14 16 18

Age (y)
Best practices for anthropometric measurements
• Standardized equipment and measuring techniques are critical for
accurate assessment of linear growth, as well as for other anthropometric
measurements

• Use child and/or infant stadiometer correctly

• Data obtained from the measurement should be recorded carefully in the

appropriate growth chart  which growth chart should be used?
Descriptive and normative reference charts

• Based on representative sample from the population

Descriptive national or
• Currently used for children > 4 years in most high-
regional growth reference income countries
chart
• NCHS, CDC

• Meant to depict “ideal” growth under favorable

Normative growth environmental and nutritional conditions
standard
• WHO-growth chart
WHO Growth Chart

 Most frequently employed

 Based on :
 0-4-year-old children from 6 countries (Brazil, Ghana, India, Norway, Oman and the US)
 Living in favorable environmental conditions
 Exclusively or predominantly breastfed for at least 4 m.o
 In whom complementary foods were introduced by 6 m.o
 who continued breastfeeding to at least 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

• CDC growth charts

• “Growth reference” showing how a large cross-section of US
infants actually grew between 1970 and the early 1990s
• Used data from infants whose feeding approximated the mix of
feeding practices of that time
• ~50% were ever breastfed and ~33% were breastfed to 3
months
• Greater percentage are breastfed now
WHO and CDC Growth Charts for Children Under 2 Years:
Differences (cont)

• WHO growth charts

• Birth to 2 years based on 882 infants who were
exclusively/predominantly breastfed for at least 4 months and
who continued breastfeeding for at least 12 months
• Cohorts of infants were from multiple sites around the world but
of high SES
• Infants were measured 21 times in 24 months
• Charts show how predominantly breastfed infants “should grow”
under ideal conditions and are considered a growth standard

SES = socioeconomic status.

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)

120 95 16 95
75
110 50 14 75
25 50

Weight (kg)
Length (cm)

100 5 12 25
90 5
10
80
8
70
60 6
50 4
40 2
0
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 0 2 4 6 8 10 12 14 16 18 20 22 24

Age (months) Age (months)

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 in
Children <24 Months

16
14 CDC

Prevalence (%)
WHO
12 Low weight for age*
10
Low length for age*
8
6
4
2
0
0-5 6-11 12-17 18-23 0-5 6-11 12-17 18-23
Age (mo)

*≤5th percentile on the CDC charts; ≤2.3rd percentile on the WHO charts.

Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2010;59(No. RR-9):1–15.
Growth Chart

Target HT

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

Stunting is multifactorial

The magnitude of
attribution of different HAZ < -2 SD
causes are not known,

But important for

intervention priorization Stunting
in resource-constrained
setting
STUNTING IN INDONESIAN
CHILDREN
 Stunting in the World
• Prevalence: estimated 40 per cent in 1990 to 26 per cent in 2011. (UNICEF, 2013)
Countries with the Largest Number of Stunting
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
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%)