CHAPTER I

INTRODUCTION

Stunting is an issue that is increasingly found in the country.

developing, including Indonesia. According to the United Nations International Children’s
Emergency Fund (UNICEF) one in three children experiences stunting. About 40% of children
in rural areas experiencing hindered growth. For this reason, UNICEF
supporting a number of initiatives to create a conducive national environment
for nutrition through the launch of the National Nutrition Awareness Movement (Scaling Up Nutrition–

SUN) where this program encompasses stunting prevention.

Stunting is defined as a condition of being short and very short in stature.
until exceeding a deficit of -2 SD below the median height or body length. Stunting
is also often referred to as Linear Growth Retardation (LGR) which occurs in
two to three years of early life and is a reflection of the consequences or
the impact of inadequate energy and nutrient intake as well as the effects of disease
infection, because under normal circumstances, a person's weight will be directly proportional

or linear with their height. There are 178 million children in the world who are too short
based on age compared to WHO standard growth.
The prevalence of stunting in children worldwide is 28.5% and across all countries.
increased by 31.2%. The prevalence of stunting in children in Asia is 30.6% and
in Southeast Asia is 29.4%. The issue of stunting in Indonesia according to the report
released by UNICEF is estimated that around 7.8 million children are experiencing
stunting, which is why UNICEF has placed Indonesia in the top 5.
the number of children experiencing high stunting. Health Research Data
In 2013, it was noted that the prevalence of stunting events at the national level
is 37.2%, consisting of 18.0% very short and 19.2% short, which
This means there has been an increase of 1.6% in 2010 (35.6%) and the year
2007 (36.8 %).1

Stunting occurs due to repeated malnutrition over a long period.

the prenatal period until the first year of a child's life. Therefore,
efforts to prevent and reduce disturbances directly (nutrition intervention
specific) and efforts to prevent and reduce indirect disturbances
(sensitive nutrition intervention). Specific nutritional intervention efforts for stunted toddlers

focused on the group of the first 1000 days of life (HPK) which is pregnant mothers, mothers
 CHAPTER II

LITERATURE REVIEW

2.1 Stunting
2.1.1 Definition
According to WHO, stunted children are children with nutritional status that
based on height or body length according to age when compared
with the WHO-MGRS (Multicentre Growth Reference Study) standard
In 2005, the z-score value was less than -2SD and categorized as very
short if the z-score is less than -3SD.
According to Decision Minister Health Number
1995/MENKES/SK/XII/2010 concerning Anthropometric Standards for Status Assessment
Child Nutrition, a very short and concise definition is the nutritional status of

based on the Body Length Index by Age (PB/U) or Height

Body according to Age (TB/U) which is the equivalent term
stunted (short) and severely stunted (very short). short toddlers
(stunting) can be known when a toddler's height or length has been measured.
the body is then compared to the standard, and the result is below
normal.2

2.1.2 Epidemiology
According to WHO, the prevalence of stunted children is a health problem.
the community if the prevalence is 20% or more. Therefore the percentage of toddlers

shortness in Indonesia is still high and is a health problem that

must be addressed. Compared to several neighboring countries, the prevalence
short news in Indonesia is also the highest compared to Myanmar (35%),
Vietnam (23%), Malaysia (17%), Thailand 16%) dan Singapura (4%)(UNSD,
2014). The Global Nutrition Report of 2014 indicates that Indonesia is included
in 17 countries, among 117 countries, that have three nutritional problems
namely stunting, wasting, and overweight in toddlers. In 2015
The Ministry of Health conducts nutritional status monitoring (PSG) which is
a cross-sectional study with a sample of households that have
child under five in Indonesia. According to the results of the PSG in 2015, it was 29% of children under five.

Indonesia falls into the category of the shortest with the highest percentage in Nusa province.

East Nusa Tenggara and West Sulawesi. In Indonesia according to research data.
 The north ranks 8th highest. National prevalence of short stature.
In children aged 5–12 years, the percentage is 30.7% with a very short amount of

12.3% and a short of 18.4%.

There are 15 provinces in Indonesia with very short prevalence.
above the national prevalence (12.3%) and North Sumatra is one of
from the province with a prevalence of short and very short above
37%. The national prevalence of stunting in adolescents aged 13–15 years is 35.1%
with very short at 13.8% and short at 21.3%. There are 16
provinces with very low prevalence above the national prevalence (13.8%).
Sumatera Utara juga termasuk salah satu dari provinsi tersebut dan prevalensi
the highest is found in Papua. The prevalence of short and very short stature in Sumatra

at the age of 13-15 years is above 40%. The national prevalence of short stature
In Indonesia, among adolescents aged 16 to 18 years, the rate is 31.4% with
very short at 7.5% and short at 23.9%. A total of 17 provinces
with a prevalence of short above the national prevalence (23.9%) and Sumatra
North is also included as one of those provinces.2

2.1.3 Etiology3
Classification of the causes of short stature is
Normal variation of short stature
1.1 Familial short stature (FSS)
1.2 Constitutional delayed growth and puberty (CDGP)
1.3 Idiopathic short stature
2. Primary growth disorders
2.1 Fetal growth is inhibited
2.2 Skeletal dysplasia
2.3 Syndrome/Chromosomal Abnormality

3. Secondary growth disorders

STUNTING
3.1 Malnutrition
3.2 Chronic Diseases
4. Endocrine Disorders
4.1 Growth hormone deficiency (Growth hormone deficiency - GHD)
4.2 Thyroid hormone deficiency
4.3 Diabetes Mellitus
4.4 Advantages of corticosteroids
food. Nutritional problems in toddlers are not easily recognized by the government,
or the community or even family because the child does not appear to be sick. The occurrence of

malnutrition is not always preceded by a disaster of food shortage and

hunger is like malnutrition in adults. This means in a condition
Abundant food may still lead to cases of malnutrition in toddlers.
Nutritional deficiencies in toddlers are referred to as hidden hunger.
hunger.
Stunting is a retardation of linear growth with a deficit in
Height or stature of -2 Z-score or below according to reference book.
growth of the World Health Organization/National Centre for Health Statistics
Stunting is caused by the accumulation of stress episodes that have occurred.
long-lasting (for example, infections and poor dietary intake) that
then not balanced by catch up growth.
The impact of malnutrition in early childhood and its continuation
in every human life cycle. Women of childbearing age and pregnant mothers who
experiencing chronic energy deficiency will result in a baby with low birth weight.
born underweight. This low birth weight will continue to be a malnourished toddler (stunting)

and continues to school children with various consequences. This group

will become a generation that lacks its golden age of growth and development from

without adequate handling, this group is feared to be lost

Malnutrition in human life needs to be addressed with
seriously, besides the impact on the growth of children, this incident usually

not standing alone but feared due to the problem of micronutrient deficiency.
Short stature (stunting) can be a normal variation, or due to
endocrine and non-endocrine disorders. The most common cause of short stature is

familial, racial or genetic. Pathological short stature occurs after

["malnutrition","IUGR","dysmorphism","psychosocial issues","systemic diseases"]
the chronic.
Classification of short stature is as follows:
Normal variation.
Primary/intrinsic (abnormalities in the cells or structure of the growth plate)
Secondary/external (disorders due to external influence from 'growth plate')
Idiopathic (generally familial or of unknown cause)
In genetic disorders (Turner syndrome), it is often unclear,
the possible psychosocial influences associated with the influence
 Familial short stature is the most common diagnosis.
found in practice or clinic. Usually, this condition is supported by history
the presence of short stature in parents or other family members
(uncle, aunt, or grandparent). The child's height is below
average, but the growth rate is normal for age. Weight will
adjusting to the height, so it also appears as if below
normal. Bone age corresponds to chronological age. In adulthood,
usually the child remains short.

Another common cause of short stature is especially

in developing countries is malnutrition. The nutritional deficiencies that occur are
prolongation causes a deceleration in growth speed due to
deficiency of calories, protein, and other nutrients that play a role in growth,
among others calcium, vitamin D, and zinc. Adequate calcium intake is important
for normal bone growth, while the vitamin D levels are adequate
functions to optimize calcium absorption in the digestive tract. Second
these nutrients work together in normal bone growth.
According to WHO, short stature due to malnutrition and/or suboptimal
stunting is referred to as a health issue. Stunting is part of short stature,
However, not every short stature is stunting. Stunting is
indicator of child nutritional status problems due to related chronic malnutrition
environmental conditions and socio-economic status.5

2.1.5 Classification6

The most common assessment of the nutritional status of toddlers is

through anthropometric assessment. In general, anthropometry is related
with various types of body dimension measurements from different levels
age and nutrition level. Anthropometry is used to assess
imbalance of protein and energy intake. Several anthropometric indices
what is often used is body weight according to age (BW/A) Height
body according to age (height/age) weight according to height (weight/height)
expressed with the unit Z standard deviation (z-score).
Stunting can be identified when a toddler has their weight measured.
the body is measured for its length or height, then
compare with the standards, and the result is below normal. So in general
The physical stature of toddlers will be shorter compared to all toddlers. This calculation
 Here is the classification of stunting nutritional status based on height indicators.

body by age (height/age).

Very Short: Zscore < -3.0
2. Short Zscore < -2.0 s.d. Zscore > -3.0
3. Normal Zscore > -2.0
And below is the classification of stunting nutritional status
based on the TB/U and BB/TB indicators.
1. Short-Thin: Z-score Height/Weight < -2.0 and Z-score Weight/Height < -2.0

2. Short-Normal: Z-score Height/Weight < -2.0 and Z-score Weight/Height between -2.0

s/d 2.0
3. Short-Fat: Z-score > -2.0 to Z-score < 2.0

2.1.6 Categories and Thresholds of Child Nutritional Status

Threshold (Z-
Index Nutritional Status Category
Score

Very Short < -3 SD

Body length according to -3SD up to

Short
Age (PB/U) or <-2SD
Height according to
Age (TB/U) of the Child
-2 SD until
Age 0-60 Months Normal
with 2 SD

Height 2 SD
Interpretation of Weight/Height according to WHO:

At < -3 SD Malnutrition
Between -2 SD and -3 SD Malnutrition
Between -2 SD and +2 SD Good/sufficient nutrition. For children with

BB/TB >+1 SD is categorized as overweight risk, action must be taken.

BMI calculation and plotted on the BMI curve
Between +2 SD and +3 SD : Nutritionmore must done
BMI calculation and plotted on the WHO BMI curve
Di > +3 SD Obesity, : must done
BMI calculation and plotted on the WHO BMI curve
2.1.7 Characteristics of Stunting7

a. Signs of delayed puberty

b. Poor performance in attention and learning memory tests
c. Delayed tooth growth
d. Children aged 8-10 become more quiet.
e. Growth slows down
f. The face looks younger than usual.

2.1.8 Clinical Manifestations

Growth is slowing down, the lower bound of the growth rate is 5

cm/year decimal.
At a growth rate of height < 4 cm/year, there is a possibility.
hormonal disorder.
Bone age can be normal or delayed for their age.
Signs of delayed puberty (breasts, menarche, pubic hair,
armpit hair, penis length and testis volume) may accompany
GH deficiency, especially when there are abnormalities in gonadotropins

occur simultaneously.
The face looks younger than its age.
Delayed tooth growth
In children, GH deficiency causes short stature.
 A short body that is different from what was expected based on the pattern
The family can be observed when there is a decrease in growth potential.
Adult-onset GH deficiency can lead to non-
specific functions, including changes in physical and mental health, functions
heart and metabolic parameters.
An adult individual with GH deficiency may experience
low energy and libido levels.

2.1.9 Stunting Diagnostic Approach

Dalam menghadapi anak dengan perawakan pendek diperlukan
anamnesis, physical examination, and supporting examinations. The examination that
Good and directed actions are needed to identify the etiology and avoid it.
unnecessary examination.
Periodic anthropometric measurements play an important role in
diagnosis of a child with short stature. The child's growth in two
The first year of life can be evaluated by measuring body length.
and then with the measurement of height. The results of the measurements
it is then plotted on the growth curve according to age and gender
child's genitalia. To avoid unnecessary examinations, as well as
On the other hand, the possibility of missing a pathological diagnosis that can

causing the loss of the opportunity to increase height, then

The first step is to determine whether short stature in children
is a pathological or normal thing.
The initial criteria for examining short children,
as follows:
Height below the third percentile or below average height
population (<-2SD)
2. Growth speed below the 25th percentile of the speed curve
growth or <5 cm/year in children aged 3 to 10 years.
3. Estimated adult height below its genetic height potential.
4. Growth rate slows down after the age of 3 years and decreases.
crossing its percentile line on the height/length curve.
5. When BMI/height is below normal and height is less than the 3rd percentile or

-2SD, then the child is categorized as stunting.5

Setelah mengetahui kriteria di atas, ada dua pertanyaan tambahan yang
or successfully found a growth disturbance, must immediately
a referral to a pediatric endocrinologist was made.3
Height
Height monitoring is conducted periodically and continuously.
in accordance with the recommendations issued by the Indonesian Pediatric Association

(IDAI) about monitoring child growth and development

Table 3. Recommendations for monitoring height schedule.
Age Monitoring schedule
0-12 months Every 1 month
1-3 years Every 3 months
3-6 years Every 6 months
6-12 years Every 1 year

b. Growth Rate
The growth phase of a child is divided into four phases: intrauterine, infant,
children, and puberty. This phase is important to be understood with the aim of
to know the specific growth patterns in each phase and whether there is or
the absence of growth disturbances in a child
Table 4. Growth rate of children
Age Growth rate (cm/year)
Intrauterine 60-100
0-12 months 23-27
1-2 years 10-14
2-5 years 6-7
Prepuberty 5-5.5
Puberty Female: 8-12
Boys: 10-14

c. Final height estimate

Final height prediction based on mid-parental height and potential
genetic height is shown in the table below.
Table 5. Calculation of mid-parental height and genetic height potential
Mid-parental height
Male = [Father's height (cm)] + [Mother's height (cm) + 13] : 2
Supporting examination
Due to malnutrition and chronic diseases still being
the main cause of SS in our country, then the first strategic step for
the search for the etiology of short stature is:

Complete peripheral blood examination for screening systemic diseases

b. Routine urine and feces,
c. Blood sedimentation rate,

d. Electrolyte serum and urine and

e. Bone age
After no abnormalities were found in the screening examination
a special examination is conducted, namely GH levels, IGF-I, analysis
chromosome, DNA analysis and others according to indications. Examination
a simple and decisive supporter is interpreting data
height data using the appropriate growth curve. Pattern
growth due to low birth weight (LBW), disease
chronic, the normal variant is a condition that can be very helpful for
differential diagnosis.8
Laboratory tests used to determine
The main causes of short stature in children include:
Measurement of serum insulin-like growth factor-I (IGF-I) and IGFBP-3
Used for the diagnosis of GHD
In patients with central nervous system malignancies, it may be
normal growth factor levels were found during puberty
Stimulation tests should be performed on patients with thyroid function.
normal but suspected GHD
Low serum IGF-1 concentration can be found in patients.
with malnutrition so that the lab results must be interpreted with
be careful
The serum concentration of IGFBP-3 has greater specificity.
compared to serum IGF-I concentration in the diagnosis of GHD.
Karyotype with G-banding
–Pada pasien dnegan sindrom Turner ditemukan pola 45X
–Because 10% of patients with Turner syndrome have a karyotype.
mosaic (for example 45X, 46 XX), it is advisable to conduct an examination

regarding a minimum of 30 cells to reduce the risk of failure

exercise, eating (when blood glucose levels drop), and during the phase
sleep in. As a result, serum GH measurements for evaluation
short stature should be addressed more than once.3
Short approach to diagnosing short stature8

2.1.10 Management of Stunting

Every child with a short stature must be addressed immediately.
evaluated. Families need to be provided with explanations regarding growth potential.

a child according to their genetic potential. Some cases do not need

immediately receive therapy and can be managed only with monitoring
periodic, but some other cases with clear causes can be direct
Some cases need hormonal therapy, some are only done
periodic monitoring or therapy according to the cause, if not
caused by growth hormone abnormalities. Short stature due to
endocrine disorders, such as GHD and hypothyroidism, as well as secondary due to
malnutrition and chronic diseases must be treated immediately according to
the cause. Patients with GHD can be given hormone replacement therapy
growth. The hormone administered is recombinant somatotropin
with a dose of 15-20U/m2/week and given 6-7 times per
The effects of therapy can be assessed by changes in growth rate.
The therapy is considered responsive if the growth rate is at least 2cm/year above.

growth rate before therapy is given. Growth rate in the year

The first therapy usually ranges from 9-12 cm/year.
Patients with idiopathic short stature have not actually been diagnosed yet.

enter into the indication for the administration of growth hormone. However, the end-

lately many centers are providing growth hormones with

idiopathic short stature. The results found are also varied. In
a study in the Netherlands found that the administration of hormones
growth can add 7 cm to the final height of a child from their height
previously. As a normal growth variation, a child who is diagnosed
with CDGP there is no need for hormone therapy because there will be a catch-up

grows during puberty. However, children often feel inferior.

because of her short stature, she can be given hormone therapy
sex like oxandrolone or testosterone to trigger puberty and chase
grow. In children with short stature due to GH deficiency, treatment may be given

growth hormone when growth spurts do not occur until the age of 4.3
The indication for Growth Hormone (GH) administration at this time is children.

short stature caused by GH deficiency, Turner syndrome, insufficiency

chronic kidney, Prader-Willi syndrome, Noonan syndrome, SHOX deficiency and
The earlier the administration of GH, the better the prognosis will be.
The prevalence of GH deficiency is estimated to be between 1:3500-4000 with 70%.

among them is isolated GH deficiency. Adult height

Untreated patients with GH deficiency are 134–146 cm (men) and 128–
134 cm (women). Turner Syndrome occurs in 1 in 2500 newborns (females)
The typical clinical manifestation is short stature with delayed puberty.
in women. Although not suffering from GH deficiency, height
 estimated between 1:20000-50000. In addition to affecting the improvement of TB,
The administration of GH also has a positive impact on body composition.

Approximately 80% of children born Small for Gestational Age (SGA)

experiencing catch up in the first 6 months of life and ending at the age of 2
years, sometimes up to the age of 4. Between 10-15% will remain short.
until adulthood.
GH administration is indicated if still SS until the age of 4.
Administration of GH in children with SHOX deficiency (short stature homeobox-
(gene-containing) has been allowed by the FDA since 2006. In this case, clinically
symptoms and signs found are short stature, Madelung deformity, and
high palate. SHOX deficiency is estimated to be the main cause.
short stature in Turner syndrome.

Diagnosis μg/kg/day mg/m2 /day

GH deficiency 23–39 0.7–1.0
turmer syndrome 45–50 1.4
Chronic enal 45–50 1.4
insufficiency
Prader–Willi Syndrome 35* 1.0*
Small Pregnancy Period 35 1.0
SHOX deficiency 45-50 1.4
Noonan Syndrome
Table 3. Indications for GH administration and dosages in children and adolescents

The administration of GH for Noonan syndrome is the latest in America.

Syndrome symptoms and signs
Noonan is a short stature accompanied by distinctive facial dysmorphism.
and congenital heart defects and mental retardation. This syndrome was formerly known
as male Turner Syndrome due to its clinical similarities. Height
the height is 135-147 cm. What is quite controversial is
the administration of GH in Idiopathic Short Stature (ISS). The diagnosis of ISS is
diagnosis of exclusion for short stature without hormonal or genetic abnormalities

or other chronic diseases. The indication of GH in ISS is that

having a height < percentile -1.2 (-2.25 SD).9
Therapy and Monitoring8
 Surgical therapy is required in certain cases, for example, tumors.
intracranial
Supportive therapy is needed for psychosocial development
Specialist referral according to etiology

2.1.11 Nutrition Management10

From birth to the age of 2, babies experience brain development.

rapid growth, as well as linear growth. Infant girls
reaching 50% of adult height at 18 months of age, while boys
at the age of 2 years. The age of 0-2 years is also a critical period of development

obesity. Body composition changes with age. Changes in fat accumulation

The body as it ages can be demonstrated using radiographic methods, measurements.
skinfold thickness, or body mass index. Body mass index is
the most common surrogate parameter for body fat
used.
Deficiencies or excesses of nutrients during the age period of 0-2 years

generally irreversible and will impact short-term quality of life

and long-term. Stunting will affect brain development in the long term.
the length that subsequently affects cognitive ability and achievement
education. In addition, linear growth will affect durability
the body and work capacity.
To improve the quality of future Indonesian people,
the most efficient effort is to prevent malnutrition by
socio-culturally socialize the correct feeding practices in the first 1000 days

first, evidence-based life. Therefore, the most important nutrition

Required during the age period of 0-2 years is exclusive breastfeeding and complementary feeding.

Exclusive ASI
Breast milk is the ideal food for babies, so the provision of breast milk
exclusive breastfeeding is recommended as long as it meets the needs of the baby. breast milk

has immunological components that can protect infants from pathogens

in the environment through specific mechanisms in the form of antibodies (IgA, IgG, and

IgM) and non-specific factors including lactoferrin, lysozyme, antiviral effects and
antiprotozoa from free fatty acids and monoglycerides. Things that
It should be noted in the provision of breastfeeding that:
 between several sucklings). The third step is to assess the adequacy of breast milk.

Sufficient breast milk is ensured by urinating 6-8 times.

In a day, the duration of breastfeeding is 10-30 minutes for one breast, and the increase...

adequate body weight.

2. MP-ASI
WHO Global Strategy for Feeding Infant and Young Children in the year
In 2003, it was recommended that complementary feeding meet 4 criteria.

namely:
1) Timely means that complementary feeding should be given while breastfeeding.

exclusive breastfeeding can no longer meet the nutritional needs of infants. Since

At 6 months old, breast milk alone is no longer sufficient to meet energy needs.

protein, iron, vitamin D, zinc, vitamin A are needed

Complementary foods for breast milk that can fulfill nutritional deficiencies

the macro and micro. Although it can no longer meet

complete nutritional needs, breastfeeding is still recommended
because compared to infant formula, breast milk contains substances
functional such as immunoglobulins, hormones, oligosaccharides, and others
that is not present in baby formula.
Adequate, meaning complementary feeding has sufficient energy, protein, and

micronutrients that can meet the needs of macronutrients and

micronutrients for infants according to their age. Exclusive breastfeeding can meet

the needs of macronutrients and micronutrients for infants up to 6 months of age

After that, a baby must receive complementary food to meet their needs.
its needs. Unfortunately, the quality of complementary food is often insufficient,

especially in terms of energy, protein, and micronutrients.

In the efforts to meet nutritional needs, there are steps
or the steps that must be taken in sequence. The first stage
is to provide foodstuffs that are high in nutrients that
needed. An example is the effort to meet the need for substances
iron, which must be fulfilled by complementary foods by around 97%. Referring to

WHO (2001), at the age of 6-12 months, infants require 11 mg of iron.

per day. To meet the iron requirements of 11 mg, a person
a 6-month-old baby receives about 0.2 mg/day from breast milk and
It is expected that the remaining 10.8 mg is met from complementary feeding.
Food
90 kcal contributed, and 28 g of rice flour contributed 102 kcal.
If referring to the energy needs of a 6-month-old baby boy weighing
The body weight is 7 kg and the length is 66 cm, then the energy requirement from breast milk.

and the complementary feeding per day is about 770 kcal, with a ratio of about 200
calories are fulfilled by complementary feeding and the rest by breast milk. This means, consumption

770-800 ml ASI plus 1 portion of rice flour @ 28 grams plus 1

the banana fruit meets the energy needs of the baby, but does not
for iron, protein, and zinc (Zn). This is indicated by the analysis
Here. A banana measuring 15 cm with a weight of 81 g.
contains 0.3 mg of iron while 28 g of rice flour
contains only 0.1 mg of iron. Based on the content analysis
iron in bananas and rice flour, it turns out to be a requirement for iron
daily needs that cannot be met by breast milk, cannot be fulfilled by
both of them so that as complementary food, food sources are needed
iron.
The best source of iron is red meat (beef)
minced meat contains 0.8 mg of iron per 28g, goat 1 mg per 28g, sheep
1.3 mg/28 g, duck 0.8 mg/28 g) and liver (chicken liver 3.6 mg/28 g, liver
sapi 1.7 mg/28 g). Vegetables, for example, boiled spinach contains substances

iron 1 mg/28 g but only 3-8% is absorbed compared to

23% from animal sources. 60 To meet the iron requirements,
infants should consume 85 g of chicken liver or 385 g of beef per
day, but consumption of chicken liver or beef in that amount
causing the baby to receive protein intake that exceeds the needs
daily.
Fortified food is the second step in
efforts to meet nutritional needs are provided when consumption
food sources of nutrients are insufficient or not possible.
Based on the Guidelines for Feeding Infants and Toddlers that
Issued by WHO in 2003, then published Codex STAN
074-1981 Rev 2006 for the industry regulating the composition of nutrients,
the use of food additives, as well as the safety of complementary feeding

fortification processed by the industry.

The third step to address micronutrient deficiencies
is the provision of nutritional supplements in the form of medicine. Supplements
 the population that does not need can cause effects that are not
desired.
3) Aman, which means that complementary feeding is prepared and stored in ways that

hygiene, provided using hands and eating utensils

clean. To ensure the cleanliness and safety of food that
consumed by children, carry out several things as follows:
get into the habit of washing hands before eating, use eating utensils
clean and sterile, cook food with
Correct, avoid mixing raw food with food that is cooked.
Already ripe, wash the vegetables and fruits before eating.
use clean water sources, and store food in a place
that's safe.
4) Properly fed means complementary food.
given by paying attention to hunger and fullness signals
a child. The frequency of feeding and the method of feeding must be
should encourage children to actively consume food
in sufficient quantities using hands, spoons, or eating
alone (adjusted to the age and stage of development of a
child). The baby will show signs of hunger and fullness with
body language (feeding cue). If the mother notices the feeding cue
from the baby and provides breast milk according to those signs
This will create the most suitable feeding schedule for the baby.
the one that is different from other babies. At the age of 6-8 months, given
2-3 times a day, increased to 3-4 times a day at the age of 9-24
Month. Between meal times, it can be given if needed.
additional snacks 1-2 times according to the child's ability
child

2.1.12 Stunting Prevention

Various efforts have been made to prevent and address
nutrition problems in society. There are indeed results, but we still need to
working hard to reduce the prevalence of stunted toddlers by 2.9% so that
the target of MDGs in 2014 was achieved, which impacted the decrease in the prevalence of malnutrition

lacking in our toddlers.

Under normal conditions, height increases along with
 the likelihood is relatively small. Therefore, there is a great opportunity to prevent stunting

done as early as possible by preventing risk factors for poor nutrition

in adolescent girls, women of childbearing age (WUS), pregnant mothers, and toddlers.

In addition, dealing with toddlers who have low height and weight that
there is a risk of stunting occurring, and for toddlers who have stunted so that they do not
increasingly heavy.

The occurrence of stunting in toddlers can be interrupted from the fetus stage.
contents by fulfilling the nutritional needs for mothers
Pregnant, meaning that every pregnant woman must receive adequate nutritional food.
receiving nutritional supplementation (iron tablets), and monitored for health.
In addition, every newborn baby only receives breast milk until the age of 6 months.
(exclusive) and after the age of 6 months given complementary foods to breastfeeding (MPASI)

that is sufficient in quantity and quality. A postpartum mother should receive enough food
Nutrition, also supplemented with nutritional elements in the form of vitamin A capsules.

The occurrence of chronic stunting in toddlers should be monitored.

and it can be prevented if the monitoring of toddler growth is carried out regularly
And true. Monitoring the growth of toddlers at the posyandu is an effort that
very strategic for early detection of growth disturbances,
so that prevention of stunting in toddlers can be carried out.
Together with other sectors, improve the quality of environmental sanitation.
and the provision of infrastructure and access for families to water sources
protected, as well as decent housing. Also improving family access
regarding the purchasing power of food and medical costs in case of illness through provision

job opportunities and income improvement.

The improvement of fathers' and mothers' education that impacts knowledge
and the ability to apply health and nutrition in their family, so that
the child is in a good nutritional status. Facilitating access
family towards information and the provision of information about health and
Nutrition for children that is easily understood and implemented by every family as well.

is an effective way to prevent stunting in toddlers.

2.2 The first 1000 days of Birth

2.2.1 Definition
1000 HPK or the first thousand days is a period within
the process of growth and development that starts from conception to
 The first thousand days of life is a period of a thousand days starting from
the occurrence of conception until the child is 2 years old. A thousand days consist of 270

The days during pregnancy and 730 days of the first life since the baby is born.
This period is called the golden period or also referred to as
a critical time, which if not utilized properly will lead to
permanent damage (window of opportunity).12,13

2.2.2 The Importance of 1000 HPK

The nutritional status and health of mothers and children as determinants of source quality

human resources, becomes increasingly clear with evidence that nutritional status and

maternal health during the pre-pregnancy period, during pregnancy, and during breastfeeding

is a very critical period. The thousand days period, which is 270 days
during her pregnancy and 730 days in the baby's first life
the birth, is a sensitive period due to the consequences it brings
For infants at this time, it will be permanent and cannot be corrected.
The impact is not only on physical growth, but also on
the development of mental and intelligence, which in adulthood is evident from
suboptimal physical size and non-competitive work quality that
resulting in low economic productivity.12,13
Inside the womb, the fetus will grow and develop through
increase in weight and height, brain development and organs
others like the heart, liver, and kidneys. The fetus has plasticity that
high, meaning the fetus will easily adapt to changes
the environment is both beneficial and detrimental at the time
that.
Why is it important to pay attention to the 1000 HPK group? The answer is
because it will reduce the number of short children in the future generation and
next. With that, the quality of humans will be improved from the aspect of
health, education, and productivity that ultimately leads to
improvement of community welfare.8For the world's economists, nutrition improvement
The 1000 HPK is a cost-effective investment in development.14

2.2.3 Factors Causing Nutritional Problems in the First 1000 Days of Life12,13

Nutritional problems are the result of various interrelated factors.

There are two direct factors that influence an individual's nutritional status, namely
 related to the high occurrence of infectious diseases and poor conditions
environmental health.

The first direct contributing factor is the consumption of food that is not
meet the amount and composition of nutrients that meet the requirements of a balanced diet

namely diverse, as needed, clean, and safe, for example, a baby does not
exclusive breastfeeding.

The second direct causal factor is related infectious diseases.

with the high incidence of infectious diseases, especially diarrhea and diseases
acute respiratory infection (ARI). This factor is closely related to the quality of health services.

the basis of immunization, the quality of environmental life, and healthy living behaviors.
The quality of the environment primarily refers to the availability of clean water, facilities

sanitation and healthy living behaviors such as the habit of washing hands with soap,
defecating in the toilet, not smoking, air circulation in the house and
etc.
Another factor that also influences is the availability of food in the family.
especially food for infants 0—6 months (Exclusive Breastfeeding) and 6—23 months

(MP-ASI), and nutritious balanced food especially for pregnant women.

All of it relates to the quality of child upbringing. Upbringing, sanitation
environment, family food access, and healthcare services are influenced by
education level, income, and access to information, especially about nutrition and
health

2.3 Government Priority Programs for Health15

In the RPJM 2015-2019, the target to be achieved is
improving the degree of health and nutritional status of the community through efforts

health and community empowerment supported by protection

financial and equitable healthcare services.
The targets of health development in the RPJM 2015-2019 are as follows:
Indikator : Meningkatkan status Kesehatan dan Gizi Masyarakat
a. maternal mortality rate per 100,000 live births
b. infant mortality rate per 1,000 live births
c. prevalence of malnutrition (underweight) in toddlers (percentage)
d. prevalence of stunting (short and very short) in toddlers
(under two years)
 A child has a distinctive characteristic, which is always growing and

developing from conception until the end of adolescence. This is what

distinguishing between children and adults. A child is not a small adult. A child

showing characteristics of growth and development that are appropriate for

old age.
Growth is the increase in size and number of cells and
intercellular networks, implying an increase in physical size and body structure
part or whole, so that it can be measured with units of length
and heavy.
Development is the increase in the structure and function of the body that

more complex in gross motor skills, fine motor skills, speech and
language and socialization and independence. Growth occurs in a
simultaneously with development. Different from growth,
development is the result of the interaction of the maturity of the central nervous system

with the organs it influences, for example the development of the system

neuromuscular, speech ability, emotions, and socialization. All functions

is crucial in the complete life of humans.
2.5 Growth Patterns17
The normal post-natal growth patterns of children are divided into the infant phase, the phase

children, and the puberty phase with characteristics as listed in the table. Characteristics
The growth phase will be clearly evident in a child when done
regular growth monitoring. As a result of the growth pattern
at the age of 2 years, the average height has reached ± 45-
50% of adult height, while at the end of the childhood phase or at the beginning of puberty.

The average has reached 80-85% of adult height.

Deceleration phase TB age 1 year =

1½ length of birth.

The growth rate in the first year is 20-25 cm/year.

Baby
The growth rate in the second year is 10-13 cm/year.
The phenomenon of catch up or catch down towards potential
height genetics, crossing percentiles occurs
 Prepuberty TB approaching

puberty (80-85%
There are no crossing percentiles, except in prepubertal. TB

Dip adult

Pubertal growth spurt Acceleration

Deceleration of growth after acceleration occurs growth

maximum growth maximum

The end of linear growth Men 11-12 cm/

Crossing percentiles can occur. Year

Women 8-9 cm

Year

2.6 Deviation in Growth and Development of Children18

2.6.1 Growth Deviations

Child growth deviations can be identified in the following way
monitoring and thorough examination since pregnancy for example by
monitoring the mother's weight gain each month and ultrasound for
Possibility of organic abnormalities. Some things to pay attention to.
as a sign of growth deviation, it needs to be detected properly
research

a. Body shape, size, symmetrical or not:

head (fontanelle, swelling), face (eye position, shape of the eyelids)
pupil, lens, ear, shape of the mandible, maxilla, nose and lips,
chest/thorax, distance of the nipple, umbilicus, abdominal muscles, vertebra
scoliosis/kyphosis, spine and position as well as the presence of anus. In adolescents;

shape and size of genitalia, breasts, pubic hair and axilla.

b. Anthropometry :
Height/body length, weight, head circumference, circumference
How to Use the WHO Growth Charts

1. determine age, body length/height, weight

2. determine the numbers that are on the horizontal line on the curve.
Garishorizontal on several WHO growth curves
3. determine the numbers that are on the vertical/straight line on the curve, line
the WHO growth chart describes height/weight,
age and BMI
4. connect the numbers on the horizontal line with the numbers on the vertical line

until reaching a meeting point (Plotted Point. this meeting point is

description of a child based on the WHO growth curve

How to Interpret the WHO Growth Curve

The 0 line on the curve represents the median.

2. The line called Z-Score is given positive numbers (1,2,3) or numbers
negative (-1, -2, -3). The intersection point that is far from the median line

describing growth problems.

3. To interpret the meaning of the intersection point on the WHO curve can

using the table below:

 2. Children in this group may have growth problems,
but it's better if measured using the ratio of weight to
PB/TB or BMI
The plot points above the number 1 indicate nutritional risk.
more.
4. Perhaps for children with short or very short stature
having excess nutrition
5. This refers to severe malnutrition in the research module
IMCI (Integrated Management of Childhood Illness in Training)
WHO Geneva, 1997

2.6.2. Development of Child Deviance

Child development assessment includes early identification of problems.

child development with screening (screening/filtering/networking) and
surveillance standard measurement non-standard, which is also combined
with information about social development, family history, history
doctor and the results of the medical examination17Development deviation
usually discussed together with behavioral deviations in the chapter
the same, with a very wide variation of abnormalities.
Development benchmarks include gross motor skills, fine motor skills, and language.

social behavior is used in screening for Denver Developmental

Screening Test (DDST) and Denver II for example. Meanwhile for
IQ (Intelligence Quotient), SQ (Social Quotient), EQ (Emotional Quotient) that
conducted by psychologists is necessary to establish boundaries
below average, normal, or gifted (in gifted children)

In the survey obtained from the information about parental concern towards
the development and behavior of their child.

Category of parental concern in detecting developmental deviations

child

1. Emotions and behavior

2. Speaking and Language
3. Social skills and self-help
4. Gross motor skills
 2.7 Early detection schedule for children16

Types of Development Detection That Must Be Done

Early Detection Early Detection Early Detection of Deviations
Child's Age
Deviation Deviation Mental Emotional
Growth Development (carried out on the indication)

BB/TB LK KPSP TDD TDL KMPE M-CHAT GPPH

0 months

3 months

6 months

9 months

12 months

15 months

18 months

21 months

24 months

30 months

36 months

42 months

48 months

54 months
72 months

Description :
Weight to Height Ratio
LK HeadCircumference
KPSP Pre-Screening Development Questionnaire
TDD Your Hearing Ability

TDL Your vision power

KMPE : Kuesioner Masalah Perilaku Emosional
M-CHAT: Modified Checklist for Autism in Toddlers
GPPH Attention Deficit Hyperactivity Disorder

2.8. Early Detection Instruments for Child Development

Early detection of children's growth and development or SDIDTK services is

activities/examinations to find early indications of deviations

growth and development in toddlers and preschoolers. Discovered through
the issues/problems of child development, then the intervention will
it is easier to do, if discovered late, then the intervention will
it is more difficult and this will affect the growth and development of children.

There are 3 types of early detection of development that can be performed by

health workers at the community health center level and its network, in the form of:

a. Early detection of growth disorders, namely determining nutritional status

is the child overweight, normal, underweight, and very underweight, short, or

very short, macrocephaly or microcephaly.

[Link] detection of developmental deviations, which is aimed at understanding

child development disorders (delays), visual impairment,

hearing impairment.
c. Early detection of emotional mental deviations, which is to know
the presence of emotional mental issues, autism, and attention disorders

perhatian dan hiperaktivitas.

 Child Nutrition Status Assessment Based on Body Mass Index
According to Body Length (Bb/Pb) or Body Weight According to Height
Body (BB/TB) For Children Aged 0 - 60 Months.

Measurement Nutritional Status

Results Action
Z-score (BB/TB or BB/PB)
2 SD Fat Determine
1. main cause
to show
Counseling
2. nutritionaccording to
cause

-2 SD up to Normal Give praise to mother and

with 2 elementary schools child

-3 SD until Kurus Determine

1. main cause

with -2 SD anakkurus
Counseling
2. nutritionin accordance
cause
Below -3 SD Very Thin Immediately refer to PKM with TFC
or to the hospital

Measurement of Children's Nutritional Status Based on Body Mass Index

According to Age (BMI/U) for Children Aged 60 - 72 Months

Results Nutritional Status

Action
Z-score measurement (IMT/U)
Above 2SD Obesity Immediately refer to the hospital

1 SD Nutritional intake adjusted

Fat
with 2SD with the needs and
children's activities

-2SD until Normal Give praise to

with 1SD mother and child

Nutritional intake is increased and

-3SD up to < -
Child Nutritional Status Assessment Based on Height/Length Index
Body According to Children Age 0–60 Months

Measurement Results Nutritional Status Action

Above 2 SD (>2SD) High Schedule the next visit

-2SD to 2 Normal Schedule the next visit

SD
Nutritional intake is increased and
-3SD up to < - Schedule the next visit
Short
2SD
Below the kurvaz-score
-3 (<-3SD) Very Short Please refer to the service facility soon.

health

Head Circumference Examination for Children Aged 0 - 72 Months

Measurement Results Classification Action

Above curve +2 Macrocephaly Refer to Home

Sick

Between the curve +2 Give praise to mother

Normal and child
dan -2

Under the curve -2 Macrocephaly Refer to Home

Sick

2.9 Pre Screening Development Questionnaire (KPSP)16

Routine monitoring of developments can detect the presence of
early developmental delays in children. IDAI together with the Ministry of Health

organizing the use of KPSP as a tool for pre-screening development until

6 year old child, examinations are conducted every 3 months for under 2
year and every 6 months until the child is 6 years old. The aim is to determine
child development normal/age-appropriate or is there any deviation. Examination
KPSP is an assessment of child development in 4 sectors of development, namely:
 a. KPSP form according to age 3, 6, 9, 12, 15, 18, 21, 24, 30, 36, 42, 48, 54, 60, 66, 72

This form contains 9-10 questions about developmental capabilities.

that has been achieved by the child.

b. Examination aids include: ball, doll, cube with a 2.5 cm side, wool yarn
red, paper, crayon, raisin, jingling, bell.

Development Screening Questionnaire Algorithm (KPSP)

Examination Results Interpretation Action

The answer is 'Yes' 9 According to age Praise success person
or 10 your/caregiver. Continue the stimulation

according age. Schedule

visit
next.

Doubtful Advice Mother/Caregiver for

Answer 'Yes' 7 stimulating more often
or 8 with full affection.
Schedule a follow-up visit for 2
week again. If result
examination next also
doubting, refer to the Hospital
growth development reference level 1.

Answer 'Yes' 6 Deviance Refer to the referral hospital

or less level 1 development.

2.10 Hearing Ability Test (HAT)

The goal of the hearing test is to detect hearing impairments early.
Dini, if possible, please take action to improve your abilities.
Listen and speak Ana, the TDD schedule is every 3 months for babies aged
less than 12 months and every 6 months for children aged 12 months and above. This test
carried out by health personnel, kindergarten teachers, early childhood education staff, and officials

other trained professionals. Health workers have an obligation to validate the results

other power checks.

How to do TDD:
Ask for the date, month, and year of the child's birth, calculate the child's age in months.
 Do not hesitate or be afraid to answer, because it's not for searching.
who is wrong.
[Link] the question slowly, clearly, and loudly, one.
unity, sequential.
c. Waiting for the answer from the parents/guardian.

[Link] YES if, according to the parents/caregivers, the child can do it.

in the last month.

e. The answer is NO if according to the parents/caregivers the child has never done so, no.

know or not able to do it in the last month.

For children aged 24 months or older:

a. Questions in the form of commands through parents/caregivers for

done by children.
[Link] the child's ability to follow the instructions of parents/caregivers.

c. Answer YES if the child can follow the commands of the parents/caregivers.

d. Answer NO if the child cannot or does not want to follow the command.
parents/caregiver.
Interpretation:
If there is one or more NO answers, the child is likely to experience

hearing impairment.
Record in the KIA Book or SDIDTK register, or child medical status/note.

2.11 Visual Acuity Test (VAT)

The purpose of vision tests is to early detect visual abnormalities.

if further action can be taken immediately so that the opportunity to
to gain sharper eyesight
The vision ability test schedule is conducted every 6 months for preschool-aged children.

ages 36 to 72 months. This test is conducted by healthcare professionals.

The tools/facilities needed are:
1. A clean, quiet room with good lighting

[Link] chairs, 1 for the child and 1 for the examiner.

[Link] 'E' to be hung and card 'E' to be held

[Link] Tool

How to perform visual power:

1. Choose a room that is clean and quiet, with good lighting.
2. Hang the poster 'E' at the eye level of the child in a sitting position.
 Direct the card 'E' to face up, down, left, and right;
as indicated on the poster 'E' by the examiner. Give compliments
every time the child wants to do it. Do this until the child
must direct the 'E' card correctly.

6. Next, the child is asked to close one eye with a book/paper.

[Link] the pointer, indicate the letter 'E' on the poster, one by one, starting

the first line to the fourth line or the smallest 'E' line that still exists
can be seen.
[Link] the child every time they can match the position of the card 'E' that

held with the letter "E" on

poster.
9. Repeat the examination on the other eye in the same way.

[Link] the smallest "E" line that can still be seen, on the text that

Provided: Right eye:............. Left eye

:...............
Interpretation:
Preschool children generally do not have difficulty seeing until
the third line on the poster 'E'. If both of the child's eyes cannot see
the third line of poster E or cannot match the direction of card 'E' which
2.12 Monitoring Child Development Based on Denver Development Screening
Test (DDST / DENVER II)
The Denver Developmental Screening Test (DDST) is a method
assessment used to evaluate children's development at age
less than 6 years. This test was developed by William K. Frankenburg and
J.B. Dodds in 1967 (William K. Frankenburg & Dodds, 1967).
Ideally, it should be done by a child aged 3 or 4 months, then at the age of
10 months and 3 years. This is done to facilitate evaluation.
child development.

DDST reflects the percentage of groups of children of a certain age that can
displaying certain developmental tasks, to be compared later
with the development of children of that age. DDST assesses 4 sectors

development, namely: 1. Social Personal (adjustment to society and

personal needs). 2. Fine Motor - Adaptive (eye-hand coordination,
the ability to play with and use small objects, as well as
problem solving). 3. Language (listening, understanding, and using
4. Gross Motor Skills, which include sitting, walking, and performing movements
other major muscle groups.19

In its development, DDST has undergone several revisions. Revision

the last is Denver II, which is the result of revision and standardization of
DDST and DDST-R (Revised Denver Developmental Screening Test) (W. K.
Frankenburg, Dodds, Archer, Shapiro, & Bresnick, 1992). Differences Denver II
with prior screening located on the test items, forms, interpretations and
reference.

Your DDST is carried out by someone who has competence in

child development. In conducting the test, the examiner uses two
instrument, namely: a paper form containing test items, and the implementation manual.
If one of the instruments is missing, the test cannot be conducted.20

2.13 Scoring in Denver ii20

1. Passed or graduated (P/L). The child has tested well, or the mother /
The caregiver reports (accurately / reliably) that the child can
 3. refuse or deny (R/M). The child refuses to take the test.
Rejection can be reduced by telling the child "what you
it must be done
to do it (trial reported by the mother / caregiver of the child does not)
discourse as a rejection).
4. By report means no opportunity (no chance). The child does not
having the opportunity to try out because there are obstacles.
This score may only be used in trials marked with R.

2.14 Scoring in Denver ii20

Normal
If there is no delay and/or at most one caution.
Do a repeat on the next control
2. Suspect
If there are ≥2 cautions and/or ≥1 lateness.
Re-test in 1-2 weeks to eliminate the factor.
a moment like fear, a state of illness, or fatigue
3. Cannot be tested
If a child refuses at least one trial located to the left of the age line.
or reject in ≥1 trial that crossed the age line in the area
75-95%
Re-test in 1-2 weeks
If the repeat test results show a suspect or cannot be tested,
to be considered for referral.
 CHAPTER III

CONCLUSION

According to WHO, short stature due to malnutrition and/or suboptimal

Health is referred to as stunting. Stunting is part of being short, but not
every short stature is stunting. Stunting is an indicator of problems
child nutritional status due to chronic malnutrition related to environmental conditions and status
socio-economics. When the weight-for-height is below normal and height is less than the 3rd percentile or -

2SD, the child is categorized as stunting.

In dealing with a child with a short stature, anamnesis is required.
physical examination, and supporting examinations. A good and directed examination
it is necessary to know the etiology and avoid unnecessary examinations
It is necessary. The management of every child with a short stature must be evaluated immediately.

Families need to be given an explanation regarding a child's growth potential according to

with its genetic potential. Some cases do not need immediate therapy and
it can only be implemented with periodic monitoring, however in some other cases
Clearly, the cause can directly receive therapy.
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