Definition

Stunting, or short stature in children, is a term used to describe chronic malnutrition characterized by a child's height being significantly shorter than the standard for their age group. According to the World Health Organization (WHO), a child is considered stunted if their height falls below three standard deviations on the growth curve. Stunted children often experience not only delayed physical development but also cognitive difficulties, such as delays in speech, walking, and frequent illnesses.

Prevention of stunting begins during the first 1,000 days of life, from conception through the toddler years. Adequate nutrition during this period can prevent stunting. Growth and development should be closely monitored at every doctor's visit. Parents should be aware of the importance of following medical advice to prevent stunting.

Stunting is a global issue. According to the WHO, 22% of the global population experienced stunting in 2021. In Indonesia, stunting rates are alarmingly high, ranking second in Southeast Asia and fifth globally in 2018. Addressing stunting is crucial because it can have long-term impacts on a child's future.

The paramount component in child nutrition is the quantity of macronutrient and micronutrient consumption prior to conception and subsequent to the infant's birth. This significantly contributes to the child's growth and development. A child's posture is significantly affected by various factors, including heredity, hormones, and dietary intake. Children with small stature are not inherently stunted. Children who are stunted exhibit a reduced stature.

Causes

Several factors can contribute to stunting, often stemming from issues during pregnancy and the first five years of life. Common causes include:

• Chronic diseases. Both infectious and non-infectious chronic diseases, such as rubella, cytomegalovirus, toxoplasmosis, and malaria during pregnancy, can lead to stunting.
• Medications. Use of certain drugs like opioids, corticosteroids, and cytotoxic medications can contribute to stunting.
• Low Birth Weight (LBW). Premature or LBW babies are at higher risk for stunting.
• Poverty. Socioeconomic factors, including low parental education and inadequate access to healthcare, can increase the risk.
• Nutritional deficiencies. Both macronutrients and micronutrients, such as iron and folic acid during pregnancy and early childhood, are critical to preventing stunting.
• Metabolic diseases. Hypoglycemia, elevated bilirubin levels, and other factors significantly contribute to first 1000 days of life.
• Bone dysplasia. This illness is a congenital disorder characterized by improper growing of the child's bones.
• Genetic abnormalities. Certain disorders, such as Down syndrome or skeletal dysplasias, can lead to short stature.
• Endocrine disorders. Hormonal imbalances, such as diabetes, can also contribute to stunting.

Risk Factor

In general, children's growth and development follow normal patterns, which result from the interaction of a variety of factors that influence their progress. To ensure optimal growth and development, it’s essential to consider these factors holistically, as they all play a crucial role in shaping how children grow.

These influencing factors can be categorized into internal and external factors:

Internal Factors

• There is often a familial tendency for children to inherit a tendency toward being tall or short, or lean or more robust.
• The most significant growth periods are during the prenatal stage, the first year of life, and adolescence.
• Gender. In terms of reproductive function, girls tend to develop faster than boys initially. However, after puberty, boys generally experience a growth spurt that results in a faster overall growth rate.
• Genetics. Genetic disorders, such as dwarfism, can directly impact a child’s physical growth patterns and development trajectory.

External Factors

• Prenatal Factors
• Nutrition. The nutritional intake of the mother, especially during the last trimester of pregnancy, directly affects fetal growth. 
• Mechanical factors. Abnormal positioning of the fetus in the womb can lead to congenital abnormalities, such as club foot.
• Toxins and chemicals. Exposure to certain drugs, such as aminopterin and thalidomide have been linked to abnormalities such as cleft palate,
• Endocrine factors. Conditions like diabetes mellitus during pregnancy can result in macrosomia (excessive fetal growth), cardiomegaly (enlarged heart), or adrenal hyperplasia (abnormal growth of the adrenal glands).
• Radiation. Exposure to radiation, including X-rays, during pregnancy can cause fetal abnormalities, including microcephaly (abnormally small head), spina bifida (a neural tube defect), and heart disorders or limb deformities. 
• Infections. Certain infections during the first and second trimesters of pregnancy, collectively known as the TORCH infections (Toxoplasma, Rubella, Cytomegalovirus, and Herpes simplex) can lead to severe fetal abnormalities.
• Immune system disorders. Conditions such as erythroblastosis fetalis, which occurs when there is a Rh factor incompatibility between the mother and fetus, can result in serious complications. The mother’s immune system produces antibodies that attack the fetus’s red blood cells, causing hemolysis and leading to jaundice, brain damage, and other long-term developmental issues.

• Postpartum Factors
• Nutrition. Adequate nutrition plays a crucial role in an infant's growth and development, as the child requires proper nutrients to thrive.
• Chronic diseases and congenital abnormalities. Conditions like tuberculosis, anemia, and congenital heart defects can lead to physical growth delays in children.
• Physical and chemical environment. The child's living environment, which provides their basic needs, can have a significant impact on their growth. Poor sanitation, limited exposure to sunlight, and environmental toxins like lead and mercury can negatively affect a child's development.
• Psychological. The relationship a child has with those around them plays a vital role in their growth. A child who feels unloved or experiences ongoing stress may face obstacles in their development.
• Endocrine factors. Hormonal imbalances, such as hypothyroidism, can lead to growth delays in children.
• Socioeconomic factors. Poverty is often linked to inadequate nutrition, poor environmental conditions, and lack of education, all of which can hinder a child's growth.
• Parenting. The quality of care, especially the interactions between the mother and child, plays a significant role in the child’s growth and development.
• Stimulation. To foster healthy development, it is important to provide stimulation, especially within the family environment. This includes giving toys, socializing the child, and involving the mother and other family members in the child’s activities.
• Drugs. Prolonged use of corticosteroids can slow growth, as can stimulant medications that interfere with the production of growth hormones.

Symptoms

Children with stunting are often overlooked by their parents, who may not notice that their child has a shorter stature or other growth abnormalities. The symptoms of stunting usually begin to become noticeable around the age of 2.

Below are the common signs that may indicate a child is stunted:

• The child is shorter than their peers
• The child weighs less than others their age
• The child is prone to frequent illness
• Learning difficulties
• Slowed bone growth
• Developmental delays

If this condition persists, additional symptoms may appear, including:

• Lack of energy and disinterest in playing
• Persistent cough, fever, and night sweats
• The child’s body may turn blue when crying
• Frequent weakness
• Shortness of breath
• Clubbing of the fingertips
• Refusal to breastfeed

Diagnosis

To diagnose stunting, a doctor will conduct a thorough process involving a medical interview, physical examination, and supporting tests.

Medical Interview

The doctor will first have a conversation with the patient or the child's guardian. The questions will focus on:

• Current symptoms
• The child’s medical history
• Pregnancy and delivery details
• Growth and development history, especially during the critical first 1000 days of life (HPK)
• Immunization and nutrition history
• Family medical history

The doctor will also review the KIA book (Mother and Child Card) to gain a detailed understanding of the child’s prenatal, postnatal, and overall health history. Since children’s health needs differ from adults, the doctor will look at the various factors that may contribute to growth and development issues.

Physical Examination

Following the interview, the doctor will perform a general and focused physical exam. During the general exam, the doctor will measure weight, height, head circumference, and body mass index (BMI). The focused physical exam will assess the child’s overall physical health, including neurological status.

Diagnostic Tests

If necessary, the doctor may recommend further tests, such as:

• Laboratory Tests
• Complete blood counts
• Imaging Studies
• X-ray
• CT Scan
• MRI (Magnetic Resonance Imaging)

Management

Treating stunting requires the expertise of a pediatrician and must be approached comprehensively, depending on the root cause. The doctor will likely recommend the following treatment options:

• Encourage a clean and healthy lifestyle
• Ensure proper nutrition for the child
• Treat any underlying conditions such as pulmonary tuberculosis (TB)
• Provide supplements, including vitamin A, zinc, iron, calcium, iodine, and other essential nutrients

Complications

If it is untreated, stunting can lead to complications such as:

• Metabolic disorders in adulthood, including obesity and diabetes
• Frequent illnesses and infections
• Cognitive delays that hinder learning

Prevention

Stunting is a preventable condition, and preventive measures can significantly reduce the risk. Here are steps to help prevent stunting:

• Ensure adequate nutrition before conception, during pregnancy, and after birth
• Understand the importance of the first 1000 days of life, which spans from conception to the child’s second birthday. Exclusively breastfeed until the child is 6 months old
• Ensure the child receives all necessary vaccinations
• Attend regular antenatal checkups with an obstetrician (at least 6 visits during pregnancy)
• Visit a pediatrician or health post regularly to monitor the child’s growth and development

When to See a Doctor?

If your child is shorter than their peers, frequently sick, or struggling with learning, it is important to consult a paediatrician for an appropriate diagnosis and intervention.

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