IO, Jakarta – Children are the future generation of Indonesia. However, there is a large threat to this next generation: stunting. Stunting is defined as a failure for toddlers to grow normally, due to chronic malnutrition, so that the child becomes too small and short for his age. The abnormal growth is caused by a failure to obtain balanced nutrition from pregnancy until the toddler years. Stunting cases are frequently found in areas with a high level of poverty and low level of education.
Indonesia is in the top five countries with widespread stunting in the world. In Southeast Asia, Indonesia’s figure of 35.6% is much higher than that of Singapore or Malaysia at 4% and 10%, respectively. This condition is even more prevalent than that in Thailand (16%), Vietnam (23%) or Myanmar (35%).
The World Health Organization (WHO) sets a maximum limit for stunting tolerance at 20%, or one-fifth of all existing toddlers. However, Indonesia’s stunting rate in toddlers is 35.6%, or 7.8 million stunted out of the 23 million toddlers, being much higher than the WHO tolerance limit. Of the 35.6% of stunted children in Indonesia, 18.5% toddlers are categorized as “extremely short” and 17.1% as “short”. These figures show that Indonesia is a malnourished country.
Meanwhile, data from Base Health Research (Hasil Riset Kesehatan Dasar – “Riskesdas”) 2013 states that the stunting rate in Indonesia is actually about 37.2%. However, after active nutrition monitoring by the Government, the stunting rate dropped to 27.6% in 2016. The results of the Nutrition Status Monitoring (Pantauan Status Gizi – “PSG”) 2017, the prevalence of stunting in toddlers younger than 5 in East Nusa Tenggara (Nusa Tenggara Timur – “NTT”) was 40.3%, the highest prevalence of all provinces. The lowest stunting prevalence in 2017 occurred in Bali, at 19.1%.
Causes of Stunting
According to Prof. Dr. Hardinsyah, M.S., Rector of Sahid University, Jakarta, there are three possible causes for a child to be stunted: genetics, malnutrition, and disease. However, the stunting suffered by Indonesian children is usually due to malnutrition, “Because they are usually given food with insufficient nutritional value,” said the man who doubles as the Professor of Nutrition of the Bogor Agricultural Institute (Institut Pertanian Bogor – “IPB”).
Meanwhile, Prof. Dr. Ir. Ali Khomsan, M.S, Professor of Foodstuffs and Nutrition of IPB, said that children become stunted because the food their parents give them does not satisfy nutritional standards, either in terms of quantity or quality. “Stunting in children generally occurs after the children are 6 months old. This is because after 6 months, these children are fed with mother’s milk supplements (makanan pendamping air susu ibu – “MPASI”) other than – or even more frequently, instead of – breast milk (air susu ibu – “ASI”). And these ASI supplements are frequently of low quality, so they don’t really support a child’s growth,” he said.
dr Paulus Linardi, Sp.A., a pediatrician from Siloam Hospital Semanggi MRCCC, explained that stunting among children does not occur spontaneously. It is actually detectable during the first 1000 days of life (hari pertama kehidupan – “HPK”). “That means 9 months in the womb, that’s 270 days, and the remaining 730 days after the baby is born. If nutrition is insufficient during 1000 HPK and no stimulation for growth and development, the child might be stunted,” he said.
Agreeing with Dr. Paulus, Dr. Raissa Edwina Djuanda, M.Gizi, Sp.GK, a nutritionist from Pondok Indah Hospital, said that if the mother does not have sufficient nutrition during pregnancy, the child is likely to be born stunted.
Mother’s Care
According to Dr. Paulus, stunting prevention must start with the awareness of pregnant mothers to undergo routine checkups at health service centers. Furthermore, they must also watch what they eat, in order to ensure balanced nutrients. “Pregnant mothers might also need supplements, such as iron and folic acid. It is probably necessary that pregnant mothers be given training in order to be able to organize a healthy diet on their own,” he said.
Dr. Raissa said that mothers need to be constantly trained and educated, especially at first-line health centers such as integrated health service posts (pos pelayanan terpadu – “posyandu”) and community health centers (pusat kesehatan masyarakat – “puskesmas”), in order to allow medical workers to detect whether these mothers’ children could suffer stunting or not.
During pregnancy, mothers should be trained how to eat nutritious food, including consuming blood supplement tablets, as iron is necessary for accelerating the distribution of nutrients throughout the body. After birth, mothers should give their babies ASI exclusively, instead of baby formulas, at least for the first 6 months. “Many mothers don’t know this and rely exclusively on formulas, while MPASI should have high nutrition value,” she said. Dr. Raissa further noted that the mother and child should be placed in a sanitary environment, which includes clean water for drinking and bathing, both during pregnancy and after childbirth.
Child malnutrition is intimately tied to economic trouble. It is far from easy for the poor to eliminate stunting, as they generally cannot afford to give themselves nutritious food, let alone feed their children with good nutrition. “If we allow people to remain impoverished, stunting will be a constant problem for the poor. In advanced countries, the stunting problem is not as severe as in developing countries. This is an economic or welfare issue – it does not always mean that the mother raises the child poorly, but they literally cannot afford to feed their children properly,” Prof. Ali said.
Poverty and Educational Level
Putih Sari, Member of Commission IX of DPR, stated that stunting is a serious threat to Indonesian children, and that this issue is very much related to the future of the nation. She stated that a lot of people don’t understand the importance of good nutrition – and even when they do, they are generally too poor and lack the buying power to buy nutritious foodstuff. “So they just feed their children until the children are full as much as possible, and not bother with checking the nutrition value,” she said.
Poverty and low level of education frequently cause the people to ignore nutrition satisfaction in themselves, let alone in their children. Information on the importance of nutrition is frequently given, but not fully understood, so that awareness of nutrition consumption is low. This awareness includes food control during pregnancy, exclusive ASI, as well as balanced ASI supplement. “We can handle it with routine counselling. This way, we can comprehend what the parents don’t understand and why,” Dr. Paulus said.
Dr. Raissa said that the lower classes are generally more difficult in accepting the importance of consuming sufficient nutrients, because they thought it is too expensive. In fact, there are plenty of good nutritious foodstuff available: omega 3 can be obtained by consuming catfish, calcium can be obtained from eggs, and tofu and tempe contain a lot of protein.
Mitigating Stunting
Stunted children have their growth and development painfully obstructed. “Their motoric activities are generally obstructed. They also tend to have lower levels of intelligence and confidence,” Dr. Paulus said. “They are generally slow to understand things,” Prof. Hardinsyah. “Other than impact to their intelligence, stunted children usually have a low level of immunity, and they get sick easily,” Dr. Raissa said.
Underfed children will have lower body weight. Prolonged underfeeding and/or malnutrition will affect their height. Extremely prolonged underfeeding and malnutrition will affect their intelligence. “Studies show that stunted children have lower cognitive abilities than normal children, as stunting and low intelligence are the impact of prolonged malnutrition. This is because optimum brain formation occurs during the toddler period,” Prof. Ali said.
Many steps must be taken to mitigate the stunting of Indonesian children. Dr. Paulus said there are 6 major steps to be taken:
- First, the mantri or orderlies stationed in remote areas where doctors are scarce must be empowered. They must be provided with additional knowledge using seminars and training, so that they understand that 1000 HPK is crucial for preventing stunting among children, and they can disseminate this fact properly to the parents.
- Second, vitamins and other supplements must be distributed to all regions, especially remote areas with little access to healthcare services. It is very difficult to obtain milk, eggs, and other nutritious foodstuff in the hinterland.
- Third, promote exclusive ASI feeding to the regions, especially during the first 6 months of the baby’s life. Also, promote good distribution of immunizations.
- Fourth, educate medical workers on the concept of ASI supplement with a balanced nutritional composition, which includes equal consumption of protein, fat, and carbohydrates, with an encouragement to eat more fruit and vegetables.
- Fifth, encourage good neighborhood and environmental sanitation and hygiene.
- Sixth, encourage post-partum medical checkups. In the first 6, the checkups are done monthly. After 6 months, the checkups are made once every 2-3 months. With regular checkups, any delay in growth of weight and height can be quickly corrected.
Government Policies
The stunting level at 35.6% is a red mark for the Government. Putih from the Gerindra Party gave an alternative through the White Revolution program the party offers, wherein nutritional satisfaction is increased by increasing protein intake, i.e. through milk consumption. “Even though protein is contained in more foodstuff than milk, we are trying to cultivate dairy consumption, as dairy consumption in Indonesia is much lower than in other countries,” she said.
Putih also encourages the Government to distribute supplements in posyandus. This will help control the satisfaction of nutrition requirement to the people. She gave the example of the Government of DKI Jakarta’s cheap food program, which helps to cover the people’s access to nutritious food. ”We appreciate this policy. We hope that other provinces would adopt it too,” she said.
Prof. Ali considers that the Family Hope Program is the Government’s way of trying to eliminate poverty. However, she requests that the Government takes better care in setting the target for the aided people, especially the mothers in poor families with toddlers. By helping them, the Government will save the future generation.
Furthermore, posyandus must be revitalized. They do well with the trainings, but the foodstuff posyandus distribute is far from being ideal, as they consist mostly of mung bean porridge and eggs. “These foods do little to help eradicate stunting, while posyandu is the primary point for helping to eradicate nutrition issues,” Prof. Ali said.
Prof. Hardinsyah believes that the Government has taken the right steps in mitigating stunting. With the issuance of relevant Presidential Regulations (Peraturan Presiden – “Perpres”), the national movement to accelerate nutrition improvement in the 1000 HPK program. However, the most important thing is that these policies can be properly executed down to the lowest levels of the Government. (Dessy Aipipidely)