1.

ELECTRONIC ARTICLE Increasing Prevalence of Overweight Among US Low-income Preschool Children: The Centers for Disease Control and Prevention Pediatric Nutrition Surveillance, 1983 to 1995

Abstract
Objective. To determine whether the prevalence of overweight in preschool children has increased among the US low-income population. Design. Analysis using weight-for-height percentiles of surveillance data adjusted for age, sex, and race or ethnicity. Setting. Data from 18 states and the District of Columbia were examined.a Subjects. Low-income children <5 years of age who were included in the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Results. The prevalence of overweight increased from 18.6% in 1983 to 21.6% in 1995 based on the 85th percentile cutoff point for weight-for-height, and from 8.5% to 10.2% for the same period based on the 95th percentile cutoff point. Analyses by single age, sex, and race or ethnic group (non-Hispanic white, nonHispanic black, and Hispanic) all showed increases in the prevalence of overweight, although changes are greatest for older preschool children. Conclusion. Overweight is an increasing public health problem among preschool children in the US lowincome population. Additional research is needed to explore the cause of the trend observed and to find effective strategies for overweight prevention beginning in the preschool years. Key Words: overweight obesity prevalence preschool children weight-for-height Childhood obesity is an increasing problem in developed countries and an increasing public health concern.1Researchers have found an association between obesity in childhood and higher levels of blood pressure,6diabetes,9,10 respiratory disease,11 adult obesity,12 and orthopedic13,14 and psychosocial disorders.15 Determining the factors that contribute to excess weight gain in children is of great interest, as is the question of whether the prevalence of obesity or overweight in children is increasing. Among US children 6 to 11 years of age, Troiano et al2reported an 7 percentage point increase from 1963 to 1991 in the prevalence of overweight, based on a body mass index (weight/height2) above the 85th percentile, and a 5 percentage point increase in the prevalence based on a body mass index above the 95th percentile. Gortmaker et al3 reported a 9.5 percentage point increase from 1963 to 1980 in the prevalence of obesity for children age 6 to 11 years of age based on triceps skinfold measurements above the 85th percentile and a 5.8 percentage point increase in the prevalence of obesity above the 95th percentile of the triceps skinfold measurements. This report3 also noted that weight-for-height among children 6 and 7 years old increased during the same period. More recently, Ogden et al16 reported a greater increase for girls (2.8 percentage points at 2 to 3 years and 5.0 at 4 to 5 years) than for boys (1 percentage point decrease at 2 to 3 years and only a 0.6 percentage point increase at 4 to 5 years, but no statistical significance in the change of prevalence both at 2 to 3 years and at 4 to 5 years of age) in the prevalence of overweight based on the 95th percentile of weight-for-height data from the National Health and Nutrition Examination Survey I (NHANES I, 1971 to 1974) to NHANES III (1988 to 1994). In this study, we try to determine whether the prevalence of overweight in preschool children among the US low-income population has increased also and to extend our analyses to include infants and toddlers (0 to 23 months of age). Previous SectionNext Section

METHODS
Since 1973, the Centers for Disease Control and Prevention (CDC) has assisted states in monitoring key growth and hematologic indicators of nutritional status of low-income US children who participate in publicly funded health and nutrition programs such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Early Periodic Screening, Diagnosis and Treatment Program; and clinics funded through Maternal and Child Health Program block grants.17,18 Data for the majority of the infants and children monitored by the Pediatric Nutrition Surveillance System (PedNSS) come from clinic

service records of WIC. The WIC program, which was initiated in 1972, is administered by the Food and Nutrition Service of the US Department of Agriculture.19,20 The PedNSS has expanded from five participating states in 1973 to 38 states, the District of Columbia, Puerto Rico, and 7 Indian Reservations in 1995. This surveillance system provides a rich source of data for studying the nutritional characteristics of low-income children on a state-by-state basis.17,18 In the PedNSS system, height or length is measured to the nearest 0.1 cm or 1/8 inch. According to the protocols, a measuring board is used to measure the child's recumbent length if the child is <24 months of age; otherwise, a standing height is measured for children >24 months. Weight was measured to the nearest 0.1 kg or pound using a pediatric scale or other beam balance scale.21,22 All the records are entered onto a standardized paper form or onto an automated computer system in the clinics. Once the records are computerized at the state level, they are transferred to the CDC for inclusion in the PedNSS database. To study the trend in prevalence of overweight from 1983 through 1995, we selected all children 0 to 59 months old from the 18 statesa(plus the District of Columbia) who participated consistently in the PedNSS during this period. Among the 18 states and the District of Columbia, we checked the data quality by using the anthropometric data quality assurance indexes22,23 across states and years within each state to verify whether the data are comparable. Because a nearly constant variance in height- and weight-based z score distributions is indicative of data quality,23 the SD units of weight-for-height z score were used to check the data quality across states and years. We found the that the SD units of thez score distribution were within the normal range (0.85 to 1.10)23 and were stable. Also, we tracked the height-for-age z score across years for each state included in this analysis to examine whether an increasing bias of measuring children too short could affect the overall overweight trend. We found that there was no change in the mean height-for-age z score across years for all the states in the dataset. Furthermore, the records of the children with missing ages were automatically excluded before they were transferred to the PedNSS database. The percents of missing height/length and weight were 1.5% and 1.1%, respectively. The percent of records with biologically implausible values of weight-for-height (z score below 4 or above +5)23 was 0.5%. To examine whether the criteria for enrollment in these publicly funded health and nutrition programs remained approximately the same from 1983 to 1995 in the selected 18 states and the District of Columbia, a survey was conducted in those states regarding any certification criterion or priority changes for overweight in the programs during the 13 years. Because the PedNSS, which receives data from publicly funded health and nutrition programs, has multiple records on children per calendar year and a disproportionate number of first visit records for young infants, one record per child per visit year was randomly selected to avoid double counting of children who visit the program more than once in a calendar year. Repeat visits were identified using the unique WIC identification number, which is maintained for WIC administration. The final sample for this study was 15029147 preschooler clinic records. To examine trends more generally for children <5 years old, we age-adjusted the prevalence estimates for each year, assuming a uniform age distribution. To do this, we weighted the data so that the prevalence of each single month of age was weighted equally. The results were also adjusted for race or ethnicity and for sex, assuming that the ethnic mix for all 13 years combined applies for each calendar year, and assuming that there should be 50% boys and 50% girls. We examined trends by the urban/rural classification of the county in which the clinical measurements were taken using the Census Bureau definition of urban and rural. To examine how the CDC PedNSS low-income preschooler population differs from the US general population at the same ages, we compared the demographic and anthropometric characteristics of the PedNSS data with NHANES II and III data. In recent years, several studies have shown that the current NCHS/CDC growth reference sections based on the Fels sample (<2 years of age) and the part based on the national representative NHANES I sample (2 years of age) are not comparable. When the two curves are compared, there is a clear disjunction of heightfor-age and weight-for-height at 24 months of age.24,25 These disjunctions make it difficult to compare the growth status of children <2 years of age with that of children >2 years of age. Because of the disjunction, we also performed the trend analysis separately for these two age groups. There is no generally accepted definition of obesity or overweight for children and adolescents.26,27 Various criteria for overweight and obesity have been used to estimate prevalence and trends among children and adolescents.3,28,29 For this study, we used weight-for-height status above the 85th and 95th percentiles of the NCHS/CDC weight-for-height reference to estimate the prevalence of overweight or obesity in our study population. We calculated weight-for-height percentiles and z scores by using the NCHS/CDC age- and sex-

specific growth reference.30,31 Any weight-for-height z scores below 4 or above +5 were excluded, because these extreme values were most likely attributable to errors in measurement or data entry.23 Previous SectionNext Section

RESULTS
From the survey among the states and district in this study, we confirmed that each of them maintained the same overweight certification criteria for preschoolers during the 13-year period, except for one state, which changed the criteria from 95th percentile to 90th percentile of weight-for-height after 1990. Exclusion of this state did not change our results. Among the preschoolers, there were no priority changes or restrictions for younger children (birth to 2 years), and only two states put the older children (age 3 to 4 years) on a waiting list or restricted program entry for a short time (1 to 3 months) in the early 1990s. However, the short time restriction did not affect the overall trend observed. The PedNSS data showed a higher proportion of young infants and more black and Hispanic children compared with NHANES II and III data (Table1). Also, the children in the PedNSS have a lower mean birth weight and a higher percentage of low birth weight, lower mean height-for-age, lower mean weight-for-age, and higher weight-for-height z scores compared with NHANES II and III data. View this table: In this window In a new window Table 1. Comparison of Demographic and Anthropometric Characteristics (%) of NHANES II and III Data With the CDC PedNSS Data The PedNSS data also showed an increasing proportion of older children from 1983 to 1995, as well as an increased proportion of Hispanic children and urban children (Table 1). The standardized adjustments in the prevalence of overweight we described in Methods account for these changes in demographic characteristics. The prevalence of overweight for the children 0 to 59 months old in the period increased from 18.6% in 1983 to 21.6% in 1995, based on the weight-for-height 85th percentile cutoff point, representing an absolute increase of 3.0 percentage points and a relative increase of 16.1%. Based on the weight-for-height 95th percentile cutoff point, the prevalence increased from 8.5% in 1983 to 10.2% in 1995, representing an absolute increase of 1.7 percentage points and a relative increase of 20% (Table 2). As shown in Fig 1, during the 13-year period, there was a consistent increase in the prevalence of overweight using both the 85th and 95th percentile cutoff points. View this table: In this window In a new window Table 2. Prevalence of Overweight (%) Among Children 059 Months by Age Group, at 85th and 95th Percentile Cutoff Pointsthe CDC PedNSS, 1983 and 1995

View larger version: In this page In a new window Download as PowerPoint Slide Fig. 1. Prevalence of overweight (weight-for-height above 85th or 95th percentile) among US low-income children 0 to 59 months of age, adjusted by race or ethnicity, sex ratio, and age in month; the CDC Pediatric Nutrition Surveillance, 19831995.

When we examine trends by single year of age, we see a similar trend in the prevalence of overweight from 1983 through 1995, with an increase observed for each year of age (Table 2). However, the increase in the prevalence of overweight is greatest for 48- to 59-month-old children, in both absolute and relative terms. Figure 2 (A and B) shows the age-specific trends in the prevalence of overweight based on the 95th percentile cutoff point. The trend is similar at the 85th percentile cutoff point (results available on request). When we compare the prevalence of overweight by sex, boys and girls show a parallel increase in the prevalence of overweight at both the 85th and 95th percentile cutoff points. Among children >24 months of age, there is an absolute increase of 2.9 percentage points for boys and 3.4 percentage points for girls using the 85th percentile. Using the 95th percentile, there is a 1.7 percentage point increase for boys and a 1.8percentage point for girls (Table3). The prevalence of overweight for girls is significantly higher than for boys (P< .05). View this table: In this window In a new window Table 3. Prevalence of Overweight (%) Among Children 059 Months by Age Group, Sex, and Race or Ethnicity, at 85th and 95th Percentile Cutoff Pointsthe CDC PedNSS, 1983 and 1995 The non-Hispanic white, non-Hispanic black, and Hispanic subgroups all demonstrated an increasing trend in the prevalence of overweight from 1983 through 1995 (Fig 3 for the children >2 years of age using the 95th percentile). Among those children <2 years old, non-Hispanic whites had the largest absolute increase in prevalence of overweight. For children >2 years of age, non-Hispanic blacks had the largest absolute increase in prevalence of overweight, at both the 85th and the 95th percentile cutoff points (Table 3). The prevalence of overweight for Hispanics is significantly higher than for non-Hispanic blacks, and for nonHispanic blacks is significantly higher than for non-Hispanic whites (P < .05).

View larger version: In this page In a new window Download as PowerPoint Slide Fig. 2. Age-specific prevalence of overweight (weight-for-height above 95th percentile) among US low-income children 0 to 23 months months of age (A) and 24 to 59 months of age (B), adjusted by race or ethnicity, sex ratio, and age in month; the CDC Pediatric Nutrition Surveillance, 19831995.

View larger version: In this page In a new window Download as PowerPoint Slide

Fig. 3. Prevalence by race or ethnicity of overweight (weight-for-height above 95th percentile) among US lowincome children 24 to 59 months of age, adjusted by sex ratio, and age in month; the CDC Pediatric Nutrition Surveillance, 19831995. When we compare the prevalence of overweight by clinic settings, both urban and rural clinics showed an increasing trend in the prevalence of overweight from 1983 to 1995 (Table 3). Among children >24 months of age, there is an absolute increase of 3.3 percentage points for urban children and of 1.6 percentage points for rural children, using the 85th percentile. Using the 95th percentile, there is a 2.0 percentage point increase for urban and a 0.7 for rural (Table 3). However, the increasing trend in rural is not consistent during the 13-year period; there is a downward trend between 1989 and 1991. To decide whether the increase in the prevalence of overweight among US low-income preschool children was related to an increase in a subpopulation of children who were heavier or to a general shift of the entire weight distribution, we used the weight-for-height zscore to compare the height-standardized weight distribution for the preschool children using records from 1983 and 1995. The 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles increase by 0.14, 0.15, 0.12, 0.07, 0.08, 0.08, 0.11 z score, respectively, from 1983 to 1995. Also, the weight-for-height distribution of the two periods had a similar variance and shape. Thus, the increase in the prevalence of overweight observed among US low-income preschool children reflects a general upward shift in the weight distribution over the 13-year period rather than simply an increase in the size of the upper tail. Previous SectionNext Section

DISCUSSION
We found that from 1983 through 1995, there was a consistent increase in the prevalence of overweight among low-income preschool children in the United States. The increase in the prevalence of overweight is the result of a general upward shift of the weight-for-height distribution in the population. This same trend has been documented in the US population in preschool children,16 school children,2,32adolescents,2,32,33 and adults.32,34 Our analysis has demonstrated that these trends are observed even before the age of 24 months. This evidence suggests that the entire population in the United States is getting heavier. The increasing prevalence of overweight was also observed for each age, sex, and racial/ethnic group. These data suggest that underlying causes of the differences in overweight prevalence by gender, and between racial/ethnic groups observed among adults,32,34,36 and between school children and adolescents32,33,37 may also be observed in preschool children. There is an increasing trend in the relative increases with age. Children 48 to 59 months of age have the highest relative increase in the prevalence of overweight compared with other age groups. This confirms the result from the NHANES study for preschoolers16 that the prevalence of overweight increase with age. The prevalence of overweight is higher for girls compared with boys. Also, we observed a parallel increase in the prevalence of overweight between boys and girls among the low-income preschoolers, whereas data from NHANES III16 showed a greater increase for girls (2.8 percentage points at 2 to 3 years and 5.0 percentage points at 4 to 5 years) than for boys (1.0 percentage point decrease at 2 to 3 years and only a 0.6 percentage point increase at 4 to 5 years, but no statistical significance in the change of prevalence at both 2 to 3 years and 4 to 5 years of age). It is not clear whether this inconsistency reflects true difference in trends for the WIC population or results from methodologic differences. Additional research is needed to understand fully the difference in gender behaviors for different socioeconomic strata. Hispanic children have a higher prevalence than other race or ethnic groups. The higher prevalence of overweight among Hispanic preschool children may be related partially to dietary, environmental, or genetic factors. The growth in height and weight of well-fed, healthy children at least <5 years old from different ethnic backgrounds and different continents is reasonably similar.38 On the other hand, Trowbridge et al41 have suggested that high weight-for-height in Hispanics is associated with lower body fat. We observed an increase in the prevalence of overweight among both urban and rural children, although trends were more marked and consistent in the urban areas. Additional research is needed to understand fully the difference in behaviors in different geographic settings for other socioeconomic strata. Our study has potential limitations commonly found in surveillance systems that use routine clinical data. Because the data come from multiple clinics and the techniques of measurement are not tightly controlled, the quality of anthropometric measurements cannot be guaranteed. However, our checks on data quality for the states in this analysis showed reasonably good data quality. Also, because there is no change in the mean height-for-age z score across the 13-year period for all the states included in this analysis, it is unlikely that a bias in height measurement could affect the observed overweight trend.

Another potential limitation is that changes in program enrollment practice at the state level could have caused changes in the prevalence of overweight. However, our survey among the states showed no systematic changes in the certification criteria or priorities served by states for preschoolers during this period. This supports the conclusion that the overweight trends observed from the study reflects an actual increase in overweight. The increasing trend in the prevalence of overweight suggests a general shift in behaviors of the population. The genetic component of obesity cannot account for the trends observed. Our analysis cannot delineate fully the reasons for this increase in overweight, because the PedNSS system does not currently collect data on health behavior, dietary intake, physical activity, or other potential contributing factors. Additional research needs to determine the underlying changes in the care of preschool children. For example, could changes in factors affecting birth weight have shifted the birth weight distribution toward higher weights without a proportionate increase in height? Have feeding patterns of young children changed toward fattier, higher calorie foods? Have activity levels of children decreased as TV watching rises? Overall, this study shows a consistent increase over the past 13 years in the prevalence of overweight among preschool children from low-income families. This finding extends previous analyses to infants and toddlers from the NHANES III for preschoolers of mixed socioeconomic backgrounds.16 However, our study differs from the NHANES III study16 in that we observed a parallel increase in the prevalence of overweight for preschool girls and boys, whereas Ogden et al16 observed an increase in overweight only for preschool girls. Additional research is needed to explore the cause of the trend observed and to find effective strategies for overweight prevention beginning in the preschool years. Previous SectionNext Section

ACKNOWLEDGMENTS
We thank all state nutrition programs participating in the CDC PedNSS, especially the 18 states and the District of Columbia, that provided the data for this study. We also thank Ellen Borland and Jimmy Simmons for providing data management support, and Bettylou Sherry, PhD, for reviewing the document.

2. BADAN LITBANG DEPKES GELAR RISET KESEHATAN DASAR

Hingga saat ini belum tersedia data berbasis komunitas yang memadai untuk perencanaan pembangunan kesehatan sampai tingkat kabupaten. Selain itu, berbagai survei/riset/studi di bidang kesehatan selama ini masih dilakukan secara terpisah dan sporadis. Demi memenuhi kebutuhan data dasar kesehatan tersebut dan mengintegrasikan berbagai hasil riset serta mendorong kegiatan riset agar lebih terarah, Badan Penelitian dan Pengembangan Kesehatan (Litbangkes) Depkes untuk pertama kalinya melakukan suatu pendekatan penelitian baru yaitu Riset Kesehatan Dasar (Riskesdas). Demikian disampaikan Kepala Badan Litbangkes dr. Triono Soendoro, Ph.D kepada pers dalam acara sosialisasi Riskesdas 2007 di kantor Depkes Pusat, Jakarta, 20 Desember 2006. Riskesdas adalah kegiatan riset yang diarahkan untuk mengetahui gambaran kesehatan dasar penduduk termasuk biomedis yang dilaksanakan dengan cara survei rumah tangga di seluruh wilayah kabupaten secara serentak dan periodik. Data kesehatan dasar dari Riskesdas diperlukan untuk mendukung salah satu strategi utama (grand strategy) Depkes yaitu meningkatkan sistem surveilans, monitoring dan informasi kesehatan dengan salah satu produknya adalah berfugsinya sistem informasi kesehatan yang berdasarkan data (evidence based) bukan saja berskala nasional, tetapi juga harus menggambarkan indikator kesehatan minimal sampai tingkat kabupaten. Rencananya pengambilan data akan dilakukan mulai bulan Juni 2007 di seluruh kabupaten/kota di Indonesia (461 kabupaten/kota). Sementara tahun 2006 ini telah dilakukan penyusunan kuesioner dan modul serta pelatihan dan uji coba di Kabupaten Sukabumi dan Bogor pada bulan November 2006, baik untuk Tim Kesehatan Masyarakat maupun Tim Biomedis. Adapun data kesehatan dasar yang diperlukan meliputi semua indikator kesehatan yang utama tentang kasus kesehatan (angka kematian, angka kesakitan, dan angka kecacatan), kesehatan lingkungan (lingkungan fisik, biologi, dan sosial), perilaku kesehatan (perilaku hidup bersih dan gaya hidup), dan berbagai aspek mengenai pelayanan kesehatan (akses, mutu layanan, pembiayaan kesehatan).

3. WHO Global Database on Child Growth and Malnutrition

Department of Nutrition for Health and Development

"We are guilty of many errors and many faults, but our worst crime is abandoning the children, neglecting the foundation of life. Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made and his senses are being developed. To him we cannot answer "Tomorrow". His name is "Today"." Gabriela Mistral, 1948
AGE GROUPS N <-3 SD (Months) WEIGHT/AGE (%) <-2 SD 1 Mean zscore SD zscore <-3 SD HEIGHT/AGE (%) <-2 SD 1 Mean zscore SD zscore <-3 SD <-2 SD
1

WEIGHT/HEIGHT (%) >+1 SD

1

>+2 SD
1

>+3 SD

Mean zscore

OTAL (0-60) 0-5 6-11 12-23 24-35 36-47 48-60 AGE GROUPS

N <-3 SD

WEIGHT/AGE (%) <-2 SD 1 Mean zscore SD zscore <-3 SD

HEIGHT/AGE (%) <-2 SD 1 Mean zscore SD zscore <-3 SD <-2 SD

1

WEIGHT/HEIGHT (%) >+1 SD

1

>+2 SD
1

>+3 SD

(Months)

Mean zscore

ale (0-60) 0-5 6-11 12-23 24-35 36-47 48-60 AGE GROUPS

N <-3 SD

WEIGHT/AGE (%) <-2 SD 1 Mean zscore SD zscore <-3 SD

HEIGHT/AGE (%) <-2 SD 1 Mean zscore SD zscore <-3 SD <-2 SD

1

WEIGHT/HEIGHT (%) >+1 SD

1

>+2 SD
1

>+3 SD

(Months)

Mean zscore

male (0-60) 0-5 6-11 12-23 24-35 36-47 48-60

4.Differential improvement among countries in child stunting is associated with

long-term development and specific interventions.
Abstract Stunting represents growth failure resulting from poor nutrition and health during the pre- and postnatal periods. Initiatives since 1980 have steadily reduced malnutrition and consequent retardation of child growth, but 1 of 3 preschool children worldwide remains stunted. Countries have varied substantially in progress achieved in reducing stunting. This study aimed to understand which underlying (i.e., proximal) and basic (i.e., distal) national factors have been most important in explaining this variation among countries, and the relation between the 2 sets of factors. Eighty-five developing countries with at least 2 surveys for stunting >4 y apart were included from the WHO Global Database on Child Growth. The analytic data set with independent variables from several sources was constructed to match closely by year for each country to initial and final stunting data. Full-information maximum likelihood estimated multiple linear regression models while accounting for missing data in independent variables. The final model explained 65.5% of the variance of change in stunting, and included both underlying and basic variables: initial and change in immunization rate, initial and change in safe water rate, initial female literacy rate, initial government consumption, initial income distribution, and the initial proportion of the economy devoted to agriculture. Although factors that were important for reducing stunting in the past may not necessarily be the ones that are important in the future, these results suggest that it possible for substantial progress to be made in reducing the current high prevalence of stunting by investing in both long-term development and in specific interventions.

5. I. I. Meshram, A. Laxmaiah, Ch. Gal Reddy, M. Ravindranath, K. Venkaiah, G. N. V. Brahmam Division of Community Studies, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, -500007, India
Correspondence: Indrapal Ishwarji Meshram, Scientist C, Division of Community Studies, National Institute of Nutrition, Indian Council of Medical Research, Jamai-Osmania (PO), Tarnaka, Hyderabad-500007, India. Tel: 91-040270197255. Fax: 040-27019141. E-mail: indrapal.m@rediffmail.com Background: Under-nutrition continues to be a major public health problem, especially among young children in India. The present study was undertaken to assess the nutritional status of under-3 year-old children and factors associated with under-nutrition. Method: A community-based cross-sectional survey was carried out in 40 Anganwadi centre villages of Medak district of Andhra Pradesh, India. A total of 805 children were selected for nutritional assessment in terms of underweight, stunting and wasting using the new WHO growth standards. Wealth index was calculated using principal components analysis. A conceptual hierarchical framework was used as a basis for controlling for the explanatory factors in multivariate analysis. Results: Prevalence of under-weight, stunting and wasting was 39%, 30% and 22%, respectively. The risk of underweight and stunting was 1.80- and 3.02-times higher among 1223 months and 3.13- and 5.50-times higher among 2436 months children as compared to children under 12 months, respectively. The risk of under-weight was 2.74and 1.73-times higher among children belonging to the lowest and middle household wealth index, respectively. Conclusions: Under-nutrition is a significant public health problem among under 3 year-old children. The prevalence of under-nutrition was significantly higher among boys and those belonging to the lowest and middle wealth index. Thus, implementation of appropriate nutritional intervention strategies and improvement in household socioeconomic condition may help in improving nutritional status.

6. Peran status kelahiran terhadap stunting pada bayi : sebuah studi prospektif
Kusharisupeni
Departemen Gizi Kesehatan Masyarakat, Fakultas Kesehatan Masyarakat Universitas Indonesia ABSTRAK
Di Indonesia, prevalensi stunting pada bayi dan anak masih cukup tinggi sebagai akibat asupan gizi yang tidak adekuat. Stunting merupakan masalah kesehatan masyarakat karena berhubungan dengan meningkatnya risiko terjadinya kesakitan, kematian, perkembangan motorik terlambat, dan terhambatnya pertumbuhan mental. Tujuan penelitian ini adalah untuk menilai peran status kelahiran terhadap stunting pada bayi. Studi prospektif kohor yang

mengikutsertakan 720 bayi diikuti selama 12 bulan di Kecamatan Sliyeg dan Gabus Wetan, Kabupaten Indramayu. Hasil penelitian menunjukkan, pada umur 3 bulan dan 6 bulan, pada bayi laki-laki terdapat perbedaan panjang badan yang bermakna antara kelompok normal dan prematur, intra uterine growth retardation - low Ponderal index (IUGR LPI) serta intra uterine growth retardation - adequate Ponderal index (IUGR API). Untuk bayi perempuan terdapat perbedaan panjang badan yang bermakna antara kelompok normal dan prematur; selain itu juga terdapat perbedaan panjang badan yang bermakna antara kelompok IUGR API dan IUGR LPI. Pada umur 12 bulan, pada bayi laki-laki terdapat perbedaan panjang badan yang bermakna antara kelompok normal dan prematur, IUGR API serta IUGR LPI, sedangkan untuk bayi perempuan terdapat perbedaan panjang badan yang bermakna antara kelompok normal dan prematur serta IUGR API. Hasil penelitian juga menunjukkan bahwa risiko relatif growth faltering lebih besar pada bayi yang telah mengalami growth faltering sebelumnya. Semua kelompok status kelahiran berkontribusi terhadap terjadinya stunting pada umur 12 bulan; kontribusi terbesar dari kelompok IUGR API dan terkecil kelompok normal. Kata kunci: Stunting, berat lahir, panjang badan, lama gestasi, bayi

The role of birth status on stunting in infants : a prospective study

ABSTRACT
In Indonesia, many infants and young children have an inadequate nutritonal status reflected by high prevalence of stunting. Stunting indicates a public health problem because of its association with an increased risk of morbidity, mortality, and delayed motor development. A cohort prospective studi was conducted to evaluate the role of birth status on stunting in infants. Seven hundred and twenty newborn were able to be measured at birth in two Subdistricts Sliyeg and Gabus Wetan, Indramayu Regency. This study showed, that at 3 and 6 months of age, there was a significant difference for boys between the mean of length of the normal group and the preterm, intra uterine growth retardation - low Ponderal index (IUGR LPI), and intra uterine growth retardation - adequate Ponderal index (IUGR API) groups. In girls there was a significant difference between the length of the normal group and preterm, and the IUGR group. At 12 months of age there was a significant difference for boys between the normal and the preterm, IUGR API and the IUGR LPI groups. For the girls there was a significant difference between the normal group and the preterm and between the normal group and the IUGR API. The relative risk for growth faltering was greater in those infants who have had falter previously and there was no catch up growth of the low birth weight group. All groups of birth status contributed on stunting at 12 months of age, the greatest with the IUGR API group, and normal group the lowest. Key words: Stunting, birth weight, length, gestation, infants

74
Kusharisupeni Status kelahiran dan stunting pada bayi

PENDAHULUAN Seperti di negara-negara berkembang lain, pendek [stunting = retardasi pertumbuhan linier dengan defisit dalam panjang badan sebesar -2Z atau lebih menurut baku rujukan pertumbuhan World Health Organization/National Center for Health Statistics (WHO/NCHS)] di Indonesia merupakan hal yang umum terjadi. Prevalensi stunting pada bayi dan anak-anak masih cukup tinggi sebagai akibat asupan gizi yang tidak adekuat.(1) Stunting disebabkan oleh kumulasi episode stres yang sudah berlangsung lama (misalnya infeksi dan asupan makanan yang buruk), yang kemudian tidak terimbangi oleh catch up growth (kejar tumbuh). Hal ini mengakibatkan menurunnya pertumbuhan apabila dibandingkan

dengan anak-anak yang tumbuh dalam lingkungan yang mendukung. Stunting merupakan masalah kesehatan masyarakat karena berhubungan dengan meningkatnya risiko terjadinya kesakitan dan kematian, perkembangan motorik terlambat, dan terhambatnya pertumbuhan mental.(2) Oleh karena itu, stunting merupakan indikator sensitif untuk sosioekonomi yang buruk dan prediktor untuk morbiditas serta mortalitas jangka panjang. Sementara berkembang konsensus tentang sebab-sebab dan konsekuensi stunting. Perdebatan terus berlanjut tentang apakah faktor genetik atau lingkungan yang lebih berpengaruh terhadap pertumbuhan, dan kriteria yang harus dipergunakan untuk mendefinisikan stunting pada kelompok populasi yang berbeda. Sebuah studi yang dilakukan di Indonesia pada anak-anak pra-sekolah menunjukkan status sosioekonomi berpengaruh terhadap pertumbuhan anak.(3) Penemuan ini mendukung perlunya satu standar pertumbuhan untuk semua kelompok ras dan etnis.(4) Di pihak lain ada pendapat yang menyatakan bahwa gen mempunyai peran terhadap variasi ukuran tubuh antar individu dalam suatu kelompok etnis, dan gen ini mempunyai pengaruh yang kuat pada pertumbuhan dalam beberapa tahun pertama kehidupan.(5) Berdasarkan berat lahir dan lama gestasi, bayi lahir dapat dikategorikan ke dalam: i) normal, ii) prematur, dan iii) intra uterine growth retardation (IUGR) yang terdiri dari dua kelompok yaitu adequate Ponderal index (API) dan low Ponderal index (LPI). Perkembangan bayi IUGR, bayi berat lahir rendah (BBLR) dengan masa kehamilan genap bulan (37 minggu), yaitu IUGR API dan IUGR LPI berhubungan dengan karakteristik lahir.(6) BBLR adalah bayi yang lahir dengan berat kurang dari 2500 g.(7) Perbedaan pertumbuhan kedua kelompok ini tergantung pada waktu terjadinya kurang gizi dalam kehamilan. Pada kelompok API, kurang gizi terjadi sejak permulaan kehamilan, sedangkan pada kelompok LPI hanya pada trimester ketiga kehamilan. Oleh karena itu baik berat maupun panjang badan lahir kelompok API terkena dampaknya (kurus dan pendek), sedangkan dampak pada kelompok LPI terlihat hanya pada berat lahir (kurus) dan kurang terlihat pada panjang badan lahir. Berbeda dengan bayi prematur, yang juga termasuk BBLR tetapi dengan umur kehamilan <37

minggu, berat dan panjang badannya selain tergantung pada status gizi ibu, juga pada umur kehamilan. Seperti juga stunting, prevalensi BBLR di Indonesia masih cukup tinggi. Angka nasional menunjukkan sebesar 14%, sedangkan hasil-hasil peneliti lain di berbagai daerah menunjukkan nilai lebih tinggi.(8) Hanya memfokuskan BBLR sebagai hal yang patologik, menyebabkan penelitianpenelitian di Indonesia kurang mampu menunjukkan prognosis dalam pertumbuhan linier dan implikasi kesehatan. Stunting harus merupakan perhatian, sebab hal ini dapat dicegah. Penelitian ini bertujuan untuk menilai peran status kelahiran terhadap stunting pada bayi. METODE Waktu dan lokasi penelitian Penelitian dilakukan pada tahun 1995-1997 sebagai bagian dari sistem pengumpulan data longitudinal yang disebut dengan Sample Registration System (SRS) dan dilakukan Center for Child Survival, Universitas Indonesia (CCSUI). Penelitian dilakukan di 22 desa Kecamatan Sliyeg dan Gabus Wetan, Kabupaten Indramayu dengan populasi yang menunjukkan fertilitas dan morbiditas tinggi, pendidikan rendah serta umumnya bekerja sebagai buruh kasar tani. 75
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Desain dan sampel penelitian Desain penelitian yang digunakan adalah studi prospektif kohor, dan besar sampel ditetapkan dari perhitungan Fliess,(9) dengan power sebesar 0,80 untuk studi longitudinal. Dari perhitungan itu didapat jumlah sampel minimal untuk bayi kelompok normal 221, untuk kelompok prematur 50, kelompok IUGR API 81 dan IUGR LPI 92. Kriteria inklusi adalah bayi lahir di daerah penelitian antara April 1995Februari 1997, genap/tidak genap bulan (>= 37 minggu/ <37 minggu), kelahiran tunggal, ibu tidak menderita diabetes atau pra diabetes, bayi tidak menderita kelainan congenital, selama penelitian bayi tetap tinggal di daerah penelitian dan tidak menderita penyakit berat. Beberapa kriteria eksklusi ditentukan untuk analisis data antropometri yaitu: panjang badan untuk umur skor Z<-1,5 dan >+3, dan berat badan untuk umur skor Z<-5 dan >+5, dengan alasan sedikit sekali harapan bayi dapat hidup hingga berakhirnya penelitian. Pengumpulan data Pada awalnya dilakukan registrasi ibu hamil oleh 10 orang petugas lapangan yang mencatat usia kehamilan dan perkiraan tanggal kelahiran dihitung sejak hari pertama haid terakhir ibu menurut rumus Naeggle. Petugas juga melakukan pengukuran berat dan panjang badan bayi yang dilakukan saat lahir, umur 3, 6, 9, dan 12 bulan pada hari tanggal lahir (maksimal ditambah 3 hari sesudah tanggal lahir). Pengukuran berat badan dilakukan menggunakan timbangan berat badan baby scale (Tanita) yang telah dikalibrasi sebelum digunakan dengan ketelitian

sebesar 0,1 kg. Panjang badan diukur dalam keadaan berbaring menggunakan alat ukur dari kayu yang dianjurkan Badan kesehatan Sedunia dengan ketelitian 0,1 cm. Setiap kunjungan pengukuran selalu disertai dengan wawancara tentang air susu ibu (ASI), makanan pendamping ASI (MPASI) dan penyakit yang diderita bayi. Kualitas data Umur kehamilan (gestasi) sangat menentukan apakah bayi lahir genap atau kurang bulan, maka umur kehamilan dikonfirmasi dengan palpasi uterus yang dilakukan oleh bidan dan dokter tim peneliti. Timbangan bayi sebelum dipakai telah ditera oleh Bidang Metrologi Departemen Perdagangan D.K.I. dan setiap 10 kali penimbangan ditera ulang dengan memakai anak timbangan yang telah distandarisasi. Papan pengukur panjang badan diperiksa kestabilannya setiap kali akan dipakai. Dan dilakukan standarisasi antar dan intra pengukur menurut WHO pada awal dan pertengahan penelitian.(10) Pengolahan data Data dimasukkan dan dikelola dengan program Fox Pro. Selanjutnya analisis dilakukan dengan program EPI INFO dan SPSS versi 7.5. Indeks Ponderal Rohrer (BB/PB x 100) dipakai untuk mengelompokkan IUGR ke dalam kategori IUGR API atau IUGR LPI dan memberikan evaluasi yang baik tentang status gizi. Untuk menghitung cut off point IUGR LPI dan IUGR API, dilakukan tahapan berikut: (i) menghitung korelasi antara indeks Ponderal Rohrer dan panjang badan pada umur-umur tertentu, (ii) mengelompokkan bayi lahir IUGR terhadap umur dengan korelasi yang tertinggi, dan (iii) cut off point dari indeks Ponderal ditentukan berdasarkan sensitivitas, spesifisitas dan nilai prediksi yang tinggi. Dalam studi ini gagal tumbuh (growth faltering) dihitung menurut Fronggillo.(11) Growth faltering ini perlu diketahui oleh karena berdampak terhadap pertumbuhan linier dengan demikian juga berdampak pada kejadian stunting. Seperti juga growth faltering maka catch up growth mempunyai dampak terhadap pertumbuhan linier, selanjutnya pada kejadian stunting. Catch up growth diketahui melalui perbandingan pertumbuhan linier kelompok BBLR dengan kelompok normal. Skor Z dihitung dan cut off point untuk stunting ditentukan pada skor -2Z. Analisis data Uji analysis of variance (Anova) dan Tuckey digunakan untuk membandingkan pertumbuhan antara kelompok normal (genap bulan dengan berat lahir >= 2500 gram), prematur (bayi dengan umur kehamilan < 37 minggu dengan berat lahir < 2500 gram), IUGR API (bayi genap bulan dengan berat lahir < 2500 gram dengan indeks Ponderal yang adekuat) dan IUGR LPI (bayi genap bulan dengan beat lahir < 2500 gram dengan indeks Ponderal rendah); analisis multivariat digunakan untuk mengetahui faktor penentu pertumbuhan linier.

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HASIL Kohor sebanyak 720 bayi diikuti sejak lahir hingga umur 12 bulan. Berdasarkan berat lahir dan lama kehamilan maka 516 (71,7%) termasuk status kelahiran normal, 63 bayi (8,7%) prematur dan 141 (19,6%) IUGR. Dari masing-masing kelompok berurutan 246 laki-laki dan 270 perempuan; 27 laki-laki dan 36 perempuan; 65 laki-laki dan 76 perempuan. Dua ratus empat (28,3%) bayi dalam penelitian ini termasuk dalam BBLR, 63 (30,9%) lahir prematur, 54 (26,5%) lahir IUGR LPI dan 87 (42,6%) lahir IUGR API. Berat dan panjang lahir Rata-rata berat lahir untuk status kelahiran normal, prematur dan IUGR berurutan 3 kg, 2,1 kg dan 2,2 kg. Dengan menggunakan indeks Ponderal dari Rohrer diperoleh cut off point untuk kelompok IUGR sebesar 2,45. Dengan demikian >= 2,45 termasuk kelompok IUGR LPI dan <2,45 kelompok lahir IUGR API. Rata-rata berat lahir IUGR LPI 2,31 kg (n=54) dan IUGR API 2,1 kg (n=87). Panjang lahir untuk kelompok normal terpanjang untuk laki-laki besarnya 48,4 cm dan perempuan sebesar 47,8 cm, diikuti oleh IUGR LPI (laki-laki 46,3 cm dan perempuan 45,4 cm); IUGR API (lakilaki 44,4 cm dan perempuan 43,9 cm) serta prematur (laki-laki 43,9 cm dan perempuan 43,0 cm). Panjang badan bayi pada saat lahir, umur 3, 6, 9, dan 12 bulan baik untuk bayi laki-laki maupun perempuan dapat dilihat pada Tabel 1 dan Tabel 2. Panjang badan terpanjang didapatkan pada kelompok normal diikuti oleh IUGR LPI, IUGR API dan prematur. Uji Anova dan Tuckey menunjukkan perbedaan yang bermakna antara panjang badan bayi laki-laki kelompok normal dan prematur (p<0,05); kelompok normal dan IUGR LPI (p<0,05) dan kelompok normal dan IUGR API (p<0,05). Tabel 2. Rata-rata panjang badan (cm) bayi perempuan menurut kelompok lahir dan umur (bulan) * IUGR LPI = intra uterine growth retardation - low Ponderal index ** IUGR API = intra uterine growth retardation adequate Ponderal index Tabel 1. Rata-rata panjang badan (cm) bayi laki-laki menurut status kelahiran dan umur (bulan) * IUGR LPI = intra uterine growth retardation - low Ponderal index ** IUGR API = intra uterine growth retardation adequate Ponderal index 77
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berkurang baik laki-laki maupun perempuan. Pada umur 12 bulan, urutan di atas berbeda. Untuk bayi laki-laki, kelompok normal (113 bayi) masih mencapai panjang badan yang tertinggi, diikuti oleh IUGR API (dengan jumlah sampel terkecil = 5 bayi), IUGR LPI (17 bayi) dan prematur (12 bayi). Hal yang sama terjadi pada bayi perempuan, kelompok lahir normal (94 bayi) mencapai panjang badan yang tertinggi, diikuti oleh IUGR LPI (9 bayi), prematur (10 bayi) dan IUGR API. Hasil uji Anova (uji Tuckey) menunjukkan untuk bayi laki-laki terdapat perbedaan panjang badan yang bermakna antara kelompok normal dan prematur (p<0,05), kelompok normal dan IUGR API (p=<0,05), dan antara kelompok normal dan IUGR LPI (p<0,05). Untuk bayi perempuan terdapat perbedaan yang bermakna antara kelompok normal dan prematur (p<0,05) dan antara kelompok normal dan IUGR API (p<0,05). Gagal tumbuh (growth faltering) dan pencapaian berat badan normal (catch up growth) Pada interval observasi pertama (umur 0-2 bulan), gagal tumbuh yang terbesar dialami oleh kelompok IUGR API (-0,74 cm; dengan rata-rata berat lahir 2,1 kg) dan yang terkecil pada kelompok IUGR LPI (-0,55 cm dengan rata-rata berat lahir 2,31 kg). Pada interval observasi ke-2 (umur 2-4 bulan), faltering yang terbesar dialami oleh kelompok prematur (-0,74 cm dengan berat lahir 2,1 kg) dan IUGR API (-0,74 cm) dan yang terkecil dialami oleh kelompok normal (-0,69 cm dengan rata-rata berat lahir 3 kg). Pada interval observasi terakhir (umur 4-6 bulan) faltering yang terbesar dialami oleh kelompok IUGR API (-0,96 cm) dan yang terkecil kelompok normal (-0,67 cm). (Tabel 3) Risiko relatif untuk faltering lebih besar pada bayi-bayi yang telah mengalami falter sebelumnya (Tabel 4). Risiko falter pada interval umur lebih tua lebih besar apabila bayi pernah falter sebelumnya. Jadi, falter merupakan prediktor untuk terjadinya falter berikutnya. Risiko falter IUGRAPI dan prematur tidak dihitung karena sampel terlalu kecil. Tabel 4. Risiko relatif growth faltering pada interval umur 2-4 bulan* dan 4-6 bulan** * pada interval umur 02 bulan bayi termasuk kelompok yang mengalami growth faltering ** pada interval umur 24 bulan bayi termasuk kelompok yang mengalami growth faltering @ tidak dihitung karena sampel terlalu kecil # intra uterine growth retardation - low Ponderal

index
Tabel 3. Rata-rata penyimpangan pertumbuhan linier faltering (cm) berdasarkan status kelahiran dan interval pengamatan umur (bulan) * IUGR LPI = intra uterine growth retardation - low Ponderal index ** IUGR API = intra uterine growth retardation adequate Ponderal index

Untuk bayi perempuan, terdapat perbedaan panjang badan yang bermakna antara kelompok normal dan prematur (p<0,05), kelompok normal dan IUGR API (p<0,05). Selain itu juga terdapat perbedaan yang bermakna antara kelompok IUGR LPI dan IUGR API (p<0,05). Sesudah umur 6 bulan jumlah bayi semakin

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Kusharisupeni Status kelahiran dan stunting pada bayi

Gambar 2. Pertumbuhan linier (cm) tiap-tiap kelompok lahir (perempuan) umur 0-12 bulan dibanding dengan rujukan pertumbuhan WHO/NCHS (P50) Gambar 1. Pertumbuhan linier (cm) tiap-tiap kelompok lahir (laki-laki) umur 0-12 bulan dibanding dengan rujukan pertumbuhan WHO/NCHS (P50) 79
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Catch up growth (kejar tumbuh) Pada umur 12 bulan kelompok BBLR (prematur, IUGR API dan IUGR LPI) tidak mencapai panjang badan yang dicapai oleh kelompok normal, meskipun kelompok normal sendiri tidak bertumbuh optimal. Dengan demikian catch up growth pada kelompok BBLR tidak memadai. (Gambar 1 dan Gambar 2) Stunting Jumlah bayi pendek (stunting) laki-laki terbanyak pada saat lahir ada pada kelompok IUGR API (91,9%), pada umur 3 bulan dan 6 bulan kelompok prematur (30,4% dan 51,2% berurutan) dan pada umur 12 bulan ada pada IUGR LPI (70,6%), diikuti oleh IUGR API (60%), prematur (53,8%) dan kelompok normal (14,2%). (Tabel 5) Hasil analisis regresi ganda menerangkan bahwa prediktor terbesar untuk stunting pada umur 6 sampai 12 bulan adalah kelompok IUGR, dan terkecil kelompok normal. PEMBAHASAN Penelitian ini mendukung pernyataan bahwa ukuran tubuh pada saat lahir mampu memprediksi pertumbuhan janin. Berat lahir kelompok normal, baik perempuan maupun laki-laki, 3,1 kg berada pada persentil ke-30 standar WHO/NCHS, berarti berat lahir kelompok normal masih termasuk dalam batas-batas normal. Panjang lahir kelompok normal baik bayi perempuan maupun laki-laki berada pada persentil ke-20 standar WHO. Temuan lain dari penelitian ini adalah rata-rata panjang badan kelompok prematur berada di persentil ke-10 atau kurang dari hasil temuan Alisyahbana.(12) Artinya, panjang badan yang jauh di bawah rata-rata prematur pada umumnya, disebabkan karena sudah mengalami retardasi pertumbuhan saat dalam kandungan. Seperti di negara-negara berkembang lain, pada kelompok BBLR, proporsi IUGR lebih besar dibandingkan prematur, dan pada dari kelompok IUGR, jumlah IUGR API lebih besar daripada IUGR LPI. Lebih besarnya proporsi IUGR daripada prematur, mendukung kenyataan bahwa IUGR berkontribusi terhadap siklus intergenerasi yang disebabkan oleh kemiskinan, penyakit dan defisiensi nutrient. Artinya ibu dengan gizi kurang sejak trimester awal sampai akhir kehamilan akan melahirkan BBLR, yang nantinya akan menjadi stunting. Pada umur 6 bulan, terdapat perbedaan panjang badan yang bermakna antara kelompok IUGR dan prematur, serta kelompok IUGR LPI dan IUGR API.

Hal di atas menjelaskan bahwa terdapat 2 pola retardasi pertumbuhan intra uterin yang berbeda pada bayi umur kehamilan genap bulan (IUGR). Lambatnya pertumbuhan kelompok prematur disebabkan karena adanya retardasi pertumbuhan linier selain singkatnya umur kehamilan. Growth faltering pada setiap kelompok status kelahiran terjadi pada umur dini (umur 2 bulan). Oleh karena lingkungan yang relatif sama, diasumsikan bahwa pola dan kualitas makanan yang dikonsumsi juga sama. Karenanya, tidak cukupnya asupan nutrien untuk bayi normal menyebabkan bertambahnya jumlah bayi dengan growth faltering. Hasil ini tidak berbeda dengan studi di Meksiko yang menunjukkan bahwa growth faltering pada usia 6 bulan dipengaruhi oleh infeksi dan asupan nutrien.(13) Tabel 5. Persentase bayi stunting laki-laki menurut status kelahiran dan umur (bulan) * IUGR LPI = intra uterine growth retardation - low Ponderal index ** IUGR API = intra uterine growth retardation adequate Ponderal index 80
Kusharisupeni Status kelahiran dan stunting pada bayi

Rendahnya pola asupan makanan, ditambah dengan keterpaparan terhadap infeksi, maka dampak pada kelompok normal paling berat. Derajat growth faltering pada kelompok IUGR API lebih besar daripada kelompok IUGR LPI. Bayi dengan growth faltering pada umur dini menunjukkan risiko untuk mengalami growth faltering pada periode umur berikutnya. Dengan demikian growth faltering merupakan prediktor untuk faltering berikutnya. Stunting, yang dibentuk oleh growth faltering dan catch up growth yang tidak memadai merupakan suatu keadaan yang patologis; stunting mencerminkan ketidakmampuan untuk mencapai pertumbuhan optimal yang disebabkan oleh status kesehatan dan atau status gizi yang suboptimal. Jumlah bayi stunting tinggi saat lahir, menurun pada umur 4-6 bulan, dan meningkat sesudahnya hingga umur 12 bulan. Semua kelompok lahir berkontribusi terhadap stunting hingga umur 12 bulan dengan kontribusi terbesar dari kelompok IUGR dan terkecil dari kelompok normal. Studi ini konsisten dengan penelitian yang dilakukan di Filipina, risiko terjadinya stunting pada bayi dipengaruhi oleh status kelahirannya terutama panjang dan berat badan saat dilahirkan.(14) KESIMPULAN DAN SARAN Growth faltering telah dimulai sejak umur dini (2 bulan) tetapi tidak diikuti oleh catch up growth yang memadai. Semua kelompok lahir berkontribusi terhadap stunting dengan kontribusi terbesar dari kelompok lahir IUGR dan terkecil dari kelompok lahir normal. Kelompok lahir normal (kelompok dengan berat lahir >= 2500 gram) merupakan prediktor terbaik untuk panjang badan baik pada umur 6 bulan maupun umur 12 bulan. UCAPAN TERIMA KASIH

Penyandang dana untuk studi ini adalah USAID melalui Center for Child Survival Universitas Indonesia. Terima kasih kami sampaikan juga kepada pewawancara/pengukur dan supervisor lapangan; kepada pak Yusron dan pak Eddy untuk manajemen data. Daftar Pustaka
1. ACC/SCN. Fourth report on the world nutrition situation: nutrition throughout the life cycle. Geneva, ACC/SCN in collaboration with IFPRI; 2000. 2. Waterlow JC, Schurch B. Causes and mechanism of linear growth retardation. Eur J Clin Nutr 1994; 48: S1-S216. 3. Droomers M, Gross R, Schultink W, Sastroamidjojo S. High socioeconomic class preschool children from Jakarta, Indonesia are taller and heavier than NCHS reference population. Eur J Clin Nutr 1995; 49: 740-4. 4. Skuse D, Reily S, Wolke D. Psychosocial adversity and growth during infancy. Eur J Clin. Nutr 1994; 48: S113-30. 5. Johnston LB, Clark AJL, Savage OM. Genetics factors contributing to birth weight. Arch Dis Child 2002; 86: 108-12. 6. Villar J. Postnatal growth of intrauterine growth retarded infant. Pediatrics 1986; 6: 265-71. 7. Child Health Research Project. Special report: reducing perinatal and neonatal mortality.

Baltimore: Child Health Research Project; 1999. 8. Unicef. Challenges for a new generation, the situation of children and woman in Indonesia, Geneva: Unicef; 2000. 9. Fleis JL. Statistical methods for rates and proportion. 2nd ed. New York: John Wiley and Sons; 1981. 10. WHO Expert Committee: Physical status: the use and interpretation of anthropometry. WHO Technical Report Series 854. Geneva: WHO; 1995. 11. Fronggillo EA. Determining growth faltering with a tracking score. Am J Human Biology 1994; 2: 491-501. 12. Alisyahbana A, Suroto AE. Perinatal mortality and morbidity in rural West Java, Part II: The result of a longitudinal survey on pregnant woman. Pediatrica Indonesiana 1994; 50: 179-90. 13. Villalpando S, Lopez-Alarcon M. Growth faltering is prevented by breast-feeding in underprivilaged infants from Mexico city. J Nutr 2000; 130: 54652. 14. Ricci JA, Becker JA. Risk factors for wasting and stunting among children in Metro Cebu, Philippines. Am J Clin Nutr 1996; 63: 966-77.

7. Dampak Berat Badan Lahir terhadap Status Gizi Bayi Latar Belakang : Kurang gizi merupakan sebuah issu global yang sangat serius dibicarakan. Setiap tahun diperkirakan 15,5% anak lahir BBLR dan 95% diantaranya lahir di Negara berkembang. Di Indonesia, berdasarkan data Depkes tahun 2004 dilaporkan bahwa angka BBLR diperkirakan mencapai 350.000 bayi setiap tahunnya. Disamping itu, banyak bayi dan anak balita mempunyai status gizi yang tidak adekuat yang direfleksikan dengan tingginya angka prevalensi underweight dan stunting (pendek). Gangguan gizi pada anak bayi dan balita akan membawa dampak terhadap peningkatan risiko kesakitan dan kematian, keterlambatan perkembangan motorik dan mental, serta menurunnya kemampuan fisik anak dan gangguan pertumbuhan yang biasanya tidak dapat diperbaiki (irreversible). Metode: Penelitian ini untuk mengungkap sejauh mana dampak berat badan lahir terhadap status gizi anak balita dan lebih khusus lagi pada bayi dengan menggunakan rancangan analisis cross sectional. Sampel adalah semua RT yang memiliki bayi (0-12 bulan) dan mempunyai data berat lahir yang terdapat pada data Riskesdas 2007 yakni sebanyak 7.930 sampel. Pengolahan data dengan menggunakan SPSS dengan uji statistik (chi-square, korelasi pearson) serta analisis odds ratio (OR)Hasil penelitian menunjukkan bahwa terdapat 378 bayi (4,8%) BBLR dan 7552 (95,2%) bayi dengan berat lahir normal. Berdasarkan status gizi, terdapat 12,4% wasting, 14,2% berstatus gizi kurus, 32,4% terkategori stunting. Analisis hubungan menunjukkan bahwa status gizi bayi dipengaruhi oleh berat badan lahir secara bermakna (p<0,05) sebesar 5% untuk indeks BBIU, indeks PBIU sebesar 1,4% dan hanya 0,7% untuk indeks BBIPB. Adapun faktor risiko status gizi bayi adalah BBLR (BBIU: OR = 2,818 ; CI = 2,218-3,580 ; PBIU : OR = 1,743; CI = 1,415-2,147; BBIPB : OR = 1,283; CI = 0,975-1,689), tidak memperoleh ASI (BBIU : OR = 1,009; CI = 0,690-1,415; BBIPB ; OR = 1,238; CI = 0,884-1,734), tidak diimunisasi BCG (BBIU : OR = 1,314; CI = 1,100-1,570; BBIPB : OR = 1,195 ; CI = 1,007-1,418), menderita diare (BBIU : OR = 1,061; CI = 0,866-1,300; PBIU : OR = 1,004 ; CI = 0,920-1,195), menderita pneumonia (BBIU : OR = 1,022 ; CI = 0,462-2,260), menderita ISPA (PBIU : OR = 1,053; CI = 0,927-1,194), defisit protein MP-ASI (PBIU : OR = 1,048; CI = 0,920-1,195), ibu berpendidikan rendah (BBIU : OR = 1,003; CI = 0,876-1,149; PBIU : OR = 1,040; CI = 0,946-1,143), ibu bekerja (BBIU : OR = 1,263; CI = 0,824-1,936; PBIU : OR = 1,205; CI = 0,908-1,598; BBIPB : OR = 1,520; CI = 0,992-2,327), keluarga miskin (BBIU : OR = 1,148; CI = 1,003-1,314; PBIU : OR = 1,117; CI = 1,017-1,228; BBIPB : OR = 1,028; CI = 0,906-1,167), defisit energi rumah tangga (BBIU : OR = 1,104; CI = 0,949-1,286; PBIU : OR = 1,079; CI = 0,970-1,199; BBIPB : OR = 1,119; CI = 0,969-1,293), defisit protein rumah tangga (BBIU : OR = 1,027; CI = 0,883-1,194; PBIU

: OR = 1,050; CI = 0,944-1,168), penggunaan bahan beracun berbahaya dan sanitasi lingkung yang buruk, serta ibu merokok saat ada anggota rumah tangga. Kesimpulan : Berat badan lahir mempengaruhi status gizi (p<0,005) dan merupakan faktor risiko undernutrition, stunting dan wasting pada bayi (OR> 1). Hasil juga menunjukkan bahwa yang menjadi faktor risiko terhadap status gizi bayi (OR >1) yakni berat badan lahir, tidak memperoleh ASI dan imunisasi BCG, penyakit infeksi (diare, pneumonia dan ISPA), defisit protein MP-ASI, ibu berpendidikan rendah, ibu bekerja, keluarga rniskin, defisit energi-protein rurmah tangga, sanitasi lingkungan yang buruk dan penggunaan bahan beracun/berbahaya. Saran: Kebijakan secara makro yakni pengentasan kemiskinan melalui perbaikan kesejahteraan rakyat untuk meningkatkan status gizi dan kesehatan masyarakat. Disamping itu, penanggulangan malnutrisi khususnya pada anak bayi lebih difokuskan terhadap perbaikan gizi dan kesehatan ibu baik pra-konsepsi maupun setelah hamil (fetal programming) untuk mengurangi kejadian BBLR yang sangat mempengaruhi kejadian malnutrisi di usia tumbuh kembang anak.

8. Child malnutrition and mortality among families not utilizing adequately iodized salt in Indonesia1,2,3
Richard D Semba, Saskia de Pee, Sonja Y Hess, Kai Sun, Mayang Sari and Martin W Bloem
1

From the Johns Hopkins School of Medicine, Baltimore, MD (RDS and KS); World Food Programme, Rome, Italy (SdP, MS, and MWB); and the Department of Nutrition, University of California, Davis, CA (SYH)

Background: Salt iodization is the main strategy for reducing iodine deficiency disorders worldwide. Characteristics of families not using iodized salt need to be known to expand coverage. Objective: The objective was to determine whether families who do not use iodized salt have a higher prevalence of child malnutrition and mortality and to identify factors associated with not using iodized salt. Design: Use of adequately iodized salt (30 ppm), measured by rapid test kits, was assessed between January 1999 and September 2003 in 145 522 and 445 546 families in urban slums and rural areas, respectively, in Indonesia. Results: Adequately iodized salt was used by 66.6% and 67.2% of families from urban slums and rural areas, respectively. Among families who used adequately iodized salt, mortality in neonates, infants, and children aged <5 y was 3.3% compared with 4.2%, 5.5% compared with 7.1%, and 6.9% compared with 9.1%, respectively (P < 0.0001 for all), in urban slums; among families who did not use adequately iodized salt, the respective values were 4.2% compared with 6.3%, 7.1% compared with 11.2%, and 8.5% compared with 13.3% (P < 0.0001 for all) in rural areas. Families not using adequately iodized salt were more likely to have children who were stunted, underweight, and wasted. In multivariate analyses that controlled for potential confounders, low maternal education was the strongest factor associated with not using adequately iodized salt. Conclusion: In Indonesia, nonuse of adequately iodized salt is associated with a higher prevalence of child malnutrition and mortality in neonates, infants, and children aged <5 y. Stronger efforts are needed to expand salt iodization in Indonesia.

9. PENGARUH SUPLEMENTASI SENG DAN BESI TERHADAP PERTUMBUHAN, PERKEMBANGAN PSIKOMORIK DAN KOGNITIF BAYI: UJI LAPANGAN DI INDRAMAYU, JAWA BARAT ABSTRAK
LATAR BELAKANG. Masalah kurang gizi pada bayi secara umum berhubungan dengan pemberian MP-ASI. Diet tradisional bayi tidak menjamin kecukupan kebutuhan nutrient mikro termasuk besi dan seng. Untuk mencegah anemi pada saat bayi umur 1 tahun dan mencegah dampak berkelanjutan pada tumbuh-kembang, maka perlu suplementasi besi paling tidak pada saat bayi berusia 6 bulan. Kekurangan seng dilaporkan mempunyai

dampak pada tumbuh-kembang bayi. Suplementasi seng dan besi tersendiri telah dilakukan dan dilaporkan mempunyai pengaruh positif pada tumbuhkembang bayi usia lebih tua. Di Negara berkembang kekuranaganmutrien mikro biasanya tidak berdiri sendiri, maka perlu dilihat ada atau tidaknya nilai tambah suplementasi kombinasi seng-besi untuk meningkatkan tumbuhkembang bayi. TUJUAN: Menilai pengaruh suplementasi kombinasi seng & besi terhadap pertumbuhan, perkembangan kognitif dan psikomotorik bayi serta mengkaji fisibilitas suplementasi kombinasi seng-besi. MEODE: Randomized Block Clinical Trial di lapangan dengan pendekatan tersamar ganda pada 800 bayi. Kriteria inklusi sample adalah: bayi waktu rekrutmen berusia 4-7 bulan, tidak cacat fisik / punya kelainan bawaan, tidak sakit berat, tidak menderita kurang gizi dan masih mendapatkan ASI. Setelah rekrutmen, bayi secara random dikelompokkan dalam 4 suplementasi, yaitu: kelompok penerima 10 mgseng sulfat atau 10 mg fero sylfat atau kombinasi seng dan besi atau placebo. Setiap bayi mendapatkan satu dosis sirup suplementasi, diberikan 5 hari dalam seminggu. Sebelum suplementasi, sample mendapatkan vitamin A sebanyak 100.000 Unit Internasional dan data dasar demografi segera dikumpulkan. Pengaruh suplementasi dilihat pada pertumbuhan dengan pengukuran antopometri: Berat Badan, Panjang Badan, dan Lingkar Lengan Atas, melalui tiga kali pengukuran, yaitu awal penelitian, 12 minggu dan 24 minggu. Pemantauan perkembangan psikomotorik bayi setiap bulan untuk melihat pencapaian tahapan milestones motorik pada umur tertentu. Perkembangan kognitif dan psikomotorik bayi diuji dengan Beyley Scale for Infant Development II setelah suplementasi berakhir, untuk mengukur Indeks Perkembangan Mental atau kognitif dan Indek Perkembangan Psikomotor. Kesakitan, kematian, kepatuhan minum suplementasi juga dievaluasi. Kadar Hb diukur pada 199 bayi dari darah kapiler tumit & pengukuran akhir pada keseluruhan bayi di akhir penelitian. Uji lingkungan anak dilakukan pada 344 bayi dengan HOME dan asupan makanan dievaluasi dari 356 (sub-sampel) dengan metode ingatan 24 jam Quality control dan quality assurance kepatuhan minum suplementasi dilakukan pengukuran kadar seng dan besi air seni pada 119 sub-sempel penelitian. Uji kandungan nutrient mikro terutama besi dan seng pada controlair minum dan sample nakanan bayi juga dilakukan. Abstrak Doktor Universitas Diponegoo, 2009 48 KESIMPULAN: Pengaruh suplementasi seng (dan kombinasi) pada pertumbuhan terutama pada bayi stunting dan pengaruh suplementasi besi (dan kombinasi) pada penurunan anemi serta perkembangan bayi. Anemi. Perkembangan kognitif suplementasi seng maupun besi lebih tinggi dibandingkan placebo. Suplementasi kombinasi seng-besi mempunyai nilai tambah dalam peningkatan pertumbuhan linier terutama bayi laki-laki stunting, perkembangan psikomotorik bayi anemi dan bayi defisiensi seng dibandingkan suplementasi seng atau besi tersendiri. Suplementasi kombinasi seng-besi terbukti tidak harmful dan dapat dipakai sebagai alternative untuk mengatasi masalah anemi dan defisiensi seng yang banyak terjadi pada bayi.

10.A community-based randomized controlled trial of iron and zinc supplementation in Indonesian infants: interactions between iron and zinc1,2,3
Torbjrn Lind, Bo Lnnerdal, Hans Stenlund, Djauhar Ismail, Rosadi Seswandhana, Eva-Charlotte Ekstrm and Lars-ke Persson
1

From the Department of Public Health and Clinical Medicine, Epidemiology, Ume University, Ume, Sweden (TL, HS, E-CE, and L-AP); the Department of Nutrition, University of California, Davis (BL); Community Health and Nutrition Research Laboratories, Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia (DI and RS); and the International Centre For Diarrhoeal Disease Research, Bangladesh, Centre for Health and Population Research, Dhaka, Bangladesh (E-CE and L-AP).

Background: Combined supplementation with iron and zinc during infancy may be effective in preventing deficiencies of these micronutrients, but knowledge of their potential interactions when given together is insufficient.

Objective: The goal was to compare the effect in infants of combined supplementation with iron and zinc and of supplementation with single micronutrients on iron and zinc status. Design: Indonesian infants (n = 680) were randomly assigned to daily supplementation with 10 mg Fe (Fe group), 10 mg Zn (Zn group), 10 mg Fe + 10 mg Zn (Fe+Zn group), or placebo from 6 to 12 mo of age. Venous blood samples were collected at the start and end of the study. Five hundred forty-nine infants completed the supplementation and had both baseline and follow-up blood samples available for analysis. Results: Baseline prevalences of anemia, iron deficiency anemia (anemia and low serum ferritin), and low serum zinc (< 10.7 mol/L) were 41%, 8%, and 78%, respectively. After supplementation, the Fe group had higher hemoglobin (119.4 compared with 115.3 g/L; P < 0.05) and serum ferritin (46.5 compared with 32.3 g/L; P < 0.05) values than did the Fe+Zn group, indicating an effect of zinc on iron absorption. The Zn group had higher serum zinc (11.58 compared with 9.06 mol/L; P < 0.05) than did the placebo group. There was a dose effect on serum ferritin in the Fe and Fe+Zn groups, but at different levels. There was a significant dose effect on serum zinc in the Zn group, whereas no dose effect was found in the Fe+Zn group beyond 7 mg Zn/d. Conclusion: Supplementation with iron and zinc was less efficacious than were single supplements in improving iron and zinc status, with evidence of an interaction between iron and zinc when the combined supplement was given.

11. Malnutrition and Morbidity Are Higher in Children Who Are Missed by Periodic Vitamin A Capsule Distribution for Child Survival in Rural Indonesia1,2
Abstract
Universal periodic high-dose vitamin A capsule distribution is a cost-effective intervention to increase child survival in developing countries. It is unclear whether children who are missed by the program are at higher risk for malnutrition and infectious disease morbidity. Based on data from the Nutritional Surveillance System, we compared nutritional status and other health indicators of children aged 1259 mo in rural Indonesia who did and did not receive a vitamin A capsule within the last 6 mo. A total of 241,087 of 335,034 children (72.0%) received a vitamin A capsule between 1999 and 2003. In children who did and did not receive a vitamin A capsule, respectively, the proportion with weight-for-age, height-for-age, and weight-for-height Z scores ,22 were 37.0 vs. 42.5%, 39.2 vs. 45.6%, and 6.9 vs. 7.4% (P , 0.0001). Similarly, the proportion with anemia, diarrhea during the last wk, current diarrhea, and current fever was 49.2 vs. 54.8%, 6.7 vs. 8.4%, 4.4 vs. 6.0%, and 1.4 vs. 1.7% (P , 0.0001). Children who did not receive vitamin A were also less likely to have received childhood immunizations and belonged to families with higher infant and under-5-y child mortality than children who receive vitamin A. Although a lack of access to other public health interventions and demographic factors may also contribute to the rate of malnutrition in children missed by the vitamin A capsule program, it is likely that increased coverage of vitamin A supplementation would help to maximize the benefits for child survival. J. Nutr. 137: 1328 1333, 2007.

Introduction
Each year, .10 million children die, most of whom reside in developing countries (1). Periodic high-dose vitamin A supplementation is one of the most cost-effective interventions to reduce

child mortality (2) and has prevented an estimated 1 million child deaths from 1998 to 2001 (3). In 2004, the Copenhagen Consensus identified vitamin A supplementation among the best

strategies to improve global welfare (4). An estimated 140 million preschool children have vitamin A deficiency and the majority of these affected children live in south and southeast Asia and sub-Saharan Africa (5). Recently, it has been suggested that child survival interventions, such as vitamin A supplementation, may not be reaching the children who need them the most (6). Vitamin A deficiency has long been recognized as a highly prevalent nutritional deficiency in women and children in Indonesia and a major cause of morbidity, mortality, and blindness (79). From 1973 to 1975, the government of Indonesia conducted a pilot program of dispensing high-dose vitamin A capsules every 6 mo to every preschool child in 20 selected subdistricts in the island of Java (10). The vitamin A capsule distribution program in Indonesia was more widely expanded in the 1980s (11). Indonesia has one of the strongest vitamin A capsule distribution programs for child survival and the intended coverage is for all infants 612 mo and all preschool children 1259 mo of age. The program consists of biannual distribution of oral vitamin A, 60 mg retinol equivalents, to children aged 1259 mo and onehalf the dose for infants 612 mo (12). The subvillage level health post (posyandu) is the main site for distribution of vitamin A capsules to children. The effectiveness of vitamin A capsule distribution programs for child survival is likely related to the extent of programmatic coverage (6). It has been suggested that vitamin A supplementation in developing countries may miss the children who are at highest risk (13), but little has been done to characterize nutritional status and infectious disease morbidity in children who are missed by vitamin A supplementation (14). It is not well known whether this important child survival program is missing children

who may actually be at greater risk of morbidity and mortality. To gain further insight into this issue, we sought to characterize the demographic and health characteristics of preschool children 1 Supported by a Lew R. Wasserman Merit Award to R. D. Semba from Research to Prevent Blindness. 2 Author disclosures: S. G. Berger, no conflicts of interest; S. de Pee, no conflicts of interest; M. W. Bloem, no conflicts of interest; S. Halati, no conflicts of interest; R. D. Semba, no conflicts of interest. * To whom correspondence should be addressed. E-mail: rdsemba@jhmi.edu. 1328 0022-3166/07 $8.00 2007 American Society for Nutrition. Manuscript received 20 December 2006. Initial review completed 9 January 2007. Revision accepted 24 February 2007. Downloaded from jn.nutrition.org by on November 5, 2008 who are reached and not reached by the national vitamin A capsule distribution program in rural Indonesia. We hypothesized that children who missed vitamin A supplementation were more likely: 1) to be stunted, wasted, and underweight; 2) to be at higher risk of diarrhea disease, fever, and anemia; 3) to have lower childhood immunization coverage; and 4) to come from families with higher rates of infant and under-5-y child mortality than children who received vitamin A. To address these hypotheses, we examined the characteristics of children who did and did not receive vitamin A capsules in rural families in Indonesia. Subjects and Methods The study subjects consisted of children from families that participated in the major Nutritional Surveillance System (NSS)7 in Indonesia that was established by the Ministry of Health, Government of Indonesia, and Helen Keller International (HKI) in 1995 (15). The NSS was conducted in the provinces of Lampung, Banten, West Java, Central Java, East Java, Lombok, and South Sulawesi. The subjects included in this analysis were surveyed between January 1, 1999 and September 27,

2003. The NSS was based upon UNICEFs conceptual framework on the causes of malnutrition (16) with the underlying principle to monitor public health problems and guide policy decisions (17). The NSS was based upon stratified multistage cluster sampling of households in ecological zones of provinces of the country and in slum areas of large cities (15). In each zone, villages were selected by probability-proportional-tosize sampling. The NSS in Indonesia involved the collection of data from ;40,000 randomly selected rural households every quarter. New households were selected every round. Data were collected by 2person field teams. A structured, coded questionnaire was used to record data, including anthropometric measurements, date of birth, and sex, on children aged 059 mo. The mother of the child or other adult member of the household was asked to provide information on the households composition, parental education, and weekly household expenditures, along with other socioeconomic, environmental sanitation, and health indicators. For each child over age 6 mo, the mother, father, or guardian was asked whether the child received a vitamin A capsule within the last 6 mo. Axillary temperature was recorded. Hemoglobin was measured using a HemoCue instrument (HemoCue AB). Morbidity histories were obtained for each child, including history of diarrhea in the previous week and current diarrhea. Data were collected on the history of any infant dying in the household ,1 mo of age, ,12 mo of age, and any child deaths ,5 y of age. The field teams measured and recorded the weight of each child aged 059 mo to a precision of 0.1 kg and the length/height to a precision of 0.1 cm. Birth dates of the children were estimated using a calendar of local and national events and converted to the Gregorian calendar. Z scores of weight-for-height (WHZ) (wasting), weightfor-age (WAZ) (underweight), and height-for-age (HAZ) (stunting) were calculated using EpiInfo software (CDC), which uses the reference population of

the U.S. National Center for Health Statistics. Children with Z scores less than ,22 SD for WHZ, WAZ, or HAZ were considered wasted, underweight, or stunted (18). Severe wasting, underweight, and stunting were defined by respective Z scores less than ,23 SD. Children who had a mid-upper arm circumference (MUAC) ,125 mm were considered at high risk of malnutrition (19). HKI provided training to new field teams, field supervisors, and assistant field officers and refresher training prior to each new round of data collection. During each round, a monitoring team from HKI visited all field sites to check and calibrate the equipment and supervise data collection. A quality control team from HKI revisited 10% of households without prior warning within 2 d of data collection by the field teams and recollected data on selected indicators, including anthropometric measurements. Data collected by these quality control teams were later compared with the data collected by the field teams to check the accuracy of the data collection. The study protocol complied with the principles enunciated in the Helsinki Declaration (20). The field teams were instructed to explain the purpose of the NSS and data collection to each childs mother or caretaker, and, if present, the father and/or household head; data collection and phlebotomy proceeded only after written informed consent. Participation was voluntary and all subjects were free to withdraw at any stage of the interview. The protocol was approved by the Medical Ethical Committee of the Ministry of Health, Government of Indonesia. Data analyses were restricted to children who were 12 59 mo of age at the start of the most recent vitamin A capsule distribution round, because these were the children who were eligible for receiving 60 mg retinol equivalent (200,000 IU) every 6 mo in the Indonesian vitamin A capsule program. Children who were 6 to ,12 mo of age at the time of the last vitamin A capsule distribution round in the local area were not included in this analysis, because supplementation of children in this age

range with a different dose and type of capsule had just been implemented at the beginning of the NSS data collection. The youngest child within 1259 mo of age was selected to represent each family for families with more than 1 child. Continuous variables were compared using Students t test and variable transformations were used when needed to normalize the data. Categorical variables were compared using chisquare tests. Anemia was defined as hemoglobin ,11 g/dL, according to WHO criteria (21). Multivariate logistic regression models were used to examine the relation between separate outcomes of stunting and history of diarrhea in the last week and not receiving a vitamin A capsule and other factors. Population-based weighting was used to account for differences in population size of the various provinces. The level of significance in this study was P , 0.05. Results There were 335,034 children, aged 1259 mo, 241,087 (72.0%) of whom received a vitamin A capsule within the last 6 mo. Demographic characteristics are shown for children who did not vs. those who did receive a vitamin A capsule (Table 1). Children who did not receive a vitamin A capsule were significantly more likely to be younger, male, have mothers who were younger and less educated, and have fathers who were less educated. The geometric mean distance and time to walk from the house to the posyandu were significantly higher for children who did not receive a vitamin A capsule compared with children who received a vitamin A capsule. Variation in coverage rates was found in the provinces, with South Sulawesi demonstrating the poorest coverage at 54.3% and Central Java the highest at 80.7%. Lampung, East Java, Lombok, Banten, and West Java showed coverage rates of 57.7, 66.5, 68.5, 77.8, and 78.6%, respectively. Logistic regression models were used to examine the relation between the child receiving a vitamin A capsule and possible risk

factors. Parental education, the number of children ,6 y in the household, and distance to the posyandu were strong predictors of failure to be reached by the vitamin A program. Adjusting for other factors, 79 y of maternal education (odds ratio [O.R.] 1.65, 95% [CI] 1.621.69, P , 0.0001) and 101 y of maternal education (O.R. 2.07, 95% [CI] 2.022.12, P , 0.0001) compared with 06 y of maternal education were associated with an increased likelihood of the child receiving a vitamin A capsule. Similarly, 79 y of paternal education (O.R. 1.48, 95% [CI] 1.450.151, P , 0.0001) and 101 y of paternal education (O.R. 1.91, 95% [CI] 1.871.95, P , 0.0001) compared with 06 y of paternal education were also associated with an increased probability of the child receiving a vitamin A capsule. An increase in the number of children under 6 y of age in the household was association with decreased odds of being reached by the vitamin 7 Abbreviations used: DPT, diphtheria-pertussistetanus; HAZ, height-for-age Z score; HKI, Helen Keller International; MUAC, mid-upper arm circumference; NSS, Nutrition Surveillance System; OPV, oral poliovirus; O.R., odds ration; WAZ, weight-for-age Z score; WHZ, weight-forheight Z score. Malnutrition in children missed by vitamin A distribution 1329 Downloaded from jn.nutrition.org by on November 5, 2008 A program. Increased distance to the posyandu, as measured by time, was also associated with decreased odds of receiving a vitamin A capsule (Table 1). Health characteristics for children who did and did not receive vitamin A capsules are shown in Table 2. Children who did not receive a vitamin A capsule were significantly more likely to have WAZ, HAZ, and WHZ ,22, WAZ, HAZ, and WHZ ,23, have a MUAC ,125 mm, current fever, current diarrhea, a history of diarrhea over the last week, and have anemia compared with children who received a vitamin A capsule. The frequency

distribution of hemoglobin levels in children who did and did not receive a vitamin A capsule shows that the distribution of hemoglobin in children who did not receive a capsule was shifted to lower values compared with children who did receive a capsule (P , 0.0001) (Fig. 1). In children who did not attend the posyandu, the 5 main reasons given by the mother, father, or guardian for not going to the posyandu were that the health post was not active (26.7%), they thought the child was already too old (11.5%), they thought immunizations were already complete (9.6%), they utilize other health services (7.4%), or that the health post was too far (7.0%). Childhood immunization coverage was compared for children who did and did not receive a vitamin A capsule (Table 3). Children who did not receive a vitamin A capsule were significantly less likely to receive diphtheria-pertussis-tetanus (DPT) immunizations 1, 2, and 3; oral poliovirus (OPV) immunizations 1, 2, and 3; and measles immunization. A history of child mortality was compared in households in which the children did or did not receive a vitamin A capsule. In the households in which the child did not receive a vitamin A capsule, the proportion of infants who died ,1 mo of age, the proportion of infants who died ,12 mo of age, and the under-5-y mortality rate were significantly higher than in households in which the child received a vitamin A capsule (Fig. 2). TABLE 1 Demographic and health characteristics of children, aged 1259 mo, by vitamin A capsule receipt1 Characteristic Did not receive vitamin A Received vitamin A P OR2 (95% CI) Child age, mo 1223.9 42.7 38.5 0.0001 1.00 2435.9 26.0 29.5 1.24 (1.221.27) 3647.9 19.0 20.1 1.16 (1.141.19) 4859 12.3 11.9 1.07 (1.041.09)

Gender, % Female 48.7 49.4 0.002 1.02 (1.01 1.04) Maternal age, y #23 26.8 23.2 0.0001 1.00 2427.9 24.5 25.1 1.19 (1.161.21) 2832.9 25.3 28.1 1.28 (1.251.30) 331 23.5 23.6 1.14 (1.121.17) Maternal education, y 06 72.5 58.4 0.0001 1.00 79 15.3 20.8 1.65 (1.621.69) $10 12.2 20.7 2.07 (2.022.12) Paternal education, y 06 64.7 51.3 0.0001 1.00 79 16.1 19.2 1.48 (1.451.51) $10 19.1 29.5 1.91 (1.871.95) Children in household ,6 y old, n 1 73.7 78.4 0.0001 1.00 2 23.3 19.7 0.80 (0.790.82) 3 2.6 1.6 0.60 (0.570.63) 4 0.3 0.2 0.66 (0.560.77) 51 0.1 0.0 0.66 (0.480.92) Year of interview 1999 14.5 10.5 0.0001 1.00 2000 26.5 23.3 1.22 (1.191.25) 2001 24.0 19.9 1.15 (1.121.18) 2002 21.8 27.4 1.75 (1.701.79) 2003 13.3 19.0 1.98 (1.932.04) Time to walk to posyandu, min3 6.36 5.01 0.0001 0.78 (0.770.79) (6.32, 6.41) (4.99, 5.03) 1 All variables were adjusted for time (year in which the interview was conducted). 2 Odds of receiving a vitamin A capsule compared with a reference group that has an O.R. of 1.00. 3 Geometric mean (95% [CI]). TABLE 2 Health characteristics of children, aged 1259 mo, by vitamin A capsule receipt1 Characteristic Did not receive vitamin A Received vitamin A P OR (95% [CI]) WAZ score ,22 42.5 37.0 0.0001 0.79 (0.780.81) ,23 8.9 6.2 0.68 (0.660.70) HAZ score ,22 45.6 39.2 0.0001 0.77 (0.760.79) ,23 15.8 11.4 0.70 (0.680.72) WHZ score ,22 7.4 6.9 0.0001 0.93 (0.900.95) ,23 0.7 0.6 0.78 (0.710.86) MUAC ,125 mm 3.2 2.5 0.0001 0.78 (0.740.81) Diarrhea today 6.0 4.4 0.0001 0.71 (0.690.74) Fever today 1.7 1.4 0.0001 0.88 (0.830.94) Diarrhea last wk 8.4 6.7 0.0001 0.81 (0.790.84) Anemic 54.8 49.2 0.0001 0.81 (0.780.84) 1 All variables were adjusted for time (year in which the interview was conducted).

FIGURE 1 Frequency distribution of hemoglobin levels in children who did not (n 18,225) and did (n 46,859) receive a vitamin A capsule (P , 0.0001 by Mantel-Haenszel chisquare). 1330 Berger et al. Downloaded from jn.nutrition.org by on November 5, 2008 Multivariate logistic regression models were used to examine the relation between history of diarrhea in the previous week and not receiving a vitamin A capsule and other factors. A history of diarrhea in the previous week was selected as the outcome, because this is a health indicator strongly associated with vitamin A deficiency (22). After adjusting for child age, maternal education, distance to the posyandu, and the year in which the interview was conducted, the lack of receipt of a vitamin A capsule was associated with a significantly increased risk of a history of diarrhea in the previous week (Table 4). Multivariate logistic regression models were also used to examine the relation between stunting (HAZ , 22) and not receiving a vitamin A capsule and other factors. Stunting is recognized as the best indicator of long-term malnutrition compared with other health indicators, such as wasting or underweight. After adjusting for child age, maternal education, distance to the posyandu, and the time of the interview, the lack of receipt of a vitamin A capsule was associated with a significantly increased risk of stunting (Table 4). Discussion This study shows that children aged 1259 mo who were not reached by universal vitamin A capsule distribution within the last 6 mo in rural Indonesia were at greater risk of underweight, stunting, and wasting, more likely to be anemic, and had higher rates of diarrhea and fever than children who received vitamin A. Moreover, the more severely underweight, stunted, and wasted

children who had Z scores ,23 were less likely to receive vitamin A. To our knowledge, this is the first study to characterize nutritional status and morbidity in children who are and are not reached by vitamin A capsule distribution. A strength of this study is that it is a population-based sample with a large sample size. The findings show that this important child survival intervention may be missing children who are at the highest risk of dying. TABLE 3 Relation of vitamin A capsule receipt with childhood vaccinations1 Characteristic Did not receive vitamin A, % Received vitamin A,% P OR2 (95% [CI]) DPT vaccine dose 1 Received, with record 33.2 57.2 0.0001 6.86 (6.697.03) Received, no record 36.2 33.6 3.47 (3.383.56) Not received 27.7 7.4 1.00 Doesn't know 2.8 1.8 2.40 (2.262.54) DPT vaccine dose 2 Received, with record 31.1 55.3 0.0001 5.88 (5.756.02) Received, no record 32.9 32.3 3.05 (2.983.12) Not received 32.9 10.6 1.00 Doesn't know 3.1 1.9 1.92 (1.812.02) DPT vaccine dose 3 Received, with record 29.3 53.5 0.0001 5.31 (5.195.43) Received, no record 31.1 31.2 2.73 (2.672.79) Not received 36.4 13.4 1.00 Doesn't know 3.2 2.0 1.66 (1.581.75) OPV vaccine dose 1 Received, with record 34.2 57.9 0.0001 7.32 (7.137.51) Received, no record 37.8 34.2 3.68 (3.583.78) Not received 25.3 6.2 1.00 Doesn't know 2.8 1.8 2.59 (2.452.75) OPV vaccine dose 2 Received, with record 32.4 56.6 0.0001 6.51 (6.356.67) Received, no record 34.6 33.1 3.35 (3.273.43) Not received 30.0 8.5 1.00 Doesn't know 2.9 1.8 2.17 (2.052.30) OPV vaccine dose 3 Received, with record 30.6 55.1 0.0001 5.79 (5.665.92) Received, no record 31.9 31.7 3.00 (2.933.07) Not received 34.3 11.3 1.00 Doesn't know 3.2 1.9 1.85 (1.751.95) Measles vaccine

Received, with record 27.9 52.3 0.0001 5.32 (5.205.44) Received, no record 31.5 32.1 2.71 (2.652.77) Not received 37.3 14.0 1.00 Doesn't know 3.4 1.6 1.38 (1.311.46) 1 All variables were adjusted for time (year in which the interview was conducted). 2 Odds of receiving a vitamin A capsule compared with a reference group that has an O.R. of 1.00. FIGURE 2 History of infant dying ,1 mo of age, infant dying ,12 mo of age, and under-5-y child mortality in families in which the child did (n 163,828) and did not (n 56,779) receive a vitamin A capsule (*P , 0.0001 by chi-square test). TABLE 4 Multivariate logistic regression models of relation between childrens vitamin A capsule receipt and other factors and stunting and history of diarrhea in previous week1 Variable OR 95% [CI] P History of diarrhea in previous week Lack of vitamin A capsule receipt 1.13 1.091.17 0.0001 Child age, mo 0.973 0.9720.974 0.0001 Maternal education, y 06.9 1.52 1.461.58 0.0001 79.9 1.23 1.171.29 0.0001 101 1.00 Loge time to walk to posyandu, min 0.99 0.97 1.00 0.050 Stunting Lack of vitamin A capsule receipt 1.19 1.171.21 0.0001 Child age, mo 1.010 1.0101.011 0.0001 Maternal education, y 06.9 2.07 2.032.12 0.0001 79.9 1.48 1.441.52 0.0001 101 1.00 Loge time to walk to posyandu, min 1.006 1.00 1.01 0.113 1 Both regression models were adjusted for time (year in which interview was conducted). Malnutrition in children missed by vitamin A distribution 1331 Downloaded from jn.nutrition.org by on November 5, 2008 In developing countries, the relation between malnutrition and diarrheal diseases is often mutually reinforcing; children who are underweight, stunted, and wasted are at a higher risk of diarrheal morbidity and mortality (23) and diarrheal disease increases the risk of vitamin A deficiency (24). In addition,

stunted and wasted children are at a higher risk of vitamin A deficiency (2527), which in turn may lead to greater susceptibility to diarrheal diseases. Interventions such as vitamin A supplementation are considered a means of interrupting this cycle. The overall rate of vitamin A coverage in these children was 72.0% and the governments target rate was 80%. Our findings challenge the assumption that targeting only 80% of children is a sufficient intervention strategy, as the 28% of children who were not reached by Indonesias vitamin A program demonstrated higher rates of child morbidity than children who were reached by the program. The coverage rate of the program in Indonesia was less than the 84% coverage in Bangladesh (28) but higher than the 34% coverage in Cambodia (28) during approximately the same time period. Ideally, vitamin A supplementation programs in developing countries should reach 85% of preschool children twice per year (29). Many programs have fallen short of this goal. An estimated 75% of children in sub-Saharan Africa and 46% of children in South Asia receive at least 1 dose of vitamin A annually (29). Two previous studies characterized children who are missed by vitamin A capsule programs. In a sample of 677 children aged 15 y in Central Java, Indonesia, children who were not participating in the vitamin A capsule program were more likely to be ,36 mo of age and from families with more than 1 preschool child (14). In the Philippines, a study of over 13,000 children showed that those who were not reached by vitamin A capsule distribution in 1993 and 1998 had mothers with lower education level and lower socioeconomic status compared with those who received vitamin A (13). The investigators concluded that the vitamin A program in the Philippines was missing some of the most vulnerable children. In our study, children who were missed by the vitamin A

capsule distribution program were less likely to have received DPT, OPV, and measles immunization, and the lack of immunization places these children at an even higher risk of infectious disease morbidity and mortality from vaccinepreventable diseases. Vitamin A deficiency increases the risk of measles morbidity, including the severity of diarrheal disease, measlesrelated pneumonia, blindness, and mortality (30). These findings suggest that demographic factors that impact a childs participation in vitamin A supplementation programs may also impact participation in other public health interventions. The leading cause for not taking a child to the posyandu was that the posyandu was not active. Because these health posts provide basic primary care, it seems that children who are missing vitamin A supplementation may also be missed by other critical child survival interventions. It is evident that strategies need to be developed to reach children who are missed by basic primary preventive care programs in developing countries. The lack of receipt of a vitamin A capsule was associated with an increased risk of stunting and an increased risk of a history of diarrhea in the previous week. Although vitamin A supplementation is associated with a reduction in diarrhea morbidity, it cannot be determined from these cross-sectional data whether the children had higher risk of diarrhea because they did not receive a vitamin A capsule or that children who did not receive a vitamin A capsule came from households where diarrheal morbidity was generally higher. The relation between vitamin A supplementation and stunting has not been consistent between studies (31). These findings suggest that children missed by vitamin A supplementation are more stunted, but, similar to the association between vitamin A capsule receipt and diarrhea, causality cannot be determined. Distance and nonfunctioning of the posyandus appeared to be important barriers to the utilization of these rural health

posts. This study also suggests that the parents did not take their children to the posyandu because they thought immunizations were complete or that the child was too old. Formal parental education was 1 of the most significant determinants of receipt of vitamin A capsules. Paternal education significantly influenced the likelihood of the child receiving a vitamin A capsule, although the strength of the correlation was not as great as that of maternal education. Little research has been done on the impact of paternal education on child health. Greater research in this area would therefore be beneficial for informing strategies for health programming. Further work is also needed to determine whether the parents have adequate knowledge of the purpose and benefits of the vitamin A capsule program and how public health promotion campaigns could be used to increase attendance at the posyandu. In September 2000, 189 countries endorsed the goals set forth by the United Nations millennium declaration to reduce under-5-y child mortality by two-thirds between 1990 and 2015 (2). Periodic high-dose vitamin A supplementation has been shown to reduce preschool child mortality, primarily from diarrheal disease, by about one-quarter (32). Given that children who are missed by the vitamin A programs are at higher risk of malnutrition and morbidity, the extent of mortality reduction by periodic vitamin A supplementation is unclear. It has been argued that vitamin A supplementation should be targeted to highrisk children; however, analyses have shown that universal supplementation is most cost effective (33). Universal periodic high-dose vitamin A supplementation is known as an effective intervention to increase child survival in developing countries. Further work is needed to expand coverage of existing programs to reach children who are at higher risk of dying. Literature Cited

1. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet. 2003;361:222634. 2. Edejer TTT, Aikins M, Black R, Wolfson L, Hutubessy R, Evans DB. Cost effectiveness analysis of strategies for child health in developing countries. BMJ. 2005;331:1177. 3. UNICEF. Ending vitamin A deficiency: a challenge to the world. New York: UNICEF; 2001. 4. Lomborg B. Global crises, global solutions. New York: Cambridge University Press; 2004. 5. Sommer A, Davidson FR. Assessment and control of vitamin A deficiency: the Annecy Accords. J Nutr. 2002;132 Suppl 9:S284550. 6. Bryce J, el Arifeen S, Pariyo G, Lanata CF, Gwatkin D, Habicht JP, Multi-Country Evaluation of IMCI Study Group. Reducing child mortality: can public health deliver? Lancet. 2003;362:15964. 7. de Haas JH. On keratomalacia in Java and Sumatra (in particular upon the Karo-Plateau) and in Holland. Mededeel Dienst Volksgezond Nederl Indie. 1931;20:111. 8. Oomen HAPC. Infant malnutrition in Indonesia. Bull World Health Organ. 1953;9:37184. 9. ten Doesschate J. Causes of blindness in and around Surabaja, East Java, Indonesia [dissertation]. Jakarta (Indonesia): University of Jakarta; 1968. 10. Fritz C. Combating nutritional blindness in children: a case study of technical assistance in Indonesia. Pergamon Policy Studies on SocioEconomic Development. New York: Pergamon Press; 1980. 1332 Berger et al. Downloaded from jn.nutrition.org by on November 5, 2008 11. Helen Keller International. National vitamin A supplementation campaign activities: August 2001. Indonesia Crisis Bulletin. 2001;3:14. 12. Semba RD, Susatio B, Muhilal, Natadisastra G. The decline of admissions for xerophthalmia at Cicendo Eye Hospital, Indonesia, 19811992. Int Ophthalmol. 1995;19:3942. 13. Choi Y, Bishai D, Hill K. Socioeconomic differentials in supplementation of vitamin A: evidence from the Philippines. J Health Popul Nutr. 2005;23:15664.

14. Pangaribuan R, Scherbaum V, Erhardt JG, Sastroamidjojo S, Biesalski HK. Socioeconomic and familial characteristics influence caretakers adherence to the periodic vitamin A capsule supplementation program in Central Java, Indonesia. J Trop Pediatr. 2004;50:1437. 15. de Pee S, Bloem MW, Sari M, Kiess L, Yip R, Kosen S. High prevalence of low hemoglobin concentration among Indonesian infants aged 35 months is related to maternal anemia. J Nutr. 2002;132:221521. 16. de Pee S, Bloem MW. Assessing and communicating impact of nutrition and health programs. In: Semba RD, Bloem MW, editors. Nutrition and health in developing countries. Totowa (NJ): Humana Press; 2001. p. 483506. 17. Mason JB, Habicht JP, Tabatabai H, Valverde V. Nutritional surveillance. Geneva: WHO; 1984. 18. de Onis M. Child growth and development. In: Semba RD, Bloem MW, editors. Nutrition and health in developing countries. Totowa (NJ): Humana Press; 2001. p. 7191. 19. Dramaix M, Hennart P, Brasseur D, Bahwere P, Mudjene O, Tonglet R, Donnen P, Smets R. Serum albumin concentrations, arm circumference, and oedema and subsequent risk of dying in children in central Africa. BMJ. 1993;307:7103. 20. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. Bull World Health Organ. 2001;79:3734. 21. WHO. Nutritional anemia: report of a WHO Scientific Group. Geneva: WHO; 1968. 22. Bloem MW, Wedel M, Egger RJ, Speek AJ, Schrijver J, Saowakontha S, Schreurs WH. Mild vitamin A deficiency and risk of respiratory tract diseases and diarrhea in preschool and school children in northeastern Thailand. Am J Epidemiol. 1990;131:3329. 23. Brown KH. Diarrhea and malnutrition. J Nutr. 2003;133:S32832. 24. Sommer A, Tarwotjo I, Katz J. Increased risk of xerophthalmia following diarrhea and respiratory disease. Am J Clin Nutr. 1987;45:97780. 25. Khatry SK,West KP Jr, Katz J, LeClerq SC, Pradhan EK,Wu LSF, Thapa

MD, Pokhrel RP. Epidemiology of xerophthalmia in Nepal: a pattern of household poverty, childhood illness, and mortality. Arch Ophthalmol. 1995;113:4259. 26. Sommer A, Katz J, Tarwotjo I. Increased risk of respiratory disease and diarrhea in children with preexisting mild vitamin A deficiency. Am J Clin Nutr. 1984;40:10905. 27. Cohen N, Jalil MA, Rahman H, Leemhuis de Regt E, Sprague J, Mitra M. Blinding malnutrition in rural Bangladesh. J Trop Pediatr. 1986;32: 738. 28. UNICEF. State of the worlds children 2005. New York: UNICEF; 2004. 29. World Bank. Public health at a glance. Vitamin A, November 2004. [cited 2006 April 16]. Available from: web.worldbank.org/WBSITE/ EXTERNAL/TOPICS/EXTHEALTHNUTRITIONAN DPOPULATION/ EXTPHAAG/0,contentMDK:20800011;menuPK:1314 810;pagePK: 642298.

30. Semba RD, Bloem MW. Measles blindness. Surv Ophthalmol. 2004;49: 24355. 31. Ramakrishnan U, Aburto N, McCabe G, Martorell R. Multimicronutrient interventions but not vitamin A or iron interventions alone improve child growth: results of 3 meta-analyses. J Nutr. 2004;134: 2592602. 32. Beaton GH, Martorell R, Aronson K, Edmonston B, McCabe G, Ross A. Effectiveness of Vitamin A supplementation in the control of young child morbidity and mortality in developing countries. ACC/SCN Stateofthe-Art Nutrition Policy Discussion Paper No. 13. New York: United Nations; 1993. 33. Loevinsohn BP, Sutter RW, Costales MO. Using cost-effectiveness analysis to evaluate targeting strategies: the case of vitamin A supplementation. Health Policy Plan. 1997;12:2937. Malnutrition in children missed by vitamin A distribution 1333 Downloaded from jn.nutrition.org by on November 5, 2008

12.Effect of parental f/ormal education on risk of child stunting in Indonesia and Bangladesh: a cross-sectional study
Background Child stunting is associated with poor child development and increased mortality. Our aim was to determine the effect of length of maternal and paternal education on stunting in children under the age of 5 years. Methods Data for indicators of child growth and of parental education and socioeconomic status were gathered from 590570 families in Indonesia and 395122 families in Bangladesh as part of major nutritional surveillance programmes. Findings The prevalence of stunting in families in Indonesia was 332%, while that in Bangladesh was 507%. In Indonesia, greater maternal formal education led to a decrease of between 44% and 5% in the odds of child stunting (odds ratio per year 0950, 95% CI 09460954 in rural settings; 0956, 09500961 in urban settings); greater paternal formal education led to a decrease of 3% in the odds of child stunting (0970, 09670974). In Bangladesh, greater maternal formal education led to a 46% decrease in the odds of child stunting (0954, 09510957), while greater paternal formal education led to a decrease of between 29% and 54% in the odds of child stunting (0971, 0969 0974 in rural settings; 0946, 09410951 in urban settings). In Indonesia, high levels of maternal and paternal education were both associated with protective caregiving behaviours, including vitamin A capsule receipt, complete childhood immunisations, better sanitation, and use of iodised salt (all p<00001). Interpretation Both maternal and paternal education are strong determinants of child stunting in families in Indonesia and Bangladesh.

13.Paternal smoking and increased risk of child malnutrition among families in rural Indonesia

Abstract
Objective: To determine whether paternal smoking is associated with an increased risk of child malnutrition among families in rural Indonesia. Methods: The relation between paternal smoking and child malnutrition was examined in a population-based sample of 438336 households in the Indonesia Nutrition and Health Surveillance System, 20002003. Main outcome measures were child underweight (weight-for-age Z score <2) and stunting (height-for-age Z score <2) and severe underweight and severe stunting, defined by respective Z scores <3, for children aged 059 months of age. Results: The prevalence of paternal smoking was 73.7%. The prevalence of underweight and stunting was 29.4% and 31.4%, and of severe underweight and severe stunting was 5.2%, and 9.1%, respectively. After adjusting for child gender, child age, maternal age, maternal education, weekly per capita household expenditure and province, paternal smoking was associated with an increased risk of underweight (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01 to 1.05, p=0.001) and stunting (OR 1.11, 95% CI 1.09 to 1.13, p<0.001) and severe underweight (OR 1.06, 95% CI 1.01 to 1.10) p=0.020) and severe stunting (OR 1.12, 95% CI 1.08 to 1.16, p<0.001). Conclusions: Paternal smoking is associated with an increased risk of child malnutrition in families living in rural Indonesia.

14.Prevalence and risk factors for stunting and severe stunting among underfives in North Maluku province of Indonesia
Abstract Background Adequate nutrition is needed to ensure optimum growth and development of infants and young children. Understanding of the risk factors for stunting and severe stunting among children aged less than five years in North Maluku province is important to guide Indonesian government public health planners to develop nutrition programs and interventions in a post conflict area. The purpose of the current study was to assess the prevalence of and the risk factors associated with stunting and severe stunting among children aged less than five years in North Maluku province of Indonesia. Methods The health and nutritional status of children aged less than five years was assessed in North Maluku province of Indonesia in 2004 using a cross-sectional multi-stage survey conducted on 750 households from each of the four island groups in North Maluku province. A total of 2168 children aged 0-59 months were used in the analysis. Results Prevalence of stunting and severe stunting were 29% (95%CI: 26.0-32.2) and 14.1% (95%CI: 11.7-17.0) for children aged 0-23 months and 38.4% (95%CI: 35.9-41.0) and 18.4% (95%CI: 16.1-20.9) for children aged 0-59 months, respectively. After controlling for potential confounders, multivariate analysis revealed that the risk factors for stunted children were child's age in months, male sex and number of family meals per day (2 times), for children aged 0-23 months, and income (poorest and middle-class family), child's age in months and male sex for children aged 0-59 months. The risk factors for severe stunting in children aged 0-23 months were income (poorest family), male sex and child's age in months and for children aged 0-59 months were income (poorest family), father's occupation (not working), male sex and child's age in months. Conclusion Programmes aimed at improving stunting in North Maluku province of Indonesia should focus on children under two years of age, of male sex and from families of low socioeconomic status.

15.
Abstract

Risk factors for stunting among under-fives in Libya

Objective: Stunting is a chronic condition reflecting poor nutrition and health. Our aim was to ascertain major predictors of stunting in children ,5 years old in Libya. Population and methods: A nationally representative, cross-sectional, two-stage stratified cluster sample survey enrolled 4549 under-fives from 6707 households. Logistic regression was used to determine individual risk factors in bivariate and multivariate analyses. Results: Anthropometric measurements were available for 4498 children. Among the 929 stunted children (20?7 %), 495 were boys (53?3%) and 434 were girls (46?5 %). In multivariate analysis, risk factors were young age (1 2 years: OR5 2?32, 95% CI 1?67, 3?22; 23 years: OR51?64, 95% CI 1?22, 2?21), resident of Al-Akhdar (OR51?67, 95% CI 1?08, 2?58), being a boy (OR51?28, 95% CI 1?05, 1?55), having a less educated father (illiterate: OR52?10, 95% CI 1?17, 3?77; preparatory school: OR51?71, 95% CI 1?11, 2?65), poor psychosocial stimulation (no family visits or trips: OR51?52, 95% CI 1?07, 2?16; father rarely/never plays with child: OR52?24, 95% CI 1?20, 4?16), filtered water (OR58?45, 95% CI 2?31, 30?95), throwing garbage in the street (OR513?81, 95% CI 2?33, 81?72), diarrhoea (OR51?58, 95% CI 1?09, 2?29) and low birth weight (OR51?8, 95% CI 1?17, 2?40). Protective factors were older age of father (OR50?53, 95% CI 0?32, 0?90) and water storage (OR50?70, 95% CI 0?54, 0?90). These variables only explained 20% of cases of stunting. Conclusion: Various multilevel actions are needed to improve nutritional status of under-fives in Libya. At risk-groups include those with young age (13 years), resident of Al-Akhdar region, boys, fathers low educational level, poor psychosocial stimulation, poor housing environment, diarrhoea and low birth weight.
Keywords Libya Children Under-fives Stunting Risk factors

Nutritional status is a sensitive indicator of the quality of life in a given population(1,2). Despite global improvement in the health of children aged ,5 years in developing countries, undernutrition remains an important public health problem(3,4). More than half of deaths of children in these countries are related to undernutrition(5). Undernutrition profoundly affects human function, with both individual and transgenerational effects. Individual effects include the well-known undernutritioninfection vicious cycle, while transgenerational effects refer to a similar vicious spiral that extends to forthcoming offspring and induces permanent effects on mental, social and physical well-being. These effects occur even in mild-to-moderate cases(3). Undernutrition also affects society at large because it leads to reduced productivity and limited ability to escape the consequences of poverty(3,6,7). Reduction of the prevalence of undernutrition in under-fives is a top priority to reduce child mortality and morbidity. Reduction of undernutrition prevalence by 50% between 1990 and 2015 is among the most important targets of the first Millennium Development Goal. Nevertheless, progress remains slow, and most international goals set for improving child nutrition and health were not met by 2000. Stunting (i.e. low height-for-age) is a chronic condition that reflects poor linear growth accumulated during preand/ or postnatal periods because of poor nutrition and/or health. It is more difficult to treat than acute forms of

undernutrition such as wasting. Its relationship to micronutrient deficiencies, obesity (particularly the abdominal type) and chronic diseases makes it an important health hazard even for countries in transition. Causes of stunting
*Corresponding author: Email tajoury@pediatrician.com r The Authors 2008

are multifactorial with roots in many sectors of development such as education, demography, agriculture and rural development(8,9). Identification of the causes in a particular setting implies the investigation of complex interactions between these multiple interrelated social, economic and environmental determinants. Such determinants usually occupy different positions in the dependence chain and they cannot adequately be modelled by including them all in a linear regression analysis(10,11). They can be better understood within an integrated conceptual framework that considers these factors and their interactions(8,11,12). One example of such a model is the UNICEF conceptual framework. This framework, which was developed in 1990 as a part of UNICEFs nutritional strategy(8), provides a holistic and pragmatic approach. It classifies the causes of undernutrition into three categories that account for the complexity of the nutritional status of children: (i) basic causes at the societal level; (ii) underlying causes at the household/family level; and (iii) immediate causes. Factors at one level influence other levels. Libya is classified as a low-prevalence area of wasting (3?3%) and stunting (15?1%) using the National Center for Health Statistics/Centers for Disease Control and Prevention/

WHO reference growth curves(13,14). Stunting in Libya is more prevalent in certain geographic regions, in rural areas and in underprivileged groups(13,15). Rates are as high as 28% in Al-Akhdar region when the newly published growth charts from the WHO Multiple Centre Growth Reference Study(16) are used. As such, the country would be reclassified as an intermediate-level country(15). Improvement in nutritional status needs effective planning that accounts for the underlying risk factors, identifying at-risk subgroups and permitting targeted interventions. There is a paucity of studies that would permit a fuller contextual assessment of the patterns and determinants of undernutrition in Libya. Analysis of national cross-sectional surveys can provide clues to fill this gap. The Libyan Maternal and Child Health Survey (LMCHS), undertaken as part of the Pan Arab Project for Child Development (PAPCHILD), is the first nationally representative maternal and child health survey ever undertaken in Libya(13,17). The present study is a secondary analysis of the raw data from the LMCHS. The aim was to ascertain predictors of childhood stunting in children aged ,5 years in this population. Population and methods Design The design, methods and nutritional status of under-fives in Libya from the LMCHS are described in more detail elsewhere(13,15,17). The LMCHS is a cross-sectional, nationally representative, two-stage stratified probability cluster sample of 6707 households that was undertaken during the summer of 1995. The country was divided into seven administrative regions. These regions were three costal (Benghazi, Tripoli and Al-Zaouia), two mountainous (Al-Akhdar and Al-Gharbi) and two predominantly desert areas (Sirt and Sabha). Each region was divided into urban and rural zones. In the first stage, a total of 307 sampling units, including 102 units from rural areas, were selected randomly. In the second stage, each sampling unit was divided into five segments of equal sizes. All households in one randomly selected segment were included in the sample. All children younger than 60 months at the time of the survey were eligible for recruitment. Data and outcome measures Data were collected in interviews with mothers during household visits using the three different standard PAPCHILD questionnaires with a few modifications to conform to local patterns of disease and determinants(17). The child questionnaire contained items related to child health and its determinants such as vaccination, birth, nutrition, etc. The reproductive health questionnaire contained items on the mothers health and reproductive history. The third questionnaire gathered data on household characteristics and the surrounding environment such as the availability of safe water supply, sanitation facilities and garbage collection. Weight, length/height and age data were used to calculate Z scores of height-for-age in comparison with

the newly published WHO growth curve. Stunting was defined as a length/height more than two standard deviations below the median height/length-for-age of the WHO Child Growth Standards from the WHO Multicentre Growth Reference Study(16). The independent variables that were chosen for their possible association with stunting are shown in Table 1. These variables were organized according to the conceptual framework developed by UNICEF(8). Socio-economic classification was based on the combination of an asset index of households with its area characteristics, and a locally validated socioeconomic classification that incorporates parental occupation and education(18). Statistical analysis Data were analysed using WHO Anthro 2005 software (WHO, Geneva, Switzerland) and SPSS version 13 (SPSS Inc., Chicago, IL, USA) statistical software package. The WHO Anthro 2005 program considers Z-score values for length/height-for-age ,26 as outliers. Each independent variable was individually evaluated in bivariate analyses for possible correlation with stunting. Statistical analysis with logistic regression was performed by SPSS, determining for each of the variables the odds ratio, 95% confidence interval and statistical significance of the association with stunting. Only statistically significant risk factors are presented here. The level of significance was set at P,0?05. In the final stage, in addition to the variables that were identified as significant in the bivariate analyses, some other potentially confounding variables as
1142 A El Taguri et al.

indicated by P,0?5 were also selected. These were all put together in a single logistic regression model to determine their net effects on stunting. Results Anthropometric measurements were available for 4498 children. Among the 929 stunted children (20?7 %), there were 495 boys (22?2%) and 434 girls (19?4 %). Other basic attributes of the children participating in the survey are shown in Table 2. In bivariate analysis, various significant factors increasing (Table 3) or decreasing (Table 4) the risk of stunting were found. Basic determinants included age 13 years, with the second year having the highest risk even in comparison with the first year (OR51?31, 95% CI 1?04, 1?64, P,0?02), being a boy, belonging to less privileged groups, living in rural areas and being a resident of Al-Akhdar, Sirt, Al-Zaouia or Al-Gharbi regions. Underlying determinants found included family and caregiver conditions such as consanguinity, large family size (having $4 siblings in the family), low paternal and/or maternal education and limited psychosocial stimulation (absent or rare interaction between the child and father, absence

of external social contact, absence of media contact). Meanwhile, being a first or a single child decreased the risk for stunting. Other underlying determinants included poor utilization of health services (absence or poor follow-up during pregnancy, incomplete immunization). Delivery in a private health establishment decreased the risk. Housing environment such as type of dwelling, lack of safe water supply, inadequate sanitation and garbage collection were among the underlying determinants that increased the risk of stunting. Many immediate factors related to feeding practices and health status such as low birth weight and diarrhoea were found also to increase the risk of stunting. Onset of weaning at 46 months of age rather than 68 months and a large birth weight decreased the risk for stunting. The logistic regression model for multivariate analysis included the factors reported above in addition to some other potentially confounding variables such as fathers age, fathers education and using water from wells without pumps. Overall, the model was significantly associated with stunting, but it explained only 20% of the variance as indicated by its R2 value (Table 5).
Table 1 Variables assessed for their possible association with stunting I Basic determinants Region of residence; urbanization; gender; age; socio-economic conditions II Underlying determinants Family and caregiver conditions Main caregiver; mothers age and age at birth; living arrangements; change of residence; type of previous residence; educational state of mother; listening, watching and reading of media; currently working for cash; working for cash before or after marriage; single mother; extended family; multiple wives; poor family social life Reproductive history of mother Age at menarche; age at first marriage; birth order of the child; number of children; blood relation with husband; history of prematurity, stillbirth, abortion and previous sibling deaths Fathers attributes Educational state; residence in the last 3 months; playing with the child; earning regular wages Health services Immunizations; check-ups during pregnancy; birth order; type, place and complications of delivery; use of Caesarean section Household environment Area of residence and household characteristics: dwelling type and ownership; number of rooms and bedrooms; keeping animals; kitchen location and fuel used; source, storage and treatment of drinking water; type and location of toilet facilities; collection, location and disposal of garbage; state of the area around dwelling (flooded or stagnant water) III Immediate determinants Diet Feeding history of the child*: onset, duration and practices of breast-feeding, infant formula-feeding and bottle-feeding; age of introduction of powdered, animal and pasteurized bottle milk; introduction of solid foods; type of weaning; giving rice, juice, herbal drinks, preserved baby foods or family foods Health Diarrhoea; cough; fever; otitis; conjunctivitis; accidents or other illnesses; measles infection; weight at birth
*Optimal breast-feeding was considered if breast-feeding started early, if

weaning started at 68 months of age and if breast-feeding continued for .12 months; whereas if weaning started between 4 and 6 months of age, breast-feeding was considered appropriate.

Table 2 Basic attributes of under-fives involved in the Libyan Maternal and Child Health Survey, 1995 Variable n % Age of child (years) ,1 780 17?3 1,2 895 19?9 2,3 968 21?5 3,4 983 21?9 4,5 871 19?4 Gender Boys 2231 49?6 Girls 2267 50?4 Socio-economic class Privileged 870 19?3 Intermediate 2877 64?0 Underprivileged 750 16?7 Area Urban 3135 69?7 Rural 1363 30?3 Region Al-Akhdar 553 12?3 Benghazi 604 13?4 Sirt 631 14?0 Tripoli 1513 33?6 Al-Zaouia 407 9?1 Al-Gharbi 487 10?8 Sabha 303 6?7 Degree of stunting Mild 1167 25?9 Moderate 591 13?1 Severe 324 7?2

Stunting risk factors in Libya 1143

Table 3 Bivariate analysis of factors associated with increased risk for stunting in under-fives in Libya: secondary analysis of data from the Libyan Maternal and Child Health Survey, 1995 Risk factor n/N OR 95% CI P I Basic determinants Living in a rural area 316/1363 1?24 1?07, 1?45 0?006 Age (ref: 4,5 years) 138/871 1?00 ,1 year 172/780 1?50 1?17, 1?92 0?001 1,2 years 242/896 1?96 1?55, 2?47 0?000 2,3 years 204/968 1?42 1?12, 1?80 0?004 Region (ref: Benghazi) 89/604 1?00 Al-Akhdar 154/552 2?24 1?67, 3?00 0?000 Sirt 157/631 1?92 1?44, 2?56 0?000 Al-Zaouia 86/407 1?55 1?12, 2?15 0?01 Al-Gharbi 122/488 1?92 1?42, 2?61 0?000 Boys 495/2230 1?21 1?05, 1?40 0?01 Socio-economic class (ref: Privileged) 150/870 1?00 Intermediate 591/2877 1?24 1?02, 1?51 0?03 Underprivileged 188/750 1?61 1?27, 2?05 0?000 II Underlying determinants Family and caregiver conditions Consanguinity (ref: No relation) 452/2381 1?00 Husband is a paternal cousin 328/1461 1?24 1?05, 1?45 0?01 Husband is a maternal cousin 122/523 1?30 1?03, 1?63 0?03 Family goes on no trips or visits 144/482 1?77 1?42, 2?20 0?000 Educational status of mother (ref: University) 39/301 1?00 Illiterate 345/1507 2?02 1?41, 2?89 0?000 Read and/or write 106/504 1?81 1?22, 2?70 0?004 Primary 184/839 1?91 1?31, 2?78 0?001 Preparatory 128/666 1?62 1?10, 2?39 0?02 Secondary 112/614 1?51 1?02, 2?24 0?04 Family does not watch television 94/323 1?75 1?35, 2?26 0?000

Family does not listen to radio 461/2100 1?17 1?01, 1?35 0?04 Number of siblings (ref: 24) 302/1494 1?00 .5 391/1743 1?18 1?00, 1?40 0?05 Father plays with child (ref: Almost every day) 585/3011 1?00 Rarely/never 31/90 2?20 1?41, 3?42 0?001 Sometimes 291/1277 1?22 1?04, 1?43 0?013 Educational status of father (ref: University) 79/550 1?00 Illiterate 122/487 2?00 1?46, 2?73 0?000 Read and/or write 89/455 1?47 1?05, 2?04 0?02 Primary 174/921 1?39 1?04, 1?86 0?03 Preparatory 207/910 1?76 1?33, 2?34 0?000 Secondary 210/944 1?72 1?29, 2?28 0?000 Health services Mother had no check-ups during pregnancy 209/868 1?29 1?08, 1?53 0?005 Place of delivery (ref: Public health establishment) 815/4022 1?00 Home 79/267 1?65 1?26, 2?17 0?000 Others 4/6 7?87 1?43, 43?45 0?02 Incomplete immunization 175/717 1?28 1?06, 1?55 0?009 Household environment Dwelling type (ref: Apartment) 88/578 1?00 Popular 252/1216 1?45 1?11, 1?89 0?006 Traditional 198/797 1?82 1?38, 2?41 0?000 Modern 342/1789 1?31 1?01, 1?69 0?04 Hut and house made from fur 22/91 1?79 1?06, 3?04 0?03 Others 27/28 149?48 19?83, 1126?81 0?000 Kitchen location (ref: Inside dwelling) 873/4296 1?00 Outside dwelling 49/185 1?41 1?01, 1?97 0?04 No kitchen 7/17 2?80 1?09, 7?21 0?03 Source of drinking water (ref: Pipe system) 521/2522 1?00 Wells without pump 88/318 1?46 1?12, 1?90 0?005 Rainwater catchment 23/70 1?84 1?11, 3?06 0?02 Water storage (ref: No water storage) 231/1068 1?00 Tin container 25/76 1?80 1?09, 2?96 0?02 Other 49/155 1?69 1?17, 2?44 0?005 Water treatment (ref: No treatment) 885/4305 1?00 Treatment by filtering 7/11 6?01 1?82, 19?82 0?003 Type of toilet facilities (ref: Flush toilet with sewer) 438/2372 1?00 Latrine with container 165/612 1?63 1?32, 2?00 0?000 Pit 17/35 4?06 2?08, 7?93 0?000 Open air 17/53 2?09 1?16, 3?76 0?02

Sudden weaning 399/1899 1?29 1?08, 1?54 0?004 Health conditions of the child Diarrhoea 94/339 1?53 1?19, 1?96 0?001 Weight at birth (ref: Normal) 758/3750 1?00 Low birth weight 88/289 1?74 1?34, 2?26 0?000
n, number of stunted children in the category; N, total number of children in the category.

1144 A El Taguri et al.

Discussion Libya is a country with an intermediate level of income, with a per capita gross domestic product of $US 6418 in 1995(19). A number of programmes were implemented to improve the nutritional status of the population in the second half of the last century. Large amounts of resources were spent on food subsidy programmes and also on food distribution activities for women and children(15). A nutritional surveillance system was introduced in maternal and child health centres. There have been marked improvements over the past few decades in the nutritional status of children(15,20). However, much work remains to be done(15).
Table 3 Continued Risk factor n/N OR 95% CI P Garbage disposal method (ref: Plastic bags) 288/1609 1?00 Container without lid 434/1871 1?38 1?17, 1?63 0?000 Thrown in street 14/44 2?18 1?15, 4?14 0?02 Others 9/15 7?26 2?58, 20?44 0?000 Garbage container located outside dwelling 276/1182 1?38 1?13, 1?70 0?002 III Immediate determinants Dietary intake

Table 4 Bivariate analysis of factors associated with decreased risk for stunting in under-fives in Libya: secondary analysis of data from the Libyan Maternal and Child Health Survey, 1995 Risk factor n/N OR 95% CI P II Underlying determinants Family and caregiver conditions Birth order (ref: 2nd4th child) 302/1494 1?00 First child 88/608 0?67 0?52, 0?87 0?002 Number of children (ref: 24) 316/1610 1?00 Single child 35/267 0?61 0?42, 0?89 0?01 Health services Place of delivery (ref: Public health establishment) 815/4022 1?00 Private establishment 12/122 0?42 0?23, 0?77 0?005 III Immediate determinants Dietary intake Time after birth breast-feeding started (ref: ,1 h) 220/919 1?00 Between 1 and 3 h 315/1585 0?79 0?65, 0?96 0?02 More than 6 h 211/1120 0?74 0?60, 0?92 0?006 Age when animal milk was given (ref: Not given) 806/3815 1?00 Delayed introduction (.12 months) 73/470 0?69 0?53, 0?89 0?005 Breast-feeding practices (ref: Optimal) 300/1248 1?00 Appropriate 50/299 0?63 0?46, 0?88 0?007 Acceptable 93/507 0?71 0?55, 0?92 0?009 Inappropriate 458/2342 0?77 0?65, 0?91 0?002 Age when powdered milk was given (ref: Not given) 309/1354 1?00 ,4 months 449/2257 0?84 0?71, 0?99 0?04 46 months 98/547 0?74 0?57, 0?95 0?02 Feeding practices (ref: Optimal) 103/426 1?00 Acceptable 60/339 0?68 0?47, 0?97 0?03 Given pasteurized bottled milk 404/2195 0?77 0?66, 0?89 0?000 Given infant powdered milk 438/2268 0?85 0?74, 0?98 0?03 Given juices 700/3547 0?77 0?65, 0?92 0?004 Given preserved baby food 269/1480 0?80 0?68, 0?93 0?005 Ever fed from infant bottle 604/3152 0?74 0?64, 0?87 0?000 Health conditions of the child Weight at birth (ref: Normal) 758/3750 1?00 Large-for-age at birth 44/329 0?62 0?44, 0?85 0?004
n, number of stunted children in the category; N, total number of children in the category.

Stunting risk factors in Libya 1145

This is the first time that data have been exploited to formulate a hypothesis on possible factors determining the problem of undernutrition among under-fives in Libya. One of the important aspects of this survey is that it was performed during the peak of political and economic difficulties that faced the country in the 1990s following UN sanctions and the counteracting measures that were taken. The result was a many-fold rise in the price of most food items. We did not find any evidence of significant collinearity in our model. However, certain inherent limitations may arise in the study such as the difficulty to examine temporal relationships, differences in seasonal distribution of risk factors, recall bias, absence of data on maternal

nutrition and food practices of the family, absence of data on parasitic infections, absence of comprehensive data on mental health of the family including different psychosocial stimulation and/or interaction between family members, and the possibility that respondents would answer in more socially desirable ways. Standard national cross-sectional studies such as PAPCHILD, the Pan Arab Project for Family Health and Multiple Indicator Cluster Surveys do not evaluate measures taken by different authorities to combat undernutrition. The complex interrelated factors associated with stunting that we found in the current study are represented according to the UNICEF conceptual framework (Fig. 1). The results of our study show the importance of the UNICEF model incorporating parental and socioeconomic characteristics in understanding the prevalence of stunting in Libya. However, such models should be interpreted only from an exploratory point of view(11). Models constitute a platform for better comprehension of potential dynamics and possible sites of intervention(21). The paths indicated by the arrows in the UNICEF framework are meant to suggest distal v. proximal relationships, and do not necessarily mean that distal factors cannot have direct effects on stunting. In the current study, being from the less privileged groups was a risk factor initially but disappeared in subsequent multivariate analysis. The effects of income are known to be mediated through other underlying determinants (4,12). These factors determine the ability of the family to combine their knowledge, resources and patterns of behaviour, to promote, recover or maintain health status and to cope with a difficult environment(4,11,12). Such factors include parental education, psychosocial stimulation and household environment(4,12,2224). In spite of equity-driven health and education service expansion in Libya during the 1970s, stunting was related to living in rural areas as well as in certain geographical regions. Stunting is known to be more prevalent in rural areas(22). People living in urban areas are provided with better access to health services, education and other social support systems which are either not available or not easily accessible to residents in rural areas. The two regions with the highest risk for stunting were the two mountainous areas. A strong inverse association between child height and altitude has been noticed previously. Possible explanations could include access to food, dietary habits, living practices, environmental conditions such as cold climate, hygienic measures such as water supply, and parasitic infections(7,25). These findings may also reflect the absence of vertical expansion that
Table 5 Multivariate analysis of risk factors associated with stunting in under-fives in Libya: secondary analysis of data from the Libyan Maternal and Child Health Survey, 1995 Risk factor OR 95% CI P I Basic determinants

Resident of Al-Akhdar (ref: Benghazi) 1?67 1?08, 2?58 0?02 Age (ref: 4,5 years) 1,2 years 2?32 1?67, 3?22 0?0001 2,3 years 1?64 1?22, 2?21 0?001 Boys 1?28 1?05, 1?55 0?02 II Underlying determinants Family and care giver conditions Fathers educational status (ref: University) Illiterate 2?10 1?17, 3?77 0?01 Preparatory 1?71 1?11, 2?65 0?02 Family goes on no trips or visits 1?52 1?07, 2?16 0?02 Father rarely/never plays with child (ref: Almost every day) 2?24 1?20, 4?16 0?01 Fathers age .50 years at birth (ref: .3050 years) 0?53 0?32, 0?90 0?02 Household environment Water storage in tanks (ref: No water storage) 0?70 0?54, 0?90 0?006 Water treatment by filtering (ref: No treatment) 8?45 2?31, 30?95 0?001 Garbage is thrown in the street (ref: Plastic bags) 13?81 2?33, 81?72 0?004 III Immediate determinants Health conditions of the child Diarrhoea 1?58 1?09, 2?29 0?02 Low birth weight 1?68 1?17, 2?40 0?005

1146 A El Taguri et al.

should have followed the horizontal expansion which occurred in the country during the 1970s. Further studies are needed to verify the exact role of these factors in this population. Gender is an important aspect of equity. Equal degree of undernutrition between under-five boys and girls by the year 2020 is accepted as a mean for evaluating gender equity in different societies(11,26). There is no evidence of gender bias in stunting in Libya based on the current study. On occasions, children may be born undernourished due to growth retardation in utero and their growth may improve exponentially over time(11,12,22,23). On other occasions, the anthropometric status of children worsens considerably only when they are weaned and particularly if low-quality solid foods are introduced. In the current study, stunting was associated with age period of 13 years. Other factors increasing the risk of stunting in this age period include loss of passive immunity, exposure to unsanitary conditions increasing the risk of infections that suppress appetite and directly affect nutrient metabolism, and return of the mother to work(11,23,27). In the current study, paternal education and age were significant factors associated with stunting in the final model. Higher education could reflect higher income and more paternal interest in child nutrition. More educated fathers are more likely to have educated wives. Educated mothers are known to be older at their first birth and are more knowledgeable about care practices. Educated families live in smaller households, in better houses, they are better able to use health-care facilities, and are more adept at keeping their environment clean(11,12,28). Parental consanguinity was a significant factor associated with stunting in bivariate analysis in the current study, but it disappeared in multivariate analysis indicating that it was a confounding variable. Studies have shown conflicting results on the impact of consanguineous marriages on child health(29).

Indicators for health services utilization such as incomplete immunization, poor check-up during pregnancy and non-supervised deliveries were all risk factors for stunting. These factors are known to influence stunting both directly and indirectly. Health knowledge and access to health care could also explain regional differences in undernutrition(11,23), as in Libya. Environmental factors refer to the availability of safe water, sanitation and environmental safety, including shelter. Environmental factors such as poor housing and exposure to untreated water are known to be associated with stunting(30,31). In fact, most of the positive effect of income on child height could be mediated by the quality of family housing(7,12). In the current study, household quality was an important risk factor in the multivariate model. In some regions of Libya and in spite of major drinking water projects, many people have to use variable methods to obtain a continuous water supply or more palatable water. Examples include boiling of water from superficial wells and the use of desalinated or filtered water from near-by factories. Such water may be either contaminated, thereby predisposing children to repeated bouts of infection, or lacking in some micronutrients, which might compromise growth. Having piped water in the home also reflects higher income levels and/or that the environmental sanitation in these homes is better.
Dietary intake Breast-feeding practices Complementary feeding and weaning practices Health Weight at birth* Diarrhoea*

Fig. 1 Explanatory model and possible interactions of different risk factors associated with stunting among under-five children in Libya based on the UNICEF conceptual framework(8) of the determinants of nutritional status (*bold italic font indicates those factors that persisted in the multivariate model)

Stunting risk factors in Libya 1147

STUNTING
Family and caregiver conditions Consanguinity Family size Parental education* Fathers age* Psychosocial stimulation* Health services Follow-up during pregnancy and delivery Immunization Household environment Dwelling type Kitchen location Source of drinking water, methods of water storage and treatment * Type of toilet facilities Garbage container location and method of disposal such as throwing in the street* Less privileged sections of the community Inhabitants of rural areas Inhabitants of certain geographical regions such as Al-Akhdar*, Sirt, Al-Zaouia, and Al-Gharbi Boys*

I. Basic determinants II. Underlying determinants III. Immediate determinants

When water is not readily available, food hygiene is frequently poor, which increases the risk of pathogen contamination and exposure to illnesses. However, the fact that storing water in tanks protects against infections in comparison to publicly supplied piped water calls for better quality control of this system. Diarrhoea is a known risk factor for stunting(11,23,30). The current survey was conducted during the summer. The prevalence of diarrhoea from our data was found to be 17?3% (779/4498). Diarrhoea could be related to food preparation and feeding practices and to increased exposure to pathogens as children become increasingly mobile throughout the first three years of life. As children get older, they may become more immune to infections due to a gradual increase in the colonization of various bacteria and viruses in the gut. Targeting health education messages to mothers with children younger than 3 years old may be an important option to consider. Breast milk contains the mix of nutrients that is best suited to the infants metabolism. An initial period of exclusive breast-feeding is essential to lower the risk of stunting, after which supplementary foods should be introduced appropriately into the childs diet(24). The use of bottle feeding predisposes to infections and may be associated with diluted non-nutritive formula preparation(24). Early introduction of complementary foods is a known predictor of undernutrition(23), but there is a debate as to the most suitable age that supplements should be first given(32). In the current study, breast-feeding was considered optimal if it started early, if it was continued for .12 months and if weaning started at 68 months. It was considered appropriate if weaning started earlier (between 4 and 6 months). In the current study, optimal breast-feeding was not as protective as appropriate breast-feeding. In addition, there was a protective effect of bottle feeding and early introduction of breast milk substitutes such as powder milk or pasteurized bottled milk. Previous studies reported a similar observation where, for example, longer breast-feeding was associated with both higher stunting and severe stunting risk(24). This should be viewed as failure of optimal complementary feeding and the inability of the household to provide supplemental foods, and should not be an argument for advertising of these substitutes(11). In other cases, when a child is severely stunted, mothers may respond by a decision to continue breast-feeding(24,33). Moreover, none of the dietary intake factors in the current study persisted

in the multivariate model. Low birth weight is a known correlate of stunting(12,28). In the current study, it had a potent effect on stunting that persisted in the single multivariate analysis. The known effect of low birth weight on child health makes it the most relevant single factor for childrens survival(34). To fight undernutrition sustainably, changes in many of the underlying factors are necessary(11). In spite of the existence of food security programmes in Libya, the broader concept of nutritional security should be implemented. This is achieved for a household when secure access to food is coupled with a sanitary environment, adequate health services and knowledgeable care. As in other studies, the risk factors of stunting that we found were diverse, complex, difficult to manage, and their effects started even before birth(35). The current study provides relevant information for determining courses of action to be taken at the meso and micro level to improve the nutrition and health of children in Libya. Policy frameworks must be established that incorporate short-, medium- and long-term strategies to solve nutritional problems in Libya. Corresponding intervention strategies should be comprehensive, culturally sensitive and addressed at various levels. Programmes should specifically target higher-risk groups such as young children (13 years), residents of Al-Akhdar, boys, less educated fathers, poor family social life, low-quality household environment, diarrhoea and low birth weight. Particular attention should be given to the particularly brief window of intervention from the mothers pregnancy through the childs first two years of life. Further research, particularly on regional differences, is required to design relevant and effective intervention programmes. Acknowledgements There are no conflicts of Interest and no sources of funding. Authors contributions: A.E.T. was responsible for data analysis and interpretation, performed statistical analysis and drafted the paper. O.G. and S.M.M. supervised data analyses and contributed to interpretation of data. P.G. and S.H. contributed to drafting the paper. A.A.M. and I.B. were responsible for study design and coordinated the supply of the data. All contributors were involved in critical revision of the paper. References
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5. Pelletier DL (1994) The potentiating effects of malnutrition on child mortality: epidemiologic evidence and policy implications. Nutr Rev 52, 409415. 6. Khuwaja S, Selwyn BJ & Shah SM (2005) Prevalence and correlates of stunting among primary school children

1148 A El Taguri et al. in rural areas of southern Pakistan. J Trop Pediatr 51, 7277. 7. Behrman JR & Skoufias E (2004) Correlates and determinants of child anthropometrics in Latin America: background and overview of the symposium. Econ Hum Biol 2, 335351. 8. UNICEF (1990) Strategy for Improved Nutrition of Children and Women in Developing Countries. New York: Oxford University Press. 9. World Health Organization (1990) Appropriate Uses of Anthropometric Indices in Children. ACC/SCN Stateofthe-Art Series, Nutrition Policy Discussion Paper no. 7. Geneva: WHO. 10. Kirkwood B & Sterne J (2003) Essential Medical Statistics, 2nd ed. Oxford: Blackwell Science. 11. Caputo A, Foraita R, Klasen S & Pigeot I (2003) Undernutrition in Benin an analysis based on graphical models. Soc Sci Med 56, 16771691. 12. Aerts D, Drachler Mde L & Giugliani ER (2004) Determinants of growth retardation in Southern Brazil. Cad Saude Publica 20, 11821190. 13. The General Peoples Committee for Health and Social Affaires (1996) The Pan Arab Project for Child Development, The Libyan Maternal and Child Health Survey. Principal Report. Sert, Libya: The General Peoples Committee for Health and Social Affairs. 14. World Health Organization (2005) Libyan Arab Jamahiriya. WHO Global Database on Child Growth and Malnutrition. http://www.who.int/nutgrowthdb/database/countries/lby/ en/ (accessed April 2008). 15. El Taguri A, Rolland-Cachera M-F, Mahmud SM, Elmrzougi N, Abdel Monem A, Betilmal I & Lenoir G (2007) Nutritional status of under-five children in Libya: a national population-based survey. Libyan J Med AOP: 071006. 16. WHO Multicentre Growth Reference Study (2006) Enrolment and baseline characteristics in the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl 450, 715. 17. League of Arab States, Pan Arab Project for Child Development (2006) Arab Maternal and Child Health Survey. http://www.papfam.org/arab_league/about_PAPFAM.htm (accessed 2006). 18. El-Tajouri RF (1979) Cross sectional study of growth in urban pre-school children in Libya. PhD Thesis, University of Zurich, Switzerland. 19. International Monetary Fund (2008) Data and Statistics, World Economic Outlook. http://www.imf.org/external/ datamapper/index.php (accessed April 2008). 20. International Bank for Reconstruction and Development (1960) The Economic Development of Libya. Report of a mission organized by the International Bank for Reconstruction and Development. Baltimore, MD: The Johns Hopkins Press. 21. Bar-Yam Y (2006) Improving the effectiveness of health care and public health: a multiscale complex systems analysis. Am J Public Health 96, 459466.

22. Steyn NP, Labadarios D, Maunder E, Nel J & Lombard C (2005) Secondary anthropometric data analysis of the National Food Consumption Survey in South Africa: the double burden. Nutrition 21, 413. 23. Bloss E, Wainaina F & Bailey RC (2004) Prevalence and predictors of underweight, stunting, and wasting among children aged 5 and under in western Kenya. J Trop Pediatr 50, 260270. 24. Brennan L, McDonald J & Shlomowitz R (2004) Infant feeding practices and chronic child malnutrition in the Indian states of Karnataka and Uttar Pradesh. Econ Hum Biol 2, 139158. 25. Dang S, Yan H & Yamamoto S (2008) High altitude and early childhood growth retardation: new evidence from Tibet. Eur J Clin Nutr 62, 342348. 26. Wamani H, Astrom AN, Peterson S, Tumwine JK & Tylleskar T (2007) Boys are more stunted than girls in sub-Saharan Africa: a meta-analysis of 16 demographic and health surveys. BMC Pediatr 7, 17. 27. Branca F & Ferrari M (2002) Impact of micronutrient deficiencies on growth: the stunting syndrome. Ann Nutr Metab 46, Suppl. 1, 817. 28. Marins VM & Almeida RM (2002) Undernutrition prevalence and social determinants in children aged 0 59 months, Niteroi, Brazil. Ann Hum Biol 29, 609618. 29. Bittles AH (2003) Consanguineous marriage and childhood health. Dev Med Child Neurol 45, 571576.

30. Fernandez ID, Himes JH & de Onis M (2002) Prevalence of nutritional wasting in populations: building explanatory models using secondary data. Bull World Health Organ 80, 282291. 31. El-Sayed N, Mohamed AG, Nofal L, Mahfouz A & Zeid HA (2001) Malnutrition among pre-school children in Alexandria, Egypt. J Health Popul Nutr 19, 275280. 32. Reilly JJ & Wells JC (2005) Duration of exclusive breastfeeding: introduction of complementary feeding may be necessary before 6 months of age. Br J Nutr 94, 869872. 33. Caulfield LE, Bentley ME & Ahmed S (1966) Is prolonged breastfeeding associated with malnutrition? Evidence from nineteen demographic and health surveys. Int J Epidemiol 25, 693703. 34. WHO Working Group (1986) Use and interpretation of anthropometric indicators of nutritional status. Bull World Health Organ 64, 929941. 35. Rappaport R (1987) Endocrine control of growth. In Linear Growth Retardation in Less Developed Countries. Nestle NutritionWorkshop Series, vol. 14, pp. 109126 [JC Waterlow, editor]. New York: Raven Press.

Stunting risk factors in Libya 1149

16.Risk factors for wasting and stunting among children in Metro Cebu, Philippines
ABSTRACT Risk factors for wasting and stunting were examined in a longitudinal study of 18 544 children younger than 30 mo in Metro Cebu, Philippines. Measures of household demographic
and socioeconomic characteristics, maternal characteristics
and behavior, and child biological variables were

developing countries indicate that, on average, stunting (a

deficit in length relative to age) and wasting (a deficit in weight relative to length) affect > 40% and > 10%, respectively, of children < 5 y (1). These figures provide important
evidence of a global nutrition problem that must be addressed. However, they mask the marked variation in proportions of stunted and wasted children that exist from country to country, by urban or

analyzed

cross-sectionally in six child age-residence strata by using logistic regression. Our results support biological and epidemiologic cvidence that wasting and stunting represent different processes of malnutrition. They also indicate that the principal risk factors for stunting and wasting in infants < 6 mo of age were

either maternal
behaviors or child biological characteristics under maternal control,

eg, breast-feeding status and birth weight. After 6 mo of age, household socioeconomic characteristics emerged with behavioral and biological variables as important determinants of malnutrition, eg, fathers education and presence of a television and/or radio. Household socioeconomic status influenced the risk of stunting earlier in rural than in urban barangays. Implications of the results for interventions are discussed. Am J Clin Nuir l996;63:96675. KEY WORDS Anthropometry, malnutrition, nutritional disorders, risk factors, stunting, wasting INTRODUCTION Statistics on the prevalence of protein-energy malnutrition in

rural residence, and among children at different ages. For example, a recent comparative analysis of Demographic and Health Survey data from 19 developing countries (8 from
Sub-Saharan Africa, 3 from the Near East/North Africa, 2 from

Asia, and 6 from Latin America/Caribbean) indicated that the prevalence of stunting in children 1 y of age ranged from 5.3% in Trinidad and Tobago to 69.4% in Guatemala (2). The preyalence of wasting in children the same age ranged from 1.2%
in Colombia to 19.4% in Sri Lanka. Biological and epidemiologic evidence indicates clearly that

stunting and wasting represent different processes of malnutrition (3, 4). Stunting signifies the accumulated consequences of

slowed skeletal growth often associated with long-term dietary

I From

inadequacy, repeated infections, or both. The prevalence of stunting gradually increases in children from birth to 2 y of age when it tends to level off (3). Wasting indicates that a child has an unusually low body
tissue and fat mass for an individual of his or her length.

Wasting can result from either weight loss or failure to gain weight. Under conditions of marginally adequate food intake,
its onset can occur rapidly, particularly during episodes of

the Maryland Department of Health and Mental Hygiene, Baltimore, and the Department of Population Dynamics, The Johns Hopkins University School of Hygiene and Public Health, Baltimore. 2 Supported in part by the United States Agency for International Dcvelopment (USAID), the Bureau for Science and Technology and USAID/ Manila through the Child Survival Project, and the Institute for International
Programs at The Johns Hopkins University, Baltimore. 3 Address reprint requests to JA Ricci, Maryland Department of Health and Mental Hygiene, 500 North Calvert Street, Baltimore, MD 21202.

acute infectious illness. Wasting peaks in prevalence between 12 and 24 mo of age when dietary insufficiency and diarheal
diseases are most frequent (3).

Received June, 1995. Accepted for publication February 1, 1996.

Both wasting and stunting are associated with poor health outcomes in infants and young children. The ramifications of wasting are well-documented. They include both an increased
risk of morbidity from infectious diseases (5-7) and of mortality (8, 9). Stunting also poses a considerable nutrition

Downloaded from www.ajcn.org by guest on December 29, 2011 RISK FACTORS FOR WASTING AND STUNTING 967 in children represents only one stage in an intergenerational continuum of impaired function that affects not only currently malnourished children, but also adolescents and adults (particularly women) who were malnourished as children, and their
subsequent offspring (19). Malnutrition, in addition to other

problem, the health consequences of which are less well understood. Many stunted children will never achieve their full growth potential and will mature into stunted adolescents and adults (10). However, being small is of lesser concern than is the process of becoming small. Small achieved body size often
indicates that conditions have detrimentally affected human

environmental factors, impairs the fulfillment of individual genetic potential throughout life (20). Research is needed on risk factors for stunting and
wasting

development (11). Developmental impairment is the most extensive public health problem among children in many developing countries (12) and its effects can be permanent (13). One
documented

at different ages and in different environmental and sociocultural settings. We know that inadequate food intake and high morbidity within the social and economic context of poverty
increases children s risk of growth faltering. However, because

malnutrition is etiologically heterogenous among populations (2 1), we also expect risk factors for malnutrition to
vary among

functional consequence of stunting includes reduced learning ability in school (14). Then, as stunted children mature, the functional consequences continue. In 1985, an estimated
500

million women of reproductive age in developing countries were stunted as a result of childhood proteinenergy malnutrition (15). These women experience an increased risk of mortality during childbirth (16) and of poor pregnancy outcomes
such as low birth weight and elevated perinatal, neonatal, and

populations. Differences in population characteristics such as patterns of dietary intake and morbidity, child caregiving behavior (including feeding practices), cultural beliefs, access to health care, and environmental ecosystems warrant a populalionspecific approach when studying risk factors for malnutrition.

The application of such study results will help to improve the outcome of interventions designed to improve
nutritional status.

infant mortality (17, 18). Thus, diminished functional capacity

The purpose of this study was to examine risk factors for wasting and stunting in children < 30 mo of age in Metro Cebu, Philippines, and to recommend interventions. The analyses

identified demographic, socioeconomic, behavioral, and biological correlates of wasting and stunting in children in three age groups residing in urban and rural sectors

participate, they were not contacted, or they were not available).

of Metro Cebu. SUBJECTS AND METHODS Data collection The data for this research were collected by the Office of Population Studies of the University of San Cabs as part of a larger longitudinal study to evaluate health services provided by the Philippines Department of Health in Metro Cebu. The evaluation included an assessment of the reach and effectiveness
of health services and an evaluation of their effect on the

Approximately 70% of study children were visited on more than one occasion, with each child contributing an average of 2.5 observations during the course of their study participation. Older children at study entry and new births during the last 6 mo of the study contributed only one record. At baseline, field personnel obtained detailed information on the demographic, anthropometric, health, and economic status of study households, mothers, and children. Household data
included the demographic composition and characteristics of the household, water and sanitation facilities, type and construction

morbidity and mortality of children younger than 2 y (22). The

study was conducted under the ethical guidelines of the Committee

on Human Research at The Johns Hopkins University School of Hygiene and Public Health, Baltimore. Metro Cebu, located on Cebu Island, one of the Central Visayan islands of the Philippines, encompasses Cebu City and its entire metropolitan area. At the time of this study, Metro Cebus population of 1.5 million people resided in
> 200

of residence, ownership of radio and television, means of transportation, and distance to nearest health facility. Maternal information included a reproductive history, prenatal
care sought for the study child, knowledge and use of oral

rehydration solution, and current contraceptive practice. Information on the child included birth weight, immunization history, current breast-feeding status, recumbent length, current
weight, and recent history of illness. During the followup surveys, field personnel measured childrens weights and lengths and interviewed mothers to update their

predominantly urban barangays (local political administrative units). Some agricultural and fishing areas are also located in Metro Cebu; these are classified officially as rural barangays
(23).

current reproductive status and their childrens recent history of illness.

Severely ill children were referred to the nearest health facility.

The study was conducted between July 1988 and December 1990. The research design called for periodic crosssectional
surveys of all households in a fixed sample of urban and rural

barangays. Households were enrolled in the study and participated as long as a child younger than 30 mo was resident. The study examined a total of 18 544 children younger than 30 mo from 7 urban and 26 rural barangays. The sampling criteria and methods were described previously (22). Data were collected on each child during an initial (baseline)
visit and then at 6-mo intervals until the child exited the study. Eighty-two percent of the children exited the study

Field staff were all college graduates with experience in data collection, including anthropometry. However, regardless of experience, all field personnel were trained to measure weights and lengths and were retrained in anthropometry twice during
the studys 2.5 y. Children were measured while wearing only

either because they reached 30 mo of age or because the study ended. Migration and death accounted for the study exit of another 12% and 3%, respectively. The remaining 3% of chilthen were lost to follow-up (eg, they quit, they refused to

light clothes at home and in the presence of and with permission from their mothers. A Salter scale (CMS Weighing Equipment, Ltd, London) and a locally made infantometer were used following standard procedures (24). Recumbent length was measured on all children, including those > 24 mo of age. Childrens recent history of illness was obtained by interview
with a validated morbidity instrument and protocol (25, 26). Mothers were asked whether children had had

an episode

of diarrhea or respiratory disease during the 2 wk before the interview, or measles during the previous 6 mo. Diarrhea was defined by the mothers account, and reported number of stools on the worst day was also recorded. Respiratory illness encompassed
symptoms from mild coughing to severe pneumonia. Measles was defined as rash with fever on _ 4 d in the past 3

Data were stratified by place of residence (urban or rural) and the childs age at the time of interview. Three age intervals were created within each residence stratum based on clear age differences in the percentage of stunting and wasting observed during preliminary analyses: birth to 5 mo, 6-1 1 mo, and I 2-30 mo of age. Data were analyzed cross-

sectionally within
each of the six age-residence strata. First, basic descriptive statistics were generated: frequency distributions for categorical and ordinal variables and medians, means, and SDs for continuous variables. In these tabulations no tests of significance were done. Approximately one-third of children in each ageresidence stratum had missing data on birth weight and/or length of previous birth interval. A comparison of the household socioeconomic characteristics of children with and without these data indicated that those without were of significantly lower socioeconomic status. Therefore, to analytically avoid the bias, we adjusted the socioeconomic distribution of the analytic sample (children with birth weights) to that of the entire sample (children with and without birth weights). To do this, we weighted observations by the socioeconomic variable presence of a television and radio in each age-residence stratum in which birth weight or length of previous birth interval was significantly associated with wasting or stunting (P < 0.05).
This variable was selected because its three levels (neither

mo. Data analysis Data were initially entered and edited on

microcomputers at

the University of San Cabs with additional data cleaning at Johns Hopkins University. Computer files were constructed with multiple records for each child and additional variables were derived to describe childrens health and anthropometnic
status. Four health states were defined: well, ill with diarrhea

only, ill with severe respiratory disease only (defined as cough with difficulty breathing and _ 2 d of fever), and ill with both
respiratory and diarrheal illnesses. Because of the very low

Downloaded from www.ajcn.org by guest on December 29, 2011 968 RICCI AND BECKER
incidence of measles in the population, it was ignored as a specific category of illness in the analyses. However,

children
with measles were included in the samples of children with diarrhea, severe respiratory disease, or both if any of

these
illnesses existed simultaneously with measles. Anthropometric measurements were converted to three

indexes:
length-for-age, weight-for-length, and weight-for-age (27, 28). These indexes were then expressed as Z scores relative
to the international [National Center for Health

radio nor television, radio only, or television with or without radio) were roughly evenly distributed among households in each of the six age-residence strata, and the data were available for all households. Bivariate associations between stunting and wasting and
season of year and demographic, socioeconomic, behavioral,

Statistics

(NCHS)/Centers for Disease Control and Prevention (CDC)/ World Health Organization] reference population to standardize the distribution (29). A childs nutritional status was then categorized by his or her length-for-age and weight-forlength z scores (30). A child was defined as wasted if his or her
weight was less than that of a child (of the same length) with

and biological variables were tested in each ageresidence stratum. Variables tested for an association with nutritional
status included type of flooring material, type of wall material,

type of cooking fuel, water source, type of toilet, presence of

television and radio, number of persons per room, distance to clinic, paternal occupation, years of paternal formal

a value 2 SDs below the reference median weight-forlength. A child was categorized as stunted if his or her length was less than that of a child (of the same age) with a value 2 SDs below the reference median length-for-age. Children who were simultaneously
wasted and stunted were included in both

education,
yeas of maternal formal education, maternal occupation, number

of prenatal visits, month of first prenatal visit, breastfeeding

categories.

Weight-for-age was not considered beyond the descriptive level because, as a composite index, it does not differentiate stunted from wasted children (3).

status at the time of interview, maternal age, length of previous birth interval, birth weight, sex, age of child, child health status, and season of year. Categorical and continuous variables that were significant (P < 0.05) according to a
chi-square or t statistic, respectively, were retained for inclusion

in regression models. Logistic-regression models were constructed for each ageresidence

stratum. Groups of covariates were added sequentially to the models, and relative changes in the magnitude and
significance of regression coefficients were noted. The order of

between urban and rural barangays (Table 1). Urban households had clearly higher socioeconomic status as measured by housing characteristics such as water source, cooking fuel, ownership of a television and radio, type of floor and wall
construction, and the parents amounts of formal education.

adding variables was determined by their conceptual relation to the outcome variables and progressed from distal to proximal.
Thus, season of year and socioeconomic variables were added

first, followed by behavioral variables, and lastly, biological

variables. Collinearity diagnostics (condition indexes) were examined for evidence of multicollinearity. Covariates with a significance level of P < 0. 1 were

retained for further testing. Variables included in the final logistic models were significant at P < 0.05 based on the chi-square
test of the difference in the -2 log likelihoods of the models

with and without the variable present (31). As a final step in refining the models, interactions were tested between variables found to be significant predictors of wasting or stunting. As a product of the longitudinal research design, the data set contained two or three observations on some children > 12 mo of age. These observations violated the assumption of independence required for statistical tests. Therefore, in this age stratum, one observation was randomly selected for each child in the sample (using the RANUNI function) and the final models were rerun. Attempts were made to apply generalized estimating equation models to adjust for the dependent observations
(32). However, the available software could not be used successfully on a data set of this size, with the number of variables

However, urban and rural households differed little in household size and density (eg, number of persons per room). Maternal reproductive characteristics and prenatal care also differed between urban and rural barangays (Table 1). Rural mothers were more likely to delay their first prenatal visit and have fewer such visits. Rural mothers also tended, on average, to have longer birth intervals. The median duration of breastfeeding in the sample was 12 mo. Virtually all women initiated breast-feeding. By 6, 12, and 18 mo of age, 80%, Downloaded from www.ajcn.org by guest on December 29, 2011
% 31

35
34 13 70 17 42

25
33 68 32 17 38

45
20

15
65

57
14 29

52
48 4599

85
15 4616 51 49

in the models and observations that required weighting. Results before and after application of the adjustment procedure were very similar. Data preparation and analysis were performed by using SAS version 6.04 statistical software for personal computers (33). Age and sex-specific Z
scores were

58
42 4317

85
15 4121

RISK FACTORS FOR WASTING AND

STUNTING 969
TABLE 1
Percentage distributions and means for selected characteristics of study children by place of residence, Metro Cebu Urban Variable (n 6698) Rural

calculated from anthropometnic measurements with an anthropometric

program of the CDC (34). RESULTS

Characteristics of the sample The socioeconomic status of households differed markedly

(n = 6072)
Categorical variables Television and radio Neither

Radio only Television Wall material

Wood
Cement All else

were longer and leaner than their urban counterparts. After 3 35 mo, the situation reversed and urban children were consistently
43 longer and leaner than rural children.

Flooring material Bamboo/all else Any wood Any cement

Cooking fuel

22 In both strata, childrens mean length was below

the NCHS
reference median length-for-age from birth through 30 mo of 27 age. The apparent improvement in mean length-forage begin59 ning at 24 mo of age can be attributed to the

Wood
Gas or oil Water source Well Purchased Pipe/pump Type of toilet None Pit Sealed

juncture of the
14 length and stature medians at 24 mo of age in the

NCHS reference population (35). Mean weight-for-length exceeded

Mothers employment
Not employed Employed in home

the NCHS reference median during the first 6 mo of life,

28 decreased through 12 mo of age, and then leveled off

and

Employed away from home

Previous birth interval _ 24 < 24 Number of observations Birth weight _ 2500 g < 2500 g Number of observations Sex of child Male

gradually improved. Childrens mean weight also fell below 86 the NCHS reference median weight-for-age. However, before 6 14 mo of age it could be attributed to low lengthfor-age whereas
after 6 mo of age it was due to both below average length-for16 age and weight-for-length.
13 The

Female
Continuous variables Age of child at study entry (mo)

Age of mother at childs study entry

Formal education of father (y)

patterns of stunting and wasting were similar between 71 urban and rural children although a larger percentage of children
were stunted in the rural barangays and a larger percent5 age were wasted in the urban barangays. The difference in 39 prevalence of stunting by place of residence was significant after 6 mo of age (P < 0.05). Significantly more rural children 57 < 6 mo of age were wasted but after 12 mo of

Formal education of mother (y)

Number of prenatal visits

Month of first prenatal visit 14.3 7.12 14.3 6.9

(y) 27.0 5.8 27.3 6.0 9.1 3.8 7.7 3.8 8.6 3.6 7.5 3.7 6.9 4.2 6.4 3.9 4.5 1.6 5.0 1.4 , Number of observations are indicated where _ 5% of children are missing data. 2j SD.

age significantly 19 more urban children were wasted (P < 0.05).

Stunting oc24 curred early; roughly 13% of infants were stunted before 6 mo

70%, and 40%, respectively, of rural children were still breastfed. These values compare with 70%, 60%, and 30% of urban children the same age (22). Data on the exclusivity of breastfeeding and other feeding practices were not collected. Considering
all visits, 10% found a child ill with diarrhea, and on
2% of

of age and the prevalence of stunting sharply increased between

6 and 23 mo of age. At 18-23 mo of age, 40% of urban children and almost one-half of rural children were stunted. The pattern of wasting was different from that of stunting.

Before 6 mo of age, < 1% of children in urban and rural

barangays were wasted. The prevalence increased between 6 and 17 mo of age, plateaued at 12%, and then dropped to

the visits the child had severe respiratory disease. In

< 1% of the visits the child had both illnesses. These

results

were similar for urban and rural children. Anthropometry A cross-sectional view of the childrens mean anthropometric status at 1 -mo intervals from birth to 30 mo of age is shown in Figures 1-3. During the first 3 mo of life, rural children

9.0% and 5.6% in urban and rural children, respectively, after

51 24moof age. 49 There were sex differences in stunting and wasting

(Table 2). In the rural barangays, more boys than girls were stunted and wasted before 2 y of age. However, after 2 y of age the
situation reversed. In the urban barangays, sex differences in

stunting and wasting followed patterns similar to those in the rural barangays. Previous research has shown that weight-forlength responds sensitively to changes in season (36). Two principal seasons occur in the Metro Cebu region: a rainy season from approximately May to October and a dry season from November to April. The percentage of wasted children varied throughout the year with a clear apex in July, the middle

of the rainy season. Risk factors for stunting and wasting Clear differences in risk factors for stunting (Table 3) and wasting (Table 4) emerged from the multiplelogistic-regression
analyses. Variables listed in Tables 3 and 4 were significantly associated during bivariate analyses with stunting and wasting, respectively, in at least one of the six child age-

ually lessened with age, low-birth-weight children were almost twice as likely as their counterparts of normal birth weight in both urban and rural areas to be stunted even after 1 2 mo of age. Protective factors against stunting included current breastfeeding (particularly for infants 5 mo of age), more frequent prenatal care, being female, and higher household socioeconomic status (as indicated by the presence of a radio and/or television in the home and the parents amounts of
formal

education). Illness (diarrhea, severe respiratory infection, or both) in the

2-wk period before the study interview was the most consistent

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0.5 0 , .0.5

.1
.1.5

.2
0 10 15 20 25 30 0.5 0 .0.5 .1.5 0 5 10 15 20 25 30

risk factor for wasting among rural children. In the urban barangays, none of the variables emerged as a risk factor for wasting in more than one age interval. Low birth weight and
Age (mo)

FIGURE 2. Mean length-for-age Z scores by age ofchild

and place ofresidence in Metro Cebu, Philippines, in rural (U; pooled SEM 0.05; n 21 852 observations on 8748 children) and urban ( #{1;49p}ooled SEM 0.05; n 24 235 observations on 9790 children) areas.

970 MCCI AND BECKER

Age (mo)

FIGURE 1. Mean weight-for-length Z scores by age of

child and place of residence in Metro Cebu, Philippines, in rural (U; pooled SEM = 0.04; n = 21 852 observations on 8748 children) and urban ( #{14; 9p}ooled SEM = 0.03; n = 24 235 observations on 9790 children) areas. residence strata (P < 0.05). The difference in factors

Downloaded from www.ajcn.org by guest on December 29, 2011

.1.5 0 5 10 15 20 25

RISK FACTORS FOR WASTING AND STUNTING 971

N
.2

associated with stunting and wasting in the six child ageresidence strata indicated that place of residence and childs age are important
risk factors for both states of malnutrition. Risk factors for
stunting showed more consistency across age groups and residence

Age (mo) 30

FIGURE 3. Mean weight-for-age Z scores by age of child

and place of residence in Metro Cebu, Philippines, in rural (U; pooled SEM 0.04; n 21 852 observations on 8748 children) and urban ( #{14:9p} ooled SEM = 0.04; n = 24 235 observations on 9790 children) areas.

season of year (ie, rainy season) were significant risk factors

for wasting in children only after 12 mo of age. Protective

strata. Risk factors for wasting exhibited much more child age-residence stratum specificity. Low birth weight (< 2500 g) and a short previous birth interval (< 24 mo) were the two most important risk factors for stunting. In rural areas, low-birth-weight infants were four times more likely than normal-weight infants (_ 2500 g) to be stunted during the first 6 mo of life. In urban areas, these odds doubled to almost eight. Although the risk associated with low birth weight was greatest in infants < 6 mo of age and gradN .1

factors against wasting for older children included higher household socioeconomic status (presence of a television in the home) and maternal employment away from home. Interestingly, the effect of maternal employment at home depended on the place of residence. It was protective in urban areas but was related to elevated risk of wasting in rural areas.
No significant changes occurred in either the magnitude or

significance of regression coefficients during the model-building process of sequential addition of groups of covariates. In

other words, distal variables (eg, season of year and indicators of household socioeconomic status) that were significant in the initial model remained significant after the addition of behavioral and biological variables more proximal to the outcome. Collinearity diagnostics did not indicate multicollineanity among model covariates.
TABLE 2 DISCUSSION

The patterns of stunting and wasting observed in Cebuano

children reflected their differential exposure to risk factors

associated

with age and residence. During the first 6 mo of life in urban and rural areas, the principal predictors of stunting and
wasting were behavioral and biological variables (eg, mothers previous birth interval and the childs birth weight, current breastfeeding status, and health status). These are factors under

Risk factor and category (17 = 221 1) (n 2230) (n 2885) (ii - 2101) (ii 2084) (n 2678) Socioeconomic variables Television and radio (reference = neither) Radio only 0.75 0.59 0.74 0.86 Television 0.60 0.61 0.56 0.77 Water source (reference = well) Purchased - - 0.92 - - 0.92 Pipe/pump 0.97 0.80 Type of toilet (reference = none) Pit - - 0.95 - 0.82 0.83 Sealed 0.77 0.66 0.71 Flooring material (reference = bamboo/all else) Wood - 0.77 0.80 - - l.0l Cement 0.66 0.74 0.81 Cooking fuel (reference = wood) Gas or oil - - 0.70 - - 0.70 Number of persons per room - - I .06 - - Years of fathers formal education - 0.92 0.95 0.93 0.94 0.93 Behavioral variables Years of mothers formal education 0.91 - 0.96 - - 0.95 Age of mother (y) - - - - - 1.02 Month of first prenatal visit - - 0.97 - - Number of prenatal visits (reference = 0-4) 5-7 0.59 - - - - 1.03 _8 0.64 .76 Previous birth interval (reference _ 24 mo) < 24 mo 1 .4 1 1 .67 1 .33 1.47 1 .46 1.13

Currently breast-feeding (reference = no)

Yes 0.30 - 0.73 0.54 - 0.80 Biological variables Age of child (mo) - 1 . I 7 1.02 1 .25 1. I 8 Sex of child (reference = male) Female - 0.57 - 0.70 0.67 Birth weight (reference = _ 2500 g) < 2500 g 7.68 2.47 1.72 4.14 3.16 1.90 I Relative odds estimates are shown for final models. Estimates are significant (P < 0.05) unless indicated otherwise. n values

direct maternal control, influenced by maternal behavior, or determined by maternal biological characteristics. Diarrheal morbidity increased
an infants risk of wasting almost four times during the first 6 mo of life in urban barangays. The risk of

are number of children.

2 Variable

stunting associated with low birth weight and short previous birth interval persisted through the childrens first 30 mo of life. Residence modified the effect of these risk factors on infants
risk of malnutrition during the first 6 mo of life. Low Prevalence (percentage) of stunting and wasting among boys and girls in Metro Cebu by age and place of residence . Anthropometnc status and age (mo) Urban Rural Boys Girls Difference Boys Girls Difference Stunted
0-5 13.2 13.1 0.1 14.2 11.4 2.82 6-1 1 24.1 17.9 6.22 27.3 20.6 6.72 12-17 35.8 32.7 3.1 41.2 34.0 7.22 18-23 39.7 40.4 -0.7 48.7 45.7 3.0 24-29 27.3 28.7 -1.4 34.6 34.9 -0.3

not included in final model. of this variable had no significant effect (P < 0.05) after adjustment for dependent observations. birth weight and infants current breast-feeding status had a
3 Categories

more pronounced effect on the risk of stunting in urban than in

rural barangays. An urban infant had twice the risk of stunting during this age interval compared with a rural infant if the child was born of low birth weight (Z 2.64, P < 0.01). Similarly, breast-feeding offered greater protection in urban areas than in rural areas by reducing an urban infants risk of stunting by two-thirds compared with the reduction by one-half observed in rural infants < 6 mo of age (Z = 2.35, P < 0.05).
As the

Wasted
0-5 0.4 0.5 -0. 1 1 .0 1 .0 0.0 6-Il 4.7 4.1 0.6 5.0 3.2 1.82 12-17 13.4 12.1 1.3 10.9 7.9 3.02 18-23 15.2 12.1 3.12 11.9 9.6 2.3 24-29 8.6 9.5 -0.9 4.8 6.3 - IS
Boys

children matured, household socioeconomic characteristics

(eg, presence of a television and/or radio in the home,

fathers amount of formal education, water source, and toilet

facilities) emerged in conjunction with behavioral and biological

minus girls. test of null hypothesis of no difference between sexes: 2 p < 0.01, p < 0.05.
2.3 For

variables (eg, mothers previous birth interval and employment

Downloaded from www.ajcn.org by guest on December 29, 2011 972 RICCI AND BECKER
TABLE 3
Relative odds for risk factors for stunting by place of residence and age of child, Metro Cebu Urban Rural 0-5 mo 6-1 1 mo 12-29 mo 0-5 mo 1 1 mo I 2-29 mo

status, and the childs birth weight, current breast feeding

status, and health status) as important risk factors for wasting and stunting. Socioeconomic factors operate indirectly to affect
childrens nutritional status by determining the quality of the childs diet, care, and physical environment.

Residence modified the effect of some of these factors on

older childrens risk of malnutrition. Household socioeconomic

status influenced the risk of stunting earlier in the rural than in

the urban barangays. After 12 mo of age, maternal employment

in the home increased childrens risk of wasting in rural barangays, but decreased it in urban barangays. Childrens health status (diarrhea, severe respiratory infection, or both) increased

Severe respiratory illness only 1.67 2.68 1.79 Both 0.93 2.43 1.82 Diarrhea in past 2 wk (reference = no) Yes 3.69 - - - 1 Relative odds estimates are shown for final models. Estimates are significant (P < 0.05) unless indicated
otherwise.
2 Results

for children aged 0-5 mo are not shown because the model failed to converge. 3 Variable not included in final model. 4 Categories of this variable had no significant effects (P
< 0.05) after adjustment for dependent observations.

childrens risk of wasting in rural but not in urban barangays after 12 mo of age. The patterns of risk factors for stunting and wasting
within and across age-residence strata support biological

and epidemiologic evidence that stunting and wasting represent

two different processes of malnutrition (3, 4). The relatively consistent pattern of risk factors for stunting suggests that continued exposure to adverse conditions over an

extended period of time retards childrens linear growth.

Adverse conditions encompass a wide range of risk factors

from measures of household socioeconomic status to mdividual

biological endowments. Conversely, the greater di-

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TABLE 4 Relative odds for risk factors for wasting by place of residence and age of child, Metro Cebu Urban Rural2 0-5 mo 6-1 1 mo I -29 mo 1 1 mo I 2-29 mo Risk factor and category (n = 4594) (n 4872) (n = 4407) (n = 4527) (,, = 3881) Season (reference = dry) Rainy - 1.46 - 1.77
Socioeconomic variables Television and radio (reference = neither) Radioonly - 1.05 - - 0.90 Television 0.66 0.58 Wall material (reference = wood) Cement - 0.80 - - -

versity observed in risk factors for wasting is consistent with the fact that a relatively short period of risk exposure can precipitate its onset in children. The observed diversity in risk factors for wasting may be unrelated to its epidemiology, and instead, an artifact of differences between numbers of stunted and wasted children in the sample. The prevalence of wasting is much lower than that of stunting (Table 2). Consequently, statistical power to detect significant associations between childrens weightforlength and other variables is low. For example, in the age group birth to S mo, the power of the test to detect a true difference of 20% in the proportion stunted between two groups with approximately equal numbers of children would be 75%, whereas the power of the test to detect the same difference of 20% in the proportion wasted between two groups would be only 9%. For the age group 6-I 1 mo, the
estimates of power to detect the same percentage difference in stunting and wasting (assuming an alpha level of 0.05)

All else 0.47 Water source (reference = well)

Purchased
- - - 1.59

Pipe/pump 0.95 Number of persons per room - - - I . I 2 Years of fathers formal education - - 0.95 - Behavioral variables Years of mothers formal education - - 0.96 - Age of mother (y) - - 0.98 - Mothers employment (reference = not employed) Employed in home - - 0.94 - I .33 Employed away from home 0.77 0.91
Number of prenatal visits (reference = 0-4) 5-7 - 0.85 - - _8 0.69

were 95% and 28%, respectively. Maternal factors, both biological and behavioral, were strongly associated with childrens nutritional status; length of preceding birth interval, birth weight, frequency of prenatal care, breast-feeding, maternal employment, and level of formal education all emerged as important risk factors for malnutrition. Birth weight < 2500 g was the most consistent risk
factor

Currently breast-feeding (reference = no) Yes 0.40 - - - l.3l Biological variables Age of child (mo) - 1.44 0.95 1.36 0.97 Sex of child (reference = male) Female - - 0.89 0.62 Birth weight (reference = _ 2500 g)
< 2500 g - - 1.51 - 2.01

for malnutrition. In Metro Cebu it elevates childrens risk of stunting at all ages in urban and rural barangays, and also
significantly increases a childs risk of being wasted after 12

mo of age. This persistent influence of birth weight on childrens

Health status (reference = well) Diarrhea only - - I . I 74 2.20 1.33

well-being is consistent with other findings that showed Downloaded from www.ajcn.org by guest on December 29, 2011
974 RICCI AND BECKER links between birth weight and growth through infancy (37)

particularly positive effects on childrens nutritional status in

urban barangays. A
We thank the administration, interviewers, supervisors, and data-management personnel at the Office of Population Studies (OPS), San Carlos
University, for their dedicated work. In addition, Judy Gehret of Johns Hopkins University assisted in data processing. We also thank William

and beyond (38). Short previous birth interval is also a consistent risk factor for stunting. Over and above its effect through birth weight, children born within 24 mo of a sibling are at a disadvantage.
This may be because they receive less adequate care from their

Flieger and Connie Gultiano (OPS) and Robert Black (Johns Hopkins
University) for comments on an earlier draft.

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University Press, 1993. 2. Sommerfelt AE, Stewart MK. Childrens nutritional status. Demographic and Health Surveys comparative studies. No. 12. Calverton,

mothers or because they experience more competition for household resources such as food or health care (39). A recent comparative analysis of Demographic and Health Survey data also indicates that short previous birth interval is a significant
risk factor for stunting among children in 19 developing countries (2).

MD: Macro International, Inc. 1994.

3. World Health Organization Working Group. Use and interpretation of anthropometnic indicators of nutritional status. Bull World Health

Organ 1986:64:929-41. 4. Victora CG. The association between wasting and stunting:
an international perspective. J Nutr 1992:122:1105-10. 5. Black RE, Brown KH, Becker S. Malnutrition is a determining factor in diarrheal duration, but not incidence, among young

The significant associations between childrens nutritional

status and maternal factors indicate that intervention must

focus not only on children but also on their mothers. The recent United Nations International Conference on Population and Development recognized this and noted that birth intervals and maternal reproductive health are closely linked to child morbidity and mortality (40). Leslie et al (41) also suggest that empowering women by improving their health may prove to be one of the best approaches to promoting the health and wellbeing of children in the Third World. The risk factors associated with malnutrition in this population suggest several potential applications for interventions to improve childrens nutritional status. Infants born of low birth weight and within 2 y of an elder sibling should be singled out for intervention. In addition, although our analyses do not show causality, we propose that women and children in this population would benefit from interventions that 1) increase
birth

children in a longitudinal study in rural Bangladesh. Am J Clin Nutr 1984:39:8794. 6. Delgado HL, Valverde V, Belizan JM, Klein RE. Diarrhoeal diseases,
nutritional status and health care: analyses of their interrelationships. Ecol Food Nutr 1983:12:229-34. 7. Tomkins A. Nutritional status and severity of diarrhoea among preschool children in rural Nigeria. Lancet 198 1;1 :860-2. 8. Chen LC, Chowdhury AKMA, Huffman SL. Anthropometnic assessment

of energy-protein malnutrition and subsequent risk of mortality among preschool aged children. Am J Clin Nutr l980;33: 1836-45. 9. Vella V, Tomkins A, Borghesi A, Migliori GB, Ndiku J, Adriko BC. Anthropometry and childhood mortality in northwest and
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Uganda. Am J Public Health l993;83:16I6-8.

10. Martorell R, Kettle Kahn L, Schroeder DO. Reversibility of stunting: epidemiological findings in children from developing countries. Eur J

Clin Nutr l994;48(suppl):S45-57. I 1. Administrative Committee on Coordination/Subcommittee on Nutrition. Report of the 15th session of the ACC/SCN. New York:

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12. Beaton OH, Kelly A, Kevany J, Martorell R, Mason J. Appropriate uses of anthropometric indices in children. ACC/SCN State-ofthe-Art

weight, 2) increase womens access to prenatal care, 3) encourage family planning to increase birth spacing, 4) promote breast-feeding, and 5) reduce childrens diarrheal and respiratory morbidity. Efforts to target low-birth-weight infants, increase birth weight, and promote breast-feeding could have

Series. Geneva: ACC/SCN, 1990. (Nutrition Policy Discussion Paper no. 7.) 13. Calloway D. The functional consequences of malnutrition and implications
for policy: case studies in Egypt, Kenya, and Mexico. PEW

Lecture. Ithaca, NY: Cornell University, 1989.

14. Pollitt E. Malnutrition and infection in the classroom.

Belgium: United Nations Educational, Scientific and Cultural Organization (UNESCO),

1992. 15. Leslie J. Womens nutrition: the key to improving family health in developing countries. Health Policy Plan 1991;6:1-19.
16. Royston E, Armstrong S. Preventing maternal deaths. Geneva: World

NCHS growth curves for children birth-18 years, Washington, DC: US

Government Printing Office, 1978. [Series 1 1, 165, DHEW publication

(PHS) 78 1650.1

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17. Habicht J-P, Yarbrough C, Lechtig A, Klein RE. Relationships of birth

weight, maternal nutrition and infant mortality. Nutr Rep Int l973;7:
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30. Waterlow JC, Buzina R, Keller W, Lane JM, Michaman MZ, Tanner JM. The presentation and use of height and weight data for

18. Martorell R, Delgado H, Valverde V. Klein RE.

Maternal stature,
fertility, and infant mortality. Hum Biol l98l;53:303-12. 19. United Nations Population Fund. State of the world population 1989.

comparing the nutritional status of groups of children under the age of 10 years. Bull World Health Organ 1977;55:489-98.
31. Kleinbaum DO, Kupper LL, Morgenstern H. Epidemiologic research.

Investing in women: the focus of the nineties. New York: United

Nations Population Fund, 1989.

20. Scrimshaw NS. The new paradigm of public health nutrition. Am J

Public Health 1995;85:622-4. 21 . Neumann CG, Harrison 0G. Onset and evaluation of stunting in

Belmont, CA: Lifetime Learning Publications, 1982.

32. Liang K-Y, Zeger SL. Longitudinal data analysis using generalized

linear models. Biometrika 1986;73:13-22.

33. SAS Institute, Inc. SAS/STAT users guide. Vols 1-2. Version 6, 4th

infants and children-examples from the Human Nutrition Collaborative Research Support Program-Kenya and Egypt studies. Eur J Clin
Nutr l994;48(suppl):S90-l02. 22. Becker 5, Peters D. Evaluation of key child survival

ed. Cary, NC: SAS Institute, 1990.

34. United States Department of Health and Human Services, Public

activities in Metro Cebu, The Philippines: results of a baseline survey.

Baltimore: The

Johns Hopkins University Institute for International Programs, 1991.

(Occasional paper no. 13.) 23. Philippines Department of Health. Annual report 1988.

Republic of the Philippines: Regional Health Office no. 7, Department of Health, 1988.
24. United Nations Department of Technical Co-operation for Development

Health Service, Centers for Disease Control and Prevention. The CDC anthropometric software package (CASP). Version 3.0. Atlanta: Centers for Disease Control and Prevention, 1986. 35. Dibley MJ, Staehling N, Nieburg P. Trowbridge FL. Interpretation of Z-score anthropometric indicators derived from the international growth reference. Am J Clin Nutr 1987:46:749-62. 36. Brown KH, Black RE, Becker S. Seasonal changes in nutritional status and the prevalence of malnutrition in a longitudinal study of young
children in rural Bangladesh. Am J Clin Nutr 1982:36:303-13. 37. Adair L. Low birth weight and intrauterine growth retardation in Filipino infants. Pediatrics 1989:84:613-22. 38. Mata L. The children of Santa Maria Cauque: a prospective field study

and Statistical Office. How to weigh and measure children.

Assessing the nutritional status of young children in household surveys. Preliminary version. New York: United Nations, l986.(Document

no. DPIUNIINT-81-04l/6E.)

25. Kalter HD, Gray RH, Black RE, Oultiano SA. Validation of the
diagnosis of childhood morbidity using maternal health interviews. mt

of health and growth. Cambridge, MA: MIT Press, 1978. 39. Administrative Committee on Coordination/Subcommittee on Nutrition.
Nutrition and population links. ACC/SCN Symposium Report. Geneva: ACC/SCN, 1992. (Nutrition Policy Discussion Paper

no. 11.)
40. United Nations. Final document. United Nations International Conference

J Epidemiol 1991 ;20: 193-8.

26. Kalter H. The validation of interviews for estimating morbidity. Health Policy Plan 1992;7:30-9. 27. Waterlow JC. Classification and definition of proteinenergy malnutrition. Br Med J 1972;3:566-9. 28. Gomez F, Galvan RR, Frenk 5, Cravioto Munoz J, Chavez R, Vazquez L. Mortality in second and third degree malnutrition. J Trop Pediatr l956;2:77-83. 29. National Center for Health Statistics, Centers for Disease Control.

on Population and Development. Cairo: United Nations, 1994. 41 . Leslie J, Lycette M, Buvinic M. Weathering economic
crises: the

crucial role of women in health. In: Bell DE, Reich MR. eds. Health, nutrition, and economic crises: approaches to policy in the Third World. Dover, MA: Auburn House Publishing Company, 1988.

17.Short stature of mothers from an area endemic for undernutrition is associated with obesity, hypertension and stunted children: a populationbased study in the semi-arid region of Alagoas, Northeast Brazil.

Abstract The objectives of the study were to investigate whether the health conditions of mothers with short stature differed from those with normal stature, and to establish if these aspects were associated with the health of the offspring. Data relating to health and socio-economic, demographic and anthropometric conditions were collected from a probabilistic sample population consisting of 1180 mothers and 1511 children ( < 10 years) living in the semi-arid region of the State of Alagoas, Brazil. Mothers were categorised according to stature, with those in the 1st quartile being defined as of short stature and those in the 4th quartile being defined as of normal stature and serving as a reference for the comparison of variables of interest. Following verification that maternal stature fulfilled parametric assumptions, its associations with the other variables were determined by calculating Pearson correlation coefficients. After excluding strongly self-correlated variables (r >or= 0.70), the remaining variables were analysed by multiple linear regression. The results showed that low maternal stature was independently associated with obesity (percentage body fat >or= 30; P = 0.045), abdominal adiposity (waist:hip ratio >or= 0.85; P = 0.007) and high systolic blood pressure ( >or= 140 mmHg; P = 0.006). Short maternal stature was associated with low birth weight ( < 3000 g; P = 0.01) and stunting (height-for-age Z score < - 2; P = 0.019) in the offspring. Thus, in the semi-arid region of Alagoas, women of short stature presented a higher prevalence of chronic degenerative diseases and produced less healthy children than women of normal stature.

18.Factors associated with stunting in infants aged 5-11 months in the DodotaSire District, rural Ethiopia.
Source Ethiopian Health and Nutrition Research Institute, Addis Ababa, Ethiopia. Abstract The contribution of various factors to malnutrition, particularly stunting, may differ among areas and communities. This cross-sectional study aimed to estimate the level of malnutrition and identify factors associated with the high level of stunting in breast-fed infants aged 5-11 mo living in Dodota-Sire District, Ethiopia. Infants (n = 305) and their mothers were examined physically, and anthropometric and demographic data were collected. The content of zinc, calcium and copper in breast milk was measured, and data collected on the type, frequency of consumption, and time of introduction of supplementary feeding. Overall, 36% were stunted, 41% underweight and 13% wasted. The highest prevalence of malnutrition was seen in infants aged 9-11 mo. Among mothers, 27% had chronic energy deficiency (body mass index, <18.5 kg/m(2)) and 20% were night blind, indicating that vitamin A deficiency was a serious problem. Infants fed >3 times/d, consuming >600 mL/d or consuming cow's milk in addition to cereals and/or legumes had markedly higher length-for-age Z-scores than their peers fed less frequently, consuming less food or not consuming cow's milk [differences: 0.39, 95% confidence interval (CI): 0.04-0.74; 0.17, 95% CI: 0.02-0.32; 0.40, 95% CI: 0.07-0.72, respectively). Infants of mothers with low concentrations of zinc in their breast milk were more stunted. In conclusion, the quality and quantity of foods consumed by infants is insufficient to prevent stunting. Thus it is necessary to increase the nutrient supply to infants by increasing intake and nutrient concentration of breast milk and of supplementary foods they consume, and by providing supplements to infants where appropriate.

19. Parental pregnancy intention and early childhood stunting: findings from Bolivia
Background This study examined the impact of maternally reported pregnancy intention, differentiating unwanted and mistimed pregnancies, on the prevalence of early childhood stunting. Additionally, it examined the influence of paternal pregnancy intention status. Methods Data were collected from a nationally representative sample of women and men interviewed in the 1998 Bolivia Demographic and Health Survey. The sample was restricted to lastborn, singleton children younger than 36 months who had complete anthropometric information. Multivariable logistic regression examined the association between pregnancy intention and stunting. Results Children from unwanted and mistimed pregnancies comprised 33% and 21% of the sample, respectively. Approximately 29% of the maternally unwanted children were stunted as compared to 19% among intended and 19% among mistimed children. Children 1235 months (toddlers) from mistimed pregnancies (adjusted prevalence risk ratio [PRadj] 1.33, 95% confidence interval [CI]: 1.031.72) and unwanted pregnancies (PRadj 1.28, 95% CI: 1.041.56) were at about a 30% greater risk for stunting than children from intended pregnancies. Infants and toddlers with both parents reporting them as unwanted had an increased risk of

being stunted as compared with children both of whose parents intended the pregnancy. No association was found for infants less than 12 months. Conclusions Reducing unintended pregnancies in Bolivia may decrease the prevalence of childhood growth stunting. Children born to parents reporting mistimed or unwanted pregnancies should be monitored for growth stunting, and appropriate interventions should be developed. Measurement of paternal pregnancy intention status is valuable in pregnancy intention studies.

20. Developmental potential in the first 5 years for children in developing countries
Introduction

A previous Lancet series1 focused attention on the more than 6 million preventable child deaths every year in developing countries. Unfortunately, death is the tip of the iceberg. We have made a conservative estimate that more than 200 million children under 5 years fail to reach their potential in cognitive development because of poverty, poor health and nutrition, and deficient care. Children's development consists of several interdependent domains, including sensory-motor, cognitive, and social-emotional, all of which are likely to be affected. However, we focus on cognitive development because of the paucity of data from developing countries on other domains of young children's development. The discrepancy between their current developmental levels and what they would have achieved in a more nurturing environment with adequate stimulation and nutrition indicates the degree of loss of potential. In later childhood these children will subsequently have poor levels of cognition and education, both of which are linked to later earnings. Furthermore, improved parental education, particularly of mothers, is related to reduced fertility, [2] and [3] and improved child survival, health, nutrition, cognition, and education. [3] , [4] , [5] , [6] and [7] Thus the failure of children to fulfil their developmental potential and achieve satisfactory educational levels plays an important part in the intergenerational transmission of poverty. In countries with a large proportion of such children, national development is likely to be affected. The first UN Millennium Development Goal is to eradicate extreme poverty and hunger, and the second is to ensure that all children complete primary schooling.8 Improving early child development is clearly an important step to reaching these goals. Although policymakers recognise that poverty and malnutrition are related to poor health and increased mortality, [5] and [9] there is less recognition of their effect on children's development or of the value of early intervention. This paper is the first of a three part series reviewing the problem of loss of developmental potential in young children in developing countries. The first paper describes the size of the issue, the second paper discusses the proximal causes of the loss, and the final paper reviews existing interventions. Here, we first examine why early child development is important and then develop a method to estimate the numbers of children who fail to fulfil their developmental potential. We then estimate the loss of income attributed to poor child development.
Why early child development is important

Children's development is affected by psychosocial and biological factors10 and by genetic inheritance. Poverty and its attendant problems are major risk factors. [11] , [12] , [13] , [14] and [15] The first few years of life are particularly important because vital development occurs in all domains.16 The brain develops rapidly through neurogenesis, axonal and dendritic growth, synaptogenesis, cell death, synaptic pruning, myelination, and gliogenesis. These ontogenetic events happen at different times (figure 1)17 and build on each other, such that small perturbations in these processes can have long-term effects on the brain's structural and functional capacity.

Full-size image (42K) High-quality image (364K)

Figure 1. Human brain development Reproduced with permission of authors and American Psychological Association17 (Thompson RA, Nelson CA. Developmental science and the media: early brain development. Am Psychol 2001; 56: 515).

Brain development is modified by the quality of the environment. Animal research shows that early undernutrition, iron-deficiency, environmental toxins, stress, and poor stimulation and social interaction can affect brain structure and function, and have lasting cognitive and emotional effects. [18] , [19] , [20] , [21] , [22] , [23]
and [24]

In humans and animals, variations in the quality of maternal care can produce lasting changes in stress reactivity,25 anxiety, and memory function in the offspring, Despite the vulnerability of the brain to early insults, remarkable recovery is often possible with interventions, [18] , [26] and [27] and generally the earlier the interventions the greater the benefit.28
Early cognitive development predicts schooling

Early cognitive and social-emotional development are strong determinants of school progress in developed countries. [29] , [30] and [31] A search of databases for longitudinal studies in developing countries that linked early child development and later educational progress identified two studies. In Guatemala, preschool cognitive ability predicted children's enrolment in secondary school32 and achievement scores in adolescence.33 In South Africa, cognitive ability and achievement at the end of grade one predicted later school progress.34 Three further studies had appropriate data that we analysed (from the Philippines [35] and [36] and Jamaica37) or requested the investigators to analyse (from Brazil [38] and [39] ). In each case, multiple regression of educational outcome (or logistic regression for dichotomous variables), controlling for a wealth index,40 maternal education, and child's sex and age, showed that early cognitive development predicted later school outcomes. Table 1 shows that each SD increase in early intelligence or developmental quotient was associated with substantially improved school outcomes. Further evidence of the importance of early childhood is that interventions at this age [37] and [41] can have sustained cognitive and school achievement benefits (table 1 [35] , [36] , [37] , [38] and [39] ).
Table 1. Change in later school outcomes per SD increase in intelligence quotient (IQ) or developmental quotient (DQ) in early life* N Independent variable Outcome variable Measure of effect Estimate 95% CI Jamaica 165 IQ on the Stanford Binet test Dropped out before (42) at 7 years grade 11 Reading and arithmetic score at age 17 Philippines 1134 Cognitive Score at 8 years Brazil Ever repeat a grade by age 14 years Odds ratio Mean difference in SD Odds ratio 053 065 060 032 087 053 078 049 075

152 DQ on Griffiths test (43) at Grades attained by age Mean difference in 071** 034 4.5 years 18 years grades achieved 107 * Adjusted for sex, age, mother's education, and wealth quintile. Sample consisted of stunted (<2 SD) children participating in an intervention trial and a non-stunted (>1 SD) comparison group. Intervention and stunting status were also adjusted for. p=00117; Hosmer-Lemeshow goodness-of-fit test p=05704. p<00001; R2=544%. p<00001; Hosmer-Lemeshow goodness-of-fit test p=05375. Boys only. ** p=00002; R2=519%. Problem of poor development

National statistics on young children's cognitive or social-emotional development are not available for most developing countries, and this gap contributes to the invisibility of the problem of poor development. Failure to complete primary education (Millennium Development Goal 2) gives some indication of the extent of the issue, although school and family characteristics also play a part. In developing countries, an estimated 99 million children of primary-school age are not enrolled, and of those enrolled, only 78% complete primary school.44 Most children who fail to complete are from sub-Saharan Africa and south Asia. Only around half of the children enrol in secondary schools. Furthermore, children in some developing countries have much lower achievement levels than children in developed countries in the same grade.45 In 12 African countries,

surveys of grade 6 (end of primary school) children showed that on average 57% had not achieved minimum reading levels (webtable). [46] , [47] , [48] , [49] , [50] , [51] , [52] , [53] , [54] , [55] , [56] and [57]
Indicators of poor development

In the following section we estimate the numbers of children who fail to reach their developmental potential. We first identify early childhood growth retardation (length-for-age less than 2 SD according to the National Center for Health Statistics growth reference58 [moderate or severe stunting]) and absolute poverty as possible indicators for poor development. We then show that they are good predictors of poor school achievement and cognition. Finally, we use these indicators to estimate the number of children involved. We identified stunting and poverty for indicators because they represent multiple biological and psychosocial risks, respectively, stunting and to a lesser extent poverty are consistently defined across countries, both are relevant to most developing countries, and worldwide data are available. We omit other risk factors that could affect children's development because they fail to fit all the above criteria and there is marked overlap between them and with stunting and poverty. However, by using only two risk factors we recognise that our estimate is conservative.
Assessment of stunting, poverty, and child development

Growth potential in preschool children is similar across countries, [59] and [60] and stunting in early childhood is caused by poor nutrition and infection rather than by genetic differences. Patterns of growth retardation are also similar across countries.61 Faltering begins in utero or soon after birth, is pronounced in the first 1218 months,62 and could continue to around 40 months, after which it levels off. Some catch-up might take place,63 but most stunted children remain stunted through to adulthood. There are multiple approaches to measuring poverty.64 One assessment used measures of deprivation of basic needs, availability of services, and infrastructure,65 and surveys in 45 developing countries reported that 37 % of children lived in absolute poverty, more so in rural areas. We use the percentage of people having an income of less than US$1 per day, adjusted for purchasing power parity by country66 because this information is available for the largest number of countries. This indicator is considered the best available despite excluding important components of poverty,67 and is more conservative than measures based on deprivation65 since it identifies only the very poorest families. Poverty is associated with inadequate food, and poor sanitation and hygiene that lead to increased infections and stunting in children. Poverty is also associated with poor maternal education, increased maternal stress and depression, [12] , [68] and [69] and inadequate stimulation in the home.70 All these factors detrimentally affect child development (figure 2). [12] and [70] Poor development on enrolment leads to poor school achievement, which is further exacerbated by inadequate schools and poor family support (due to economic stress, and little knowledge and appreciation of the benefits of education).

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Figure 2. Hypothesised relations between poverty, stunting, child development, and school achievement Risk factors related to poverty frequently occur together, and the developmental deficit increases with the number of risk factors. [15] , [33] and [71] Deficits in development are often seen in infancy [31] and [72] and increase with age. [71] , [73] and [74] For example, a cross sectional study in Ecuador reported that the language deficit in poor children increased from 36 to 72 months of age compared with wealthier children (figure 3).70

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Figure 3. Vocabulary scores of Ecuadorian children aged 36 to 72 months by wealth quartiles TVIP=Test de Vacabulario en Imagenes Peabody. Reproduced with permission from the authors.70 As a first step to examining the use of poverty and stunting as indicators, we did regression analyses of the relation between the percentage of children completing primary school44 and poverty and stunting, with data from developing countries (defined as the non-industrialised countries in UNICEF classification).75 Stunting prevalence was based on the WHO Global Database on Child Growth and Malnutrition,76 and absolute poverty prevalence came from UNICEF.75 In 79 countries with information on stunting and education, the average prevalence of stunting was 260%. For every 10% increase in stunting (less than 2 SD), the proportion of children reaching the final grade of primary school dropped by 79% (b=079, 95% CI 103 to 055, R2=362%, p<00001). In 64 countries with information on absolute poverty, the average prevalence was 20%; for every 10% increase in the prevalence of poverty there was a decrease of 64% (b=064, 95% CI=081 to 046, R2=463%, p<00001) of children entering the final grade of primary school. To establish whether stunting and absolute poverty were useful predictors of poor child development in individual studies, we searched the published papers and identified all observational studies that related stunting and poverty in early childhood to concurrent or later child development or educational outcomes. We also identified all studies that related stunting at school age to cognition or education, based on the assumption that stunting developed in early childhood. We selectively reviewed studies of older children that linked economic status to school achievement or cognition, choosing examples with international or nationally representative samples. We assessed whether measurements of the risk factors and developmental outcome were clearly reported, and the relation between them (adjusted or unadjusted) was examined. We did not assess causality.
Stunting and poor development Cross-sectional studies

Many cross-sectional studies of high-risk children have noted associations between concurrent stunting and poor school progress or cognitive ability. Stunted children, compared with non-stunted children, were less likely to be enrolled in school (Tanzania77), more likely to enrol late (eg, Nepal,78 and Ghana and Tanzania79), to attain lower achievement levels or grades for their age (Nepal,78 China,80 Jamaica, [81] and [82] India,83 Philippines, [84] , [85] and [86] Malaysia,87 Vietnam,88 Brazil,89 Turkey,90 Guatemala [only in boys]91), and have poorer cognitive ability or achievement scores (Kenya,92 Guatemala,93 Indonesia,94 Ethiopia, Peru, India, and Vietnam,95 and Chile96). Only three studies [97] , [98] and [99] reported no significant relation between stunting and poor school progress. In the Philippines, associations were recorded with weight-for-height,99 and in Ghana98 stunted children enrolled in school late but taller children left school early to earn money or help with family farming. There are fewer studies with younger children. In Guatemala,100 Jamaica,101 Chile,102 and Kenya,103 associations between height and child development measures were reported. Age of walking was related to height-for-age in Zanzibarian104 and Nepalese children,105 but height was not related to motor development in Kenyans at 6 months of age.106 Weight-for-age, which indicates a combination of weight-for-height and height-for-age, has often been used instead of stunting to measure nutrition in young children. Weight-forage was associated with child development in India,107 Ethiopia,108 and Bangladesh. [109] and [110]
Longitudinal studies

In Pakistan111 and Guatemala,112 growth retardation in infancy predicted age of walking. Excluding studies of children hospitalised for severe malnutrition, four published longitudinal studies showed that early

stunting predicted later cognition, school progress, or both. Stunting at 24 months was related to cognition at 9 years in Peru113 and, in the Philippines to intelligent quotient (IQ) at 8 and 11 years, age at enrolment in school, grade repetition, and dropout from school. [35] and [36] In Jamaica, stunting before 24 months was related to cognition and school achievement at 1718 years and dropout from school.37 In Guatemala, height at 36 months was related to cognition, literacy, numeracy, and general knowledge in late adolescence,114 and stunting at 72 months was related to cognition between 2542 years.115 In Indonesia,116 weight-for-age at 1 year of age did not predict scores on a cognitive test at 7 years, whereas growth in weight between 1 and 7 years did. To assess the size of the deficit in later function associated with a loss of 1 SD in height in early childhood, we reanalysed the data from Philippines,36 Jamaica, 37 Peru,113 and Indonesia 116 (Guatemala had too few well-nourished children to be included). We added two other longitudinal studies, from Brazil38 and South Africa,117 that had not previously analysed the effect of stunting (table 2). In these studies, stunting between 12 and 36 months was related to later measures of cognition117 or grade attainment.38 Being moderately or severely stunted compared with not stunted (height-for-age greater than 1 SD) was associated with scores for cognition in every study, and the effect size varied from 04 to 105 SD. Stunting was also associated with attained grades. The consistent relation between early childhood stunting and poor child development, with moderate to large effects, justifies its use as an indicator of poor development.
Table 2. Descriptive summary of follow-up studies showing associations between stunting in early childhood and later scores on cognitive tests and school outcomes Philippines South Africa Indonesia Brazil* Peru Jamaica Cognitive score (8 years, n=2489) Not stunted 564 Mildly stunted 538 (021) Ravens Reasoning and Attained 120 Matrices (7 arithmetic (9 grades (18 years, n=603) years, n=368) years, n=2041) 017 005 (012) 112 103 (026) 81 72 (04) WISC IQ119 (9 years, n=72) 923 898 (020) WAIS Reading and 118 IQ (17 arithmetic 18 years, (1718 years) n=165) 038 040

Moderately or 496 (054) 023 (040) 97 (043) 65 (07) 792 055 060 (100) severely (105) (093) stunted Data are mean (effect size as unadjusted difference from non-stunted children in z scores). * Males only. The sample comprised stunted (<2 SD) children participating in an intervention trial and a non-stunted (>1 SD) comparison group. SD scores. WISC=Wechsler Intelligence Scale for Children. WAIS=Wechsler Adult Intelligence Scale. Poverty and poor development Cross-sectional studies

Nationally representative studies from many countries have seen relations between household wealth and school enrolment, early dropout, grades attained, and achievement. [46] , [47] , [48] , [49] , [50] , [51] , [52] , [53] , [54] , [55] , [56] , [57] , [95] , [121] , [122] and [123] Gaps in mean attained grades between the richest and poorest children were particularly large in western and central Africa and south Asia, reaching as high as ten grades in India.123 In Zambia, poor children were four times more likely to start school late than the richest children, and in Uganda the difference was ten times. Representative surveys in 16 Latin American countries124 also reported that family income predicted the probability of completing secondary schooling. Rural children were worse off in most studies.123 There are fewer studies on wealth and development in preschool children. In 3668 Indian children under 6 years, paternal occupation was associated with developmental milestones.107 In Ecuador, wealth was related to vocabulary scores of children from 3 to 6 years of age.70 In Jamaica, 714% of 3887 children from more affluent families entering fee-paying preparatory schools had mastery of all four school-readiness subjects tested, compared with 427% of 22241 children entering free government primary schools.125 An association between poverty and child development was recorded at as early as 6 months of age in Egypt,126

12 months in Brazil,127 10 months in India,128 and 18 months in Bangladesh.68 In another Brazilian study, preschool children's language scores were associated with maternal working but not income.129
Longitudinal studies

Several longitudinal studies have assessed the association between wealth at birth and later educational and cognitive attainment. Socioeconomic status in infancy was associated with children's cognition at 5 years of age in Kenya.130 In Brazil, parental income at birth was associated with poor performance on a developmental screening test at 12 months in 1400 infants, and with school grades attained at 18 years in 2222 men on army enlistment.38 In Guatemala,131 socioeconomic status at birth was associated with school attainment and cognition in 1469 adults. We analysed data from three other longitudinal studies (table 3). Wealth quintiles at birth were related to IQ at 8 years in the Philippines,36 and to cognitive scores at 7 years in South Africa117 and 9 years in Indonesia.116 The effect size in all these studies was substantial, ranging from 070 to 124 SD scores between the top and bottom quintiles in children from varied socioeconomic backgrounds, and from 045 to 053 SD scores in Guatemala where all study children were poor. We had to use wealth quintiles rather than the cutoff of US$1 per day because of limitations in the data. Poor children consistently had considerable developmental deficits compared with more affluent children. Thus poverty can be used as an indicator of poor development.
Table 3. Descriptive summary of follow-up studies showing association between wealth quintiles in early childhood, and later cognitive and school outcomes Philippines Indonesia South Africa Brazil Guatemala* Cognitive score (8 years of age at assessment, n=2485) Reasoning and arithmetic (9 years of age at assessment, n=371) Ravens progressive matrices120 (7 years of age at assessment, n=1143) Attained grades (18 years of age at assessment, n=2222) Reading and vocabulary (2641 years of age at assessment) Boys (n=683) Fifth quintile 569 (wealthiest) Fourth quintile 525 (035) 121 110 (031) 110 (031) 95 (074) 047 013 (034) 016 (063) 020 (067) 93 82 (048) 74 (084) 68 (111) 410 (053) 376 (045) 433 (045) 436 (001) 509 Girls (n=786) 448

Third quintile 516 (042) Second quintile 494 (060)

First quintile 464 (084) 84 (106) 023 (070) 65 (124) (poorest) Data are mean (effect size as unadjusted difference from the richest quintile in z scores). * Tertiles. SD scores. Estimate of number of children who are stunted or living in poverty

We estimated the prevalence of children under 5 years who are stunted or living in absolute poverty in developing countries. Data for the number of children in 2004 and percent living in poverty were obtained from UNICEF75 and data for stunting obtained from WHO.76 Of the 156 countries analysed, 126 have a known stunting prevalence and 88 have a known proportion living in absolute poverty (table 4). We replaced missing country values of stunting and poverty with the average prevalence of the region for the purpose of estimating the proportion and number of disadvantaged children. Sensitivity analysis based on imputing stunting by poverty and imputing poverty by stunting through regression analysis gave similar results to using the regional average (webappendix). The most recent poverty data we obtained was up to year 2003, with median 2000 and inter-quartile range of 4 years. The most recent stunting data were up to year 2004, with median 2000 and inter-quartile range of 3 years. We extrapolated all the stunting and poverty data to the year 2004 (table 4). [75] , [76] , [132] and [133]

Table 4. Prevalence and number (in millions) of disadvantaged children under 5 years by region in 2004 Population Percentage Number Percentage Number Percentage Number younger than living in living in stunted stunted, living in stunted, living 5 years* poverty* poverty poverty or both in poverty or both Sub-Saharan Africa Middle east and north Africa South Asia East Asia and Pacific 1170 441 46% 4% 543 16 37% 21% 437 91 61% 22% 709 99

1693 1457

27% 11% 10%

463 166 59

39% 17% 14%

656 252 79

52% 23% 19%

888 336 108

Latin America 565 and the Caribbean Central and eastern Europe 264

4%

10

16%

42

18%

47

Developing 5591 22% 1256 28% 1557 39% 2187 countries * Population and poverty source data from UNICEF State of the World's Children, 2006.75 Where data missing, regional averages were used for percentage living in poverty and percentage stunted. We extrapolated poverty figures to 2004 based on findings from Chen and Ravallion132 that, in the 1990s and early 2000s, decline in absolute poverty (less than US$1 per day) was stagnant in all developing regions except east Asia and south Asia. In east Asia, the decline was levelling off and could be captured accurately by a non-linear regression equation (R2=93%); in south Asia the decline could be accurately captured by a linear equation (R2=99%). We used their equations132 to estimate the expected poverty figures for east Asia and Pacific and south Asia for each country in these regions in the latest years with available poverty data, and then calculated the difference between the expected and observed figures for each country. We added this country-level difference to the regional figure in 2004 projected by Chen and Ravallion's equations to obtain the projected poverty level in 2004 for each country. We used the observed poverty figures as the 2004 estimates for other developing countries. We projected stunting figures for every country except those in the central and eastern Europe region to 2004 based on sub-regional linear trends estimated by de Onis, et al.133 de Onis, et al, did not include the central and eastern Europe region in their analysis. Poverty reduction was stagnant in the 1990s and early 2000s132 in central and eastern Europe. We therefore assume that for countries in this region there has been no change in stunting prevalence in the period concerned.3 Stunting source data taken from WHO Global Database on Child Growth and Malnutrition.76 Based on estimate that prevalence of stunting among children in poverty is 50%.

There are 559 million children under 5 years in developing countries, 156 million of whom are stunted and 126 million are living in absolute poverty (table 4). To avoid the double-counting of children who are both stunted and living in poverty, we estimated the prevalence of stunting among children in poverty in countries with both indicators available, and calculated the numbers of stunted children plus the number of non-stunted children living in poverty. We refer to these children as disadvantaged. The relation between prevalence of stunting and poverty at the country level is non-linear and can be captured by a regression line of percentage stunted=78+42%poverty (using the 82 countries with available data; R2=409%). Extrapolation of this regression line gives an estimate of the prevalence of stunting in people living in poverty to be 50%. Hence, the number of children stunted or living in poverty is the sum of the total number of stunted children (156 million) plus 50% of children living in poverty (63 million) making a total of 219 million disadvantaged children, or 39% of all children under 5 in developing countries. An alternative estimate of the prevalence of stunting in children in poverty was obtained by analysis of micro-level data from 13 Multiple Indicator Cluster Surveys134 in developing countries with data for both stunting and a wealth index. A meta-analysis of the datasets showed that 43% of children below the poverty line were stunted. Based on this estimate, the total number of disadvantaged children is 227 million.

Although the estimate of 219 million is inevitably crude, it is more conservative than the alternative estimate of 227 million; we use the lower estimate in the rest of the paper. Figure 4 shows the numbers of disadvantaged children in millions by region. Most disadvantaged children (89 million) are in south Asia. The top ten countries with the largest number of disadvantaged children (in millions) are: India 65, Nigeria 16, China 15, Bangladesh 10, Ethiopia 8, Indonesia 8, Pakistan 8, Democratic Republic of the Congo 6, Uganda 5, and Tanzania 4. These ten countries account for 145 (66%) of the 219 million disadvantaged children in the developing world.

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Figure 4. Regional distribution of the number of children under 5 years in millions (A) stunted, (B) living in poverty, and (C) disadvantaged (either stunted, living in poverty, or both) in year 2004. Figure 5 shows the prevalence by country. Sub-Saharan Africa has the highest prevalence of disadvantaged children under 5 years, 61% (table 4), followed by south Asia with 52%.

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Figure 5. Percentage of disadvantaged children under 5 years by country in year 2004

Limitations of the estimate of numbers of disadvantaged children

More than 200 million disadvantaged children is an exceedingly large amount. However, limitations in the data suggest that the estimate is conservative. We assumed that the percentage of people in absolute poverty was equal to the percentage of children in absolute poverty. This assumption probably underestimates the number of children because poverty is associated with higher fertility levels and larger household size. Furthermore, less than US$1 per day is an extreme measure of poverty, and children in slightly better off households are probably also at risk. Also, we did not take into account many other risk factors for poor development, such as maternal illiteracy, unstimulating homes, and micronutrient deficiencies. WHO recently produced new growth standards,135 and the 2 SD curves for length and height-for-age are slightly higher than the 2SD curves of the previous standards in certain age ranges under 60 months. Therefore, if we used the new growth standards our estimate of prevalence of stunting and disadvantaged children would be slightly higher. The precision of the estimate of disadvantaged children would be improved with internationally comparable data for maternal education and stimulation in the home. We also need data to establish which cutoff for income and poverty is best for identifying children at high risk. Internationally comparable and feasible measures of child development would produce the best estimate of disadvantaged children, and there is an

urgent need to develop such measures both to more accurately assess the problem and to assess interventions. Some of the disadvantaged children would have IQs of less than 2 SD, the level used to diagnose mild mental retardation (IQ 5069).136 However, a deficit in adaptive behaviour is usually needed to make the diagnosis and these data are not available, although most would have learning problems in school and restricted employment opportunities. We are concerned in this series about the loss of potential across the whole range of cognitive ability.
Economic implications of poor child development

Disadvantaged children in developing countries who do not reach their developmental potential are less likely to be productive adults. Two pathways reduce their productivity: fewer years of schooling, and less learning per year in school. What is the economic cost of one less year of schooling? Studies from 51 countries show that, on average, each year of schooling increases wages by 97%.137 Although some of the studies had methodological weaknesses, this average matches another more rigorous study,138 which reported that each year of schooling in Indonesia increased wages by 711%. Both stunting and poverty are associated with reduced years of schooling. Table 5 presents data for school grades attained in 18-year-old Brazilian men,38 by income quintile at birth and stunting status in the first 2 years. We estimate from these data that the deficit attributed to being stunted (height-for-age less than 2 z scores compared with non-stunted greater than 1 z scores), stratified for income quintiles was 091 grades, and the deficit from living in poverty (first vs third quintile of income) stratified for stunting status was 071 grades. Furthermore, the deficit from being both stunted and in poverty (first income quintile) compared with being non-stunted and in the third income quintile was 215 grades.
Table 5. Attained grades in 18-year-old Brazilian men, by income level, and stunting status in early childhood* Income quintile Poorest 20% 2nd quintile 3rd quintile 4th quintile Wealthiest 20% HAZ 1 n n HAZ < 2 696 (211) 141 116 554 (217) 710 (217) 213 644 (208) 123 656 (198) 769 (205) 843 (189) 940 (183) 274 127 325 111 336 59 706 (192) 774 (191) 927 (203) 703 (205) 665 (242) 869 (229)

HAZ 1 to 2 667 (205)

n 71 77 38 17 13 Data are mean (SD) unless otherwise stated. HAZ=height-for-age z score. * Data provided by the Pelotas Birth Cohort Study, Brazil.38

Stunted children also learn less per year in school. Data from the Philippines has shown that, controlling for years of schooling and income, the combined reading and math test score of stunted children was 072 SD below that of non-stunted children. This reduction was equivalent to 20 fewer years of schooling.86 Regression analysis with Jamaican data37 corroborate this finding; controlling for wealth and grade level, stunted children's combined math and reading test score was 078 SD below those of non-stunted children. Controlling for stunting, poor children almost certainly learn less per year in school, but we know of no studies that convincingly estimate the deficit. Assuming that every year of schooling increases adult yearly income by 9%, [137] and [138] we estimate that the loss in adult income from being stunted but not in poverty is 222%, the loss from living in poverty but not being stunted is 59% and from being both stunted and in poverty is 301% (table 6). Taking into account the number of children who are stunted, living in poverty, or both (table 6), we calculate the average deficit in adult yearly income for all 219 million disadvantaged children to be 198%. This estimate is limited by the scarcity of data for the loss of learning ability of children in poverty, and almost certainly underestimates the true loss.
Table 6. Deficit associated with stunting, poverty (first vs third quintile of wealth), and both, in schooling and percentage loss in yearly income in developing countries

Deficit in school grades attained

Deficit in Total deficit learning in grade ability per equivalents grade in grade equivalents 20 0 20 291 071 415

Percentage loss of adult yearly income per grade* 83% 83% 83%

Total percentage lossof adult yearly income (compounded)

Number (%) of children younger than 5 years in developing countries 929 (166%) 628 (112%) 628 (112%)

Average percentage loss of adult yearly income per disadvantaged child 198%

Stunted only Poor only

091 071

222% 59% 301%

Stunted 215 and poor Evidence Brazil38

51 Combining See table 4 Weighted countries137 columns 3 and 4 average from plus columns 5 and 6 Indonesian study138 * An increase of one grade of schooling is assumed to increase income by 9%. [137] and [138] Implies that a reduction of 1 year of schooling will reduce income by 83% (1/1091 = 0083); that is, a person with an income of 917 due to a loss of 1 year of schooling would have had an income of 100 (917109) had that person not lost that year of schooling. (1/1092.91)1=0222; (1/109071)1=0059; (1/109415)1=0301. Deficit associated with stunting, controlling for wealth quintiles. (The estimate is a weighted average of the differences between stunted *<2 z+vs non-stunted *>1 z+ children in the five wealth quintiles, with the weights inversely proportional to the square of the SE of the quintile-specific difference). Deficit associated with poverty, controlling for stunting (similar method to []). Indicates that the figure is lower bound and under-estimates true figure because the effect of poverty on learning per year of schooling is unknown. Difference between non-stunted and third quintile vs stunted and first quintile in Brazil (table 5).

Philippines86 Sum of and Jamaica37 columns 1 and 2

Clearly, disadvantaged children are destined not only to be less educated and have poorer cognitive function than their peers but also to be less productive. In consideration of the total cost to society of poor early child development, we need to take into account that the next generation will be affected, sustaining existing inequities in society with their attendant problems.67 Where large numbers of children are affected, national development will also be substantially affected. These costs have to be weighed against those of interventions.
Conclusion

Many children in developing countries are exposed to multiple risks for poor development including poverty and poor health and nutrition. There are few national data for children's development but our conservative estimate is that more than 200 million children under 5 years of age in developing countries are not developing to their full potential. Sub-Saharan African countries have the highest percentage of disadvantaged children but the largest number live in south Asia. The children will subsequently do poorly in school and are likely to transfer poverty to the next generation. We estimate that this loss of human potential is associated with more than a 20% deficit in adult income and will have implications for national development. The proximal causes of poor child development are analysed in the second paper in this series. The problem of poor child development will remain unless a substantial effort is made to mount appropriate integrated programmes. There is increasing evidence that early interventions can help prevent the loss of potential in affected children and improvements can happen rapidly (see third paper in this series). In view of the high cost of poor child development, both economically and in terms of equity and individual wellbeing, and the availability of effective interventions, we can no longer justify inactivity.

Search strategy and selection criteria

The following databases were searched for studies in developing countries reported in English from 1985, to February, 2006: BIOSIS via ISI web of science, PubMed, ERIC, PsychInfo, LILACS, EMBASE, SIGLE, and Cochrane Review, along with published documents from the World Bank, UNICEF, and UNESCO's International Bureau of Education. References in retrieved papers were examined and further information sought from experts in the field. Keywords used for search 1 were: developing countries or developing nations or third world and child development or cognitive development or language development or cognition or education or school enrolment, school dropout, grade retention, grade attained, educational achievement. For search 2 we also used stunting or malnutrition or undernutrition, and for search 3 we used search 1 keywords and poverty or income or economic status. Conflict of interest statement We declare that we have no conflict of interest.

21.Severity and Timing of Stunting in the First Two Years of Life Affect Performance on Cognitive Tests in Late Childhood1,2
Undernutrition in infancy and early childhood is thought to adversely affect cognitive development, although evidence of lasting effects is not well established. With the use of data from the Cebu Longitudinal Health and Nutrition Study, we assesshere the relationship between stunting in the first 2 y of life and later cognitive development, focusing on the significance of severity, timing and persistence of early stunting. The sample included > 2000 Filipino children administered a cognitive ability test at ages 8 and 11 y. Stunting status was determined on the basis of anthropometric data collected prospectively between birth and age 2 y. Children stunted between birth and age 2 y had significantly lower test scores than nonstunted children, especially when stunting was severe. The shortfall in test scores among children stunted in the first 2 y was strongly related to reduced schooling, which was the result of a substantial delay in initial enrollment as well as higher absenteeism and repetition of school years among stunted children. Interactions between stunting and schooling were not significant, indicating that stunted and nonstunted children benefitted similarly from additional schooling. After multivariate adjustment, severe stunting at age 2 y remained significantly associated with later deficits in cognitive ability. The timing of stunting was also related to test performance, largely because children stunted very earl y also tended to be severely stunted (2 P = 0.000). Deficits in children's scores were smaller at age 11 y than at age 8 y, suggesting that adverse effects may decline over time. Results emphasize the need to prevent early stunting and to provide adequate schooling to disadvantaged children.

22. Global Developmental Delay and Its Determinants Among Urban Infants and Toddlers: A Cross Sectional Study
Abstract Objective To estimate the prevalence of global developmental delay among children under 3 years of age and study the determinant factors. Methods Cross sectional descriptive study was conducted in field practice areas of the Department of Community Medicine, JN Medical College, Aligarh, India. A total of 468 (243 boys and 225 girls) children aged 03 years were included. Developmental screening was performed for each child. A multitude of biological and environmental factors were analysed. Results As many as 7.1% of the children screened positive for global developmental delay. Maximum delay was observed in the 012 months age group (7.0%). Undernutrition and prematurity were the two most prevalent etiological diagnoses (21% each). Stunting and maternal illiteracy were the microenvironmental predictors on stepwise binary logistic regression while prematurity and a history of seizures emerged significant biological predictors. Conclusions Developmental delay can be predicted by specific biological and environmental factors which would help in initiating appropriate interventions. Keywords Global developmental delay . Biological . Microenvironmental factors Introduction

More than 200 million children under 5 years of age in developing countries do not reach their developmental potential [1]. Children, especially infants and toddlers constitute the most disadvantaged group as far as psychosocial development is concerned. This is attributable to the greater vulnerability of the developing brain in the early formative years. Besides biological determinants, family environments of young children are major predictors of cognitive and socioemotional abilities. Early identification and timely intervention in populations with established risk can go a long way towards improving their functional capacity [2]. The present study is an attempt to assess the magnitude of global developmental delay among children under 3 years of age and to analyse the impact of important biological and ambient environmental factors on their psychosocial development. Material and Methods Study Areas and Subjects This community based cross sectional study was conducted (during the period of August 2007 to June 2008) in the field practice areas of the Department of Community Medicine, J N Medical College, Aligarh, India. The urban health training center (U.H.T.C) has four registered peri-urban localities with 1410 households and a registered population of 9,250. A community based household survey was conducted in the registered areas. S. Sachdeva (*) : A. Amir : S. Alam : Z. Khan : N. Khalique : M. A. Ansari JN Medical college, AMU, Aligarh, India e-mail: sandeepsemail@rediffmail.com Indian J Pediatr (2010) 77:975980 DOI 10.1007/s12098-010-0151-9 Sample Size and Sampling Method The estimated sample size was calculated according to the formula: N=4pq/d2 where p is the prevalence of

global developmental delay, q=1-p, and d is relative error. Taking the prevalence of Global Developmental Delay (GDD) in children under 3 years of age as p=11.1% [3] and relative precision d as 5% of p, the sample size calculated was 157. It was however decided to inflate this estimated sample size to the order of almost trebling to around 500 in order to augment validity. Among the 1410 households surveyed, a total of 1496 children in this age group were listed. A systematic sample consisting of every third child listed was pre-selected for developmental screening [4]. In terms of demographic characteristics, the systematic sample was representative of the overall population of children surveyed. The final sample however comprised of 468 children (225 females and 243 males) as 32 kids from the initial cohort did not participate because of parental refusal and, their probable lack of awareness regarding benefits of developmental screening. Study Instruments The ICMR Developmental Screening Test questionnaire [5] developed and standardized on more than 13,000 children aged 06 years was used for developmental screening of the children. The screening test comprised of five major developmental areas, namely (i) gross motor, (ii) vision and fine motor, (iii) hearing, language and concept development, (iv) personal skills and (v) social skills. The age of attainment of skills in each of these developmental areas was compared with the average age of attainment (50th centile) of a milestone and any lag from this reference was deemed as a delayed milestone. Global Developmental Delay was operationally defined as a significant delay, below the mean in two

or more domains (gross/fine motor skills, cognition, speech/language, personal/social skills, or activities in daily living) [6]. General Information The exact age of the child was computed from the childs date of birth. When data on the exact date of birth was not available, the age as told by the mother was used, corrected to the nearest month. A regional local-events calendar was used to assist the mothers for better recall. The social class of the childs family was determined using the Modified Prasad Scale [7]. Social classes I, II and III of the modified Prasads classification were categorized as upper class and IV and V as lower classes. Microenvironmental Factors The microenvironmental factors assessed were the type of family, dwellings, caste, parental literacy, single parenting and social class. Nutrition Variables pertinent to nutrition were appropriateness of breast feeding, underweight, stunting, wasting and pallor. A precise history of dietary intake of the child was elicited from the mother (recall of food items consumed in last 24 h). Anthropometry was carried out for each child and stigmata of micronutrient deficiencies were sought for. Height and weight measurements were recorded following standard techniques. Indices for wasting and stunting were used to evaluate the nutritional status of the subjects as per the Centre for Disease Control 2000 norms. Age and sex specific2 z-scores were followed to define wasting and stunting. Biological Factors The impact of the following biological factors was assessed: consanguinity, mode of delivery, gestation at birth, birth asphyxia, multiple gestation, neonatal jaundice,

seizures and facial dysmorphism. If the child was born prematurely, the age was corrected by subtracting the number of weeks of missed gestation from present (chronological) age. For this study, children born before 34 weeks gestation fulfilled the criterion for prematurity. Statistical Analysis Analysis was performed using SPSS version 10.0 (SPSS, Chicago, IL). Continuous variables were expressed as mean standard deviation (Gaussian distribution) or range and qualitative data was expressed as percentage. Chi square test and Fishers exact test were used for univariate analysis. All p values were two tailed and values of <0.05 were considered to indicate statistical significance All confidence intervals were calculated at 95% level. Binary logistic regression was used to do the multivariate analysis. Results The majority (186/39.7%) of children were seen in the 0 12 months age group and the least (120/25.6%) in the 24 36 months age group (Fig. 1). Female children constituted 48.08% of the study group. Around 10% children were born preterm. Half (51.46%) of the children belonged to Muslim families and rest were from Hindu families. Sixty 976 Indian J Pediatr (2010) 77:975980 percent were living in nuclear families. Eightythree percent children were living in overcrowded dwellings and 76.5% belonged to the lower socio economic class. There were an aggregate of 13 (of 186), 10 (of 162) and 4 (of 120) children with developmental delay in each of the age groups of 012, 1224 and 2436 months respectively. The trend therefore was of a marginal decline in the proportion of this group of children (from 7.0% to 6.2%) as the age

group progressed from 012 months to 1224 months, only to exhibit a steep fall to 3.5% in the 2436 months age group (Table 1). More girls were affected in comparison to boys among the 012 months age group. The relative distribution of the most probable etiologies to the developmental lapses observed in the study population is illustrated in the pie chart below (Fig. 2). Undernutrition (PEM) and prematurity could be attributed as the major causes (21% each) whereas in as many as 28% of cases, a definitive clinical condition could not be discerned. Birth asphyxia (9%), sequelae of (meningo) encephalitides, varying degrees of hearing loss, visual impairment (vitamin A deficiency in our case), maternal deprivation (3% each) and dysmorphic syndromes (9%) contributed to the rest. Undernutrition was a common denominator in almost half of the children with history of premature birth, and in children with maternal deprivation and Downs syndrome. Child with Downs syndrome phenotype had history of birth asphyxia as well. Nutrition related factors, particularly chronic energy deficiency manifesting in the form of decreased height for age. (OR= 2.2; 95% CI 1.1 to 4.6) and pallor (OR=2.3; 95% CI 1.2 to 4.7) were significantly associated with poor developmental performance on univariate analysis. Variables pertaining to home environment like social class (OR=3.7;95% CI 1.4 to 9.7), pucca dwellings(OR=2.5;95% CI 1.1 to 5.9) and literate mother (OR=3.09;95% CI 1.25 to 7.63) were found to be positive deviants towards developmental performance in these children, whereas single parenting (OR=2.5;95%CI 1.3 to 5.2) correlated with poor outcome. (Table 2) Amongst the biological factors analysed in the

univariate analysis; facial dysmorphism, (OR=62.2; 95% CI 6.7 to 574.67), seizures (OR=45; 95% CI 4.5 to 446.3) and birth asphyxia(OR=21.65; 95% CI 3.48 to 134.56) in decreasing order of their relative risks, were associated with developmental lag. A history of consanguinity among parents and prematurity, too were predictors of poor developmental performance among the children studied. (Table 3). The model for binary logistic regression of important predictor variables obviated the effect of a few factors found significant on univariate analysis except for maternal literacy (Adjusted OR=4.44) and stunting (Adjusted OR=5.69). The biological factors of significance that were brought into fore were gestational age (Adjusted OR=3.66) and seizures (Adjusted OR=6.62). (Table 4). Factors as pallor and pucca dwellings significant on univariate analysis did not emerge significant on binary logistic regression analysis. Discussion As many as 7.1% of the children screened positive for global developmental delay in the present study. Comparable rates were observed by workers from the UAE [8] who observed a prevalence of 8.4% of GDD in children under 3 years of age. Investigators from Korea reported a prevalence of 11.1% [3] of questionable development in children under 2 years of age. Workers from India [9] Fig. 1 Bar chart representing age and gender distribution of the study population Age group (months) Development 012 months 1224 months 2436 months Normal Female Male Female Male Female Male 76 97 80 72 55 61 (89.5) (96.1) (96.4) (91.2) (96.5) (96.8) Delayed 9 4 3 7 2 2 (10.5) (3.9) (3.6) (8.8) (3.5) (3.2) Total 85 101 83 79 57 63 (100) (100) (100) (100) (100) (100) Table 1 Age and sex distribution

of normal and delayed development in the study population Numbers in parentheses indicate percentages Indian J Pediatr (2010) 77:975980 977 observed the same to be of the order of 2.5% in children under 2 years from deprived urban settlements of Hyderabad city. There is limited information regarding prevalence of neurodevelopmental delay in developing nations, including India. The prevalence of developmental delay reported by various authors in different studies varies over a wide range. This could be a result of a lack of uniformity in the instruments employed to assess developmental performance. The decline in the rate of developmental faltering with age corroborates with the observation made by Persha and Arya et al. [10]. This indicates a positive impact of certain factors that accumulate with age, as for example better child rearing practices on part of the mother. However, this view has been refuted by few other workers [11, 12]. Nearly a third of the children could not be assigned a specific etiology of their delayed development. This has been confirmed in other studies [13, 14]. Analysts from Canada have also confirmed that etiologic yield in an unselected series of young children with global developmental delay is close to 40% overall and 55% in the absence of any coexisting autistic features [15]. Investigators have opined that ultimate developmental potential is multifactorial and is a function of a multitude of genetic and environmental factors. This interplay of nature vs nurture renders identification a difficult task [16]. The maximum detriment to child development was posed by undernutrition and prematurity as observed in other studies as well [10, 17]. Besides, a minor proportion was afflicted with

easily remediable impairments as deafness. Although a history of delayed birth cry was common, birth asphyxia was not the most prevalent of the recognizable etiologies as in other studies [10]. Randomised clinical trials conducted at several centres including India [18] have proven that room air is as good as 100% oxygen for resuscitation of term asphyxic newborns without causing adverse neurodevelopment at 2 years. This could explain an otherwise normal developmental outcome in several of the home deliveries with history of delayed cry at birth. Chronic undernutrition manifest in the form of stunting was observed in as many as 59% of children. Several other studies have also shown that stunted growth adversely affects a childs cognitive ability later in childhood [1921]. Reduced school performance has been observed in stunted children in Guatemala [22]. In another Indian study, it was noted that development of gross motor milestones was Fig. 2 Pie chart showing relative proportions of different etiologies of developmental delay among children in the study population. Coexistent etiologies are depicted in similar colours Table 2 Univariate analysis of microenvironmental and co morbidity related determinants of developmental performance S.No Variable Development Normal Delayed OR(95% CI) 1 Social class Lower 262 28 3.7(1.4 to 9.7) Upper 173 5 2 Caste Upper 152 8 0.6 (0.3 to1.4) Lower 283 25 3 Family Nuclear 272 19 0.7 (0.4 to 1.6) Joint 163 14 4 Dwellings Katcha 392 27 2.5 (1.1 to 5.9) Pucca 43 6 5 Mother Illiterate 258 27 3.1 (1.3 to 7.6) Literate 177 6 6 Father

Illiterate 273 23 0.7 (0.4 to 1.6) Literate 162 10 7 Single parenting Yes 118 16 2.5 (1.3 to 5.2) No 317 17 8 Breastfeeding Appropriate 262 15 0.5 (0.3 to 1.2) Inappropriate 173 18 9 Weight for age Normal 320 19 1.8 (0.9 to 3.9) Underweight 115 14 10 Height for age Normal 312 17 2.2 (1.1 to 4.6) Stunted 123 16 11 Weight for height Normal 402 30 0.7 (0.2 to 3.5) Wasted 33 3 12 Pallor Present 162 19 2.3 (1.2 to 4.7) Absent 273 14 OR Odds ratio 978 Indian J Pediatr (2010) 77:975980 delayed in significantly high percentage of stunted infants with H/A<2S.D (22.2%) compared to normal H/A (5.6%, p value=0.003) [23]. This is because poor linear growth creates an overall comparative disadvantage in an already deprived environment. Either a lack of adequate total calories or a deficiency of protein may impede the development of the neurological system. Another possibility is that the poorly nourished child, pre-and postpartum, has insufficient energy to take advantage of opportunities for social contacts and learning. Finally, it may be that adults and older children treat the larger child as a more mature individual, which leads to increased social learning opportunities. Pallor is a usual accompaniment of undernutrition and was significant in the univariate analysis. Several workers have reported an independent association between nutritional anemia and developmental outcome [24, 25] but this was not found in our case. Another determinant that emerged significant in the logistic regression was maternal illiteracy which was noted by several other investigators as well. Maternal schooling was believed

to affect childrens cognitive development by means of environmental organization, parental expectations and practices, provision of materials for childs cognitive stimulation, and variety in daily stimulation [26]. The results of our analysis suggest that both the nutritional and social domains are related to cognitive development, and that their relative importance depends, probably on the particular domain of development. We, however, have not studied the effect of these factors on individual spheres of development. Apart from the above microenvironmental factors, the biological factors also deserve mention as two of them were independently significant with developmental outcome. Because a majority of the informers had no record of the birth weight, prematurity of less than 34 weeks gestation was operationally used as a marker to indicate significantly small size at birth. A highly significant association with the outcome variable in the present study was elicited. With state of the art intensive care, the survival of extremely preterm/ELBW neonates is improving. It is therefore undesirable to neglect the developmental prognosis of these children. Preterm neonates faltered significantly in psychomotor development as found in the present study as well as in other contemporary works [27, 28]. Morris BH et al. in their prospective longitudinal study also demonstrated a greater length of time required to reach full enteral feeding and mental developmental outcome at 24 months corrected age [29]. Preterm births secondary to congenital infections/malformations may develop CNS complications. Complications like intraventricular hemorrhage peculiar to the premature state could well be responsible for developmental

problems including cerebral palsy among survivors. Recurrent seizures in the neonatal or early childhood period can cause chronic brain hypoxia resulting in poor brain development. The spectrum of etiology could include Table 3 Univariate analysis of biological determinants of developmental performance S.No Variable Development Normal Delayed OR(95% CI) 1 Consanguinity Yes 86 12 2.1 (1.1 to 4.5) No 349 21 2 Delivery Normal 285 21 1.1 (0.5 to 2.3) Caesarean 150 12 3 Gestation Term 396 26 2.7 (1.2 to 6.7) Preterm 39 7 4 Multiple gestation Yes 262 23 0.6 (0.3 to 1.4) No 173 10 5 Birth asphyxia Yes 2 3 21.6 (3.5 to 134.5) No 433 30 6 Seizures Yes 2 4 45 (4.5 to 446.3) No 433 29 7 Jaundice Yes 11 2 2.5(0.5to11.7) No 424 31 8 Facial dysmorphism Yes 1 5 62.2 (6.7 to 574.7) No 434 28 Variable Estimated coefficient S.E of estimate Odds ratio Significance (p) Stunting 1.55 0.65 5.69 0.02 Single parenting 12.04 29.43 0.63 0.68 Gestation 5.88 0.55 3.66 0.04 Pallor 2.55 28.90 0.89 0.84 Pucca dwellings 12.70 30.86 0.59 0.68 Maternal literacy 8.88 1.20 4.44 0.03 Seizures 6.48 2.45 6.62 0.01 Table 4 Model for logistic regression of significant predictor variables for developmental performance

Indian J Pediatr (2010) 77:975980 979 varied causes like epilepsy or sequelae to encephalitides/birth asphyxia. A significant independent association with seizures as in our case was observed by Barnard C and coworkers who concluded that 34% of children with refractory epilepsy demonstrated developmental deterioration [30]. However, in a large European cohort study, it was noted that the outcome in children after lengthy febrile convulsions and status epilepticus was better than reported from studies of selected groups and seems determined more by the underlying cause than by the seizures themselves [31]. Conclusion Developmental performance of children is a function of several biological and social factors. The proximate factors in the childs mileu such as nutrition, gestation and seizures were more significant than the distal factors; thereby making a case for their easy and cost effective prevention. Children exposed to these factors are at risk of developmental delay. It is cost effective to detect early developmental lags (including hearing impairment) in at risk children through simple screening tests. Research is required to investigate the hidden etiologies of developmental delay. The study falls short of not being able to study correlates of individual domains of child development. Its retrospective design is a limitation as well. However, the study attempts at being a sensitizing exercise for health care providers towards this extremely crucial issue of the lives of our future generation.

23. Children with iron deficiency, iron deficiency anemia, stunting, or malaria have lower motor activity scores and spend less time in locomotion.
Abstract

Motor activity improves cognitive and social-emotional development through a child's exploration of his or her physical and social environment. This study assessed anemia, iron deficiency, hemoglobin (Hb), lengthfor-age Z-score (LAZ), and malaria infection as predictors of motor activity in 771 children aged 5-19 mo. Trained observers conducted 2- to 4-h observations of children's motor activity in and around their homes. Binary logistic regression assessed the predictors of any locomotion. Children who did not locomote during

the observation (nonmovers) were excluded from further analyses. Linear regression evaluated the predictors of total motor activity (TMA) and time spent in locomotion for all children who locomoted during the observation combined (movers) and then separately for crawlers and walkers. Iron deficiency (77.0%), anemia (58.9%), malaria infection (33.9%), and stunting (34.6%) were prevalent. Iron deficiency with and without anemia, Hb, LAZ, and malaria infection significantly predicted TMA and locomotion in all movers. Malaria infection significantly predicted less TMA and locomotion in crawlers. In walkers, iron deficiency anemia predicted less activity and locomotion, whereas higher Hb and LAZ significantly predicted more activity and locomotion, even after controlling for attained milestone. Improvements in iron status and growth and prevention or effective treatment of malaria may improve children's motor, cognitive, and social-emotional development either directly or through improvements in motor activity. However, the relative importance of these factors is dependent on motor development, with malaria being important for the younger, less developmentally advanced children and Hb and LAZ becoming important as children begin to attain walking skills.

24.Fetal undernutrition and disease in later life

Abstract

Recent findings suggest that coronary heart disease and stroke, and the associated conditions, hypertension and non-insulin dependent diabetes, originate through impaired growth and development during fetal life and infancy. These diseases may be consequences of 'programming', whereby a stimulus or insult at a critical, sensitive period of early life results in long-term changes in physiology or metabolism. Animal studies provide many examples of programming, which occurs because the systems and organs of the body mature during periods of rapid growth in fetal life and infancy. There are critical windows of time during which maturation must be achieved; and failure of maturation is largely irrecoverable.

25.Dinas kesehatan Semarang. Profil kesehatan kota Semarang 2009

BAB I PENDAHULUAN 1.1. Latar Belakang Kesehatan merupakan salah komponen utama dalam Index Pembangunan Manusia (IPM) yang dapat mendukung terciptanya SDM yang sehat, cerdas, terampil dan ahli menuju keberhasilan Pembangunan Kesehatan. Pembangunan kesehatan merupakan salah satu hak dasar masyarakat yaitu hak untuk memperoleh pelayanan kesehatan sesuai dapat dipenuhi. Oleh sebab itu dalam pelaksanaan pembangunan kesehatan telah dilakukan perubahan cara pandang (mindset) dari paradigma sakit menuju paradigma sehat sejalan dengan Visi Indonesia Sehat 2010. Seiring dengan visi tersebut, maka Visi Pembangunan Kesehatan di Kota Semarang yang merupakan Ibu Kota Provinsi Jawa Tengah adalah Terwujudnya Masyarakat Kota Pantai Metropolitan yang Sehat Didukung dengan Profesionalisme dan Kinerja yang Tinggi. Dalam rangka memberikan gambaran situasi kesehatan di Kota Semarang Tahun 2009 perlu diterbitkan Buku Profil Kesehatan Kota Semarang Tahun 2009. Media Profil Kesehatan Kota Semarang merupakan salah satu sarana untuk menilai pencapaian kinerja pembangunan kesehatan dalam rangka mewujudkan Kota Semarang Sehat 2010. Profil Kesehatan menyajikan berbagai data dan informasi diantaranya meliputi data kependudukan, fasilitas kesehatan, pencapaian program program kesehatan, masalah kesehatan dan lain -lain. Tersusunnya Buku Profil Kesehatan Kota Semarang Tahun 2009 didukung oleh pengelola data dan informasi Dinas Kesehatan Kota Semarang, Puskesmas, Instalasi

Perbekalan Farmasi, juga lintas sektor terkait (Badan Pusat Statistik, ASKES, JAMSOSTEK, BKKBN, POLWILTABES Kota Semarang). 1.2. T u j u a n 1.2.1. U mum Tujuan disusunnya Profil Kesehatan Kota Semarang Tahun 2009 adalah tersedianya data / informasi yang elevan, akurat, tepat waktu dan sesuai kebutuhan dalam rangka meningkatkan kemampuan manajemen kesehatan secara berhasilguna dan berdayaguna sebagai upaya menuju Kota Semarang yang Sehat. 1.2.2. Khusus Secara khusus tujuan penyusunan Profil Kesehatan adalah : 1.2.2.1. Diperolehnya Data / informasi umum dan lingkungan yang meliputi lingkungan fisik dan biologi, perilaku masyarakat yang berkaitan dengan kesehatan masyarakat, data kependudukan dan sosial ekonomi; 1.2.2.2. Diperolehnya Data / informasi tentang status kesehatan masyarakat yang meliputi angka kematian, angka kesakitan dan status gizi masyarakat; 1.2.2.3. Diperolehnya Data / informasi tentang upaya kesehatan, yang meliputi cakupan kegiatan dan sumber daya kesehatan. 1.2.2.4. Diperolehnya Data / informasi untuk bahan penyusunan perencanaan kegiatan program kesehatan; 1.2.2.5. Tersedianya alat untuk pemantauan dan evaluasi tahunan program program kesehatan; 1.2.2.6. Tersedianya wadah integrasi berbagai data yang telah dikumpulkan oleh berbagai sistem pencatatan dan pelaporan yang ada di Puskesmas, Rumah Sakit maupun Unit-Unit Kesehatan lainnya; 1.2.2.7. Tersedianya alat untuk memacu penyempurnaan sistem pencatatan dan pelaporan kesehatan.