The World Health Organisation (WHO) defines stunting as: “the impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation. BYY expert, paediatrician, Dr Maraschin, looks at the various scenarios in which stunting could occur, the long-term, effects and what we can do to protect children from stunting.
It’s important to understand the role these play in growth stunting:
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- Impaired growth is when a child is not growing as they should—in other words, the child’s height is well below average for their age.
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- Impaired development is when a child does not achieve their milestones as they should. These includes rolling over, sitting and walking. It may also mean that the child has delayed mental and social skills.
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- Poor nutrition. The right amount of protein, vitamins and minerals is critical for your baby’s development. The developing brain is very sensitive to nutrients in weeks 24 to 42 of pregnancy. Many of the brain’s functions develop in this phase of the pregnancy. For this reason, pregnancy vitamins are essential.
Other factors like smoking will also affect a baby’s growth during pregnancy. Once the baby is born, there is rapid brain growth for the first two years of life. If a pregnant woman or young child does not get the nutrition they need, then this will have long-term effects on development. Constant malnutrition stops a child from growing as tall as they are supposed to and impacts the child in many ways.
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- Repeated infection. Children who are constantly ill, who have chronic diseases (like asthma, diabetes, cystic fibrosis, coeliac disease and heart disease) or those with digestive tract and kidney disorders often suffer from stunting if their condition is difficult to manage. A sick child doesn’t eat well, and others may not be able to absorb the nutrients they require due to the condition, leading to stunting.
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- Inadequate psychosocial stimulation. A child requires physical stimulation, sensory input and emotional input to develop, which is critical in the first 1000 days of life. Parents who interact with their babies by encouraging them to clap, wave or walk is physical stimulation. The parents also touch their babies, speak to them and make eye contact which stimulates the senses.
If the child gets a vaccination, the parents will cuddle and console the baby– this is emotional input. A baby requires all of these inputs to achieve their development potential. Think of a baby in an overcrowded orphanage where it lies in a cot for many hours a day versus the babies I have described above. The child that is not being stimulated will not develop at the same rate that a nurtured baby would.
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- Child Growth Standards. In the “Road to Health” book are graphs for your baby’s weight, height and head circumference. Your healthcare professional will most likely plot your child’s growth on these graphs at each visit. The 50th percentile is the average for age. The stunted child will fall well below the average, usually in the 3rd percentile or lower.
Also read: Formula feeding and optimal growth
Scenarios in which stunting may occur:
I’m not going to go into detail about how children living in extreme poverty, war-torn countries or in a country where there is famine, could suffer long-term malnutrition. Undoubtedly these children’s growth will be stunted. But what about children in the general community who may be at risk?
1. Baby A – Baby A was brought to see the paediatrician at 18 months. She was extremely small for her age. Her weight and height were plotted below the 3rd percentile, meaning she was the average weight and height of a 3-month-old baby. She could sit, not crawl. She hadn’t as yet started pulling herself up to a standing position. She was communicating verbally well for her age.
During the consultation, it was revealed that Baby A was born at a normal weight and breastfed. Her mother had been afraid to introduce solids because each time she tried, Baby A gagged. As a result, the complementary feeding was significantly delayed. We understand that children need a variety of solid food after the age of 6 months. This is critical to ensure the baby doesn’t lack protein, iron, zinc, vitamin B and vitamin D, as this will suppress growth and lead to feeding problems.
Since Baby A’s mother was reluctant to feed her anything other than milk until the age of a year and had then only given baby a bit of cereal, Baby A now avoided food and was severely malnourished. The paediatrician did various blood tests and investigations to exclude any other causes of the poor growth. These tests revealed nothing. It was established that this baby was highly sensory-defensive. The various textures of food had caused the gagging and food avoidance. Since the problem remained unaddressed, the child’s growth and development had been significantly affected.
An occupational therapist was called in to assist Baby A with chewing, swallowing and food aversion. A dietician developed an eating plan to ensure Baby A received all the necessary nutrients while overcoming his food aversions. Once Baby A got stronger, a physiotherapist worked with her to speed up the developmental milestones.
Both the dietician and occupational therapist needed to educate the parents on the need to feed Baby A properly and to feel secure while doing so. Baby A was followed up monthly for six months by the paediatrician. The interventions made a remarkable difference. Baby A began to grow and achieve her milestones, and the family was thriving because food was no longer a battle.
2. Baby B – Baby B saw the paediatrician at 7 months old. The baby was measured and found to be the size of a new-born. He weighed just 3,2 kg and was only 50cm in length. The child had a long history of admission to the hospital for severe vomiting. He was being treated for reflux, but his condition was not improving on the medication.
Sadly, many tests had been performed and had not revealed anything. The paediatrician decided to do a barium meal study. The child was given a white mixture to drink, followed by an X-ray to see what happened when Baby B was fed. The barium meal swallow revealed a condition known as a Gastric Volvulus.
This is a dangerous and rare condition. With this condition, the stomach rotates more than 180 degrees when the child eats. This causes the child to vomit. In many cases, babies with this condition are treated for reflux, but the condition doesn’t correct. Baby B underwent surgery to repair the stomach. To help him grow and to receive the correct nourishment, a PEG was put into his tummy. This is a tube that goes into the tummy through the abdominal wall.
The parents could ensure that Baby B got enough food and nourishment even when he could not eat himself. His progress was slow but steady. At the age of two, Baby B was developmentally still delayed. An MRI revealed that he had suffered brain damage as a result of the lack of nutrition in the formative months. The child continued to be PEG-fed for a few years. He could ultimately tolerate all his food and attended a school for children with special needs. His parents reported that he was a happy child with good social skills and a delightful personality.
3. Child C – A child, age 3, went to see a paediatrician as her parents are concerned about the frequent bouts of diarrhoea, ongoing complaints of a sore tummy and the child’s size relative to her peers. Her teachers reported that she didn’t have the same energy levels as the other children and would often opt to remain lying on her mattress when nap time is over.
Her growth parameters were below the average for her age. In the first six months of life, Child C had grown normally. Her mother breastfed her until the age of six months. Solids were then started, and Child C continued to grow well until she was eating the regular family diet at around 1 year of age. Her growth began to slow down and she became sicklier than before. Her diarrhoea was treated with fluids and a bland diet, as stool results never revealed infection.
Since starting school at the age of 2, her health was deteriorating. The parents felt that there must be something more going on than the odd bout of gastroenteritis. The paediatrician did various blood tests. The blood work revealed that Child C was very anaemic. Her iron stores were very low. She also severely lacked calcium, Vitamin D, magnesium, zinc, folate and other vitamins.
With these results on hand and the history given by the parents, the paediatrician decided to test for coeliac disease. The tests (Total IgA, IgA-tTG and IgA-EMA) were used to see how child C responded to gluten. These tests, together with a biopsy of the upper intestine, confirmed that Child C had coeliac disease.
Her parents were counselled on the disease so that they were equipped to care for their child. The disease affects about 1 in 100 children. It is an autoimmune condition which mainly affects the digestive tract. It can occur at any age, but symptoms in children often begin when they are introduced to gluten-containing foods. These include food made with wheat, barley or rye. This is why Child C had started getting ill when she moved to the normal family diet.
Gluten had damaged the lining of the small intestine to such an extent that it could not absorb the nutrients needed for growth. If the condition were left untreated, then the growth problems would persist. Child C would most likely have delayed puberty, damage to her tooth enamel, anaemia, chronic fatigue and even osteoporosis.
It was crucial that all gluten had to be entirely eliminated from Child C’s diet. A dietician was consulted to ensure she would get all the nutrients she required from gluten-free products. Child C was followed up monthly for one year after diagnosis. Her symptoms had improved almost overnight with the elimination of gluten from her diet. She no longer suffered from diarrhoea and became a live wire at school. Her growth had improved, but it was unlikely that she would reach her full growth potential as she had only been diagnosed after the age of three years and had suffered along the way.
The topic of stunting is very broad. There are many other causes of stunting, including intrauterine growth restriction during pregnancy, growth hormone deficiencies, syndromes, and chromosomal abnormalities. The list goes on.
It’s essential to understand that your child’s growth is critical to allow them to reach their full potential. Children with stunted growth suffer the consequences into adulthood. Studies have shown that as teenagers, these children suffer from anxiety, low self-esteem and depression owing to their learning difficulties, small stature and lack of social skills.
After school, these individuals earn lower wages and struggle in the work environment. Their risk of chronic disease is also much higher than a child who never suffered the effect of malnutrition.
If your child is not growing as they should and you are concerned, then literally “follow your gut”. Good food and nutrition are key factors to growth and development. Stunting focuses on height, but as we have noted, stunting and brain development are very closely related.
Early intervention into any of the conditions described has the potential to reverse some of the effects of stunting. Even if the condition can’t be treated, ensuring the best nutrition for your child will ensure that they get to achieve the very best of their capabilities. When we tell our children to reach for the stars, not all their little fingers will achieve the same height, but they are still reaching, and we are there to ensure that they get what they need during pregnancy and childhood.
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References
https://www.who.int/news/item/19-11-2015-stunting-in-a-nutshell
https://www.sciencedirect.com/science/article/abs/pii/S2212267214013598
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6821046/
https://pubmed.ncbi.nlm.nih.gov/33086477/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC361789
https://neurosciencenews.com/celiac-disease-brain-15829
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