Response to the correspondence referring to our article "Stunting is not a synonym of malnutrition" (2018EJCN0997RR) by Conny Tanjung, Titis Prawitasari, Damayanti Rusli Sjarif
Thank you for the opportunity to answer the correspondence [1] referring to our article, "Stunting is not a synonym of malnutrition" [2] Stunting defined as height for age 2SD of the WHO child growth standards, is not a synonym of malnutrition. The lack of association between nutrition and stature has explicitly been described already 100 years ago. In view of thousands of severely starving children shortly after World War I, Schlesinger stated: "The child's longitudinal growth is largely independent of the extent and nature of the diet. Even during severe dietary restrictions, impairments of infant growth are markedly small, and occur slowly and delayed" [3] In view of the rich literature on nutrition and growth of the early 20th century, and the still amazingly diverse professional opinions on this issue, we are pleased to reply to the comments of Tanjung et al. [1] They precisely reflect the current state of debate, and we will thus try to provide some more insights into this fascinating topic. Tanjung et al. [1] refer to the widespread opinion that "stunting may begin very early in life, typically in utero" This may be right for some populations, but it does not apply for Indonesians. Pulungan et al. published Indonesian national growth charts [4] The average lengths of newborn boys with 50.12 cm, and newborn girls with 49.81 cm are even greater than WHO standards (boys 49.88, girls 49.15) The same applies for birth weights (average Indonesian boys' birth weight is 3.46 (WHO 3.35) kg, girls' weight is 3.39 (WHO 3.232) kg. The data clearly show that though stunted at later age, Indonesian children do not suffer from prenatal growth impairment. This is in line with historic European observations. Mid 19th century European children and adults were significantly shorter than WHO standards and references, but their birth weights and lengths were close to or even above WHO values. The authors cite "many important factors that can cause stunting such as household and family factors, inadequate infant feeding practices and infection" This is true. Yet, we feel it would be insolent to assume that 50% of the parents in rural Soe, among them many civil servants, government employees, teachers, dentists, and architects, with diplomas, magister, and university degrees, would had offered adverse housing conditions or inadequate feeding practices resulting in child stunting. We agree that stunting may be caused by familial short stature, constitutional delay of growth and development, and genetic and endocrine disorders. We did not measure parental height. But we documented timely eruption of the deciduous teeth in children of the first to third year of primary school, and there was no delay in age of menarche in older girls. We failed to find evidence supporting constitutional delay of growth and development. And we feel that it may be quite preposterous to assume that half of the Michael Hermanussen michael.hermanussen@gmail.com
European Journal of Clinical Nutrition