Linear growth retardation, or stunting, affects approximately one quarter of children under 5 globally. It is caused by repeated insults to the growth plate from chronic malnutrition and infections, resulting in reduced bone growth. Stunting can cause long term health consequences including impaired cognitive ability, higher risk of infectious disease, chronic conditions like cardiovascular disease later in life, and even intergenerational effects through lower birth weights in children of stunted mothers. Key micronutrients involved in growth include zinc, copper, manganese, vitamin D, calcium, iron, and vitamin A. Appropriate child feeding and care practices are also important to prevent stunting.

1. Linear Growth Retardation

2. Linear Growth
Retardation
Linear growth retardation (stunting) is
prevalent (10-80%) in developing
countries. It takes place between 6 and
18 months of age and can be
characterized by the delayed onset of
the childhood phase of growth.

3. Epidemiology
The global prevalence of stunting in children
younger than 5 years was estimated to be 26%
(95% confidence interval [CI], 24–28%) for 2011,
the most recent data (UNICEF-WHO-The World
Bank, 2012). The number of stunted children in
that year was estimated to be 165 million. The
prevalence of stunting has declined from 40% in
1990, with an average annual rate of reduction of
2.1%. The prevalence of stunting varies
substantially by world region (Fig. 2.1), with the
highest prevalence in Africa and South-Central
Asia (which includes India).

4.  Growth curve in a male with intrinsic

5. Signs & Symptoms
 The umbilical cord is often thin and dull instead of thick
and shiny.
 If they have certain forms of dwarfism, the size of their
arms or legs may be out of normal proportion to their
torso.
 If low levels of the hormone thyroxine are causing their
growth delay, they may experience a loss of energy,
constipation, dry skin, dry hair, and trouble staying warm.
 If they have low levels of GH, it can affect the growth of
their face, causing your child to look abnormally young.
 If their delayed growth is caused by stomach or bowel
disease, they may have blood in their stool, diarrhea,
constipation, vomiting, or nausea.

6. Causes of Growth
Retardation A family history of growth delays
 Smaller birth and fetal weight
 Low levels of GH
 Low levels of thyroxine due to hypothyroidism
 Turner syndrome, which is a genetic condition that
affects females who are missing some or all of one X
chromosome
 Down syndrome, which is a genetic condition in which
individuals have 47 chromosomes instead of the usual
46

7. Causes of Growth
Retardation
 Skeletal dysplasia, which is a group of
conditions that cause problems with bone
growth
 Certain types of anemia, such as sickle cell
anemia
 Kidney, heart, digestive, or lung diseases
 The use of certain drugs by their birth mother
while she was pregnant
 Poor nutrition
 Severe stress

8. Detection Growth Retardation
through Growth Chart
A child is considered short if
he or she has a height that is
below the fifth percentile;
alternatively, some define short
stature as height less than 2
standard deviations below the
mean, which is near the third
percentile. Thus, 3-5% of all
children are considered short.
In order to maintain the same
height percentile on the growth
chart, growth velocity must be
at least at the 25th percentile
(see image).

9. Diagnosis of Growth
Retardation
Certain tests and imaging studies can also help
their doctor develop a diagnosis.
 A hand and wrist X-ray can provide important
information about child’s bone development in
relationship to their age.
 Blood tests can pick up problems with hormone
imbalances or help detect certain diseases of
the: stomach, bowel, kidney & bone.

10. Treatment For Growth
Retardation
Depend on the cause of their delayed
growth.
For example, if child is diagnosed with a GH
deficiency, their doctor may recommend
giving them injections of GH at home. They
may ask you to give them shots three times
per week or as often as every day. This
treatment will likely continue for several
years as your child continues to grow.

11. Stunting
Globally, one in four children under the age
of five suffers from stunting. Stunting is the
result of repeated insults to the growth
plate, with reduced chondrocyte
proliferation and maturation. A stunted
child will have a lower height than her/ his
peers and will resemble a younger child,
usually 2–3 years younger.

12. Health consequences of
stunting
 Stunted growth caused by chronic malnutrition during the
first 2 years of life had an adverse affect on a child’s
cognitive ability later in childhood. In most cases the
micronutrient status of stunted children has not been
investigated, both because of the technical difficulties and
because of the failure to identify stunting as an active
condition of poor health.
 For infants and young children, stunting is associated with
a weaker immune system and higher risk of severe
infectious diseases. When undernourished children
become adults, they are more likely to suffer from high
blood pressure, diabetes, heart disease, and obesity.
 It is estimated that children under the age of five who are
born to the shortest mothers (less than 145 centimeters)
have a 40 percent increased risk of mortality.

13. Health consequences of
stunting
 Stunted women have higher maternal mortality rates and are
more likely to have small and underweight babies—leading to
a cycle of poor nutrition and poverty. A low birth weight child
is more likely to be shorter during adulthood than one not
born with a low birth weight.
 A stunted child also has a higher risk of developing chronic
diseases, impaired fat oxidation such as occurs in obesity,
and reduced glucose tolerance. Stunted children were more
likely to have problems oxidising fat and, as a result, stored
more fat in their adipose tissues. The mechanisms behind
this relation are unclear, but the researchers speculated that
long-term undernutrition might have damaged the enzymes
and hormones responsible for optimal lipid oxidation.
Stunting can also lead to increased risk of hypertension.

14. Health consequences of
stunting
 A small adult has some functional limitations compared to a
taller one, such as reduced working capacity. In societies
where manpower is essential for subsistence this may have
further consequences on the health and well-being not only
of the individual, but also of his/her dependants . Stunted
individuals often remain in a state of poverty throughout their
lives, as they are not able to produce the extra income that
might allow them to escape the cycle of mere subsistence.
 Reproductive performance may also be affected by stature: a
small woman will usually deliver a small child. The
occurrence of IUGR is higher in stunted girls and this creates
an inter-generational cycle of stunting
(fig. 2.3).

15. Figure 2.3.The poor nutrition cycle.

16.  Several micronutrients are required for adequate
growth among children.
 The outcome typical of the stunting syndrome,
i.e. retarded growth, developmental delays, poor
cognitive function, lower IQ, weakened immune
systems and greater risk of serious diseases like
diabetes and cancer later in life, increased
morbidity and mortality could be caused by poor
status of such micronutrients.
 However, it has been still unclear as to which
nutrient deficiencies contribute most often to
growth faltering in populations at risk for poor
nutrition and poor growth.
Impact of Micronutrient
Deficiencies on Stunting
Syndrome (Linear Growth)

17. Micronutrients
Impact of Deficiencies
Zinc
observed to affect bone metabolism.
poor zinc status would compromise immunity and neurological
function.
result in anorexia & also may contribute to growth retardation
indirectly by reducing the intake of other growth limiting factors,
such as energy and protein.
Copper involved in growth through its role in cross-linking collagen
fibers.
deficiency would produce anaemia and affect development of
cognitive function.
Manganese deficiency is associated with skeletal abnormalities, including
retarded growth.
Vitamin D and
calcium
also affect bone development, as manifested through the
condition known as rickets.
Iron deficiency would produce anaemia, and affect development of
cognitive function.
result in anorexia & also may contribute to growth retardation
indirectly by reducing the intake of other growth limiting factors,
such as energy and protein.

18. Micronutrients
Impact of Deficiencies
Vitamin A
Inadequate vitamin A status would also lead to increased
susceptibility to infections.
Magnesium
result in anorexia & also may contribute to growth retardation
indirectly by reducing the intake of other growth limiting factors,
such as energy and protein.
Others
Children are very often recurrently infected by
parasites or other pathogens that affect pathological
action on skeletal metabolism. Helminth infections are
known to cause malnutrition through the induction of
anorexia, while infections of the gastrointestinal tract
lead to chronic diarrhoea and nutrient malabsorption.

19. Classification of nutrients(according
to their impact on growth)
 Two types
 For the type 1 nutrients, tissue levels are variable
and deficiency is often associated with
characteristic clinical signs and symptoms. When
a type 1 deficiency occurs body stores are
depleted, followed by a fall in tissue
concentration. Metabolic pathways become
compromised leading to clinical symptoms.
However, growth is rarely affected. Type 2
nutrients are involved in essential physiological
functions, tissue levels are fixed and there is no
body store on which to draw upon.

21. Care practices
Appropriate care practices include breastfeeding,
complementary feeding, the use of health care
and good hygiene practices. Education,
knowledge, beliefs, workload and time availability,
health and nutritional status of the caregivers,
usually the mothers, are essential. In a study
carried out in rural Chad, caregiver decisions on
child feeding, actions taken when a child is ill,
domestic workload and even caregiver’s level of
satisfaction with life have shown to have an
influence on children’s height-for-age.