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High stunting rates: Are childcare centres the cause?

16/06/2022 05:02 PM

By Sakina Mohamed, Wan Muhammad Aslah Wan Razali & Muhammad Mikhail Mohazar

KUALA LUMPUR, June 16 (Bernama) -- Putrajaya is the second richest state in Malaysia by median income, but has the fourth highest rate of stunting. Why?

When the 2016 National Health and Morbidity Survey (NHMS) revealed Putrajaya’s stunting rate was 24.3 percent, many were left stumped. It was higher than the national stunting prevalence at the time, which was 20.7 percent.

Higher stunting prevalence is often associated with rural areas and hardcore poverty. The Department of Statistics Malaysia (DOSM) in 2020, however, revealed Putrajaya to have the lowest rate of poverty in Malaysia.

Meanwhile, NHMS 2016 statistics show that the states with the highest rates of stunting in Malaysia to be Kelantan, Terengganu and Pahang, which also recorded some of the highest rates of absolute poverty in the country.

The DOSM statistics showed that out of the 32,700 households in the administrative capital, 79.7 percent were under paid employment.

Why then would Putrajaya have stunting rates that supersedes even Sabah, the state with the highest incidence of absolute poverty?  


Zaiton Daud, Deputy Director of Family Nutrition in the Ministry of Health’s Nutrition Division has similar questions.

“We talk about how developed Putrajaya is, and how in terms of income security there isn’t much of a problem because majority of them are civil servants. Why then do they have such a high stunting rate?

“The same set of data showed that the lowest rate of stunting is in Kuala Lumpur at 10.5 percent. This is strange. What’s the difference between Kuala Lumpur and Putrajaya?” she questioned, during an online forum titled Isu Kanak-Kanak Bantut: Pencegahan dan Model Solusi, organised by Pertubuhan IKRAM Malaysia.

She said the Health Ministry has acknowledged that stunting was not simply a nutritional issue. Many other factors influenced stunting rates such as health literacy, environment and access to healthcare.

Zaiton believed that what happened in Putrajaya was due to young children spending long hours in the care of childminders, thus potentially subjecting them to poor feeding practices.

“Majority of families in Putrajaya have both parents working so their children spend a bulk of the day in childcare.

“That is when the child’s feeding becomes unregulated. By the time parents fetch their children after work, it’s already late. They’re tired. It’s difficult to give the best when you’re exhausted.

“Would the parents still have the energy to prepare a nutritious meal, or would they just get take-away food?” she asked.

The question is an important one, because stunting is the most common measurement used to identify chronic malnutrition in children. In addition to being short, chronic malnutrition can cause a child to experience lifelong health problems.  


Zaiton pointed out that not all nurseries in Putrajaya are registered and as such it was difficult to monitor and regulate them.

Registered nurseries have to abide by strict rules and regulations to ensure children receive the best care possible in accordance with Child Act 611 and Child Care Centre Act 1984.

Under the Child Care Centre Act 1984, any childminder working at registered nurseries would need to undergo a compulsory basic PERMATA childcare course which include training on providing proper care, balanced diet and safety for infants and young children in childcare premises.

There are currently 63 registered nurseries in Putrajaya with 28 of them located within the workplace (as of March 8, 2022).

However, these numbers are hardly enough to cater to the population of children under 5 in Putrajaya – which, according to DOSM in 2020 are around 13,200. It is therefore unsurprising that a number of parents resort to engaging unregistered childcare services.

This action, however, can lead to some very serious consequences.

While it has yet to be conclusively proven, poor practices at childcare centres may be one of the major reasons why Putrajaya has such a high stunting rate. It certainly helps explain why Malaysia’s stunting rates cut across income groups and ethnicity, and even the urban-rural divide.

However, it cannot be denied that children from lower income households are more likely to become stunted simply because they are more vulnerable to underlying determinants of the condition such as poor access to nutrition, healthcare and even proper sanitation.

Although childminders at registered nurseries and childcare centres are routinely trained and educated on proper care and feeding guidelines for infants and young children, those in unregistered centres may not be.

The waiting list to enrol in these centres may also not be as long and their rates cheaper, which make them the more attractive option for low-income parents.  


Prof Dr Norhasmah Sulaiman who heads the Department of Nutrition and Dietetics at Universiti Putra Malaysia believes that this was also the case in Putrajaya.

“Not everyone living in Putrajaya has high income. Many can even classified as being in the B40 group. So I think one of the reasons the stunting prevalence is so high in Putrajaya is poverty – urban poverty.

“The income gap in Putrajaya is very wide. The living cost is also high. I believe the majority of mothers in Putrajaya are working so they send their children to nurseries, where they have little control of feeding practices,” she opined.

Having control of nutritional intake in the first 1,000 days of a child’s life is crucial in preventing stunting. This is because failure to prevent or remedy the condition within that period may cause the child to spend an entire lifetime dealing with the repercussions of stunting, some of which includes poor academic performance, inability to get good jobs as adults and high susceptibility to illnesses.

Countries with high stunting prevalence also lose an average of 7 percent per capita income, according to a World Bank study.

Norhasmah said that the Health Ministry has put in concerted efforts to educate childminders at nurseries on proper feeding practices for children, but a lot more factors were at play.

Referring to a paper published in The Lancet, she said there were a cluster of reasons contributing to the increase in stunting rates. Among them, she said, were parental education or more specifically, maternal education.

“Look at the infra-household resource allocation – do mothers prioritise proper feeding practices? Children spend over eight hours with childcare providers. How do they ensure that their children get nutritious food?

“Look at feeding practices at home. The parents may bring home good income but the stunting prevalence in such households is still high. Why? It could be due to their busyness. Parents don’t have the time to prepare nutritious meals for their kids, or are not aware of how crucial such meals are for their kids’ growth,” she said.

According to the NHMS 2016, an estimated 19.2 percent of Malaysian children aged 6-23 months do not achieve the prescribed minimum meal frequency.  


There are other indicators that show childcare centres in Putrajaya may not have the best track record in safeguarding the welfare of children.

“If we look at the data, child abuse rates are also very high in Putrajaya nurseries. I believe that the high child abuse rate in Putrajaya are linked to the stunting rate as well,” said Dr Amar HSS Singh, a former paediatrician with over forty years of experience serving the Health Ministry.

Garasi Bernama tried to obtain these data from the Welfare Department but they are not publicly available. Available data from the Welfare Department were simply a summary of abuse cases according to offences within the Children Act 2001. It did not provide the prevalence of such cases by states or childcare centres.

Even before the COVID-19 pandemic, many households are finding it hard to keep up with monthly expenses with only one parent working. The pandemic has undoubtedly made the situation worse, forcing more people to seek employment to make ends meet. With both parents working, childcare would inevitably need to be outsourced.

“Welfare Department data shows there are only about 6,000 licensed childcare centres or nurseries in the country. This is less than 10 percent of the number of childcare centres we need in the country, which is probably more than 60,000.

 “Imagine, 90 percent of our childcare centres are unlicensed,” he said.

In 2018, the Women, Family and Community Development Ministry revealed that that there were only 4,302 registered childcare centres in Malaysia. It further said that calculations based on a census done by DOSM showed 38,333 more were needed.

Dr Amar acknowledged that most parents feel stuck between a rock and a hard place.

“It’s very hard for parents to complain about unlicensed childcare centres. They need the childcare.

“If they’re unhappy with the quality of care and report them, they will lose the service. So they’re unlikely to report them,” he said.


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