# Effectiveness of a Tiered Referral System and Early Nutritional Intervention to Prevent and Recover Stunting in Under‐Five Indonesian Children

## TL;DR

This study shows that a tiered healthcare system with animal protein supplements and early intervention can effectively prevent and treat stunting in Indonesian children under five.

## Contribution

The study introduces a tiered referral system with animal protein supplementation and FSMP for stunting prevention and recovery in Indonesia.

## Key findings

- Protein supplementation prevented weight faltering in 71.7% of children.
- Early intervention prevented stunting in 75.6% of cases within two weeks.
- FSMP helped 43.6% of stunted children recover within six months.

## Abstract

Stunting remains a major global malnutrition problem in children. A protocol for stunting prevention and management in Indonesia is needed to achieve the WHO's stunting reduction target by 40% in 2025. This study aimed to evaluate the effectiveness of a tiered referral system across different healthcare levels and the importance of animal proteins and food for special medical purposes (FSMP) in preventing and managing stunting in Indonesia. This one‐group pre–post experimental study involved children under 5 years old from 14 regencies in Indonesia. All subjects initially received education about breastfeeding and animal proteins. Eligible subjects were then given daily animal protein (milk and/or egg) supplementation. Subjects with weight faltering, underweight, or wasting were referred and given nutritional intervention for 2 weeks. If treatments failed to normalize undernutrition, subjects were referred to regional hospitals. Those confirmed as stunted or with low birth weight were directly referred for treatment and FSMP as indicated. A total of 1841 subjects received egg and/or milk supplementation. In 6 months, animal protein supplementation prevented weight faltering in 1320/1841 subjects (71.7%; 95% CI 69.6%–73.8%). Red flags management successfully prevented stunting in 536/709 subjects (75.6%; 95% CI 72.4%–78.8%) in 2 weeks. FSMP prescription for catch‐up growth in regional hospitals led to stunting recovery in 166/381 subjects (43.6%; 95% CI 38.6%–48.5%) in ±14 weeks. A tiered referral system with well‐defined treatment guidelines is crucial to address stunting in Indonesia. Timely referral and FSMP prescription for catch‐up growth can effectively treat stunting. Animal proteins and education are keys to preventing stunting in children.

Protein‐based supplementation at the community level (e.g., milk and/or egg) prevented weight faltering in 71.7% of children. Early diagnosis and timely treatment in primary healthcare services prevented stunting in 75.6% of cases. Among stunted children referred to regional hospitals, 43.6% recovered within 6 months with FSMP for catch‐up growth. This comprehensive strategy, along with proper education at all levels of care, offers an effective protocol for stunting prevention and management.