Evaluating the Risk of Stunting and Wasting in Newborns

Abstract

The scope of this topic is the measurement and assessment of the risk of stunting and wasting in newborns and infants under 2 years of age. This chapter was compiled in an effort to facilitate the handling of stunting. The topic of stunting is discussed in this chapter according to trend issues that are widely discussed globally. Apart from being a global issue, we also see the impact of stunting, which can hamper children’s intelligence. The information presented in this chapter is how to detect the risk of stunting and wasting through an assessment of signs and symptoms. Any data obtained from the results of the assessment become evidence-based evidence to be used in overcoming the causes of stunting and wasting through interventions that will be given to the baby later. Then, the baby’s development during the next year’s life was monitored. This chapter was prepared by adopting information from previous research and needs to be published as a guideline for health workers to prevent babies from experiencing the risk of stunting and wasting.

1. Introduction

Stunting is a manifestation of growth and development disorders in children and is one of the causes of stunted height in children. According to UNICEF (2020), Indonesia is one of the countries with the most cases of stunting and wasting among children in the world. According to the results of a basic health survey, in Indonesia in 2007, the prevalence of stunting was 36.8%. The percentage of stunted toddlers increased to 37.2% in 2013. According to the 2018 survey, the prevalence of stunting in children under 2 years of age was 29.9%. Among toddlers, 30.8% [1]. In 2019, the incidence of stunting was 27.67% [2]. Before COVID-19, Indonesia faced high levels of malnutrition. During the COVID-19 period, malnutrition in children under 5 years of age experienced an increase in the impact of a declining family economy. This condition affects child morbidity and mortality related to malnutrition. Currently, more than two million children are severely underweight, and more than seven million children under the age of 5 are stunted [3]. Globally, editing is also a case that is currently being discussed.

Several countries have overcome stunting based on data from current cases. An evidence-based approach is urgently needed to prevent and reduce the problems of stunting and wasting. The identification of signs and symptoms of stunting risk in newborns is carried out at the best time, namely, early in pregnancy and after delivery. Therefore, a preventive approach to overcome the risk of stunting and wasting needs to be considered in the perinatal period, namely, pregnancy to delivery [4]. It is hoped that fetuses in the womb who are at high risk of experiencing stunting and wasting can be detected early so that, after birth, interventions can be carried out according to the triggering factors. The role of the mother is a key factor in preventing stunting and wasting. The mother is the only source of nutrition for the developing child during the critical period of 1000 days, the first 6 months of a baby’s life through exclusive breastfeeding [5]. Then, the risk of stunting in newborns was evaluated for the following year via anthropometric assessments and clinical nutritional assessments. The chapter that will be compiled outlines the elements that will be identified in assessing babies at risk of stunting and wasting.

The scope of this topic is the assessment of the risk of stunting and wasting in newborns and infants under 2 years of age. This chapter was compiled in an effort to facilitate the handling of stunting. The topic of stunting is discussed in this chapter according to trend issues that are widely discussed globally. Apart from being a global issue, we also see the impact of stunting, which can hamper children’s intelligence. The information presented in this chapter is how to detect the risk of stunting and wasting through an assessment of signs and symptoms. Any data obtained from the results of the assessment become evidence-based evidence to be used in overcoming the causes of stunting and wasting through interventions that will be given to the baby later. Then, the baby’s development during the next year’s life was monitored. This chapter was prepared by adopting information from previous research and needs to be published as a guideline for health workers to prevent babies from experiencing the risk of stunting and wasting.

2. Overview of stunting and wasting

Malnutrition is expressed as stunting and wasting. These two problems often appear together as a form of malnutrition in the same population. Several findings illustrate that wasting and stunting have many of the same causative factors [6]. Wasting is a condition in which individuals tend to look too thin for a person’s height or in terms of weight for height. Wasting can occur due to food shortages and/or acute illness [6]. Stunting can occur in the womb and continue for the first 2 years after birth [7].

Stunting is an indication of chronic malnutrition, which is illustrated by a short body structure. Features of wasting and stunting, for example, children under 5 years of age, have a low weight for age (stunting) and a low weight for height (wasting). This indicator can be considered an indicator of malnutrition [6]. Thus, the WHO defines stunting as growth retardation when the child’s weight is less than 2 SD of the z score for height or weight-for-height Z scores (WHZ) or height/length for age (lengthfor-age z score) (HAZ) [8]. Stunting can affect a child’s development process from conception to after birth in the third or fourth year of life [6].

The incidence of detected babies experiencing stunting is related to pregnancy and the postpartum period [9]. Several prenatal factors include maternal anemia during pregnancy, nutritional variations, knowledge during pregnancy, family economy, accompanying diseases, and infections. All of these factors are associated with the incidence of stunting in newborns [9, 10]. Malnutrition in cases of stunting includes inadequate maternal nutrition, intrauterine malnutrition, lack/not breastfeeding until 6 months of age, delay in introduction and provision of complementary foods, inadequate complementary foods (quantity and quality), and impaired absorption of nutrients due to infectious or digestive disease. Similarly, births are related to stunting, namely, babies born at a premature age [9]. During the postpartum period, mothers’ knowledge and education related to stunting [11].

The critical window (sensitive period) for fetal growth and development is expressed as the critical period, i.e., from the intrauterine period to early after birth [12]. The period from conception to the second year after birth (the first thousand days) is a critical window for intervention. The period of rapid intrauterine brain growth is characterized by rapid development, which describes the physical characteristics and abilities of a person in the next life. To maintain brain growth, environmental conditions and atmosphere during the critical window period are moments that need to be considered so that postpartum wasting and stunting do not occur until the following year.

Chronic malnutrition caused by stunting is associated with structural and functional pathologies of the brain [7]. Chronic nutritional deficiency causes damage to the brain’s nerve tissue, which affects the growth and development of children. Chronic malnutrition triggers stunting accompanied by disturbances and cognitive delays during infancy, childhood, and adolescence. The delay in growth and development can be measured according to the child’s age group, namely, three to 5 years, and differences in cognitive abilities [13]. The syndrome of stunting tends to occur more frequently in developing countries. The per capita income of the family does not yet have the ability to provide sufficient nutrition for pregnant women and newborns [13]. In connection with this crisis, health workers and the public need to be facilitated with information for assessing the signs and symptoms of newborns who are at risk of stunting.

3. Stunting syndrome determinants

The term “determinant of health” is used synonymously with “risk factors”. In the context of health policy, determinants are defined as health risks that are general, abstract, related to inequality, and difficult for individuals to control. Abstract understanding is then presented in an operational form. The presence of stunting syndrome is a set of risk factors that can be used to predict the risk of stunting. In this case, quoted from several sources, there are 20 predictors of the risk of stunting. The twenty predictors are categorized into 4 groups: (1) household and housing characteristics; (2) maternal and paternal characteristics; (3) antenatal care services; and (4) child characteristics [4]. The following is the relationship between risk predictors for stunting (Figure 1).

Figure 1.

Relationships between the characteristics of the stunting predictors (source: Titaley et al. [4]).

First, determinants based on household and housing, namely, the number of family members, number of children under five, fuel for cooking, source of drinking water, toilet facilities, and family income, were identified. Both are determinants of the characteristics of the mother and father. Education, employment status, and maternal age at birth were included. The third antenatal care service consists of the number of visits to pregnant women and the number of iron/folic acid supplements consumed during pregnancy. The four determinants of child characteristics are the sex of the child, the weight at birth, gestational age at delivery, past breastfeeding, time to start breastfeeding the baby after birth, history of diarrhea during the last 2 weeks, and the child’s age when studied.

The results of the stunting predictor test show that the determinant predictor of stunting is related to the incidence of stunting in several areas both in cities and in villages [4]. Testing the quality of the determinants of stunting syndrome is applied to a wide area of coverage. The data obtained were representative of the population and could be used to describe the incidence of stunting in that area. The collection of stunting data on the determinants of stunting can be used as a foundation for formulating policy decisions. This policy decision helps to design an effective evidence-based intervention to reduce the prevalence of stunting in children under 2 years of age in Indonesia, particularly in the perinatal period [14].

4. Measurement instrument for stunting and wasting syndrome

Decision-making on the incidence of stunting and wasting syndrome begins with gathering information on risk factors. Therefore, the data collected to address the problem of stunting and wasting are supported by comprehensive data and interventions that are based on triggering factors. Information obtained from risk factors is supported by data obtained from mothers and family members. The following assessment tools were used from previous research on risk factors [4, 14].

4.1 Risk factor data collection

The following information related to risk factors for stunting syndrome and wasting must be collected:

4.1.1 Household and housing conditions

The following information needs to be collected regarding the risk of stunting and wasting for household and housing conditions:

• Number of family members living together in one house (identifying all family members in reducing the risk of infection transmission)

• The size of the house occupied (identify the eligibility of the residence divided by the number of occupants and the risk of other sources of infection)

• Number of children under five in the family (identify the amount of costs as well as duties and responsibilities that must be fulfilled by the family to maintain family health, especially for children under five).

• Facilities for the use of fuel in cooking (identifying the risk of sources of pollution for respiratory problems that can physically aggravate children under five or pregnant women)

• Consumption of drinking water sources (identifying the availability of drinking water needs for consumption that meets health standards)

• Availability of washing and toilet facilities (identifying sources of risk of infection that may impact the baby’s health problems)

• Family income in 1 month (identifying the financial ability to meet household needs and consumption of nutrition for each household member, especially toddlers)

4.1.2 Characteristics of mothers and fathers

The following information needs to be collected regarding the risk of stunting and wasting on the characteristics of mothers and fathers:

• Parent education (identifying the level of education, good education facilitates good knowledge, can more easily reach and evaluate the health status of family members and toddlers, especially in terms of nutritional status)

• Parents’ work status (identifying parents’ work can determine the amount of time parents spend caring for toddlers and the amount of finances earned to meet household needs and toddlers’ nutritional needs).

• Maternal age at delivery (identifying risk factors that affect the health of toddlers in the womb)

• Parents’ cultural traditions (identifying traditions that deviate from health principles so that they have the potential to trigger toddlers to experience illness) [15].

4.1.3 Prenatal care services

The following information needs to be collected regarding the risk of stunting and wasting for antenatal care services:

• The number of visits for pregnant women (the implementation of ANC is highly recommended to be at least eight (8) times for each pregnant woman to reduce the incidence of death during pregnancy and childbirth). ANC visits can identify risk factors and comorbidities during pregnancy as early as possible so as not to interfere with fetal growth and intrauterine development. Therefore, the risk of experiencing stunting and wasting after birth can be overcome.)

• The amount of iron/folic acid supplements consumed during pregnancy (Fe is the most important element for the formation of red blood cells). Therefore, pregnant women are required to consume a minimum of 60 tablets of Fe during pregnancy to prevent anemia and nutritional intake for the fetus, while in the womb, folic acid reduces free radicals that can interfere with fetal growth.

4.1.4 Child characteristics

The following information needs to be collected regarding the risk of stunting and wasting for children’s characteristics:

• The sex of the child (there is no difference in the sex of the child for stunting, but it is necessary to study the differences in child care according to the preferred sex in one tribe) [16].

• Child’s weight at birth. (The risk of stunting can be seen from the child’s weight at birth with a history of maternal weight gain during small pregnancies) [16, 17].

• Gestational age at delivery (identified gestational age at delivery as an indicator of stunting risk) [18].

• The duration of breastfeeding (one of the causes of stunting and wasting) is a history of exclusive breastfeeding. Previous studies have shown that toddlers who exclusively breastfeed have a lower risk of experiencing stunting and wasting. Exclusive breastfeeding provides a protective effect against stunting in infants [15, 19].

• The time to start breastfeeding the baby after birth (breastfeeding that starts immediately after birth (IMD/early initiation of breastfeeding)) provides coverage of the baby’s nutrition and immunity [15].

• A history of diarrhea during the last 2 weeks was reviewed (identifying poor hygiene practices in families that have an impact on diarrhea in infants and can reduce the immune system of babies who are stunted or wasted and those who are not stunted) [20].

• Age of the child at the time of the study (identifying the age of the child under 5 years at risk of stunting for follow-up in anthropometric measurements).

4.2 Physical examination of nutritional status at risk of stunting and wasting

The nutritional status of newborn babies can be determined based on their height and weight. The height and weight of the newborns were measured using anthropometric standards. Interpretation of height and weight based on anthropometric standards can reveal the risk of stunting, wasting or obesity. Anthropometry is a standard for measuring the nutritional status of babies under 5 years of age. This standard has been socialized to health workers in primary to tertiary health services. Height and weight checks can be applied universally at all ages, including for pregnant women. Measuring the weight and height of the uterine fundus of pregnant women can aid in determining the nutritional status of pregnant women and interpreting the weight of the fetus in the womb. Low fetal weight in the womb can cause a baby to experience low weight after birth. Therefore, identifying measurements of a baby’s height and weight after birth is very precise for identifying the risk of stunting and wasting.

4.2.1 Anthropometric measurements

Anthropometric measurements included weight for height, height for age, weight for age, and other indices such as weight gain for pregnant women. The anthropometric standards for children in Indonesia refer to the WHO Child Growth Standards for Children Aged 0–5 Years. (Mentri Kesehatan Republik Indonesia, 2020) Anthropometric standard sizes for identifying categories of nutritional problems for infants aged 0 (zero) to 60 (sixty) months, one of which is the index of weight according to body length or height (WB/BL or WB/HB). The category indices are malnutrition (severely wasted); malnutrition (wasted); good nutrition (normal); greater nutritional risk (possible risk of overweight); greater nutrition (overweight); and obesity (obese). (Mentri Kesehatan Republik Indonesia, 2020).

Another physical examination for measuring nutritional status uses the Waterlow classification. Body weight was measured as height or weight-for-height Z scores (WHZ) according to the Waterlow classification, which consists of (1) low WHZ (stunting and wasting at the same time), (2) normal WHZ (stunting only), and (3) high WHZ (short stature with excess weight appearing side by side). (Ferreira, 2020) Medium The size value is usually expressed in the form of a z score. The height-for-age z score (HAZ) is used to measure stunting.

The following is a physical examination to detect the risk of stunting and wasting based on anthropometry and clinical assessment of nutritional status (CAN score).

4.3 Clinical assessment of the nutritional status of the newborn

4.3.1 Anthropometric neonatal data

Body weight/weight-for-height z score (WHZ) or height-for-age/height/length-for-age z score (HAZ) were measured (Table 1).

Nutritional condition	HAZ (SD)		WHZ (SD)
	Normal (≥ − 2)	Low (< − 2)	Normal (≥ −2 to ≤2)	Low (< −2)
Eutrophy	V		V
Chronic undernutrition (stunting)		V	V
Acute undernutrition (wasting)	V			V
Decompensated chronic undernutritiona		V		V
Overweight
Short stature with overweight
Total

Table 1.

Anthropometric assessment of the nutritional status of children: A new approach based on an adaptation of the waterlow classification [21].

^a

Concurrently wasting and stunting.

This table describes the six categories defined as indicators of nutritional conditions, namely, eutrophic (normal height and weight), acute undernutrition (wasting), chronic undernutrition (stunting), decompensated chronic undernutrition, and overweight.

The classification of nutritional status was adapted from Waterlow. The difference between stunting and wasting is based on measurements of body weight and height. Wasting has a low weight-for-height z score (WHZ). Stunting was defined as a low height/length-for-age z score (HAZ). (Ferreira, 2020).

There is a table for detecting wasting based on gender.

Tables 2–5. Measurement of body weight-for-height Z scores (WHZ) for children adapted according to the Waterlow classification consists of (1) At the same time, the WHZ exhibits low stunting and wasting; (2) the WHZ is normal (stunting only); and (3) the WHZ is high (short stature with excess weight appears side by side) [21]. Interpretation of the size of the height-for-age z score (HAZ) explains stunting with a low HAZ for chronic undernutrition (stunting) and decompensated chronic undernutrition (stunting and wasting).

Table 2.

The standard weight-for-height z score for boys was reported [22].

This table describes the standard weight according to body length (weight/l height) based on the threshold (ZScore) for boys to be declared: severely wasted (< −3 SD), wasted (−3 SD to < −2 SD), good nutrition (−2 SD to +1 SD), possible risk of overweight (> +1 SD to +2 SD), and obese (> +3 SD).

Table 3.

The standard weight-for-height z -scores of the girls are shown in Tables 2 and 3 [22].

This table describes the standard weight according to body length (weight/ height) based on the threshold (Z Score) for girls to be declared: severely wasted (< −-3 SD), wasted (−3 SD to > −2 SD), good nutrition (−2 SD to +1 SD), possible risk of overweight (> +1 SD to +2 SD), and obese (> +3 SD).

Table 4.

Standard height/length for age z score (HAZ) of boys aged 0–24 months.

* Weight measurement is performed with the child on his back [22]. This table describes body length according to age in boys with the following criteria: severely stunted (< −3 SD), stunted (−3 SD to < −2 SD), normal (−2 SD to +3 SD), and tall (> +3 SD).

Table 5.

The standard height/length for age z score (HAZ) was calculated for girls aged 0–24 months.

* Weight measurement is performed with the child on his back [22].This table describes body length according to age in girls with the following criteria: severely stunted (< −3 SD), stunted (−3 SD to < −2 SD), normal (−2 SD to +3 SD), and tall (> +3 SD)

4.4 Clinical nutritional assessment (CAN)

4.4.1 Hair

Hair condition was assessed by four indicators. Indicator 1. There is a space on the head where hair does not grow, hair is straight, hair pigmentation is reduced, and hair is gathered together. Indicator 2: Thicker, straight thin hair and more hair growth. Indicator 3: thick hair, sparse growth, few straight hairs. Indicator 4: the hair is thick, dense, smooth, shiny, and easy to comb.

4.4.2 Cheek

The structure and texture of the cheeks are assessed by four indicators. Indicator (1). There is almost no fat structure on the cheeks, and the face is narrow. (2). The structure of the cheek pads is significantly reduced (3). The cushion structure of the cheek pads is slightly reduced to a slightly flattened structure (4). The cheeks are fully developed, and the face is round.

4.4.3 Neck and chin

The structure of the neck and chin was assessed by four indicators. Indicator 4. When the neck and chin overlap, the fat is doubled or tripled, and the neck is closed. Indicator 3.

The fat on the neck is slightly reduced, and the fat on the chin is thin. Indicator 2. Thin chin fat pad, visible neck. Indicator 1. No fat folds on the chin or neck look loose and are very clearly visible. Wrinkle skin.

4.4.4 Arm

The structure of the arm was assessed by four indicators. Indicator 4. Fully rounded sleeves, absent accordion pleats. Indicator 3. The arm has little fat, and there are folds of skin in the elbow or triceps area. Indicator 2: small arms to the accordion. Indicator 1 The forearms have very thin skin and loose skin and are easy to grip and pull from the elbow.

4.4.5 Foot

The measurements are the same as those for the arm.

4.4.6 Behind the scapula

The rear structure is rated on four indicators. Indicator 4: the skin in the interscapular area is difficult to pull. Indicator 3. Slightly retractable skin indicator 2. The skin is loose and easy to pull. Indicator 1 had no fat, wrinkled skin or loose skin and was easy to pull.

4.4.7 Buttocks

The rear structure is assessed based on four indicators. Indicator 4 gluteal fat pads are round and full. Indicator 3. looks a bit fat. Indicator 2. It significantly reduces fat and wrinkles. In indicator 1, there was almost no gluteal fat, and the skin of the upper posterior buttock was loose and very wrinkled.

4.4.8 Chest

The structure of the chest was assessed by four indicators. Indicator 4. The chest was full and rounded, and the ribs were not visible. Indicator 3 intercostal spaces are slightly visible. The indicators of the 2 intercostal spaces are visible. Indicator 1: Ribs are increasingly prominent due to the loss of intercostal tissue.

4.4.9 Abdomen

Abdominal structure was assessed in four categories. Indicator 4. The skin is full, rounded, and not sagging. Indicator 3 reduces fat. Indicator 2 is thinning of the abdominal wall from the accordion to the crease. Indicator 1 belly or scaphoid, but with very loose skin, easy to remove.

Nutritional status was based on the cutoff point CANScore divided by two, which is a score ≥ 25. The authors stated that the baby has good nutrition, and a score < 25 indicated undernutrition (Figures 2 and 3) [21]. The measurement instrument CAN scores can be found in Table 6.

Figure 2.

Nutrition assessment with the CAN score [21].

Figure 3.

Anthropometric classification of nutritional status (adapted to the Waterlow classification) of children under five [21].

Project	CANSCORE
	4	3	2	1 point
Hair	Thick, dense, smooth, satintike, easy to comb	Thick, scarce, there is little hair straight	Hair thin, straight and put up with more hair	Sparse, straight and erect hair, the hair bundle associated with reduced pigmentation
Cheek	Plump, round face	Slightly reduced fat	Significantly reduced	Fat is almost gone, narrow face
Neck chin	Fat overlap into double or triple chin, neck cover	Slightly reduced fat chin, the neck can be seen	Fat pad thin chin, neck revealed	Chin fat disappears, the neck is clear, loose skin, wrinkle
Arm	Fullness, can not lift the skin	Arm a little thin, check on the pressure of hands, the accordion-like folds can be formed	Small arms, to form accordion like folds	Very little fat, loose skin, accordion-like folds significantly
Back	Interscapular area of skin can not be picked	Little to lift the skin	Easy to lift and skin	Loose skin, easy to lift, wrinkles can form
Buttock	Fat pad thickness	Slightly reduced fat	Significantly reduced fat, hips tip, wrinkle	Fat disappears, fight wrinkles, loose skin and a very, kind of hip, such as pipe
Leg	Described with the same arm	Described with the same arm	Described with the same arm	Described with the same arm
Chest	Full, see the intercostal space	Intercostal space slightly visible	Intercostal space revealed	Intercostal space very dear, obvious loss of subcutaneous tissue
	Abdomen fullness, thickness of subcutaneous fat	Slightly reduced fat	Abdominal wall thinning, can form the accordion-like folds	Abdominal bulging or boatshaped abdomen, loose skin, can form the accordion-like folds

Table 6.

Can scoring.

Source: [21].

4.5 Measuring tools for detecting stunting and wasting in children

4.5.1 Weight scales

Infantometer: The baby’s weight (baby scale) was measured (Figure 4).

Figure 4.

The baby weight scale [22].

Weighing gloves are used in posyandu throughout Indonesia. An instrument was used to measure body weight (Figure 5).

Figure 5.

Dacin tripod scale. This scale is used to assess the weight of babies under 5 years old. This scale uses cloth material that can be folded and is easy to carry. This scale is usually used in posyandu services [22].

4.5.2 Height scale

Infantometer: an infrared measuring tool that is used for babies and toddlers (Figure 6).

Figure 6.

Infantometer scale for body height. Measuring tools used by Indonesia in health services at community health centers and hospitals the tool measures the baby’s height from head to toe [22].

4.5.3 Growth mat

The use of a growth mat is a tool for the early detection of stunting in posyandu throughout Indonesia. This tool is used to measure the body length of children under the age of two (Figure 7).

Figure 7.

Growth mat scale. The growth mat is a height measuring instrument made of wood and plastic. This tool is still used in Indonesia for Posyandu services. The tool is foldable and easy to carry [22].

5. Conclusions

Stunting and wasting are characteristic features of neonatal and infant growth disorders. Stunting and waste are influenced by many factors. One of the events is a problem that occurs since the neonate is in the mother’s womb. One of the efforts to prevent stunting and wasting from becoming more serious is early detection of the risk of stunting during pregnancy. Then, detection continued after birth. With the hope that the risk of stunting and wasting in neonates and infants can be prevented. This chapter can serve as a reference for obtaining information to detect stunting and wasting in neonates and infants. The users are health workers, health cadres, and the community who help reduce the incidence of stunting and wasting.

Acknowledgments

We would like to thank the Ministry of Health of the Republic of Indonesia for facilitating the use of baby growth measuring devices and socializing research on maternal and infant health and stunting. To the Jakarta 1 Health Polytechnic for promoting research on maternal and infant health and stunting.

Conflict of interest

There is no conflict of interest in writing this chapter.

Acronyms and abbreviations

COVID-19	coronavirus disease 2019
WHZ	weight-for-height Z scores
HAZ	height-for-age z score
IMD	inisiasi menyusi dini/early initiation of breastfeeding
ANC	ante natal care
WB/BL or WB/HB	weight/body or weight body/height body
CAN	clinical nutritional assessment