**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.

**Keywords:** assessment, measurement, newborn, perinatal, stunting

## **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**).

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,

**Figure 1.** *Relationships between the characteristics of the stunting predictors (source: Titaley et al. [4]).*

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].
