*4.1.4 Child characteristics*

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


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-forage 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/lengthfor-age z score (HAZ) were measured (**Table 1**).


*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.*

#### **Table 1.**

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

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).

#### **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


*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 2.**

*The standard weight-for-height z score for boys was reported [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 3.**

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


*\* 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 4.**

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

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.


*\* 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)*

#### **Table 5.**

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

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**.

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

### *4.5.2 Height scale*

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

**Figure 2.** *Nutrition assessment with the CAN score [21].*

*Evaluating the Risk of Stunting and Wasting in Newborns DOI: http://dx.doi.org/10.5772/intechopen.112683*

**Figure 3.**

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



*Source: [21].*

**Table 6.** *Can scoring.*

**Figure 4.** *The baby weight scale [22].*

#### **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].*

#### *4.5.3 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**).

*Evaluating the Risk of Stunting and Wasting in Newborns DOI: http://dx.doi.org/10.5772/intechopen.112683*

#### **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].*

#### **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].*
