ABSTRACT

Objective:

To identify predictors of stunting among children 0-24 months in Southeast Asia.

Methods:

This scoping review focused on articles with observational study design in English published from 2012 to 2023 from five international databases. The primary keyword used were: “stunting” OR “growth disorder” AND “newborn” AND “predict” AND “Southeast Asia”.

Results:

Of the 27 articles selected for the final analysis there are thirteen predictors of stunting in seven Southeast Asia countries. The thirteen predictors include the child, mother, home, inadequate complementary feeding, inadequate breastfeeding, inadequate care, poor quality foods, food and water safety, infection, political economy, health and healthcare, water, sanitation, and environment, and social culture factor.

Conclusion:

All these predictors can lead to stunting in Southeast Asia. To prevent it, health service providers and other related sectors need to carry out health promotion and health prevention according to the predictors found.

Descriptors:
Children; Infant; Epidemiologic Factors; Southeast Asia; Stunting

RESUMO

Objetivo:

Identificar preditores de nanismo entre crianças de 0 a 24 meses no Sudeste Asiático.

Métodos:

Esta revisão de escopo se concentrou em artigos com desenho de estudo observacional em inglês publicados de 2012 a 2023 em cinco bases de dados internacionais. As palavras-chave primárias usadas foram: “stunting” (nanismo) OU “growth disorder” (distúrbio de crescimento) E “newborn” (recém-nascido) E “predict” (previsão) E “Southeast Asia” (Sudeste Asiático).

Resultados:

Dos 27 artigos selecionados para análise final, existem treze preditores de nanismo em sete países do Sudeste Asiático. Os treze preditores incluem a criança, a mãe, a casa, a alimentação complementar inadequada, a amamentação inadequada, os cuidados inadequados, os alimentos de má qualidade, a segurança alimentar e da água, a infeção, a economia política, a saúde e os cuidados de saúde, a água, o saneamento e o meio ambiente, e o fator cultura social.

Conclusão:

Todos estes preditores podem levar ao nanismo no Sudeste Asiático. Para preveni-lo, os prestadores de serviços de saúde e outros setores relacionados precisam realizar a promoção e a prevenção da saúde de acordo com os preditores encontrados.

Descritores:
Crianças; Lactente; Fatores Epidemiológicos; Sudeste da Ásia; Transtornos do Crescimento

RESUMEN

Objetivo:

Identificar indicadores de desnutrición crónica entre niños de 0 a 24 meses en el Sudeste Asiático.

Métodos:

Esta revisión de alcance se centró en artículos con diseño de estudio observacional publicados en inglés, entre los años 2012 y 2023 de cinco bases de datos internacionales. Las principales palabras clave utilizadas fueron: “stunting (Desnutrición crónica)” o “growth disorder (Desorden del crecimiento)”, y “newborn (Recién nacido)”, y “predict (Predecir)”, y “Southeast Asia (Sudeste Asiático)”.

Resultados:

De los 27 artículos seleccionados para el análisis final, se encontraron trece indicadores que influyen en la desnutrición crónica en siete países del Sudeste Asiático. Los trece indicadores incluyen el niño, la madre, el hogar, la alimentación inadequada complementaria, la lactancia materna inadecuada, la atención inadecuada, los alimentos de mala calidad, la seguridad de los alimentos y el agua, la infección, la economía política, la salud y la asistencia sanitaria, el agua, el saneamiento y el medio ambiente, y por último el factor sociocultural.

Conclusión:

Todos estos indicadores pueden provocar desnutrición crónica en niños del Sudeste Asiático. Para poder prevenirlo los prestadores de servicios de salud y otros sectores relacionados, necesitan realizar actividades de promoción y prevención de la salud de acuerdo con los indicadores encontrados en este artículo.

Descriptores:
Niños; Lactente; Factores Epidemiológicos; Sudeste de Asia; Trastornos del Crecimiento

INTRODUCTION

Stunting is a manifestation of severe, irreversible physical, mental and cognitive impairment due to chronic malnutrition in early life, which becomes a global serious health problem, particularly in low-middle income countries and developing countries(¹1 Otiti MI, Allen SJ. Severe acute malnutrition in lowand middle-income countries. Paediatr Child Health (Oxford). 2021;31(8):301-7. https://doi.org/10.1016/j.paed.2021.05.001
https://doi.org/10.1016/j.paed.2021.05.0... ). Based on global prevalence, there are as many as 22% or 149,2 million children under five with these cases, 35.2% in poor countries and 22.4% in developing countries, especially those spread across Asia, which has the largest stunting cases with a prevalence of 56%(²2 World Health Organization (WHO). Joint Child Malnutrition Estimates[Internet]. 2021 [cited 2022 Apr 10];24(2):51-78. Available from: https://www.who.int/publications/i/item/9789240025257
https://www.who.int/publications/i/item/... ). Although the level of stunting across the world is reduced, stunting in Southeast Asia is still high with a prevalence of stunting of 27.4%(²2 World Health Organization (WHO). Joint Child Malnutrition Estimates[Internet]. 2021 [cited 2022 Apr 10];24(2):51-78. Available from: https://www.who.int/publications/i/item/9789240025257
https://www.who.int/publications/i/item/... ).

Stunting has negative adverse effects, include short-term and long-term impact; short-term adverse effects cause impaired brain development, intelligence, physical growth disorders and metabolic disorders, and long-term effects are decreased cognitive abilities and learning achievement, decreased immunity and risk of other complications(³3 De Sanctis V, Soliman A, Alaaraj N, Ahmed S, Alyafei F, Hamed N. Early and long-term consequences of nutritional stunting: from childhood to adulthood. Acta Biomed. 2021;92(1):e2021168. https://doi.org/10.23750/abm.v92i1.11346
https://doi.org/10.23750/abm.v92i1.11346... ). Moreover, one million deaths are attributable to stunting, especially in developing countries, and 28% of child mortality is caused by malnutrition(⁴4 Kwami CS, Godfrey S, Gavilan H, Lakhanpaul M, Parikh P. Water, sanitation, and hygiene: linkages with stunting in rural Ethiopia. Int J Environ Res Public Health. 2019;16(20):3793. https://doi.org/10.3390/ijerph16203793
https://doi.org/10.3390/ijerph16203793... ). Along with this prevalence, stunting can be caused by several factors, both direct and indirect, which include history of breastfeeding, low birth weight, short maternal posture, socioeconomic, environment and sanitation, and health services(⁵5 Nshimyiryo A, Hedt-Gauthier B, Mutaganzwa C, Kirk CM, Beck K, Ndayisaba A, et al. Risk factors for stunting among children under five years: a cross-sectional population-based study in Rwanda using the 2015 Demographic and Health Survey. BMC Public Health. 2019;19(1):175. https://doi.org/10.1186/s12889-019-6504-z
https://doi.org/10.1186/s12889-019-6504-... ).

Despite the various stunting interventions that have been provided by governments in Southeast Asia, the prevalence of stunting is still reported to be high and is also a major burden(⁶6 Tadesse SE, Mekonnen TC, Adane M. Priorities for intervention of childhood stunting in northeastern Ethiopia: a matched case-control study. PLoS One. 2020;15(9):e0239255. https://doi.org/10.1371/journal.pone.0239255
https://doi.org/10.1371/journal.pone.023... ). Tono added that this was happening because the existing stunting interventions were not in accordance with the determinants that should be addressed(⁷7 Wali N, Agho KE, Renzaho AMN. Factors associated with stunting among children under 5 years in five South Asian countries (2014-2018): analysis of demographic health surveys. Nutrients. 2020;12(12):3875. https://doi.org/10.3390/nu12123875
https://doi.org/10.3390/nu12123875... ). Although there are many studies that have found factors that cause stunting, the predictors of stunting in the golden period of children in Southeast Asia are still not known with certainty. Because information regarding predictors of stunting is very important to know in Southeast Asia, we conducted this scoping review to find out what are the predictors of stunting in children aged 0-24 months in Southeast Asia. It is hoped that the stunting predictors that we have summarized based on the WHO stunting conceptual framework can help determine better interventions and become material for further exploring various predictors for which the evidence is not clear enough.

OBJECTIVE

To identify predictors of stunting among children 0-24 months in Southeast Asia.

METHODS

This scoping review was conducted by following the guidelines of the Joanna Briggs Institute (JBI) methodology for Scoping reviews(⁸8 Peters M, Godfrey C, McInerney P, Munn Z, Trico A, Khalil H. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth. 2020;18(10):2119-26. https://doi.org/10.11124/JBIES-20-00167
https://doi.org/10.11124/JBIES-20-00167... ) and reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) extension for Scoping Reviews(⁹9 Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-73. https://doi.org/10.7326/M18-0850
https://doi.org/10.7326/M18-0850... ). The steps followed include: developing objectives and research questions, determining inclusion and exclusion criteria for data on evidence, planning search strategies, determining sources of evidence selection, data extraction, analysis of evidence, and presenting results(⁸8 Peters M, Godfrey C, McInerney P, Munn Z, Trico A, Khalil H. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth. 2020;18(10):2119-26. https://doi.org/10.11124/JBIES-20-00167
https://doi.org/10.11124/JBIES-20-00167... ).

We used PCC (Population, Concept and Context) framework to formulate the review question. The population were children aged under 24 months. The concept focused on the predictors of stunting. The context of article was countries in Southeast Asia.

All articles included in this study were searched in five international databases on March 14, 2023. The five databases were MEDLINE/PubMed, Cumulative Index for Nursing and Allied Health Literature (CINAHL) plus with full text via EBSCOhost, Web of Science, Scopus, and Cochrane Library. The descriptors used contained the Medical Subject Heading (MeSH) and not limited to “stunting” OR “growth disorder” AND “infant” AND “epidemiologic factor” AND “Southeast Asia”. The full search strategy can be seen in Chart 1.

To clearly identify the most recent and specific predictors of stunting in the Southeast Asia region, there were two search limitations that we considered important to be applied. First, we only included peer-reviewed articles in English language and published from January 2012 to February 2023. Second, we limited the geographic location of the study to Southeast Asia only. In addition, we included only original studies with observational designs and secondary data analysis. The secondary data analysis was included because the nature of the study is basically observational and retrospective. All relevant full text articles that were not found after being searched by the authors, including asking as to the author of the article, were excluded from the review.

Following the search, all identified articles were collated and uploaded into a website application named Rayyan for review(¹⁰10 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan: a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. https://doi.org/10.1186/s13643-016-0384-4
https://doi.org/10.1186/s13643-016-0384-... ), to immediately proceed with the removal of duplicates and screening. Titles and abstracts were also immediately screened by the first and fourth authors, thereby obtaining relevant articles for review. Potentially relevant articles were retrieved in full text and assessed in detail based on inclusion criteria by all authors independently. The article selection process was recorded and reported in the PRISMA 2020 flow diagram(¹¹11 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;71. https://doi.org/10.1136/bmj.n71
https://doi.org/10.1136/bmj.n71... ). Any disagreements that arose between authors at each stage of the selection process were resolved through discussion.

The article data were extracted by all authors independently using the JBI data extraction instrument which had been developed according to the purpose of the review. The data extraction covered the characteristics of article, study objectives, population, and outcomes. For the characteristics of the articles, we extracted the authors, year of publication, country of origin, and study design. For the population, we extracted the numbers and the main criteria of the sample. Finally, for the outcome, we only extracted the predictors of stunting found in children aged 0-24 months, including their statistical values. Any disagreements that arose in the data extraction process were resolved through discussion.

According to the guidelines used(⁸8 Peters M, Godfrey C, McInerney P, Munn Z, Trico A, Khalil H. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth. 2020;18(10):2119-26. https://doi.org/10.11124/JBIES-20-00167
https://doi.org/10.11124/JBIES-20-00167... ), this scoping review presents two tables of the data extraction results, which were agreed upon by all authors and provide a narrative summary of the findings of the articles reviewed. The first table describes the characteristics of the articles and the predictors of stunting found. The second table provides a summary of the predictors of stunting classified by factors from the WHO stunting conceptual framework(¹²12 World Health Organization (WHO). Childhood stunting: context, causes and consequences[Internet]. 2016 [cited 2023 Mar 21]. Available from: https://www.who.int/publications/m/item/childhood-stunting-context-causes-and-consequences-framework
https://www.who.int/publications/m/item/... ). The narrative summary focused on describing the number of existing predictors of stunting and the most common predictors of stunting in Southeast Asia. The chart’s template also presents the checklist for review articles.

RESULTS

The results of identification and screening of 747 articles showed that there were 27 articles that met the inclusion criteria. Another 720 articles were excluded following the PRISMA-ScR flow diagram (see Figure 1). Of 27 studies, the predictors of stunting have been widely studied in Indonesia(¹³13 Torlesse H, Cronin AA, Sebayang SK, Nandy R. Determinants of stunting in Indonesian children: evidence from a cross-sectional survey indicate a prominent role for the water, sanitation and hygiene sector in stunting reduction. BMC Public Health. 2016;16(1):669. https://doi.org/10.1186/s12889-016-3339-8
https://doi.org/10.1186/s12889-016-3339-...

14 Sari K, Sartika RAD. The effect of the physical factors of parents and children on stunting at birth among newborns in Indonesia. J Prev Med Public Health. 2021;54(5):309-16. http://doi.org/10.3961/jpmph.21.120
http://doi.org/10.3961/jpmph.21.120...

15 Hadi H, Fatimatasari F, Irwanti W, Kusuma C, Alfiana RD, Asshiddiqi MIN. Exclusive breastfeeding protects young children from stunting in a low-income population: a study from eastern Indonesia. Nutrients. 2021;13(12):4264. https://doi.org/10.3390/nu13124264
https://doi.org/10.3390/nu13124264...

16 Gunardi H, Soedjatmiko S, Sekartini R, Medise BE, Darmawan AC, Armeilia R. Association between parental socio-demographic factors and declined linear growth of young children in Jakarta. Med J Indones. 2018;26(4):286-92. https://doi.org/10.13181/mji.v26i4.1819
https://doi.org/10.13181/mji.v26i4.1819...

17 Sartika AN, Khoirunnisa M, Meiyetriani E, Ermayani E, Pramesthi IL, Nur Ananda AJ. Prenatal and postnatal determinants of stunting at age 0-11 months: a cross-sectional study in Indonesia. PLoS One. 2021;16:1-14. https://doi.org/10.1371/journal.pone.0254662
https://doi.org/10.1371/journal.pone.025...

18 Titaley CR, Ariawan I, Hapsari D, Muasyaroh A, Dibley MJ. Determinants of the stunting of children under two years old in Indonesia: a multilevel analysis of the 2013 Indonesia Basic Health Survey. Nutrients. 2019;11(5):1106. https://doi.org/10.3390/nu11051106
https://doi.org/10.3390/nu11051106...

19 Nurhayati E, Paramashanti BA, Astiti D, Aji AS. Dietary diversity, vitamin D intake and childhood stunting: a case-control study in Bantul, Indonesia. Malays J Nutr. 2020;26(2):273-87. https://doi.org/10.31246/mjn-2020-0021
https://doi.org/10.31246/mjn-2020-0021...

20 Madinar M, Andina E, Achadi EL. Fulfilment of minimum acceptable diet (MAD), short birth length and family income level are associated with stunting in children aged 6-23 months in Central Jakarta. Malays J Nutr. 2021;27(2):259-70. https://doi.org/10.31246/mjn-2020-0045
https://doi.org/10.31246/mjn-2020-0045...

21 Utami N, Rachmalina R, Irawati A, Sari K, Rosha BC, Amaliah N, et al. Short birth length, low birth weight and maternal short stature are dominant risks of stunting among children aged 0-23 months: evidence from Bogor longitudinal study on child growth and development, Indonesia. Malays J Nutr [Internet]. 2018 [cited 2023 Mar 15];24:11-23. Available from: https://nutriweb.org.my/mjn/publication/24-1/b.pdf
https://nutriweb.org.my/mjn/publication/...

22 Hanifah L, Wulansari R, Meiandayati R, Achadi EL. Stunting trends and associated factors among Indonesian children aged 0-23 months: evidence from Indonesian Family Life Surveys (IFLS) 2000, 2007 and 2014. Malays J Nutr [Internet]. 2018 [cited 2023 Mar 15];24(3):315-22. Available from: https://nutriweb.org.my/mjn/publication/24-3/b.pdf
https://nutriweb.org.my/mjn/publication/... -²³23 Diana A, Haszard JJ, Sari SYI, Rahmannia S, Fathonah A, Sofiah WN. Determination of modifiable risk factors for length-for-age z-scores among resource-poor Indonesian infants. PLoS One. 2021;16(2):e0247247. https://doi.org/10.1371/journal.pone.0247247
https://doi.org/10.1371/journal.pone.024... ). Other Southeast Asian countries that have also studied the predictors of stunting are the Philippines(²⁴24 Rohner F, Woodruff BA, Aaron GJ, Yakes EA, Lebanan MAO, Rayco-Solon P. Infant and young child feeding practices in urban Philippines and their associations with stunting, anemia, and deficiencies of iron and vitamin A. Food Nutr Bull. 2013;34(2 Suppl):17-34. https://doi.org/10.1177/15648265130342S104
https://doi.org/10.1177/15648265130342S1...

25 Maravilla JC, Betts K, Adair L, Alati R. Stunting of children under two from repeated pregnancy among young mothers. Sci Rep. 2020;10(1):14265. https://doi.org/10.1038/s41598-020-71106-7
https://doi.org/10.1038/s41598-020-71106...

26 Hinojosa AP V., Tandang NA, Domingo DGC. Relationship between maternal characteristics and stunting in children aged 0 to 23 months in the Philippines. Malays J Nutr. 2021;27(3). https://doi.org/10.31246/mjn-2021-0010
https://doi.org/10.31246/mjn-2021-0010...

27 Guirindola MO, Goyena EA, Maniego ML V. Risk factors of stunting during the complementary feeding period 6-23 months in the Philippines. Malays J Nutr. 2021;27(1):123-40. https://doi.org/10.31246/mjn-2020-0112
https://doi.org/10.31246/mjn-2020-0112...

28 Ulep VGT, Uy J, Casas LD. What explains the large disparity in child stunting in the Philippines? a decomposition analysis. Public Health Nutr. 2022;25(11):2995-3007. https://doi.org/10.1017/S136898002100416X
https://doi.org/10.1017/S136898002100416... -²⁹29 Blake RA, Park S, Baltazar P, Ayaso EB, Monterde DBS, Acosta LP. LBW and SGA impact longitudinal growth and nutritional status of Filipino infants. PLoS One. 2016;11(7):1-13. https://doi.org/10.1371/journal.pone.0159461
https://doi.org/10.1371/journal.pone.015... ), Cambodia(³⁰30 Kpewou DE, Poirot E, Berger J, Som SV, Laillou A, Belayneh SN. Maternal mid-upper arm circumference during pregnancy and linear growth among Cambodian infants during the first months of life. Matern Child Nutr. 2020;16(S2). https://doi.org/10.1111/mcn.12951
https://doi.org/10.1111/mcn.12951...

31 Laillou A, Gauthier L, Wieringa F, Berger J, Chea S, Poirot E. Reducing malnutrition in Cambodia. a modeling exercise to prioritize multisectoral interventions. Matern Child Nutr. 2020;16(S2). https://doi.org//doi/10.1111/mcn.12770
https://doi.org//doi/10.1111/mcn.12770... -³²32 Harvey CM, Newell M-L, Padmadas S. Maternal socioeconomic status and infant feeding practices underlying pathways to child stunting in Cambodia: structural path analysis using cross-sectional population data. BMJ Open. 2022;12(11):e055853. https://doi.org/10.1136/bmjopen-2021-055853
https://doi.org/10.1136/bmjopen-2021-055... ), Vietnam(³³33 Beal T, Le DT, Trinh TH, Burra DD, Huynh T, Duong TT. Child stunting is associated with child, maternal, and environmental factors in Vietnam. Matern Child Nutr. 2019;15(4). https://doi.org/10.1111/mcn.12826
https://doi.org/10.1111/mcn.12826... -³⁴34 Young MF, Nguyen PH, Gonzalez Casanova I, Addo OY, Tran LM, Nguyen S, et al. Role of maternal preconception nutrition on offspring growth and risk of stunting across the first 1000 days in Vietnam: a prospective cohort study. PLoS One. 2018;13(8):e0203201. https://doi.org/10.1371/journal.pone.0203201
https://doi.org/10.1371/journal.pone.020... ), Myanmar(³⁵35 Mya KS, Kyaw AT, Tun T. Feeding practices and nutritional status of children age 6-23 months in Myanmar: a secondary analysis of the 2015-16 demographic and health survey. PLoS One. 2019;14(1):e0209044. https://doi.org/10.1371/journal.pone.0209044
https://doi.org/10.1371/journal.pone.020... -³⁶36 Phu KWW, Wittayasooporn J, Kongsaktrakul C. Influence of child feeding practices and selected basic conditioning factors on stunting in children between 6 and 24 months of age in Myanmar. Makara J Health Res. 2019;23(2). https://doi.org/10.7454/msk.v23i2.10397
https://doi.org/10.7454/msk.v23i2.10397... ), Malaysia(³⁷37 Ahmad N, Sutan R, Tamil AM, Hajib N. Growth patterns and nutritional status of small for gestational age infants in Malaysia during the first year of life. Child Health Nurs Res. 2021;27(4):317-27. https://doi.org/10.4094/chnr.2021.27.4.317
https://doi.org/10.4094/chnr.2021.27.4.3... -³⁸38 Masroor N, Rahman J, TinMyo H, Khattak MAK, Aye A. Factors affecting nutritional status of children below 24 months in Pekan district, Pahang, Malaysia. Malays J Nutr [Internet]. 2014 [cited 2023 Mar 15];20:197-207. Available from: https://nutriweb.org.my/mjn/publication/20-2/e.pdf
https://nutriweb.org.my/mjn/publication/... ), and Brunei Darussalam(³⁹39 Boylan S, Mihrshahi S, Louie JCY, Rangan A, Salleh HN, Ali HI. Prevalence and risk of moderate stunting among a sample of children aged 0-24 months in Brunei. Matern Child Health J. 2017;21(12):2256-66. https://doi.org/10.1007/s10995-017-2348-2
https://doi.org/10.1007/s10995-017-2348-... ). From our defined population, few studies appear to have specifically studied the predictors of stunting in children aged 6-24 months only(¹⁹19 Nurhayati E, Paramashanti BA, Astiti D, Aji AS. Dietary diversity, vitamin D intake and childhood stunting: a case-control study in Bantul, Indonesia. Malays J Nutr. 2020;26(2):273-87. https://doi.org/10.31246/mjn-2020-0021
https://doi.org/10.31246/mjn-2020-0021... -²⁰20 Madinar M, Andina E, Achadi EL. Fulfilment of minimum acceptable diet (MAD), short birth length and family income level are associated with stunting in children aged 6-23 months in Central Jakarta. Malays J Nutr. 2021;27(2):259-70. https://doi.org/10.31246/mjn-2020-0045
https://doi.org/10.31246/mjn-2020-0045... ,²⁷27 Guirindola MO, Goyena EA, Maniego ML V. Risk factors of stunting during the complementary feeding period 6-23 months in the Philippines. Malays J Nutr. 2021;27(1):123-40. https://doi.org/10.31246/mjn-2020-0112
https://doi.org/10.31246/mjn-2020-0112... -²⁸28 Ulep VGT, Uy J, Casas LD. What explains the large disparity in child stunting in the Philippines? a decomposition analysis. Public Health Nutr. 2022;25(11):2995-3007. https://doi.org/10.1017/S136898002100416X
https://doi.org/10.1017/S136898002100416... ,³¹31 Laillou A, Gauthier L, Wieringa F, Berger J, Chea S, Poirot E. Reducing malnutrition in Cambodia. a modeling exercise to prioritize multisectoral interventions. Matern Child Nutr. 2020;16(S2). https://doi.org//doi/10.1111/mcn.12770
https://doi.org//doi/10.1111/mcn.12770...

32 Harvey CM, Newell M-L, Padmadas S. Maternal socioeconomic status and infant feeding practices underlying pathways to child stunting in Cambodia: structural path analysis using cross-sectional population data. BMJ Open. 2022;12(11):e055853. https://doi.org/10.1136/bmjopen-2021-055853
https://doi.org/10.1136/bmjopen-2021-055... -³³33 Beal T, Le DT, Trinh TH, Burra DD, Huynh T, Duong TT. Child stunting is associated with child, maternal, and environmental factors in Vietnam. Matern Child Nutr. 2019;15(4). https://doi.org/10.1111/mcn.12826
https://doi.org/10.1111/mcn.12826... ,³⁵35 Mya KS, Kyaw AT, Tun T. Feeding practices and nutritional status of children age 6-23 months in Myanmar: a secondary analysis of the 2015-16 demographic and health survey. PLoS One. 2019;14(1):e0209044. https://doi.org/10.1371/journal.pone.0209044
https://doi.org/10.1371/journal.pone.020... -³⁶36 Phu KWW, Wittayasooporn J, Kongsaktrakul C. Influence of child feeding practices and selected basic conditioning factors on stunting in children between 6 and 24 months of age in Myanmar. Makara J Health Res. 2019;23(2). https://doi.org/10.7454/msk.v23i2.10397
https://doi.org/10.7454/msk.v23i2.10397... ) and/or have also examined the caregiver or household of children(¹⁵15 Hadi H, Fatimatasari F, Irwanti W, Kusuma C, Alfiana RD, Asshiddiqi MIN. Exclusive breastfeeding protects young children from stunting in a low-income population: a study from eastern Indonesia. Nutrients. 2021;13(12):4264. https://doi.org/10.3390/nu13124264
https://doi.org/10.3390/nu13124264... ,²⁴24 Rohner F, Woodruff BA, Aaron GJ, Yakes EA, Lebanan MAO, Rayco-Solon P. Infant and young child feeding practices in urban Philippines and their associations with stunting, anemia, and deficiencies of iron and vitamin A. Food Nutr Bull. 2013;34(2 Suppl):17-34. https://doi.org/10.1177/15648265130342S104
https://doi.org/10.1177/15648265130342S1... -²⁵25 Maravilla JC, Betts K, Adair L, Alati R. Stunting of children under two from repeated pregnancy among young mothers. Sci Rep. 2020;10(1):14265. https://doi.org/10.1038/s41598-020-71106-7
https://doi.org/10.1038/s41598-020-71106... ,²⁹29 Blake RA, Park S, Baltazar P, Ayaso EB, Monterde DBS, Acosta LP. LBW and SGA impact longitudinal growth and nutritional status of Filipino infants. PLoS One. 2016;11(7):1-13. https://doi.org/10.1371/journal.pone.0159461
https://doi.org/10.1371/journal.pone.015... -³⁰30 Kpewou DE, Poirot E, Berger J, Som SV, Laillou A, Belayneh SN. Maternal mid-upper arm circumference during pregnancy and linear growth among Cambodian infants during the first months of life. Matern Child Nutr. 2020;16(S2). https://doi.org/10.1111/mcn.12951
https://doi.org/10.1111/mcn.12951... ,³⁴34 Young MF, Nguyen PH, Gonzalez Casanova I, Addo OY, Tran LM, Nguyen S, et al. Role of maternal preconception nutrition on offspring growth and risk of stunting across the first 1000 days in Vietnam: a prospective cohort study. PLoS One. 2018;13(8):e0203201. https://doi.org/10.1371/journal.pone.0203201
https://doi.org/10.1371/journal.pone.020... ). Regarding the study designs used, secondary data analysis (14/27 studies) is the most widely used study design. Others were identified using case-control (1/27 studies), cohort (5/27 studies) and cross-sectional (7/27 studies) (see Chart 2).

By adapting the WHO stunting conceptual framework(¹²12 World Health Organization (WHO). Childhood stunting: context, causes and consequences[Internet]. 2016 [cited 2023 Mar 21]. Available from: https://www.who.int/publications/m/item/childhood-stunting-context-causes-and-consequences-framework
https://www.who.int/publications/m/item/... ), there are 13 factors of stunting in Southeast Asia (see Chart 3). Those factors are the child, mother, home, inadequate complementary feeding, inadequate breastfeeding, inadequate care, poor quality foods, food and water safety, infection, political economy, health and healthcare, water, sanitation, and environment, and social culture factor. Each of these factors has its own predictor of stunting, in which the total predictors are 34. Based on our summary, the predictors of stunting in Southeast Asia are mostly categorized in the mother factor (7/34 predictors).

Of the 34 predictors, there are 13 new predictors of stunting, which previously did not exist in the WHO stunting conceptual framework(¹²12 World Health Organization (WHO). Childhood stunting: context, causes and consequences[Internet]. 2016 [cited 2023 Mar 21]. Available from: https://www.who.int/publications/m/item/childhood-stunting-context-causes-and-consequences-framework
https://www.who.int/publications/m/item/... ). Specifically, from the results of categorizing these new predictors, it appears that five of them are highly related to the child’s condition. Thus, the child factor which was previously stated to be related to the consequences of stunting, is considered as one of the causal factors of stunting itself in Southeast Asia. Then, the remaining seven predictors are categorized into three factors related to the household (mother, home, and complementary feeding) and one factor related to the community (society and culture).

Based on the reported measures of effect, age of child (at 12-23 months or annually)(²⁷27 Guirindola MO, Goyena EA, Maniego ML V. Risk factors of stunting during the complementary feeding period 6-23 months in the Philippines. Malays J Nutr. 2021;27(1):123-40. https://doi.org/10.31246/mjn-2020-0112
https://doi.org/10.31246/mjn-2020-0112... ,³³33 Beal T, Le DT, Trinh TH, Burra DD, Huynh T, Duong TT. Child stunting is associated with child, maternal, and environmental factors in Vietnam. Matern Child Nutr. 2019;15(4). https://doi.org/10.1111/mcn.12826
https://doi.org/10.1111/mcn.12826... ), maternal education (≤9 years or only primary or secondary)(¹⁶16 Gunardi H, Soedjatmiko S, Sekartini R, Medise BE, Darmawan AC, Armeilia R. Association between parental socio-demographic factors and declined linear growth of young children in Jakarta. Med J Indones. 2018;26(4):286-92. https://doi.org/10.13181/mji.v26i4.1819
https://doi.org/10.13181/mji.v26i4.1819... ,³⁴34 Young MF, Nguyen PH, Gonzalez Casanova I, Addo OY, Tran LM, Nguyen S, et al. Role of maternal preconception nutrition on offspring growth and risk of stunting across the first 1000 days in Vietnam: a prospective cohort study. PLoS One. 2018;13(8):e0203201. https://doi.org/10.1371/journal.pone.0203201
https://doi.org/10.1371/journal.pone.020... ), low birth weight(²⁷27 Guirindola MO, Goyena EA, Maniego ML V. Risk factors of stunting during the complementary feeding period 6-23 months in the Philippines. Malays J Nutr. 2021;27(1):123-40. https://doi.org/10.31246/mjn-2020-0112
https://doi.org/10.31246/mjn-2020-0112... ), and short maternal stature (<151 cm)(²⁷27 Guirindola MO, Goyena EA, Maniego ML V. Risk factors of stunting during the complementary feeding period 6-23 months in the Philippines. Malays J Nutr. 2021;27(1):123-40. https://doi.org/10.31246/mjn-2020-0112
https://doi.org/10.31246/mjn-2020-0112... ,³⁴34 Young MF, Nguyen PH, Gonzalez Casanova I, Addo OY, Tran LM, Nguyen S, et al. Role of maternal preconception nutrition on offspring growth and risk of stunting across the first 1000 days in Vietnam: a prospective cohort study. PLoS One. 2018;13(8):e0203201. https://doi.org/10.1371/journal.pone.0203201
https://doi.org/10.1371/journal.pone.020... ) are the predictors with the largest relative ratio, which increases the risk of stunting in Southeast Asian countries by up to two times. Then, regarding the odds of stunting in children aged 0-24 months, the odds increase up to five times in children who are male (at six months; aOR 9.20, at 12 months; aOR 5.66)(³⁷37 Ahmad N, Sutan R, Tamil AM, Hajib N. Growth patterns and nutritional status of small for gestational age infants in Malaysia during the first year of life. Child Health Nurs Res. 2021;27(4):317-27. https://doi.org/10.4094/chnr.2021.27.4.317
https://doi.org/10.4094/chnr.2021.27.4.3... ), have low birth weight (<2500 gr)(³⁷37 Ahmad N, Sutan R, Tamil AM, Hajib N. Growth patterns and nutritional status of small for gestational age infants in Malaysia during the first year of life. Child Health Nurs Res. 2021;27(4):317-27. https://doi.org/10.4094/chnr.2021.27.4.317
https://doi.org/10.4094/chnr.2021.27.4.3... ), are born prematurely (aOR 5.10)(¹⁷17 Sartika AN, Khoirunnisa M, Meiyetriani E, Ermayani E, Pramesthi IL, Nur Ananda AJ. Prenatal and postnatal determinants of stunting at age 0-11 months: a cross-sectional study in Indonesia. PLoS One. 2021;16:1-14. https://doi.org/10.1371/journal.pone.0254662
https://doi.org/10.1371/journal.pone.025... ), have short parental height (mother <145 cm and father <161.9 cm; aOR 5.93)(¹⁴14 Sari K, Sartika RAD. The effect of the physical factors of parents and children on stunting at birth among newborns in Indonesia. J Prev Med Public Health. 2021;54(5):309-16. http://doi.org/10.3961/jpmph.21.120
http://doi.org/10.3961/jpmph.21.120... ), have unemployed mothers (aOR 8.40)(¹⁵15 Hadi H, Fatimatasari F, Irwanti W, Kusuma C, Alfiana RD, Asshiddiqi MIN. Exclusive breastfeeding protects young children from stunting in a low-income population: a study from eastern Indonesia. Nutrients. 2021;13(12):4264. https://doi.org/10.3390/nu13124264
https://doi.org/10.3390/nu13124264... ) or whose mother work as farmer/breeder (aOR 11.74)(¹⁵15 Hadi H, Fatimatasari F, Irwanti W, Kusuma C, Alfiana RD, Asshiddiqi MIN. Exclusive breastfeeding protects young children from stunting in a low-income population: a study from eastern Indonesia. Nutrients. 2021;13(12):4264. https://doi.org/10.3390/nu13124264
https://doi.org/10.3390/nu13124264... ). Specifically for low birth weight, it was identified that the odds of a child becoming stunted increased by more than 25 times in the first month (aOR 25.47) and six times in the sixth month (aOR 6.62)(³⁷37 Ahmad N, Sutan R, Tamil AM, Hajib N. Growth patterns and nutritional status of small for gestational age infants in Malaysia during the first year of life. Child Health Nurs Res. 2021;27(4):317-27. https://doi.org/10.4094/chnr.2021.27.4.317
https://doi.org/10.4094/chnr.2021.27.4.3... ).

DISCUSSION

Stunting is a type of malnutrition in children. Apart from having a negative impact on the growth and development of children, the quality of life and the future of children is also at great risk of decreasing due to stunting. Especially in Southeast Asia, which has the second highest prevalence of stunting among other subregions in Asia, there are 13 factors which consist of 34 predictors of stunting. Specifically, nine of these causal factors are closely related to the household and the rest are related to the community. However, because to the best of our knowledge, this review is the first to discuss predictors of stunting in children 0-24 months in Southeast Asia, further studies are still urgently needed in order to better understand predictors of stunting in all Southeast Asian countries.

The Mother

Aside from being a causal factor that has the most predictors of stunting, the mother’s factor is very important to be targeted for the stunting prevention interventions. Of the seven predictors found, the majority of them were closely related to preconception and pregnancy conditions. Given the magnitude of the odds and risks of stunting from the reported predictors, it seems that all of these predictors may have to be addressed from the preconception period with a focus on nutrition and the mother’s readiness to care for her child since pregnancy. Particularly in predictors of prenatal care, nutrition, infection, and preterm birth, perhaps the management should be repeated and more focused during the pregnancy. This is because it is proven that the low number of prenatal care visits and not receiving Fe tablets during pregnancy increases the odds and risk of stunting by 22%(¹⁸18 Titaley CR, Ariawan I, Hapsari D, Muasyaroh A, Dibley MJ. Determinants of the stunting of children under two years old in Indonesia: a multilevel analysis of the 2013 Indonesia Basic Health Survey. Nutrients. 2019;11(5):1106. https://doi.org/10.3390/nu11051106
https://doi.org/10.3390/nu11051106... ) and 15%(³³33 Beal T, Le DT, Trinh TH, Burra DD, Huynh T, Duong TT. Child stunting is associated with child, maternal, and environmental factors in Vietnam. Matern Child Nutr. 2019;15(4). https://doi.org/10.1111/mcn.12826
https://doi.org/10.1111/mcn.12826... ), respectively. Meanwhile, for the short maternal stature, because the high risk of stunting given by this predictor may be influenced by genetic mechanisms(⁴⁰40 Zhang G, Bacelis J, Lengyel C, Teramo K, Hallman M, Helgeland Ø, et al. Assessing the causal relationship of maternal height on birth size and gestational age at birth: a mendelian randomization analysis. PLOS Med. 2015;12(8):e1001865. https://doi.org/10.1371/journal.pmed.1001865
https://doi.org/10.1371/journal.pmed.100... ) and intergenerational effect(⁴¹41 Khatun W, Rasheed S, Alam A, Huda TM, Dibley MJ. Assessing the intergenerational linkage between short maternal stature and under-five stunting and wasting in Bangladesh. Nutrients. 2019;11(8):1818. https://doi.org/10.3390/nu11081818
https://doi.org/10.3390/nu11081818... ), this predictor may be difficult to overcome.

Furthermore, of all the predictors, only the predictors of age at first pregnancy and infection were proven to reduce the odds of stunting. It was reported that giving the tetanus vaccine in prenatal care could reduce the odds of stunting by 33%(²⁶26 Hinojosa AP V., Tandang NA, Domingo DGC. Relationship between maternal characteristics and stunting in children aged 0 to 23 months in the Philippines. Malays J Nutr. 2021;27(3). https://doi.org/10.31246/mjn-2021-0010
https://doi.org/10.31246/mjn-2021-0010... ), and, interestingly, the younger (15-19 years) or older (≥25 years) age at first pregnancy was shown to reduce the odds of stunting events by 63% and 20% respectively(¹⁴14 Sari K, Sartika RAD. The effect of the physical factors of parents and children on stunting at birth among newborns in Indonesia. J Prev Med Public Health. 2021;54(5):309-16. http://doi.org/10.3961/jpmph.21.120
http://doi.org/10.3961/jpmph.21.120... ). Regarding the age at first pregnancy, mothers who are ≥25 years old are more likely to live with guaranteed conditions, both in terms of sanitation, socioeconomic, education or urban living areas(⁴²42 Finlay JE, Ozaltin E, Canning D. The association of maternal age with infant mortality, child anthropometric failure, diarrhoea and anaemia for first births: evidence from 55 lowand middle-income countries. BMJ Open. 2011;1(2):e000226-e000226. https://doi.org/10.1136/bmjopen-2011-000226
https://doi.org/10.1136/bmjopen-2011-000... ), but for the younger age range, further studies may be needed to confirm the results.

The Child

In the child factor, even though this factor was not initially determined to be a causal factor for stunting, all of its predictors, except for the predictor of SGA, are supported by many studies. Gender, age, and birth weight of the child are predictors with the most supporting studies. However, specifically the age and gender of the child, due to their nature, this predictor which has also been shown to increase the risk of stunting up to three times (RR 3.04) and 99% (RR 1.99) respectively(²⁷27 Guirindola MO, Goyena EA, Maniego ML V. Risk factors of stunting during the complementary feeding period 6-23 months in the Philippines. Malays J Nutr. 2021;27(1):123-40. https://doi.org/10.31246/mjn-2020-0112
https://doi.org/10.31246/mjn-2020-0112... ), cannot be modified directly.

Apart from the fact that from 12 months to 24 months of age there will be a difference in body length between normal and LBW children(⁴³43 Mbuya M, Chideme M, Chasekwa B, Mishra V. Biological, social, and environmental determinants of low birth weight and stunting among infants and young children in Zimbabwe. Zimbabwe working paper No. 7. Calverton, Maryland, USA; 2010. Available from: https://dhsprogram.com/pubs/pdf/WPZ7/WPZ7.pdf
https://dhsprogram.com/pubs/pdf/WPZ7/WPZ... ), as they get older, they may be exposed to many diseases and poor environmental conditions(⁴⁴44 Akombi BJ, Agho KE, Hall JJ, Merom D, Astell-Burt T, Renzaho AMN. Stunting and severe stunting among children under-5 years in Nigeria: a multilevel analysis. BMC Pediatr. 2017;17(1):15. https://doi.org/10.1186/s12887-016-0770-z
https://doi.org/10.1186/s12887-016-0770-... ). Furthermore, it is also known that the nutrition and diet that children need must be more adapted to their age, especially in relation to the child feeding practices(⁴⁴44 Akombi BJ, Agho KE, Hall JJ, Merom D, Astell-Burt T, Renzaho AMN. Stunting and severe stunting among children under-5 years in Nigeria: a multilevel analysis. BMC Pediatr. 2017;17(1):15. https://doi.org/10.1186/s12887-016-0770-z
https://doi.org/10.1186/s12887-016-0770-... ). Thus, we consider that, in order to overcome the increased odds or risk of stunting due to the child’s age, the direct cause must be clearly known.

Regarding birth weight, we note that this predictor provides the greatest odds of stunting compared to other predictors. Ahmad et al. analyzed that children with LBW could have a 25.47 times the odds of stunting in the first month of life(³⁷37 Ahmad N, Sutan R, Tamil AM, Hajib N. Growth patterns and nutritional status of small for gestational age infants in Malaysia during the first year of life. Child Health Nurs Res. 2021;27(4):317-27. https://doi.org/10.4094/chnr.2021.27.4.317
https://doi.org/10.4094/chnr.2021.27.4.3... ). Even though there will be a decrease in the odds as the child gets older, in the sixth month of life, the odds of stunting are still 6.62 times(³⁷37 Ahmad N, Sutan R, Tamil AM, Hajib N. Growth patterns and nutritional status of small for gestational age infants in Malaysia during the first year of life. Child Health Nurs Res. 2021;27(4):317-27. https://doi.org/10.4094/chnr.2021.27.4.317
https://doi.org/10.4094/chnr.2021.27.4.3... ). Guirindola et al. also explained that, based on the risk ratio, children with low birth weight were proven to have an increased risk of stunting by 2.19 times(²⁷27 Guirindola MO, Goyena EA, Maniego ML V. Risk factors of stunting during the complementary feeding period 6-23 months in the Philippines. Malays J Nutr. 2021;27(1):123-40. https://doi.org/10.31246/mjn-2020-0112
https://doi.org/10.31246/mjn-2020-0112... ). As with SGA, which also doubles the odds of stunting(²⁹29 Blake RA, Park S, Baltazar P, Ayaso EB, Monterde DBS, Acosta LP. LBW and SGA impact longitudinal growth and nutritional status of Filipino infants. PLoS One. 2016;11(7):1-13. https://doi.org/10.1371/journal.pone.0159461
https://doi.org/10.1371/journal.pone.015... ), we think that the magnitude of all the odds and the risk of stunting is caused by the high vulnerability of children to contracting diseases and infections, as well as the immaturity of several children’s organs to be able to digest food properly. Therefore, in order to prevent the odds and risks posed by these predictors, stunting interventions may indeed have to be focused on nutrition during the golden period or the mother during her pregnancy, so that the child is not born with a low birth weight.

The Home

As one of the causal factors of stunting, we consider that the home is a fairly comprehensive factor. This is because the predictors in this factor appear to be not only causal, but also contextual in a small scope (i.e. the child’s household). These contextual predictors include wealth and socioeconomic status and sanitation and water supply. Even though it was explained that wealth and socioeconomic status increased the risk of stunting by 69%(²⁷27 Guirindola MO, Goyena EA, Maniego ML V. Risk factors of stunting during the complementary feeding period 6-23 months in the Philippines. Malays J Nutr. 2021;27(1):123-40. https://doi.org/10.31246/mjn-2020-0112
https://doi.org/10.31246/mjn-2020-0112... ), another study also showed that this predictor also had an indirect effect on the incidence of stunting by 28%(³²32 Harvey CM, Newell M-L, Padmadas S. Maternal socioeconomic status and infant feeding practices underlying pathways to child stunting in Cambodia: structural path analysis using cross-sectional population data. BMJ Open. 2022;12(11):e055853. https://doi.org/10.1136/bmjopen-2021-055853
https://doi.org/10.1136/bmjopen-2021-055... ). Regarding the indirect effect, dietary diversity and breastfeeding are the two other predictors that have been shown to significantly mediate the effect(³²32 Harvey CM, Newell M-L, Padmadas S. Maternal socioeconomic status and infant feeding practices underlying pathways to child stunting in Cambodia: structural path analysis using cross-sectional population data. BMJ Open. 2022;12(11):e055853. https://doi.org/10.1136/bmjopen-2021-055853
https://doi.org/10.1136/bmjopen-2021-055... ). Thus, the predictors in this factor may not always directly cause stunting in children 0-24 months, but it can make other predictors to be media in causing stunting.

Of all the existing predictors, the education of the caregiver, which is the mother, is the predictor that gives the greatest risk of stunting in children 0-24 months. Literature shows that the risk of stunting is significantly greater when the mother has only primary education or even less(¹⁶16 Gunardi H, Soedjatmiko S, Sekartini R, Medise BE, Darmawan AC, Armeilia R. Association between parental socio-demographic factors and declined linear growth of young children in Jakarta. Med J Indones. 2018;26(4):286-92. https://doi.org/10.13181/mji.v26i4.1819
https://doi.org/10.13181/mji.v26i4.1819... ,²⁷27 Guirindola MO, Goyena EA, Maniego ML V. Risk factors of stunting during the complementary feeding period 6-23 months in the Philippines. Malays J Nutr. 2021;27(1):123-40. https://doi.org/10.31246/mjn-2020-0112
https://doi.org/10.31246/mjn-2020-0112... ,³³33 Beal T, Le DT, Trinh TH, Burra DD, Huynh T, Duong TT. Child stunting is associated with child, maternal, and environmental factors in Vietnam. Matern Child Nutr. 2019;15(4). https://doi.org/10.1111/mcn.12826
https://doi.org/10.1111/mcn.12826... -³⁴34 Young MF, Nguyen PH, Gonzalez Casanova I, Addo OY, Tran LM, Nguyen S, et al. Role of maternal preconception nutrition on offspring growth and risk of stunting across the first 1000 days in Vietnam: a prospective cohort study. PLoS One. 2018;13(8):e0203201. https://doi.org/10.1371/journal.pone.0203201
https://doi.org/10.1371/journal.pone.020... ), but when the mother has a secondary education level or even college it can reduce the risk or odds of stunting in children(²⁶26 Hinojosa AP V., Tandang NA, Domingo DGC. Relationship between maternal characteristics and stunting in children aged 0 to 23 months in the Philippines. Malays J Nutr. 2021;27(3). https://doi.org/10.31246/mjn-2021-0010
https://doi.org/10.31246/mjn-2021-0010... ,³⁰30 Kpewou DE, Poirot E, Berger J, Som SV, Laillou A, Belayneh SN. Maternal mid-upper arm circumference during pregnancy and linear growth among Cambodian infants during the first months of life. Matern Child Nutr. 2020;16(S2). https://doi.org/10.1111/mcn.12951
https://doi.org/10.1111/mcn.12951... ). With regard to those findings, we consider that the education level of mothers seems to have an indirect effect on stunting(³²32 Harvey CM, Newell M-L, Padmadas S. Maternal socioeconomic status and infant feeding practices underlying pathways to child stunting in Cambodia: structural path analysis using cross-sectional population data. BMJ Open. 2022;12(11):e055853. https://doi.org/10.1136/bmjopen-2021-055853
https://doi.org/10.1136/bmjopen-2021-055... ), in which mothers will only be able to provide good quality care to their children, even from pregnancy, if their knowledge is high enough and/ or they understand their child’s nutritional needs.

Inadequate Breastfeeding and Inadequate Complementary Feeding

Based on the studies reviewed, inadequate breastfeeding and inadequate complementary feeding are two other causal factors of stunting which are also especially important to be promptly managed in Southeast Asia. Although the number of predictors of these two factors is not as great as the previous factors, these predictors are closely related to child nutrition in the golden period. Thus, we suspect that any problems that arise in these two factors seem to be able to directly cause children to become stunted(³²32 Harvey CM, Newell M-L, Padmadas S. Maternal socioeconomic status and infant feeding practices underlying pathways to child stunting in Cambodia: structural path analysis using cross-sectional population data. BMJ Open. 2022;12(11):e055853. https://doi.org/10.1136/bmjopen-2021-055853
https://doi.org/10.1136/bmjopen-2021-055... ).

Of the three predictors of breastfeeding factor, we note that early cessation from breastfeeding provides the greatest increase in the risk of stunting, which is up to 44%(³³33 Beal T, Le DT, Trinh TH, Burra DD, Huynh T, Duong TT. Child stunting is associated with child, maternal, and environmental factors in Vietnam. Matern Child Nutr. 2019;15(4). https://doi.org/10.1111/mcn.12826
https://doi.org/10.1111/mcn.12826... ). In fact, if breastfeeding is weaned properly, the odds and risk of stunting can be reduced by 37% and 35%, respectively. It was also explained that, apart from helping the growth and development(²⁶26 Hinojosa AP V., Tandang NA, Domingo DGC. Relationship between maternal characteristics and stunting in children aged 0 to 23 months in the Philippines. Malays J Nutr. 2021;27(3). https://doi.org/10.31246/mjn-2021-0010
https://doi.org/10.31246/mjn-2021-0010... ,²⁹29 Blake RA, Park S, Baltazar P, Ayaso EB, Monterde DBS, Acosta LP. LBW and SGA impact longitudinal growth and nutritional status of Filipino infants. PLoS One. 2016;11(7):1-13. https://doi.org/10.1371/journal.pone.0159461
https://doi.org/10.1371/journal.pone.015... ,⁴⁵45 Tello B, Rivadeneira MF, Moncayo AL, Buitrón J, Astudillo F, Estrella A, et al. Breastfeeding, feeding practices and stunting in indigenous Ecuadorians under 2 years of age. Int Breastfeed J. 2022;17(1):19. https://doi.org//10.1186/s13006-022-00461-0
https://doi.org//10.1186/s13006-022-0046... ), by weaning only when the child is two years old, the child will be protected from many infectious diseases, and even increase the chances of life(⁴⁶46 Scherbaum V, Srour ML. The Role of Breastfeeding in the Prevention of Childhood Malnutrition. In Hidden Hunger: Malnutrition and the First 1,000 Days of Life. 2016. p. 82-97. Available from: https://www.karger.com/Article/FullText/442075
https://www.karger.com/Article/FullText/... ). However, for proper weaning to occur, two other predictors of breastfeeding, which are the initiation and exclusive breastfeeding, must also be considered and introduced to the mother.

Regarding the complementary feeding factor, including the one we just added, there are only two predictors of this factor in Southeast Asia. Both predictors are closely related to feeding practices, especially the initiation and frequency. It was shown that the initiation of complementary feeding, which was carried out properly, namely at the age of 6-8 months, was able to significantly reduce the odds of stunting by 69%(²⁵25 Maravilla JC, Betts K, Adair L, Alati R. Stunting of children under two from repeated pregnancy among young mothers. Sci Rep. 2020;10(1):14265. https://doi.org/10.1038/s41598-020-71106-7
https://doi.org/10.1038/s41598-020-71106... ). However, when the minimum meal frequency is not met, the risk of stunting increases significantly by 82%(²⁷27 Guirindola MO, Goyena EA, Maniego ML V. Risk factors of stunting during the complementary feeding period 6-23 months in the Philippines. Malays J Nutr. 2021;27(1):123-40. https://doi.org/10.31246/mjn-2020-0112
https://doi.org/10.31246/mjn-2020-0112... ). Based on the WHO guidelines(⁴⁷47 World Health Organization (WHO). Indicators for assessing infant and young child feeding practices: conclusion of a consensus meeting held 6-8 November 2007 in Washington D.C. Geneva: WHO; 2008.), to get the energy intake needed, the minimum meal frequency must be highly adjusted to the age of child, which is two times for breastfed infants aged 6-8 months, three times for breastfed children aged 9-23 months, and four times for non-breastfed children aged 6-23 months. Therefore, we consider that for a child’s nutrition to be fulfilled, whether the child is still breastfeeding and/or has entered the complementary feeding phase, feeding practices must be carried out in a timely manner and according to age.

Poor Quality Foods

Furthermore, another causal factor that is also related to feeding practices is low food quality. Of the two predictors classified in this factor, low micronutrient quality is the predictor that appears to provide the greatest increased risk of causing stunting, which is equal to 13%(³³33 Beal T, Le DT, Trinh TH, Burra DD, Huynh T, Duong TT. Child stunting is associated with child, maternal, and environmental factors in Vietnam. Matern Child Nutr. 2019;15(4). https://doi.org/10.1111/mcn.12826
https://doi.org/10.1111/mcn.12826... ). Although few studies have reported it, it was identified that vitamin D(¹⁹19 Nurhayati E, Paramashanti BA, Astiti D, Aji AS. Dietary diversity, vitamin D intake and childhood stunting: a case-control study in Bantul, Indonesia. Malays J Nutr. 2020;26(2):273-87. https://doi.org/10.31246/mjn-2020-0021
https://doi.org/10.31246/mjn-2020-0021... ), iodine(³³33 Beal T, Le DT, Trinh TH, Burra DD, Huynh T, Duong TT. Child stunting is associated with child, maternal, and environmental factors in Vietnam. Matern Child Nutr. 2019;15(4). https://doi.org/10.1111/mcn.12826
https://doi.org/10.1111/mcn.12826... ), iron(²⁸28 Ulep VGT, Uy J, Casas LD. What explains the large disparity in child stunting in the Philippines? a decomposition analysis. Public Health Nutr. 2022;25(11):2995-3007. https://doi.org/10.1017/S136898002100416X
https://doi.org/10.1017/S136898002100416... ), and vitamin A(³¹31 Laillou A, Gauthier L, Wieringa F, Berger J, Chea S, Poirot E. Reducing malnutrition in Cambodia. a modeling exercise to prioritize multisectoral interventions. Matern Child Nutr. 2020;16(S2). https://doi.org//doi/10.1111/mcn.12770
https://doi.org//doi/10.1111/mcn.12770... ,³³33 Beal T, Le DT, Trinh TH, Burra DD, Huynh T, Duong TT. Child stunting is associated with child, maternal, and environmental factors in Vietnam. Matern Child Nutr. 2019;15(4). https://doi.org/10.1111/mcn.12826
https://doi.org/10.1111/mcn.12826... ) are micronutrients associated with stunting in Southeast Asia. This finding is also the same as that of another study on stunting in other middleand low-income countries(⁴⁸48 Gowele VF, Kinabo J, Jumbe T, Rybak C, Stuetz W. High prevalence of stunting and anaemia is associated with multiple micronutrient deficiencies in school children of small-scale farmers from Chamwino and Kilosa Districts, Tanzania. Nutrients. 2021;13(5):1576. https://doi.org/10.3390/nu13051576
https://doi.org/10.3390/nu13051576... ). Despite the increased risk reported not being as large as other predictors, interventions related to increasing micronutrients in children still need to be focused on Southeast Asia.

Then, for one other predictor, dietary diversity seems to reduce the odds of stunting by 83% if the food group given has more than four variations(¹⁹19 Nurhayati E, Paramashanti BA, Astiti D, Aji AS. Dietary diversity, vitamin D intake and childhood stunting: a case-control study in Bantul, Indonesia. Malays J Nutr. 2020;26(2):273-87. https://doi.org/10.31246/mjn-2020-0021
https://doi.org/10.31246/mjn-2020-0021... ). Apart from being able to provide the energy and macronutrients needed, it was explained that the more diverse types of food, it will promote a more diverse gut microbial community, thereby affecting linear growth(⁴⁹49 Robertson RC, Manges AR, Finlay BB, Prendergast AJ. The human microbiome and child growth: first 1000 days and beyond. Trends Microbiol. 2019;27(2):131-47. https://doi.org/10.1016/j.tim.2018.09.008
https://doi.org/10.1016/j.tim.2018.09.00... ). However, WHO guidelines(⁴⁷47 World Health Organization (WHO). Indicators for assessing infant and young child feeding practices: conclusion of a consensus meeting held 6-8 November 2007 in Washington D.C. Geneva: WHO; 2008.) explained that there are only seven recommended food groups, including grains, roots, and tubers, legumes and nuts, dairy products, flesh foods, eggs, vitamin-A rich fruits and vegetables, and other fruits and vegetables.

Inadequate Care

Inadequate care is the next stunting causal factor and which is closely related to the poor way of caring for children. Specifically for children 0-24 months in the Southeast Asia region, we found that poor care practices were the only predictor of this factor. It was also found that incomplete immunization(¹⁷17 Sartika AN, Khoirunnisa M, Meiyetriani E, Ermayani E, Pramesthi IL, Nur Ananda AJ. Prenatal and postnatal determinants of stunting at age 0-11 months: a cross-sectional study in Indonesia. PLoS One. 2021;16:1-14. https://doi.org/10.1371/journal.pone.0254662
https://doi.org/10.1371/journal.pone.025... ,²²22 Hanifah L, Wulansari R, Meiandayati R, Achadi EL. Stunting trends and associated factors among Indonesian children aged 0-23 months: evidence from Indonesian Family Life Surveys (IFLS) 2000, 2007 and 2014. Malays J Nutr [Internet]. 2018 [cited 2023 Mar 15];24(3):315-22. Available from: https://nutriweb.org.my/mjn/publication/24-3/b.pdf
https://nutriweb.org.my/mjn/publication/... ) and health care practices carried out by third trimester pregnant women(²⁶26 Hinojosa AP V., Tandang NA, Domingo DGC. Relationship between maternal characteristics and stunting in children aged 0 to 23 months in the Philippines. Malays J Nutr. 2021;27(3). https://doi.org/10.31246/mjn-2021-0010
https://doi.org/10.31246/mjn-2021-0010... ) were the two manifestations of this predictor. Regarding the reported odds ratio, it is evident that these two manifestations can increase the odds of stunting events up to two times(¹⁷17 Sartika AN, Khoirunnisa M, Meiyetriani E, Ermayani E, Pramesthi IL, Nur Ananda AJ. Prenatal and postnatal determinants of stunting at age 0-11 months: a cross-sectional study in Indonesia. PLoS One. 2021;16:1-14. https://doi.org/10.1371/journal.pone.0254662
https://doi.org/10.1371/journal.pone.025... ,²⁶26 Hinojosa AP V., Tandang NA, Domingo DGC. Relationship between maternal characteristics and stunting in children aged 0 to 23 months in the Philippines. Malays J Nutr. 2021;27(3). https://doi.org/10.31246/mjn-2021-0010
https://doi.org/10.31246/mjn-2021-0010... ).

Apriliana et al. (2022) explained that depression and unreadiness, which are felt by most mothers in dealing with their roles during pregnancy, are the reasons that are often associated with poor health care practices of pregnant women(⁵⁰50 Apriliana T, Keliat BA, Mustikasari, Primasari Y. A contributing factor of maternal pregnancy depression in the occurrence of stunting on toddlers. J Public Health Res. 2022;11(2):jphr.2021.2738. https://doi.org/10.4081/jphr.2021.2738
https://doi.org/10.4081/jphr.2021.2738... ). It was explained that, when these reasons are not managed adequately, several hormonal imbalances that affect the health of the fetus and the mother, leading to stunting can very likely occur(⁵⁰50 Apriliana T, Keliat BA, Mustikasari, Primasari Y. A contributing factor of maternal pregnancy depression in the occurrence of stunting on toddlers. J Public Health Res. 2022;11(2):jphr.2021.2738. https://doi.org/10.4081/jphr.2021.2738
https://doi.org/10.4081/jphr.2021.2738... ). Then, regarding incomplete immunization, it was explained that the susceptibility of children to many infectious diseases and recurrent infections could increase higher than those who were complete. In addition to causing other stunting predictors, especially infection, which definitely increases the odds or risk of stunting, children with this condition have high levels of cytokines that interfere with their appetite and growth hormone. In connection with all these explanations, we consider that this predictor does not actually cause stunting directly, so the management must be adjusted to the poor practices that occur.

Infection

Specifically for infection factors, there is only one predictor of stunting found in Southeast Asia, namely enteric infection. Sartika et al. (2021) showed that children with enteric infections, namely diarrhea, would increase the odds of stunting in children up to three times(¹⁷17 Sartika AN, Khoirunnisa M, Meiyetriani E, Ermayani E, Pramesthi IL, Nur Ananda AJ. Prenatal and postnatal determinants of stunting at age 0-11 months: a cross-sectional study in Indonesia. PLoS One. 2021;16:1-14. https://doi.org/10.1371/journal.pone.0254662
https://doi.org/10.1371/journal.pone.025... ). Despite providing a high odds of occurrence, no other studies found in Southeast Asia can support this evidence. In addition, no other factors, which were associated with this infection factor to be able to identify other predictors could be found. Furthermore, specifically the food safety factor, which has a predictor of unsafe food preparation, which uses traditional fuels for cooking, which increases the odds of stunting by 50%(²⁴24 Rohner F, Woodruff BA, Aaron GJ, Yakes EA, Lebanan MAO, Rayco-Solon P. Infant and young child feeding practices in urban Philippines and their associations with stunting, anemia, and deficiencies of iron and vitamin A. Food Nutr Bull. 2013;34(2 Suppl):17-34. https://doi.org/10.1177/15648265130342S104
https://doi.org/10.1177/15648265130342S1... ), can cause another predictor of infection, namely respiratory infections. However, for the evidence, especially on this infection factor to be even stronger, further research that identifies predictors of stunting in Southeast Asia is still urgently needed.

The Contextual Factor

Regarding the four stunting contextual factors found, there are eight significant predictors of stunting. Of the eight predictors, the mother’s employment, ethnicity, and population density are the three predictors that have been shown to provide the greatest increased risk of stunting among other predictors. Sequentially, each of these predictors represents political economy, society and culture, and water, sanitation, and environment factors. Then, specifically on health and health care factors, we review that all studies that support the identified predictors do not analyze the risk or odds of the predictors, so the measure of association with stunting events cannot be clearly known. With these findings, we suggest that further studies are urgently needed to be able to identify in more detail the contextual factors of stunting and their predictors in Southeast Asia.

Limitations of the Study

There are some limitations found in this review, namely we limit the search for articles in English only, so there may be other articles in national languages that are relevant but cannot be reviewed. Then, not all countries in Southeast Asia provide the articles we need according to our inclusion criteria. However, with the level of socioeconomic status that tends to be the same in each country, the findings of this stunting predictor can represent countries in Southeast Asia.

Contribution to the Public Health Policy

In reducing stunting, national, and international governments are dominantly focused on nutrition interventions alone. Even though nutritional intervention is not the main key, it is necessary to know other factors first that are in accordance with the causative factors so that they can provide appropriate interventions. With this review, the predictor of factors found can be taken into consideration by policy makers in Southeast Asia in making intervention policies related to stunting, so that interventions and problems found can be resolved. We also recommend that it is necessary to develop integrated health promotion, prevention and intervention in an integrated manner using a multi-sectoral approach to reducing stunting in Southeast Asia involving health care professionals, families, government, and communities. It should always be presented separately from the results.

CONCLUSION

This scoping review found that of the 13 stunting factors identified using the WHO stunting framework, there are 34 important predictors that must be considered to address the incidence of stunting in children aged 0-24 months in Southeast Asia. Our findings underscore that while Southeast Asian countries should give more focus to maternal conditions, especially before and during pregnancy, and to the suitability of children feeding practice from the time they are born, the development of interventions must remain multi-sectoral and comprehensive. Health promotion and prevention strategies that take an integrated approach and involve health workers, families, governments and communities are essential to effectively address this complex issue.

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