Anemia and amino acid profiles among stunted children in rural areas

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Limited dietary diversity, which is more common in rural areas, can lead to protein deficiency, anemia, and disrupted metabolic processes. The purpose of this study was to explore anemia and amino acid profiles in stunted children living in rural settings. Methods: A total of 80 children, 54 stunted and 26 non-stunted, participated in this study. Collected data included anthropometric measurement (height-for-age Z-score); hematological parameters of red blood cells (RBCs), including the hemoglobin (Hb), hematocrit (Ht), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), erythrocytes; iron status indicators, such as serum iron, total iron binding capacity (TIBC), serum ferritin, transferrin saturation (TS), protein status markers (albumin, total protein), and 21 amino acid profiles. Results: The findings revealed that 63% of stunted children were anemic with low Hb and 24.1% of them was anemic with iron deficiency. Lower levels of albumin and total protein were also observed in stunted children as well as lower concentrations of amino acid arginine and branched-chain amino acids (BCAA), specifically valine and leucine compared to non-stunted children (p<0.05). On the other hand, they exhibited high concentrations of histidine, glycine, tyrosine, asparagine, and citrulline, p<0.05. Conclusions: This study showed that stunted children had anemia and low levels of BCAA. stunting amino acids anemia BCAA Figures Figure 1 Background Stunting is a major global health problem that negatively impacts children’s growth, development, and long-term productivity. In 2022, the World Health Organization (WHO) reported that 148.1 million (22.3%) children under five were stunted [ 1 ]. Although prevalence has declined globally, it remains high in regions such as East Africa, South Asia, and Southeast Asia [ 2 ]. In Indonesia, stunting prevalence decreased from 23.7% in 2022 to 22.6% in 2024, but this remains above the WHO target of < 20% [ 3 ]. The prevalence of stunting was reported to be quite high in island provinces, one of which is the Bangka Belitung islands, with a stunting prevalence of 20.1% [ 4 ]. South Bangka District ranks among the top five most populated districts in Bangka Belitung Province and has the highest stunting prevalence compared to other districts in the province. Based on the Indonesian Nutritional Status Survey in 2022, South Bangka districts had stunting rate of 23% and 24,6% in 2024, [ 4 ] which has not reached the national target of 14% [ 5 ]. The consequences of stunting are extensive, affecting both short- and long-term impacts. In the short term, it impairs brain development, intelligence, physical growth, and metabolism, while in the long term, it reduces cognitive and learning abilities, weakens the immune system, increases the risk of non-communicable diseases, and lowers economic productivity [ 6 ]. Multiple interrelated factors have been reported to contribute to stunting [ 6 ]. Inadequate nutritional intake and infections are two important determining factors that cause stunting [ 7 ]. A study reported that infectious diseases such as acute respiratory infections, diarrhea, pneumonia, and helminth infections were significantly associated with stunting in Indonesia [ 8 ]. Several studies had reported low amino acid levels in stunted children compared to non-stunted children [ 9 , 10 ]. Moreover, studies also demonstrated a strong association between stunting and anemia in children under five, since hemoglobin synthesis depends on the availability of amino acids [ 11 ]. The hematological profiles of stunted children frequently reveal abnormalities related to malnutrition, with iron deficiency being the most common cause of anemia due to reduced hemoglobin synthesis and impaired growth and development [ 12 , 13 ]. Adequate availability of essential amino acids, particularly branched-chain amino acids (BCAAs), has been shown to enhance erythropoiesis and improve iron status, underscoring their critical role in maintaining hematological function and supporting overall growth and development [ 14 – 16 ]. The present study aimed to investigate the hematological and amino acid profiles of stunted children residing in rural areas. Materials and Methods Study Design A cross-sectional study involving stunted and non-stunted children was performed in five primary health centers (The districts of Rias, Toboali, Payung, Pulau Besar and Air Gegas) in South Bangka District, Bangka Belitung Province, Bangka Islands, Indonesia. The selected areas were determined based on the 2024 Indonesian Nutritional Status Survey [ 4 ]. Study Participants Recruitment of 104 children aged 17–60 months living in five sub-districts was conducted through a purposive sampling technique. Those children were grouped into stunted and non-stunted based on the WHO growth standards. The stunted group consisted of children with a height-for-age score (HAZ) below − 2SD from the median height of the WHO growth standards, while the non-stunted group was children with HAZ between − 2SD to +3SD. Children with a history of chronic diseases, including tuberculosis, congenital heart disease, diabetes, cancer, epilepsy, HIV/AIDS, sickle cell anemia, and mental illness, were excluded from this study. Parents or guardians completed a questionnaire on age, gender, birth weight, number of family members, parental education, occupation, and total household income. Data and Sample Collection Parents or guardians and selected children were invited to each primary health center. After explaining the study objectives, written consent was obtained from their parents or guardians, after which enumerators conducted interviews and completed the questionnaires. Subsequently, data collection, including anthropometric measurements and blood sample collection, was performed from each child. Anthropometric Measurements Anthropometric measurements, such as weight and height, were measured on each child by trained field officers. Weight was measured to the nearest 5 g using a digital scale (SECA 876), and height was measured to the nearest 0.1 cm using a rigid height board (SECA 217). After measurements, all the data were entered into the WHO Anthro software. Blood Collection A 5 ml of venous blood was collected via venipuncture method from each child, using a winged needle set. Of this, 3 ml was placed in K2- Ethylene Diamine Tetra Acetic (EDTA) tube (BD) for hematological examination. The remaining 2 ml was placed in a serum separator tube (SST) (BD). After 15 minutes, centrifuged at 3000 RPM for 10 minutes to separate serum, which was then pipetted into 2 ml Eppendorf tubes and stored at -20ᴼC for biochemical assessment. Hematological Measurement In this study, hematological parameters such as hemoglobin (Hb), hematocrit (Ht), erythrocytes, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) were measured using a fully automated analyzer (Mindray BC-6800, Shenzhen, China). Biochemical Measurement Other parameters such as serum ferritin, serum iron, total iron binding capacity (TIBC), transferrin saturation, serum albumin and total protein were also measured. Serum ferritin was measured by an enzyme-linked fluorescent assay (EFLA) technique using the semi-automated VIDAS® ferritin kit (bioMerieux, France) [ 17 ]. Serum iron and total iron binding capacity (TIBC) were measured by Vitros Chemistry Products Fe Slides and dTIBC reagen (Vitros 5600 Integrated System/2008, US), [ 18 , 19 ]. Transferrin saturation was calculated as the ratio of serum iron to TIBC and multiplied by 100 [ 20 ]. Albumin and total protein were analyzed using VITROS chemistry products assays on the 250/350/5, 1 FS/4600/XT 3400 and VITROS 5600/XT 7600 integrated system, US [ 21 ]. Normal reference values for hematological and biochemical parameters were based on the Cipto Mangunkusumo General Hospital laboratory standards. Diagnosis for iron deficiency anemia were based on the values of Hb < 11.1 g/dl, serum ferritin < 12 µg/L, dan ST < 15%. Anemia was classified according to WHO criteria: mild (10-10.9 g/dL), moderate (7-9.9 g/dL) and severe (< 7 g/dL) [ 22 ]. Amino Acid Measurement Blood samples for amino acid analysis were collected using dried blood spot (DBS) and stored in 4ᴼC. For DBS, whole blood 80 µl was pipeted into each circle (2 circles in total) onto ID-labelled filter paper (Whatman 903). Amino acid concentrations were examined using Waters Xevo TQD liquid chromatography tandem mass spectrometry (LC-MS/MS), UK, with a 21-amino acid Chrom-system kit, Germany, following standard protocols [ 23 ]. Amino acids analysis was conducted at the Human Genetic Research Center, Indonesian Medical Education and Research Institute (IMERI) laboratory, Faculty of Medicine, Universitas Indonesia. Statistical Analysis All data on differences between stunted and non-stunted child groups were analyzed using IBM SPSS Statistics version 26. The relationship between respondent characteristics and stunting was analyzed using the Chi-squared test, while data on education level and occupation were analyzed using Fisher’s exact test. Normally distributed data were presented as the mean and standard deviation and analyzed using an independent-t-test. Non-normally distributed data were presented as median (interquartile range (IQR), and analyzed using the Mann-Whitney test. A p-value < 0.05 was considered statistically significant. Results Characteristics of The Children Only 80 (45 girls and 35 boys) of the 90 children between the ages of 17 and 60 months met the inclusion criteria and agreed to take part in the study (Fig. 1 ). By measuring height for age, 54 out of 80 children were classified as stunted (67.5%). Table 1 displayed the characteristics of stunted children and non-stunted children. Children who were stunted had a mean age (± SD) of 37.52 (± 12.13) months, whereas children who were not stunted had a slightly lower mean age (± SD) of 32.77 (± 9.55) months. Table 1 Characteristics of the children Characteristics Stunted, n (%) Non-Stunted, n (%) p value Age (month) 17–24 12 (22.2) 3 (11.5) 0.363‡ 25–60 42 (77.8) 23 (88.5) Sex Male 29 (53.7) 6 (23.1) 0.010†* Female 25 (46.3) 20 (76.9) Birth Weight (gram) < 2500 15 (27.8) 3 (11.5) 0.103† ≥ 2500 39 (72.2) 23 (88.5) Birth Length (cm) 4 25 (46.3) 8 (30.8) 0.230† ≤ 4 29 (53.7) 18 (69.2) Father’s Education NFE 3 (5.5) 0 (0.0) 0.734‡ Elementary 28 (51.9) 12 (46.2) Junior High 10 (18.5) 5 (19.2) Senior High 9 (16.7) 7 (26.9) College/University 4 (7.4) 2 (7.7) Mother’s Education NFE 1 (1.9) 1 (3.8) 0.895‡ Elementary 23 (42.6) 9 (34.6) Junior High 14 (25.9) 9 (34.6) Senior High 14 (25.9) 6 (23.1) College/University 2 (3.7) 1 (3.8) Occupation Formal 2 (3.7) 4 (15.4) 0.084‡ Non Formal 52 (96.3) 22 (84.6) Formal (Employee); Non-Formal (Self-employed, Farmer, Fisherman, Laborer);†chi-square test;‡Fisher’s Exact test *p value < 0.05; Not Finished Elementary (NFE) The percentage of stunted children was slightly higher in boys (53.7%) than girls (46.3%). The findings showed that 64.8% of stunted children had birth lengths less than 48 cm. Low birth weight was proven not contribute to stunted children. Most of the parents, fathers and mothers, who participated in this study had graduated from elementary school therefore, it reflected in their occupation that 96.3% of the stunted children had parents with non-formal occupation. The number of family numbers below or above 4 showed no different in stunting cases of children. Hematological, Iron and Protein Profile Significant differences were observed between stunted and non-stunted children in several hematological parameters (Table 2 ). The hemoglobin and hematocrit levels in stunted children were significantly lower than in the non-stunted group (Hb:10.74 ± 0.98 vs 11.73 ± 1.21 g/dl, p < 0.001; Ht: 33 (31–35) vs 35 (33-38.25)%, p < 0.001, respectively). Serum albumin and total protein levels in the stunted group were also significantly lower than in the non-stunted group (serum albumin: 3.24 ± 0.93 vs 4.2 ± 1.02 g/dL, p < 0.001; total protein: 5.6 (4.87–6.4) vs 6.43 (5.6–6.9 g/dL. p < 0.05, respectively). Table 2 Hematological, iron and protein serum profiles in stunted and non-stunted children Parameters Stunted (n = 54) Non-stunted (n = 26) p value Reference values Hemoglobin (g/dL), mean ± SD 10.74 ± 0.98 11.73 ± 1.21 < 0.001†* 11-14.1 MCV (fl), median (IQR) 75 (63.75–77.25) 75.5 (71.75–78.25) 0.287‡ 72–84 MCH (pg), median (IQR) 25 (20–26) 25 (23-26.25) 0.379‡ 25–29 MCHC (g/dL), median (IQR) 33 (32–34) 33 (32–34) 0.735‡ 32–36 Hematocrit (%), median (IQR) 33 (31–35) 35 (33-38.25) < 0.001‡* 30–38 Erythrocytes (10 6 /µL) median (IQR) 4.5 (4.2–5.01) 4.8 (4.3–5.21) 0.090‡ 3.9–5.1 Iron Status and Protein Status Feritin (µg/L), median (IQR) 30.30 (10.75–41.50) 31.89 (11.63–47.15) 0.558‡ < 12 µg/L SI (µg/dL), mean ± SD 53.24 ± 28.40 65.97 ± 26.20 0.058† 9-151 µg/dL TIBC (µg/dL), median (IQR) 295.5 (255.3-345.3) 322.5 (268-335.8) 0.552‡ 228–428 µg/dL TS (%), median (IQR) 16.31 (9.85–25.94) 22.62 (15.79–28.45) 0.064‡ 15–45% Albumin (g/dL), mean ± SD 3.24 ± 0.93 4.2 ± 1.02 < 0.001†* 3.5–4.5 g/dL Protein Total (g/dL), median (IQR) 5.6 (4.87–6.4) 6.43 (5.6–6.9) 0.016‡* 6.6-8 g/dL ‡Mann-Whitney Test;†=Unpaired-t-test; *p value < 0.05; Mean Corpuscular Volume (MCV); Mean Corpuscular Hemoglobin (MCH); Mean Corpuscular Hemoglobin Concentration (MCHC); Serum Iron (SI); Total Iron Binding Capacity (TIBC); Transferrin Saturation (TS), Inter-quartile Range (IQR) Amino Acid Profile Tables 3 shows the concentrations of essential amino acids (EAA) in both groups. Among the nine essential amino acids that were examined, stunted children had lower concentrations of valine, leucine, and phenylalanine than non-stunted children, whereas isoleucine, lysine, histidine, methionine, tryptophan, and threonine were present at higher concentrations. Only three EAAs, valine, leucine, and histidine, showed statistically significant differences in concentrations between the two groups (p < 0.05). This study also showed that stunted groups had lower total essential amino acid compared to the non-stunted groups and statistically significant differences between the two groups (p < 0.05). For non-essential amino acids, there were significant differences in the concentration of arginine, glycine, tyrosine, asparagine and citrulline between stunted and non-stunted children (Table 4 ). Stunted children exhibited a lower concentration of arginine compared to non-stunted children (p = < 0.001). In contrast, the concentrations of glycine (p = 0.006), tyrosine (p = 0.004), asparagine (p = < 0.001), and citrulline (p = 0.004) were higher in stunted children compared than non-stunted children. This study also showed that stunted groups had lower total non-essential amino acid compared to the non-stunted groups and statistically significant differences between the two groups (p < 0.05). Table 3 Essential amino acid concentrations in stunted and non-stunted children Amino Acids Stunted (n = 54), µmol/L Non-stunted (n = 26), µmol/L p value Valine 18.39 (6.11–38.24) 39.1 (12.06–75.80) 0.028* Leucine 8.48 (3.55–28.87) 29.86 (6.35–68.80) 0.019* Isoleucine 3.18 (2.41–5.59) 1.71 (0.71–5.68) 0.065 Lysine 32.84 (17.89–53.34) 26.5 (21.62–57.55) 0.941 Histidine 12.98 (10.26–28.23) 6.35 (5.89–10.61) < 0.0001* Methionine 7.97 (2.08–8.83) 7.82 (0.35–8.03) 0.054 Phenylalanine 6.33 (4.37–9.93) 9.11 (4.97–227.9) 0.072 Tryptophan 7.56 (6.51–8.37) 6.96 (2.65–8.73) 0.345 Threonine 30.79 (19.25–44.62) 29.94 (23.98-56) 0.597 Total EAA 170.3 (128.4-226.4) 192.6 (147.4-545.3) 0.048* Data were expressed as median (IQR); Mann-Whitney Test; *p value < 0.05. Essential amino acid (EAA) Table 4 Non-essential amino acid concentrations in stunted and non-stunted children Amino Acids Stunted (n = 54), µmol/L Non-stunted (n = 26), µmol/L p value Arginine 54.11 (9.95–84.45) 147.6 (67.38–272.7) < 0.001* Glutamine 2.51 (0.11–2.51) 0.24 (0.05–2.55) 0.379 Glycine 91.15 (38.33–162.7) 25.46 (18.11–90.93) 0.006* Proline 19.48 (12.45–27.89) 18.04 (8.83–24.84) 0.418 Tyrosine 12.29 (8.96–15.08) 8.73 (3.87–12.74) 0.004* Alanin 97.10 (64.25–138.5) 98.51 (64.65–148.1) 0.998 Serine 22.06 (14.17–48.52) 24.85 (15.75–39.5) 0.880 Aspartate 2.99 (1.87–5.71) 4.42 (1.44–12.49) 0.491 Glutamate 32.74 (21.93–70.09) 55.45 (23.04–120.9) 0.140 Asparagine 31.83 (24.28–63.91) 11.16 (0.01–29.05) < 0.001* Citrulline 3.66 (2.67–4.64) 3.05 (2.07–3.68) 0.018* Ornithine 31.99 (20.62–51.27) 61.99 (16.93–323.2) 0.081 Total NEAA 474.9 (394.6-657.5) 684.9 (460–1129) 0.014* Data were expressed as median (IQR); Mann-Whitney Test; *p value < 0.05, Non-Essential Amino Acid (NEAA) We also analyzed the branched-chain amino acids (BCAAs), such as valine, leucine, and isoleucine, which is known for its role in the normal physical growth and neurodevelopment of children. The statistical analysis revealed a significant difference in the concentration of BCAAs between stunted and non-stunted children (p = 0.008). The median concentration of BCAAs in stunted children was lower, 43.32 µmol/L (23.28–60.32 µmol/L) compared to non-stunted children, 83.33 µmol/L (29.8-164.2 µmol/L). When we calculated and compared the total 21-amino acid between the two groups, the median concentration of total 21-amino acid in stunted groups was lower, 741.3 µmol/L (562.5-826.1 µmol/L) compared to non-stunted groups, 1034 µmol/L (644.2–1566 µmol/L). Discussion In this study, the hematological and biochemical status in stunted children was significantly lower compared to non-stunted children. For essential amino acids (EAAs), the concentrations of three EAAs (valine, leucine, and histidine) varied significantly between stunted and non-stunted children. Stunted children only exhibited lower levels of valine and leucine. We also found that significantly low concentrations of BCAAs in stunted children. Among the non-essential amino acids, five (arginine, glycine, tyrosine, asparagine, and citrulline) showed noteworthy differences between the two groups. Lower concentration of arginine was found in stunted children while the concentrations of glycine, tyrosine, asparagine, and citrulline were high in the stunted children. In this study, two factors, gender (boys) and birth length (> 48cm), had been identified in contributing to stunting in South of Bangka. Similar findings have been reported in other studies, which suggest that boys are more vulnerable to growth faltering due to higher nutritional demands and greater susceptibility to infections [ 6 , 24 – 26 ]. However, contrasting evidence from Pakistan and East Nusa Tenggara, Indonesia, indicated that girls were more likely to experience stunting [ 27 , 28 ]. However, in the present study, birth length, was identified as a risk factor for stunting. The finding of birth length < 48 cm contributed to stunting is consistent with the research conducted by Rahayu et al. [ 29 ] and Hastuti et al. [ 30 ], which reported that short birth length can also be a risk factor for stunting, likely reflecting inadequate maternal nutrition or infections during pregnancy, which may impair fetal growth, increase the risk of stunting. The study found that 34 (63%) of stunted children were anemia. Lower Hb and Ht levels of stunted children may be caused by the nutrients availabilities which was lower in stunted compared to the non-stunted groups. According to WHO guidelines [ 22 ], the anemia in stunted children was primarily mild. These findings are supported by several studies. Sais et al. [ 31 ] found anemia prevalence exceeding 50% among stunted children aged 1–59 months, and Fadhilah et al. [ 32 ] observed lower hematological indices in stunted children. In addition, thirteen (24.1%) of anemia children in stunted children had iron deficiency, which was accompanied by low serum ferritin and transferrin saturation. The occurrence of iron deficiency anemia in stunted children may result from chronic nutritional deficiencies that impair erythropoiesis, leading to reduced red blood cell counts and hemoglobin concentrations [ 33 ]. However, findings across studies vary. Lio et al. [ 34 ], reported no significant differences in hematological parameters between stunted and non-stunted children, suggesting that the relationship between stunting and anemia may vary depending on the severity and duration of nutritional deficiencies and the presence of infections or inflammation. Wijaya et al. [ 35 ] reported that there was no direct relationship between low serum ferritin level and stunting status. Ferritin is an acute-phase reactant, and its levels may appear normal or elevated in the presence of inflammation [ 36 ], potentially masking true iron deficiency. Iron is critical for oxygen transport and bone development; insufficient iron reduces oxygen supply to growing tissues, impairing skeletal growth and increasing the risk of physical and cognitive impairment [ 37 ]. Therefore, children experiencing stunting should be encouraged to consume iron-rich foods, particularly from animal protein sources, to improve nutritional status and support healthy growth. Stunted children in the South Bangka District exhibited significantly lower albumin and total protein levels compared to non-stunted children. Two factors may contribute to this condition. First, inadequate dietary protein intake limits essential processes such as tissue growth and repair, hormone and enzyme synthesis, and immune function [ 38 ]. Second, reduced albumin and total protein—clinical indicators of protein–energy malnutrition—may result from chronic inflammation or nutrient malabsorption related to environmental enteric dysfunction, which is prevalent in settings with poor sanitation and hygiene and is known to contribute to stunting [ 39 , 40 ]. Of the nine essential amino acids, three amino acids (valine, leucine, and histidine) were significantly different between the two groups. Stunted children had lower concentrations of valine and leucine, while histidine was higher in stunted compared to non-stunted children. Valine, leucine, and isoleucine, known as the branched-chain amino acids (BCAAs), were found to be lower in stunted than non-stunted children, consistent with findings from Semba et al. [ 9 ] and others [ 41 ]. BCAAs are essential for protein synthesis, muscle development, and activation of growth-related pathways such as mTOR [ 9 , 41 ]; thus, their deficiency may contribute to impaired linear growth. Supporting this, Strømmen et al. [ 42 ] reported that BCAA supplementation improved growth in low-birth-weight infants, while McCormack et al. [ 43 ] noted that elevated BCAA levels were linked to obesity in children, suggesting that amino acid profiles reflect distinct metabolic states. An interesting result was found in histidine levels. The median histidine concentration in the stunted group was significantly greater than in the non-stunted group. It is known that excessive levels of histidine can arise in people who are deficient in vitamin B9 or B12 [ 44 ]. Deficiencies in folic acid (vitamin B9) or vitamin B12 might impede the last steps of the histidine breakdown pathway, resulting in increased histidine levels [ 44 , 45 ]. This study found a significant frequency of anemia in stunted children (63%), with iron deficiency (24.1%). It is known that there is a variety of causes nutritional anemia in stunted children including deficiencies of iron, vitamin B12, and folate [ 46 ]. We assumed that the remaining anemia children in this study may have vitamin B or folate deficiencies. In this study, stunted children exhibited significantly lower arginine. Arginine plays an important role in innate immune function [ 47 ], growth hormone stimulation [ 48 ], and endothelial regulation [ 49 ]; therefore, its reduction may contribute to impaired growth pathways. This interpretation is consistent with findings from a study in children aged 7–13 years, which demonstrated that arginine supplementation had a stronger association with growth velocity than protein intake lacking arginine [ 48 ]. It was also reported that chronic infection could cause argininemia [ 50 ]. Asparagine and citrulline concentrations were also higher in stunted children, which contrasts with previous findings reporting lower levels [ 9 ]. Their elevation may represent compensatory mechanisms in response to chronic inflammation or intestinal injury. These amino acids—together with glutamine—are involved in immune modulation and mucosal repair, and their increase levels may reflect heightened metabolic demand under these conditions [ 51 ]. Overall, this study could identify hematological and biochemical markers in stunted children and demonstrated the feasibility of DBS sampling for amino acids profiling in Indonesia children. However, the study had several limitations, including the absence of measurements for other anemia-related micronutrients, such as vitamin B12 and folate, and the lack of dietary intake assessment, which is important to understand nutritional patterns in these children. Conclusion Stunted children living in rural areas were affected by anemia with low iron levels and were also suspected of having vitamin B9 or B12 deficiency, as indicated by elevated histidine concentrations. Reduced levels of valine, leucine, arginine, and other branched-chain amino acids were also observed in stunted children, which may impair protein synthesis and disrupt normal growth processes. In contrast, elevated glycine, tyrosine, asparagine and citrulline levels may reflect metabolic adaptation or dysregulation associated with chronic undernutrition, inflammation, and impaired growth. Further studies are needed to elucidate the underlying causes of anemia in stunted children and to determine whether iron deficiency alone or vitamin B deficiencies constitutes the primary risk factor for anemia among stunted children living in rural settings. Abbreviations HAZ Height-for-age score RBCs Red blood cells Hb Hemoglobin Ht Hematocrit MCV Mean corpuscular volume MCH Mean corpuscular hemoglobin MCHC Mean corpuscular hemoglobin concentration SI Serum iron TIBC Total iron binding capacity TS Transferrin saturation BCAA Branched-chain amino acid DBS Dry blood spot LCMS-MS Liquid chromatography tandem mass spectrometry IQR Inter-quartile range EAA Essential amino acid NEAA Non-essential amino acid NFE Not finished elementary MTOR Mammalian target of rapamycin EDTA Ethylene diamine tetra acetic SST Serum separator tube SD Standar deviation Declarations Ethics Consideration The study received approval from the ethics committee of the Faculty of Medicine of Universitas Indonesia (number: 1296/UN2.F1/ETIK/PPM.00.02/2024). Written consent was obtained from parents or guardians. Conflict of Interest: The authors declare that they have no conflict of interest Consent for publication : not applicable. Funding: This research was supported by the Faculty of Medicine, University of Indonesia through an internal grant with number ND-898/UN2.RST/PPM.00.00/2024. Author Contribution Conceptions and design **:** MPS, TS, RRT, RPS; Acquisition, analysis and interpretation: MPS, TS, ML, IST, YD; Drafting article: MPS, TS, YD; Revising it critically for important intellectual content: MPS, TS. All authors approve the manuscripts to which journal to be submitted. Acknowledgement The author would like to thanks the Head of Primary Health Service, South Bangka Districts, enumerators, and research respondents for their assistance in the research data collection process. Data Availability The raw data used or analyzed during the current study are available from the corresponding author on reasonable request. References UNICEF. Malnutrition in children. 2023. [cited 2024 Apr 20]. Available from: https://data.unicef.org/topic/nutrition/malnutrition/ UNICEF, WHO. UNICEF-WHO-The World Bank: Joint child malnutrition estimates (JME)—levels and trends. Geneva, Switzerland. 2023. Available from: https://data.unicef.org/resources/jme/ WHO. Stunting prevalence among children under 5 years of age (%) (model-based estimates). 2025 [cited 2025 Jun 19]. Available from: https://www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-jme-stunting-prevalence Kementerian Kesehatan Republik Indonesia. Survei status gizi Indonesia tahun 2024 (dalam angka). Kemenkes; 2025. Kementerian Kesehatan Republik Indonesia. Buku saku hasil survei status gizi Indonesia (SSGI) 2022. Kemenkes RI; 2022. Beal T, Tumilowicz A, Sutrisna A, Izwardy D, Neufeld LM. A review of child stunting determinants in Indonesia. Matern Child Nutr. 2018;14(e12617):1–10. https://doi.org/10.1111/mcn.12617 . Setianingsih PD, Sawitri E, Ratnadilah D. Impact of stunting on development of children aged 12–60 months. In: Proceedings of the 1st International Conference on Science, Health, Economics, Education and Technology (ICoSHEET 2019). Atlantis Press; 2020. pp. 186–9. https://doi.org/10.2991/ahsr.k.200723.047 Suratri MA, Indriasih E, Warouw TS, Edwin VA, Yulianto A, Faizal DR, et al. The Relationship between infectious diseases and stunting among toddlers in Indonesia. Iran J Nurs Midwifery Res. 2025;30:936–40. https://doi.org/10.4103/ijnmr.ijnmr_87_24 . Semba RD, Shardell M, Sakr Ashour FA, Moaddel R, Trehan I, Maleta KM, et al. Child stunting is associated with low circulating essential amino acids. EBioMedicine. 2016;6:246–52. https://dx.doi.org/10.1016/j.ebiom.2016.02.030 . Kumar M, Ji B, Babaei P, Das P, Lappa D, Ramakrishnan G, et al. Gut microbiota dysbiosis is associated with malnutrition and reduced plasma amino acid levels: lessons from genome-scale metabolic modeling. Metab Eng. 2019;49:128–42. https://doi.org/10.1016/j.ymben.2018.07.018 . Semba R, de Pee S, Kim B, McKenzie S, Nachman K, Bloem M. Adoption of the planetary health diet has different impacts on countries’ greenhouse gas emissions. Nat Food. 2020;1(8):481–4. https://doi.org/10.1038/s43016-020-0128-4 . de Benoist B, McLean E, Egli I, Cogswell M. Worldwide prevalence of anaemia 1993–2005: WHO Global Database on Anaemia. Geneva, Switzerland: WHO; 2008. pp. 1–51. Mccarthy EK, Murray DM, Kiely ME. Iron deficiency during the fi rst 1000 days of life: are we doing enough to protect the developing brain? In: The Nutrition Society Irish Section Conference. Cambridge University Press; 2021. pp. 1–11. Dallman PR. Biochemical basis for the manifestations of iron deficiency. Ann Rev Nutr. 1986;6:13–40. https://doi.org/10.1146/annurev.nu.06.070186.000305 . Ohtani M, Maruyama K, Sugita M, Kobayashi K. Amino acid supplementation affects hematological and biochemical parameters in Elite Rugby Players. Biosci Biotechnol Biochem. 2001;65(9):1970–6. https://doi.org/10.1271/bbb.65.1970 . Enko D, Moro T, Holasek S, Baranyi A, Schnedl WJ, Zelzer S, et al. Branched-chain amino acids are linked with iron metabolism. Ann Transl Med. 2020;8(23):1–8. http://dx.doi.org/10.21037/atm-20-624a . VIDAS. Feritin 30 411. 2015. Available from: https://www.biomerieux-diagnostics.com/vidasr-ferritin Fretellier N, Poteau, Factor C, Mayer J, Medina C, Port M, et al. Analytical interference in serum iron determination reveals iron versus gadolinium transmetallation with linear gadolinium-based contrast agents. Invest Radiol. 2014;49(12):766–72. https://doi.org/10.1097/RLI.0000000000000081 . Vitros chemistry products dTIBC reagen instructions for use. 2019. Available from: https://www.quidelortho.com/ Lee R, Nieman D. Nutritional assessment. 4th Edition. McGraw Hill, Newyork; 2007. 169–221 p. Vitros XT. chemistry products ALB-TP slides instructions for use. 2019. Available from: https://www.accessdata.fda.gov/cdrh_docs/pdf19/ World Health Organization (WHO). Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. 2025. pp. 1–6. Available from: https://iris.who.int/bitstream/handle/10665/85839/WHO_NMH_NHD_MNM_11.1_eng.pdf Chromsystem. Instruction manual for LCMS-MS analysis mass chrom amino acid and acylcarnitines from dried blood spot. Chromsystem Instruments and Chemicals GmbH, Germany.; 2019. Hafid F, Nasrul N, Amsal A, Ramadhan K, Taufiqurahman T, Sariman S. Low birth weight, child gender, number of children, and maternal education as risk factors for stunting in Palu City - Indonesia. Amerta Nutr. 2024;8(2):75–84. https://doi.org/10.20473/amnt.v8i2SP.2024.75 . Gebreayohanes M, Dessie A. Prevalence of stunting and its associated factors among children 6–59 months of age in pastoralist community, Northeast Ethiopia : A community-based cross-sectional study. PLoS ONE. 2022;17(2):1–15. http://dx.doi.org/10.1371/journal.pone.0256722 . Wamani H, Åstrøm AN, Peterson S, Tumwine JK, Tylleskär T. Boys are more stunted than girls in Sub-Saharan Africa: a meta-analysis of 16 demographic and health surveys. BMC Pediatr. 2007;7(17):1–10. http://dx.doi.org/10.1186/1471-2431-7-17 . Suratri MAL, Putro G, Rachmat B, Nurhayati, Ristrini, Pracoyo NE, et al. Risk factors for stunting among children under five years in the province of East Nusa Tenggara (NTT), Indonesia. Int J Env Res Public Heal Heal. 2023;20(1640):1–13. https://doi.org/10.3390/ijerph20021640 . ul haq I, Mehmood Z, Afzal T, Khan N, Ahmed B, Nawsherwan, et al. Prevalence and determinants of stunting among preschool and school-going children in the flood-affected areas of Pakistan. Brazilian J Biol. 2022;82(e249971):1–9. https://doi.org/10.1590/1519-6984.249971 . Rahayu HK, Muhlis ANA, Bakhtiar R, Wijaya RH, Akbar MF, Dzakwan SA, et al. Association between birth weight, birth length, and stunting: an analysis of cases at Lempake Public Health Center, East Borneo, Indonesia. J Community Med Public Heal Res. 2025;06(01):50–9. https://doi.org/10.20473/jcmphr.v6i1.61270 . Hastuti HV, Citrakesumasari, Maddeppungeng M. Stunting prevalence and its relationship to birth length of 18–23 months old infants in Indonesia. Enfermería Clínica. 2020;30(S4):205–9. https://doi.org/10.1016/j.enfcli.2019.10.069 . Sais VC, Halim H, Sari M, Alfara LD. Prevalence, characteristic and hematologic profile of anemia cases among stunting children in a Jakarta Secondary Hospital. Intisari Sains Medis. 2024;15(3):1180–8. https://doi.org/10.15562/ism.v15i3.2072 . Fadhilah S, Astuti DW, Dewi EU, Muhajir NF. Stunting case study in Grogol Bejiharjo Karangmojo Gunungkidul D. I. Yogyakarta, Indonesia based on routine blood examination. J Eduhealth. 2022;13(02):1153–7. Dessie G, Li J, Nghiem S, Doan T. Prevalence and determinants of stunting-anemia and wasting-anemia comorbidities and micronutrient deficiencies in children under 5 in the least-developed countries: a systematic review and meta-analysis. Nutr Rev. 2024;83(2):e178–94. https://doi.org/10.1093/nutrit/nuae063 . Lio TMP, Wibowo H, Sadikin M, Jusman SWA. Hematology study on stunting children in Sampuabalo, Coastal Area of Buton : effect of nutritional status on red blood cell profile. SEEJPH. 2025;26:877–86. Widjaja NA, Atmaja NMID, Irawan R, Ardianah E. Stunted and ferritin levels in children aged 0–24 months: Does gender influence the incidence ? Prog Nutr. 2024;26(3–4):1–7. https://doi.org/10.23751/pn.v26i3-4.14935 . Lee NH. Iron deficiency in children with a focus on inflammatory conditions. Clin Exp Pediatr. 2024;67(6):283–93. https://doi.org/10.3345/cep.2023.0052 . Dewi EK, Nindya TS. Hubungan tingkat kecukupan zat besi dan seng dengan kejadian stunting pada balita 6–23 bulan. Amerta Nutr. 2017;361–8. https://doi.org/10.20473/amnt.v1i4.2017.361-368 . Ernawati F, Prihatini M, Yuriestia A. Gambaran konsumsi protein nabati dan hewani pada anak balita stunting dan gizi kurang di Indonesia. J Gizi dan Makanan. 2016;39(2):95–102. Dewey KG, Mayers DR. Early child growth: how do nutrition and infection interact ? 7(Suppl.3):129–42. https://doi.org/10.1111/j.1740-8709.2011.00357.x Crane RJ, Berkley JA. Environmental enteric dysfunction: An overview. Food Nutr Bull. 2015;36(1 0):1–18. https://doi.org/10.1177/15648265150361S113 . Semba RD, Trehan I, Gonzales-Freire M, Kraemer K, Moaddel R, Ordiz MI, et al. Perspective: the potential role of essential amino acids and the mechanistic target of rapamycin complex 1 (mTORC1) pathway in the pathogenesis of child stunting. Adv Nutr. 2016;7:853–65. https://doi.org/10.3945/an.116.013276 . Strømmen K, Haag A, Moltu SJ, Veierød MB, Blakstad EW, Nakstad B, et al. Enhanced nutrient supply to very low birth weight infants is associated with higher blood amino acid concentrations and improved growth. Clin Nutr ESPEN. 2017;18:16–22. http://dx.doi.org/10.1016/j.clnesp.2017.01.003 . McCormack SE, Shaham O, Mccarthy MA, Deik AA, Wang TJ, Gerszten RE, et al. Circulating branched-chain amino acid concentrations are associated with obesity and future insulin resistance in children and adolescents. Pediatr Obes. 2013;8(1):52–61. https://doi.org/10.1111/j.2047-6310.2012.00087.x . Stokstad ELR, Reisenauer A, Kusano G, Keating J. Effect of high levels of dietary folic acid on folate metabolism vitamin B12 deficiency. Arch Biochem Biophys. 1988;265(2):407–14. https://doi.org/10.1016/0003-9861(88)90143-9 . Cooperman JM, Lopez R. The role of histidine in the anemia of folate deficiency. Exp Biol Med (Maywood). 2002;227(11):998–1000. https://doi.org/10.1177/153537020222701107 . World Health Organization (WHO). International statistical classification of diseases and related health problems 10th revision (ICD-10). WHO. Geneva, Switzerland: WHO; 2016. Rath M, Müller I, Kropf P, Closs EI, Munder M. Metabolism via arginase or nitric oxide synthase: two competing arginine pathways in macrophages. Front Immunol. 2014;5(532):1–10. https://doi.org/10.3389/fimmu.2014.0053 . Vught AJAH, Van, Dagnelie PC, Arts ICW, Froberg K, Andersen LB, El-naaman B, et al. Dietary arginine and linear growth: the Copenhagen school child intervention study. Br J Nutr. 2013;109(6):1031–9. https://doi.org/10.3389/fimmu.2014.0053 . Flynn NE, Meininger CJ, Haynes TE, Wu G. The metabolic basis of arginine nutrition and pharmacotherapy. Biomed Pharmacother. 2002;56(9):427–38. https://doi.org/10.1016/s0753-3322(02)00273-1 . King N, Alvizures R, García P, Wessel A, Rohloff P. Argininemia as a cause of severe chronic stunting in a low-resource developing country setting: a case report. BMC Pediatr. 2016;16(142):1–4. http://dx.doi.org/10.1186/s12887-016-0668-9 . Newsholme P. Why is l -glutamine metabolism important to cells of the immune system in health, postinjury, surgery or infection ? Am Soc Nutr Sci. 2001;January2515–22. https://doi.org/10.1093/jn/131.9.2515S . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 28 Apr, 2026 Reviews received at journal 14 Apr, 2026 Reviewers agreed at journal 12 Apr, 2026 Reviewers agreed at journal 10 Apr, 2026 Reviewers invited by journal 02 Apr, 2026 Editor invited by journal 11 Mar, 2026 Editor assigned by journal 01 Feb, 2026 Submission checks completed at journal 01 Feb, 2026 First submitted to journal 29 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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In 2022, the World Health Organization (WHO) reported that 148.1\u0026nbsp;million (22.3%) children under five were stunted [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although prevalence has declined globally, it remains high in regions such as East Africa, South Asia, and Southeast Asia [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In Indonesia, stunting prevalence decreased from 23.7% in 2022 to 22.6% in 2024, but this remains above the WHO target of \u0026lt;\u0026thinsp;20% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe prevalence of stunting was reported to be quite high in island provinces, one of which is the Bangka Belitung islands, with a stunting prevalence of 20.1% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. South Bangka District ranks among the top five most populated districts in Bangka Belitung Province and has the highest stunting prevalence compared to other districts in the province. Based on the Indonesian Nutritional Status Survey in 2022, South Bangka districts had stunting rate of 23% and 24,6% in 2024, [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] which has not reached the national target of 14% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe consequences of stunting are extensive, affecting both short- and long-term impacts. In the short term, it impairs brain development, intelligence, physical growth, and metabolism, while in the long term, it reduces cognitive and learning abilities, weakens the immune system, increases the risk of non-communicable diseases, and lowers economic productivity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Multiple interrelated factors have been reported to contribute to stunting [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Inadequate nutritional intake and infections are two important determining factors that cause stunting [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A study reported that infectious diseases such as acute respiratory infections, diarrhea, pneumonia, and helminth infections were significantly associated with stunting in Indonesia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral studies had reported low amino acid levels in stunted children compared to non-stunted children [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Moreover, studies also demonstrated a strong association between stunting and anemia in children under five, since hemoglobin synthesis depends on the availability of amino acids [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The hematological profiles of stunted children frequently reveal abnormalities related to malnutrition, with iron deficiency being the most common cause of anemia due to reduced hemoglobin synthesis and impaired growth and development [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Adequate availability of essential amino acids, particularly branched-chain amino acids (BCAAs), has been shown to enhance erythropoiesis and improve iron status, underscoring their critical role in maintaining hematological function and supporting overall growth and development [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The present study aimed to investigate the hematological and amino acid profiles of stunted children residing in rural areas.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eA cross-sectional study involving stunted and non-stunted children was performed in five primary health centers (The districts of Rias, Toboali, Payung, Pulau Besar and Air Gegas) in South Bangka District, Bangka Belitung Province, Bangka Islands, Indonesia. The selected areas were determined based on the 2024 Indonesian Nutritional Status Survey [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Participants\u003c/h3\u003e\n\u003cp\u003eRecruitment of 104 children aged 17\u0026ndash;60 months living in five sub-districts was conducted through a purposive sampling technique. Those children were grouped into stunted and non-stunted based on the WHO growth standards. The stunted group consisted of children with a height-for-age score (HAZ) below \u0026minus;\u0026thinsp;2SD from the median height of the WHO growth standards, while the non-stunted group was children with HAZ between \u0026minus;\u0026thinsp;2SD to +3SD. Children with a history of chronic diseases, including tuberculosis, congenital heart disease, diabetes, cancer, epilepsy, HIV/AIDS, sickle cell anemia, and mental illness, were excluded from this study. Parents or guardians completed a questionnaire on age, gender, birth weight, number of family members, parental education, occupation, and total household income.\u003c/p\u003e\n\u003ch3\u003eData and Sample Collection\u003c/h3\u003e\n\u003cp\u003e Parents or guardians and selected children were invited to each primary health center. After explaining the study objectives, written consent was obtained from their parents or guardians, after which enumerators conducted interviews and completed the questionnaires. Subsequently, data collection, including anthropometric measurements and blood sample collection, was performed from each child.\u003c/p\u003e\n\u003ch3\u003eAnthropometric Measurements\u003c/h3\u003e\n\u003cp\u003eAnthropometric measurements, such as weight and height, were measured on each child by trained field officers. Weight was measured to the nearest 5 g using a digital scale (SECA 876), and height was measured to the nearest 0.1 cm using a rigid height board (SECA 217). After measurements, all the data were entered into the WHO Anthro software.\u003c/p\u003e\n\u003ch3\u003eBlood Collection\u003c/h3\u003e\n\u003cp\u003eA 5 ml of venous blood was collected via venipuncture method from each child, using a winged needle set. Of this, 3 ml was placed in K2-\u003cem\u003eEthylene Diamine Tetra Acetic\u003c/em\u003e (EDTA) tube (BD) for hematological examination. The remaining 2 ml was placed in a serum separator tube (SST) (BD). After 15 minutes, centrifuged at 3000 RPM for 10 minutes to separate serum, which was then pipetted into 2 ml Eppendorf tubes and stored at -20ᴼC for biochemical assessment.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eHematological Measurement\u003c/h2\u003e \u003cp\u003eIn this study, hematological parameters such as hemoglobin (Hb), hematocrit (Ht), erythrocytes, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC) were measured using a fully automated analyzer (Mindray BC-6800, Shenzhen, China).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBiochemical Measurement\u003c/h3\u003e\n\u003cp\u003eOther parameters such as serum ferritin, serum iron, total iron binding capacity (TIBC), transferrin saturation, serum albumin and total protein were also measured. Serum ferritin was measured by an enzyme-linked fluorescent assay (EFLA) technique using the semi-automated VIDAS\u0026reg; ferritin kit (bioMerieux, France) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Serum iron and total iron binding capacity (TIBC) were measured by Vitros Chemistry Products Fe Slides and dTIBC reagen (Vitros 5600 Integrated System/2008, US), [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Transferrin saturation was calculated as the ratio of serum iron to TIBC and multiplied by 100 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Albumin and total protein were analyzed using VITROS chemistry products assays on the 250/350/5, 1 FS/4600/XT 3400 and VITROS 5600/XT 7600 integrated system, US [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNormal reference values for hematological and biochemical parameters were based on the Cipto Mangunkusumo General Hospital laboratory standards. Diagnosis for iron deficiency anemia were based on the values of Hb\u0026thinsp;\u0026lt;\u0026thinsp;11.1 g/dl, serum ferritin\u0026thinsp;\u0026lt;\u0026thinsp;12 \u0026micro;g/L, dan ST\u0026thinsp;\u0026lt;\u0026thinsp;15%. Anemia was classified according to WHO criteria: mild (10-10.9 g/dL), moderate (7-9.9 g/dL) and severe (\u0026lt;\u0026thinsp;7 g/dL) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eAmino Acid Measurement\u003c/h3\u003e\n\u003cp\u003eBlood samples for amino acid analysis were collected using dried blood spot (DBS) and stored in 4ᴼC. For DBS, whole blood 80 \u0026micro;l was pipeted into each circle (2 circles in total) onto ID-labelled filter paper (Whatman 903). Amino acid concentrations were examined using Waters Xevo TQD liquid chromatography tandem mass spectrometry (LC-MS/MS), UK, with a 21-amino acid Chrom-system kit, Germany, following standard protocols [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Amino acids analysis was conducted at the Human Genetic Research Center, Indonesian Medical Education and Research Institute (IMERI) laboratory, Faculty of Medicine, Universitas Indonesia.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAll data on differences between stunted and non-stunted child groups were analyzed using IBM SPSS Statistics version 26. The relationship between respondent characteristics and stunting was analyzed using the \u003cem\u003eChi-squared\u003c/em\u003e test, while data on education level and occupation were analyzed using \u003cem\u003eFisher\u0026rsquo;s\u003c/em\u003e exact test. Normally distributed data were presented as the mean and standard deviation and analyzed using an independent-t-test. Non-normally distributed data were presented as median (interquartile range (IQR), and analyzed using the \u003cem\u003eMann-Whitney\u003c/em\u003e test. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of The Children\u003c/h2\u003e \u003cp\u003eOnly 80 (45 girls and 35 boys) of the 90 children between the ages of 17 and 60 months met the inclusion criteria and agreed to take part in the study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBy measuring height for age, 54 out of 80 children were classified as stunted (67.5%). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displayed the characteristics of stunted children and non-stunted children. Children who were stunted had a mean age (\u0026plusmn;\u0026thinsp;SD) of 37.52 (\u0026plusmn;\u0026thinsp;12.13) months, whereas children who were not stunted had a slightly lower mean age (\u0026plusmn;\u0026thinsp;SD) of 32.77 (\u0026plusmn;\u0026thinsp;9.55) months.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the children\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStunted,\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-Stunted, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (month)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (22.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.363\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (77.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (88.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (53.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (23.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.010\u0026dagger;*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (46.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (76.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirth Weight (gram)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 2500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (27.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (11.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.103\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge; 2500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39 (72.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (88.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBirth Length (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35 (64.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (34.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.011\u0026dagger;*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge; 48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (35.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (65.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Family Members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (46.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.230\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le; 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (53.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (69.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFather\u0026rsquo;s Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNFE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.734\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (51.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (46.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior High\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (19.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior High\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (26.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege/University\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (7.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMother\u0026rsquo;s Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNFE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.895\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (42.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (34.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior High\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (34.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSenior High\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (25.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (23.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege/University\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.084\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon Formal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52 (96.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (84.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFormal (Employee); Non-Formal (Self-employed, Farmer, Fisherman, Laborer);\u0026dagger;chi-square test;\u0026Dagger;Fisher\u0026rsquo;s Exact test *p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Not Finished Elementary (NFE)\u003c/p\u003e \u003cp\u003eThe percentage of stunted children was slightly higher in boys (53.7%) than girls (46.3%). The findings showed that 64.8% of stunted children had birth lengths less than 48 cm. Low birth weight was proven not contribute to stunted children. Most of the parents, fathers and mothers, who participated in this study had graduated from elementary school therefore, it reflected in their occupation that 96.3% of the stunted children had parents with non-formal occupation. The number of family numbers below or above 4 showed no different in stunting cases of children.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eHematological, Iron and Protein Profile\u003c/h2\u003e \u003cp\u003eSignificant differences were observed between stunted and non-stunted children in several hematological parameters (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The hemoglobin and hematocrit levels in stunted children were significantly lower than in the non-stunted group (Hb:10.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98 vs 11.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.21 g/dl, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Ht: 33 (31\u0026ndash;35) vs 35 (33-38.25)%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively). Serum albumin and total protein levels in the stunted group were also significantly lower than in the non-stunted group (serum albumin: 3.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93 vs 4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02 g/dL, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; total protein: 5.6 (4.87\u0026ndash;6.4) vs 6.43 (5.6\u0026ndash;6.9 g/dL. p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, respectively).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHematological, iron and protein serum profiles in stunted and non-stunted children\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStunted\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-stunted\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003cp\u003evalues\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (g/dL), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026dagger;*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11-14.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCV (fl), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (63.75\u0026ndash;77.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.5 (71.75\u0026ndash;78.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.287\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72\u0026ndash;84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCH (pg), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (20\u0026ndash;26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (23-26.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.379\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMCHC (g/dL), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (32\u0026ndash;34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (32\u0026ndash;34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.735\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u0026ndash;36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHematocrit (%), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (31\u0026ndash;35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (33-38.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026Dagger;*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30\u0026ndash;38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eErythrocytes (10\u003csup\u003e6\u003c/sup\u003e/\u0026micro;L) median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.5 (4.2\u0026ndash;5.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.8 (4.3\u0026ndash;5.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.090\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.9\u0026ndash;5.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIron Status and Protein Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeritin (\u0026micro;g/L), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.30 (10.75\u0026ndash;41.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.89 (11.63\u0026ndash;47.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.558\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;12 \u0026micro;g/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSI (\u0026micro;g/dL), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.24\u0026thinsp;\u0026plusmn;\u0026thinsp;28.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.97\u0026thinsp;\u0026plusmn;\u0026thinsp;26.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.058\u0026dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9-151 \u0026micro;g/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTIBC (\u0026micro;g/dL), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e295.5 (255.3-345.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e322.5 (268-335.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.552\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e228\u0026ndash;428 \u0026micro;g/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTS (%), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.31 (9.85\u0026ndash;25.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.62 (15.79\u0026ndash;28.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.064\u0026Dagger;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u0026ndash;45%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlbumin (g/dL), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u0026dagger;*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.5\u0026ndash;4.5 g/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProtein Total (g/dL), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.6 (4.87\u0026ndash;6.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.43 (5.6\u0026ndash;6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.016\u0026Dagger;*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.6-8 g/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u0026Dagger;Mann-Whitney Test;\u0026dagger;=Unpaired-t-test; *p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Mean Corpuscular Volume (MCV); Mean Corpuscular Hemoglobin (MCH); Mean Corpuscular Hemoglobin Concentration (MCHC); Serum Iron (SI); Total Iron Binding Capacity (TIBC); Transferrin Saturation (TS), Inter-quartile Range (IQR)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAmino Acid Profile\u003c/h2\u003e \u003cp\u003eTables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the concentrations of essential amino acids (EAA) in both groups. Among the nine essential amino acids that were examined, stunted children had lower concentrations of valine, leucine, and phenylalanine than non-stunted children, whereas isoleucine, lysine, histidine, methionine, tryptophan, and threonine were present at higher concentrations. Only three EAAs, valine, leucine, and histidine, showed statistically significant differences in concentrations between the two groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). This study also showed that stunted groups had lower total essential amino acid compared to the non-stunted groups and statistically significant differences between the two groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eFor non-essential amino acids, there were significant differences in the concentration of arginine, glycine, tyrosine, asparagine and citrulline between stunted and non-stunted children (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Stunted children exhibited a lower concentration of arginine compared to non-stunted children (p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In contrast, the concentrations of glycine (p\u0026thinsp;=\u0026thinsp;0.006), tyrosine (p\u0026thinsp;=\u0026thinsp;0.004), asparagine (p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and citrulline (p\u0026thinsp;=\u0026thinsp;0.004) were higher in stunted children compared than non-stunted children. This study also showed that stunted groups had lower total non-essential amino acid compared to the non-stunted groups and statistically significant differences between the two groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEssential amino acid concentrations in stunted and non-stunted children\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmino Acids\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStunted (n\u0026thinsp;=\u0026thinsp;54),\u003c/p\u003e \u003cp\u003e\u0026micro;mol/L\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-stunted (n\u0026thinsp;=\u0026thinsp;26), \u0026micro;mol/L\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18.39 (6.11\u0026ndash;38.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.1 (12.06\u0026ndash;75.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.028*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeucine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.48 (3.55\u0026ndash;28.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.86 (6.35\u0026ndash;68.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.019*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIsoleucine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.18 (2.41\u0026ndash;5.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.71 (0.71\u0026ndash;5.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.065\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLysine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32.84 (17.89\u0026ndash;53.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.5 (21.62\u0026ndash;57.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistidine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.98 (10.26\u0026ndash;28.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.35 (5.89\u0026ndash;10.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMethionine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.97 (2.08\u0026ndash;8.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.82 (0.35\u0026ndash;8.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.054\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhenylalanine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.33 (4.37\u0026ndash;9.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.11 (4.97\u0026ndash;227.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTryptophan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.56 (6.51\u0026ndash;8.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.96 (2.65\u0026ndash;8.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.345\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThreonine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30.79 (19.25\u0026ndash;44.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.94 (23.98-56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.597\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal EAA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e170.3 (128.4-226.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e192.6 (147.4-545.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.048*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eData were expressed as median (IQR); Mann-Whitney Test; *p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Essential amino acid (EAA)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNon-essential amino acid concentrations in stunted and non-stunted children\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmino Acids\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStunted (n\u0026thinsp;=\u0026thinsp;54),\u003c/p\u003e \u003cp\u003e\u0026micro;mol/L\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-stunted (n\u0026thinsp;=\u0026thinsp;26), \u0026micro;mol/L\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArginine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54.11 (9.95\u0026ndash;84.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e147.6 (67.38\u0026ndash;272.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlutamine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.51 (0.11\u0026ndash;2.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.24 (0.05\u0026ndash;2.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.379\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlycine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e91.15 (38.33\u0026ndash;162.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.46 (18.11\u0026ndash;90.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.006*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19.48 (12.45\u0026ndash;27.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.04 (8.83\u0026ndash;24.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.418\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTyrosine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.29 (8.96\u0026ndash;15.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.73 (3.87\u0026ndash;12.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.004*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlanin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e97.10 (64.25\u0026ndash;138.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e98.51 (64.65\u0026ndash;148.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22.06 (14.17\u0026ndash;48.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.85 (15.75\u0026ndash;39.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.880\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspartate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.99 (1.87\u0026ndash;5.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.42 (1.44\u0026ndash;12.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.491\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlutamate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32.74 (21.93\u0026ndash;70.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.45 (23.04\u0026ndash;120.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsparagine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31.83 (24.28\u0026ndash;63.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.16 (0.01\u0026ndash;29.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCitrulline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.66 (2.67\u0026ndash;4.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.05 (2.07\u0026ndash;3.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.018*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOrnithine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31.99 (20.62\u0026ndash;51.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61.99 (16.93\u0026ndash;323.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal NEAA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e474.9 (394.6-657.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e684.9 (460\u0026ndash;1129)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.014*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eData were expressed as median (IQR); Mann-Whitney Test; *p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05, Non-Essential Amino Acid (NEAA)\u003c/p\u003e \u003cp\u003eWe also analyzed the branched-chain amino acids (BCAAs), such as valine, leucine, and isoleucine, which is known for its role in the normal physical growth and neurodevelopment of children. The statistical analysis revealed a significant difference in the concentration of BCAAs between stunted and non-stunted children (p\u0026thinsp;=\u0026thinsp;0.008). The median concentration of BCAAs in stunted children was lower, 43.32 \u0026micro;mol/L (23.28\u0026ndash;60.32 \u0026micro;mol/L) compared to non-stunted children, 83.33 \u0026micro;mol/L (29.8-164.2 \u0026micro;mol/L). When we calculated and compared the total 21-amino acid between the two groups, the median concentration of total 21-amino acid in stunted groups was lower, 741.3 \u0026micro;mol/L (562.5-826.1 \u0026micro;mol/L) compared to non-stunted groups, 1034 \u0026micro;mol/L (644.2\u0026ndash;1566 \u0026micro;mol/L).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, the hematological and biochemical status in stunted children was significantly lower compared to non-stunted children. For essential amino acids (EAAs), the concentrations of three EAAs (valine, leucine, and histidine) varied significantly between stunted and non-stunted children. Stunted children only exhibited lower levels of valine and leucine. We also found that significantly low concentrations of BCAAs in stunted children. Among the non-essential amino acids, five (arginine, glycine, tyrosine, asparagine, and citrulline) showed noteworthy differences between the two groups. Lower concentration of arginine was found in stunted children while the concentrations of glycine, tyrosine, asparagine, and citrulline were high in the stunted children.\u003c/p\u003e \u003cp\u003eIn this study, two factors, gender (boys) and birth length (\u0026gt;\u0026thinsp;48cm), had been identified in contributing to stunting in South of Bangka. Similar findings have been reported in other studies, which suggest that boys are more vulnerable to growth faltering due to higher nutritional demands and greater susceptibility to infections [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, contrasting evidence from Pakistan and East Nusa Tenggara, Indonesia, indicated that girls were more likely to experience stunting [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, in the present study, birth length, was identified as a risk factor for stunting. The finding of birth length\u0026thinsp;\u0026lt;\u0026thinsp;48 cm contributed to stunting is consistent with the research conducted by Rahayu et al. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and Hastuti et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], which reported that short birth length can also be a risk factor for stunting, likely reflecting inadequate maternal nutrition or infections during pregnancy, which may impair fetal growth, increase the risk of stunting.\u003c/p\u003e \u003cp\u003eThe study found that 34 (63%) of stunted children were anemia. Lower Hb and Ht levels of stunted children may be caused by the nutrients availabilities which was lower in stunted compared to the non-stunted groups. According to WHO guidelines [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], the anemia in stunted children was primarily mild. These findings are supported by several studies. Sais et al. [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] found anemia prevalence exceeding 50% among stunted children aged 1\u0026ndash;59 months, and Fadhilah et al. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] observed lower hematological indices in stunted children. In addition, thirteen (24.1%) of anemia children in stunted children had iron deficiency, which was accompanied by low serum ferritin and transferrin saturation. The occurrence of iron deficiency anemia in stunted children may result from chronic nutritional deficiencies that impair erythropoiesis, leading to reduced red blood cell counts and hemoglobin concentrations [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, findings across studies vary. Lio et al. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], reported no significant differences in hematological parameters between stunted and non-stunted children, suggesting that the relationship between stunting and anemia may vary depending on the severity and duration of nutritional deficiencies and the presence of infections or inflammation. Wijaya et al. [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] reported that there was no direct relationship between low serum ferritin level and stunting status. Ferritin is an acute-phase reactant, and its levels may appear normal or elevated in the presence of inflammation [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], potentially masking true iron deficiency. Iron is critical for oxygen transport and bone development; insufficient iron reduces oxygen supply to growing tissues, impairing skeletal growth and increasing the risk of physical and cognitive impairment [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Therefore, children experiencing stunting should be encouraged to consume iron-rich foods, particularly from animal protein sources, to improve nutritional status and support healthy growth.\u003c/p\u003e \u003cp\u003eStunted children in the South Bangka District exhibited significantly lower albumin and total protein levels compared to non-stunted children. Two factors may contribute to this condition. First, inadequate dietary protein intake limits essential processes such as tissue growth and repair, hormone and enzyme synthesis, and immune function [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Second, reduced albumin and total protein\u0026mdash;clinical indicators of protein\u0026ndash;energy malnutrition\u0026mdash;may result from chronic inflammation or nutrient malabsorption related to environmental enteric dysfunction, which is prevalent in settings with poor sanitation and hygiene and is known to contribute to stunting [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOf the nine essential amino acids, three amino acids (valine, leucine, and histidine) were significantly different between the two groups. Stunted children had lower concentrations of valine and leucine, while histidine was higher in stunted compared to non-stunted children. Valine, leucine, and isoleucine, known as the branched-chain amino acids (BCAAs), were found to be lower in stunted than non-stunted children, consistent with findings from Semba et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and others [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. BCAAs are essential for protein synthesis, muscle development, and activation of growth-related pathways such as mTOR [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]; thus, their deficiency may contribute to impaired linear growth. Supporting this, Str\u0026oslash;mmen et al. [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] reported that BCAA supplementation improved growth in low-birth-weight infants, while McCormack et al. [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] noted that elevated BCAA levels were linked to obesity in children, suggesting that amino acid profiles reflect distinct metabolic states.\u003c/p\u003e \u003cp\u003eAn interesting result was found in histidine levels. The median histidine concentration in the stunted group was significantly greater than in the non-stunted group. It is known that excessive levels of histidine can arise in people who are deficient in vitamin B9 or B12 [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Deficiencies in folic acid (vitamin B9) or vitamin B12 might impede the last steps of the histidine breakdown pathway, resulting in increased histidine levels [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. This study found a significant frequency of anemia in stunted children (63%), with iron deficiency (24.1%). It is known that there is a variety of causes nutritional anemia in stunted children including deficiencies of iron, vitamin B12, and folate [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. We assumed that the remaining anemia children in this study may have vitamin B or folate deficiencies.\u003c/p\u003e \u003cp\u003eIn this study, stunted children exhibited significantly lower arginine. Arginine plays an important role in innate immune function [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], growth hormone stimulation [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], and endothelial regulation [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]; therefore, its reduction may contribute to impaired growth pathways. This interpretation is consistent with findings from a study in children aged 7\u0026ndash;13 years, which demonstrated that arginine supplementation had a stronger association with growth velocity than protein intake lacking arginine [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. It was also reported that chronic infection could cause argininemia [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAsparagine and citrulline concentrations were also higher in stunted children, which contrasts with previous findings reporting lower levels [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Their elevation may represent compensatory mechanisms in response to chronic inflammation or intestinal injury. These amino acids\u0026mdash;together with glutamine\u0026mdash;are involved in immune modulation and mucosal repair, and their increase levels may reflect heightened metabolic demand under these conditions [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, this study could identify hematological and biochemical markers in stunted children and demonstrated the feasibility of DBS sampling for amino acids profiling in Indonesia children. However, the study had several limitations, including the absence of measurements for other anemia-related micronutrients, such as vitamin B12 and folate, and the lack of dietary intake assessment, which is important to understand nutritional patterns in these children.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eStunted children living in rural areas were affected by anemia with low iron levels and were also suspected of having vitamin B9 or B12 deficiency, as indicated by elevated histidine concentrations. Reduced levels of valine, leucine, arginine, and other branched-chain amino acids were also observed in stunted children, which may impair protein synthesis and disrupt normal growth processes. In contrast, elevated glycine, tyrosine, asparagine and citrulline levels may reflect metabolic adaptation or dysregulation associated with chronic undernutrition, inflammation, and impaired growth. Further studies are needed to elucidate the underlying causes of anemia in stunted children and to determine whether iron deficiency alone or vitamin B deficiencies constitutes the primary risk factor for anemia among stunted children living in rural settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHAZ\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Height-for-age score\u003c/p\u003e\n\u003cp\u003eRBCs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Red blood cells\u003c/p\u003e\n\u003cp\u003eHb\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Hemoglobin\u003c/p\u003e\n\u003cp\u003eHt\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Hematocrit\u003c/p\u003e\n\u003cp\u003eMCV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mean corpuscular volume\u003c/p\u003e\n\u003cp\u003eMCH\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mean corpuscular hemoglobin\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMCHC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mean corpuscular hemoglobin concentration\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Serum iron\u003c/p\u003e\n\u003cp\u003eTIBC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Total iron binding capacity\u003c/p\u003e\n\u003cp\u003eTS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Transferrin saturation\u003c/p\u003e\n\u003cp\u003eBCAA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Branched-chain amino acid\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDBS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Dry blood spot\u003c/p\u003e\n\u003cp\u003eLCMS-MS\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Liquid chromatography tandem mass spectrometry\u003c/p\u003e\n\u003cp\u003eIQR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Inter-quartile range\u003c/p\u003e\n\u003cp\u003eEAA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Essential amino acid\u003c/p\u003e\n\u003cp\u003eNEAA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Non-essential amino acid\u003c/p\u003e\n\u003cp\u003eNFE \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Not finished elementary\u003c/p\u003e\n\u003cp\u003eMTOR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mammalian target of rapamycin\u003c/p\u003e\n\u003cp\u003eEDTA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Ethylene diamine tetra acetic\u003c/p\u003e\n\u003cp\u003eSST\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Serum separator tube\u003c/p\u003e\n\u003cp\u003eSD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Standar deviation\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cb\u003eEthics Consideration\u003c/b\u003e \u003c/p\u003e \u003cp\u003e The study received approval from the ethics committee of the Faculty of Medicine of Universitas Indonesia (number: 1296/UN2.F1/ETIK/PPM.00.02/2024). Written consent was obtained from parents or guardians.\u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflict of Interest:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no conflict of interest\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cb\u003eConsent for publication\u003c/b\u003e :\u003c/strong\u003e \u003cp\u003enot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research was supported by the Faculty of Medicine, University of Indonesia through an internal grant with number ND-898/UN2.RST/PPM.00.00/2024.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptions and design **:** MPS, TS, RRT, RPS; Acquisition, analysis and interpretation: MPS, TS, ML, IST, YD; Drafting article: MPS, TS, YD; Revising it critically for important intellectual content: MPS, TS. All authors approve the manuscripts to which journal to be submitted.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe author would like to thanks the Head of Primary Health Service, South Bangka Districts, enumerators, and research respondents for their assistance in the research data collection process.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe raw data used or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNICEF. Malnutrition in children. 2023. [cited 2024 Apr 20]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.unicef.org/topic/nutrition/malnutrition/\u003c/span\u003e\u003cspan address=\"https://data.unicef.org/topic/nutrition/malnutrition/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF, WHO. UNICEF-WHO-The World Bank: Joint child malnutrition estimates (JME)\u0026mdash;levels and trends. Geneva, Switzerland. 2023. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.unicef.org/resources/jme/\u003c/span\u003e\u003cspan address=\"https://data.unicef.org/resources/jme/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. Stunting prevalence among children under 5 years of age (%) (model-based estimates). 2025 [cited 2025 Jun 19]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-jme-stunting-prevalence\u003c/span\u003e\u003cspan address=\"https://www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-jme-stunting-prevalence\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKementerian Kesehatan Republik Indonesia. Survei status gizi Indonesia tahun 2024 (dalam angka). Kemenkes; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKementerian Kesehatan Republik Indonesia. Buku saku hasil survei status gizi Indonesia (SSGI) 2022. Kemenkes RI; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeal T, Tumilowicz A, Sutrisna A, Izwardy D, Neufeld LM. A review of child stunting determinants in Indonesia. Matern Child Nutr. 2018;14(e12617):1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/mcn.12617\u003c/span\u003e\u003cspan address=\"10.1111/mcn.12617\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSetianingsih PD, Sawitri E, Ratnadilah D. Impact of stunting on development of children aged 12\u0026ndash;60 months. In: Proceedings of the 1st International Conference on Science, Health, Economics, Education and Technology (ICoSHEET 2019). Atlantis Press; 2020. pp. 186\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2991/ahsr.k.200723.047\u003c/span\u003e\u003cspan address=\"10.2991/ahsr.k.200723.047\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuratri MA, Indriasih E, Warouw TS, Edwin VA, Yulianto A, Faizal DR, et al. The Relationship between infectious diseases and stunting among toddlers in Indonesia. Iran J Nurs Midwifery Res. 2025;30:936\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/ijnmr.ijnmr_87_24\u003c/span\u003e\u003cspan address=\"10.4103/ijnmr.ijnmr_87_24\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSemba RD, Shardell M, Sakr Ashour FA, Moaddel R, Trehan I, Maleta KM, et al. Child stunting is associated with low circulating essential amino acids. EBioMedicine. 2016;6:246\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dx.doi.org/10.1016/j.ebiom.2016.02.030\u003c/span\u003e\u003cspan address=\"10.1016/j.ebiom.2016.02.030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumar M, Ji B, Babaei P, Das P, Lappa D, Ramakrishnan G, et al. Gut microbiota dysbiosis is associated with malnutrition and reduced plasma amino acid levels: lessons from genome-scale metabolic modeling. Metab Eng. 2019;49:128\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ymben.2018.07.018\u003c/span\u003e\u003cspan address=\"10.1016/j.ymben.2018.07.018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSemba R, de Pee S, Kim B, McKenzie S, Nachman K, Bloem M. Adoption of the planetary health diet has different impacts on countries\u0026rsquo; greenhouse gas emissions. Nat Food. 2020;1(8):481\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s43016-020-0128-4\u003c/span\u003e\u003cspan address=\"10.1038/s43016-020-0128-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Benoist B, McLean E, Egli I, Cogswell M. Worldwide prevalence of anaemia 1993\u0026ndash;2005: WHO Global Database on Anaemia. Geneva, Switzerland: WHO; 2008. pp. 1\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMccarthy EK, Murray DM, Kiely ME. Iron deficiency during the fi rst 1000 days of life: are we doing enough to protect the developing brain? In: The Nutrition Society Irish Section Conference. Cambridge University Press; 2021. pp. 1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDallman PR. Biochemical basis for the manifestations of iron deficiency. Ann Rev Nutr. 1986;6:13\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1146/annurev.nu.06.070186.000305\u003c/span\u003e\u003cspan address=\"10.1146/annurev.nu.06.070186.000305\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOhtani M, Maruyama K, Sugita M, Kobayashi K. Amino acid supplementation affects hematological and biochemical parameters in Elite Rugby Players. Biosci Biotechnol Biochem. 2001;65(9):1970\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1271/bbb.65.1970\u003c/span\u003e\u003cspan address=\"10.1271/bbb.65.1970\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnko D, Moro T, Holasek S, Baranyi A, Schnedl WJ, Zelzer S, et al. Branched-chain amino acids are linked with iron metabolism. Ann Transl Med. 2020;8(23):1\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.21037/atm-20-624a\u003c/span\u003e\u003cspan address=\"10.21037/atm-20-624a\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVIDAS. Feritin 30 411. 2015. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.biomerieux-diagnostics.com/vidasr-ferritin\u003c/span\u003e\u003cspan address=\"https://www.biomerieux-diagnostics.com/vidasr-ferritin\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFretellier N, Poteau, Factor C, Mayer J, Medina C, Port M, et al. Analytical interference in serum iron determination reveals iron versus gadolinium transmetallation with linear gadolinium-based contrast agents. Invest Radiol. 2014;49(12):766\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/RLI.0000000000000081\u003c/span\u003e\u003cspan address=\"10.1097/RLI.0000000000000081\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVitros chemistry products dTIBC reagen instructions for use. 2019. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.quidelortho.com/\u003c/span\u003e\u003cspan address=\"https://www.quidelortho.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee R, Nieman D. Nutritional assessment. 4th Edition. McGraw Hill, Newyork; 2007. 169\u0026ndash;221 p.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVitros XT. chemistry products ALB-TP slides instructions for use. 2019. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.accessdata.fda.gov/cdrh_docs/pdf19/\u003c/span\u003e\u003cspan address=\"https://www.accessdata.fda.gov/cdrh_docs/pdf19/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization (WHO). Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. 2025. pp. 1\u0026ndash;6. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/bitstream/handle/10665/85839/WHO_NMH_NHD_MNM_11.1_eng.pdf\u003c/span\u003e\u003cspan address=\"https://iris.who.int/bitstream/handle/10665/85839/WHO_NMH_NHD_MNM_11.1_eng.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChromsystem. Instruction manual for LCMS-MS analysis mass chrom amino acid and acylcarnitines from dried blood spot. Chromsystem Instruments and Chemicals GmbH, Germany.; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHafid F, Nasrul N, Amsal A, Ramadhan K, Taufiqurahman T, Sariman S. Low birth weight, child gender, number of children, and maternal education as risk factors for stunting in Palu City - Indonesia. Amerta Nutr. 2024;8(2):75\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.20473/amnt.v8i2SP.2024.75\u003c/span\u003e\u003cspan address=\"10.20473/amnt.v8i2SP.2024.75\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGebreayohanes M, Dessie A. Prevalence of stunting and its associated factors among children 6\u0026ndash;59 months of age in pastoralist community, Northeast Ethiopia : A community-based cross-sectional study. PLoS ONE. 2022;17(2):1\u0026ndash;15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1371/journal.pone.0256722\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0256722\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWamani H, \u0026Aring;str\u0026oslash;m AN, Peterson S, Tumwine JK, Tyllesk\u0026auml;r T. Boys are more stunted than girls in Sub-Saharan Africa: a meta-analysis of 16 demographic and health surveys. BMC Pediatr. 2007;7(17):1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1186/1471-2431-7-17\u003c/span\u003e\u003cspan address=\"10.1186/1471-2431-7-17\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuratri MAL, Putro G, Rachmat B, Nurhayati, Ristrini, Pracoyo NE, et al. Risk factors for stunting among children under five years in the province of East Nusa Tenggara (NTT), Indonesia. Int J Env Res Public Heal Heal. 2023;20(1640):1\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijerph20021640\u003c/span\u003e\u003cspan address=\"10.3390/ijerph20021640\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eul haq I, Mehmood Z, Afzal T, Khan N, Ahmed B, Nawsherwan, et al. Prevalence and determinants of stunting among preschool and school-going children in the flood-affected areas of Pakistan. Brazilian J Biol. 2022;82(e249971):1\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1519-6984.249971\u003c/span\u003e\u003cspan address=\"10.1590/1519-6984.249971\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahayu HK, Muhlis ANA, Bakhtiar R, Wijaya RH, Akbar MF, Dzakwan SA, et al. Association between birth weight, birth length, and stunting: an analysis of cases at Lempake Public Health Center, East Borneo, Indonesia. J Community Med Public Heal Res. 2025;06(01):50\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.20473/jcmphr.v6i1.61270\u003c/span\u003e\u003cspan address=\"10.20473/jcmphr.v6i1.61270\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHastuti HV, Citrakesumasari, Maddeppungeng M. Stunting prevalence and its relationship to birth length of 18\u0026ndash;23 months old infants in Indonesia. Enfermer\u0026iacute;a Cl\u0026iacute;nica. 2020;30(S4):205\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.enfcli.2019.10.069\u003c/span\u003e\u003cspan address=\"10.1016/j.enfcli.2019.10.069\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSais VC, Halim H, Sari M, Alfara LD. Prevalence, characteristic and hematologic profile of anemia cases among stunting children in a Jakarta Secondary Hospital. Intisari Sains Medis. 2024;15(3):1180\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.15562/ism.v15i3.2072\u003c/span\u003e\u003cspan address=\"10.15562/ism.v15i3.2072\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFadhilah S, Astuti DW, Dewi EU, Muhajir NF. Stunting case study in Grogol Bejiharjo Karangmojo Gunungkidul D. I. Yogyakarta, Indonesia based on routine blood examination. J Eduhealth. 2022;13(02):1153\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDessie G, Li J, Nghiem S, Doan T. Prevalence and determinants of stunting-anemia and wasting-anemia comorbidities and micronutrient deficiencies in children under 5 in the least-developed countries: a systematic review and meta-analysis. Nutr Rev. 2024;83(2):e178\u0026ndash;94. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/nutrit/nuae063\u003c/span\u003e\u003cspan address=\"10.1093/nutrit/nuae063\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLio TMP, Wibowo H, Sadikin M, Jusman SWA. Hematology study on stunting children in Sampuabalo, Coastal Area of Buton : effect of nutritional status on red blood cell profile. SEEJPH. 2025;26:877\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWidjaja NA, Atmaja NMID, Irawan R, Ardianah E. Stunted and ferritin levels in children aged 0\u0026ndash;24 months: Does gender influence the incidence ? Prog Nutr. 2024;26(3\u0026ndash;4):1\u0026ndash;7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.23751/pn.v26i3-4.14935\u003c/span\u003e\u003cspan address=\"10.23751/pn.v26i3-4.14935\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee NH. Iron deficiency in children with a focus on inflammatory conditions. Clin Exp Pediatr. 2024;67(6):283\u0026ndash;93. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3345/cep.2023.0052\u003c/span\u003e\u003cspan address=\"10.3345/cep.2023.0052\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDewi EK, Nindya TS. Hubungan tingkat kecukupan zat besi dan seng dengan kejadian stunting pada balita 6\u0026ndash;23 bulan. Amerta Nutr. 2017;361\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.20473/amnt.v1i4.2017.361-368\u003c/span\u003e\u003cspan address=\"10.20473/amnt.v1i4.2017.361-368\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErnawati F, Prihatini M, Yuriestia A. Gambaran konsumsi protein nabati dan hewani pada anak balita stunting dan gizi kurang di Indonesia. J Gizi dan Makanan. 2016;39(2):95\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDewey KG, Mayers DR. Early child growth: how do nutrition and infection interact ? 7(Suppl.3):129\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1740-8709.2011.00357.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1740-8709.2011.00357.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrane RJ, Berkley JA. Environmental enteric dysfunction: An overview. Food Nutr Bull. 2015;36(1 0):1\u0026ndash;18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/15648265150361S113\u003c/span\u003e\u003cspan address=\"10.1177/15648265150361S113\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSemba RD, Trehan I, Gonzales-Freire M, Kraemer K, Moaddel R, Ordiz MI, et al. Perspective: the potential role of essential amino acids and the mechanistic target of rapamycin complex 1 (mTORC1) pathway in the pathogenesis of child stunting. Adv Nutr. 2016;7:853\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3945/an.116.013276\u003c/span\u003e\u003cspan address=\"10.3945/an.116.013276\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStr\u0026oslash;mmen K, Haag A, Moltu SJ, Veier\u0026oslash;d MB, Blakstad EW, Nakstad B, et al. Enhanced nutrient supply to very low birth weight infants is associated with higher blood amino acid concentrations and improved growth. Clin Nutr ESPEN. 2017;18:16\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1016/j.clnesp.2017.01.003\u003c/span\u003e\u003cspan address=\"10.1016/j.clnesp.2017.01.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCormack SE, Shaham O, Mccarthy MA, Deik AA, Wang TJ, Gerszten RE, et al. Circulating branched-chain amino acid concentrations are associated with obesity and future insulin resistance in children and adolescents. Pediatr Obes. 2013;8(1):52\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.2047-6310.2012.00087.x\u003c/span\u003e\u003cspan address=\"10.1111/j.2047-6310.2012.00087.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStokstad ELR, Reisenauer A, Kusano G, Keating J. Effect of high levels of dietary folic acid on folate metabolism vitamin B12 deficiency. Arch Biochem Biophys. 1988;265(2):407\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/0003-9861(88)90143-9\u003c/span\u003e\u003cspan address=\"10.1016/0003-9861(88)90143-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooperman JM, Lopez R. The role of histidine in the anemia of folate deficiency. Exp Biol Med (Maywood). 2002;227(11):998\u0026ndash;1000. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/153537020222701107\u003c/span\u003e\u003cspan address=\"10.1177/153537020222701107\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization (WHO). International statistical classification of diseases and related health problems 10th revision (ICD-10). WHO. Geneva, Switzerland: WHO; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRath M, M\u0026uuml;ller I, Kropf P, Closs EI, Munder M. Metabolism via arginase or nitric oxide synthase: two competing arginine pathways in macrophages. Front Immunol. 2014;5(532):1\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fimmu.2014.0053\u003c/span\u003e\u003cspan address=\"10.3389/fimmu.2014.0053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVught AJAH, Van, Dagnelie PC, Arts ICW, Froberg K, Andersen LB, El-naaman B, et al. Dietary arginine and linear growth: the Copenhagen school child intervention study. Br J Nutr. 2013;109(6):1031\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fimmu.2014.0053\u003c/span\u003e\u003cspan address=\"10.3389/fimmu.2014.0053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlynn NE, Meininger CJ, Haynes TE, Wu G. The metabolic basis of arginine nutrition and pharmacotherapy. Biomed Pharmacother. 2002;56(9):427\u0026ndash;38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s0753-3322(02)00273-1\u003c/span\u003e\u003cspan address=\"10.1016/s0753-3322(02)00273-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKing N, Alvizures R, Garc\u0026iacute;a P, Wessel A, Rohloff P. Argininemia as a cause of severe chronic stunting in a low-resource developing country setting: a case report. BMC Pediatr. 2016;16(142):1\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1186/s12887-016-0668-9\u003c/span\u003e\u003cspan address=\"10.1186/s12887-016-0668-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNewsholme P. Why is l -glutamine metabolism important to cells of the immune system in health, postinjury, surgery or infection ? Am Soc Nutr Sci. 2001;January2515\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/jn/131.9.2515S\u003c/span\u003e\u003cspan address=\"10.1093/jn/131.9.2515S\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"stunting, amino acids, anemia, BCAA","lastPublishedDoi":"10.21203/rs.3.rs-8732685/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8732685/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003eProtein intake is essential\u003cstrong\u003e \u003c/strong\u003efor children’s growth. Limited dietary diversity, which is more common in rural areas, can lead to protein deficiency, anemia, and disrupted metabolic processes. The purpose of this study was to explore anemia and amino acid profiles in stunted children living in rural settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eA total of 80 children, 54 stunted and 26 non-stunted, participated in this study. Collected data included anthropometric measurement (height-for-age Z-score); hematological parameters of red blood cells (RBCs), including the hemoglobin (Hb), hematocrit (Ht), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), erythrocytes; iron status indicators, such as serum iron, total iron binding capacity (TIBC), serum ferritin, transferrin saturation (TS), protein status markers (albumin, total protein), and 21 amino acid profiles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eThe findings revealed that 63% of stunted children were anemic with low Hb and 24.1% of them was anemic with iron deficiency. Lower levels of albumin and total protein were also observed in stunted children as well as lower concentrations of amino acid arginine and branched-chain amino acids (BCAA), specifically valine and leucine compared to non-stunted children (p\u0026lt;0.05). On the other hand, they exhibited high concentrations of histidine, glycine, tyrosine, asparagine, and citrulline, p\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003eThis study showed that stunted children had anemia and low levels of BCAA.\u003c/p\u003e","manuscriptTitle":"Anemia and amino acid profiles among stunted children in rural areas","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 00:41:58","doi":"10.21203/rs.3.rs-8732685/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-28T12:49:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-14T14:36:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126456797477593014840479959371431355069","date":"2026-04-12T21:49:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313352679422730361467376381437593998288","date":"2026-04-10T07:48:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-02T06:27:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-11T18:59:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-02T03:20:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-02T03:18:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nutrition","date":"2026-01-29T14:04:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ae055ba4-180f-4bd9-8d4f-2f634496b8a6","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T00:41:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 00:41:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8732685","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8732685","identity":"rs-8732685","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}