Stunting remains a major public health issue in low-resource settings, with emerging evidence linking it not only to nutritional deficiencies but also to environmental toxicants such as lead. Despite this, limited research has explored the interplay between lead exposure, microminerals, and child growth in non-industrial rural areas. This study aimed to investigate the association between blood lead levels (BLLs), essential microminerals (zinc, manganese, and iron), and stunting in children, while also identifying environmental sources of lead. A cross-sectional study was conducted among 58 children aged 0–59 months in Datar Village, Central Java, Indonesia. Anthropometric assessments and venous blood samples were collected, and trace elements were quantified using ICP-MS. Lead content in environmental samples (water, food, foliage, soil, and paint dust) was also analyzed by ICP-MS. BLL ≥5 μg/dL was found in 55.2% of children, with manganese levels exceeding the safe threshold in 67.2% of children. Normal zinc levels were found in 91.4% of subjects, while iron deficiency was detected in 65.5% of subjects. No significant association was observed between trace element levels and height-for-age Z-scores. Environmental analysis revealed excess lead in spinach, foliage (longan, hairy fruit), soil samples, and some paint dust samples. Elevated BLL and widespread micronutrient deficiencies may co-exist in non-industrial rural environments and contribute to child health risks. Integrated environmental monitoring is recommended.

blood lead, environmental exposure, iron deficiency, ICP-MS, rural health, stunting

Stunting remains one of the most pressing public health challenges affecting children in low- and middle-income countries (Akbar et al. 2023). Defined as impaired linear growth resulting in a height-for-age Z-score (HAZ) below –2 standard deviations from the WHO Child Growth Standards, stunting affects approximately 22% of children under five globally, with Indonesia reporting a national prevalence of 21.6% in 2022 and higher rates in rural and socioeconomically disadvantaged communities (Paramitha et al. 2024). The consequences of stunting extend beyond childhood, contributing to increased morbidity, poor cognitive outcomes, reduced productivity, and elevated risks for non-communicable diseases in adulthood (Lestari et al. 2024). While inadequate nutrition and repeated infections are well-established determinants of stunting, emerging evidence highlights toxic environmental exposures—particularly lead (Pb)—as overlooked contributors to growth retardation (Gleason et al. 2016). Lead is a pervasive neurotoxin that accumulates in the body, with no level of exposure considered safe in children. Although most studies have focused on urban or industrial areas, growing concern exists over rural exposure routes, including drinking water, contaminated soil, traditional cookware, and deteriorated paint, especially where environmental monitoring is limited (Yeter et al. 2022).

Recent international studies have documented elevated blood lead levels (BLLs) in children and their association with impaired growth. In Uganda, a study by Moody et al. (2020) found that 65% of children had BLLs ≥ 5 μg/dL, and lead was significantly associated with decreased height-for-age scores (Moody et al. 2020). Similarly, Gleason et al. (2020) used causal mediation analysis in a Bangladesh cohort and reported that stunting may modify the neurotoxic effects of lead, with stronger associations observed in stunted children (Gleason et al. 2020). In Mexico, Cantoral et al. (2015) observed that the negative association between lead and child height was more pronounced in zinc-deficient children, suggesting that micromineral status, particularly zinc, may influence the toxicity of lead (Cantoral et al. 2015).

Despite these important findings, few studies have simultaneously examined the interaction between blood lead levels, essential microminerals (e.g., zinc, manganese, and iron), and stunting in rural, non-industrial settings, especially in Southeast Asia (Irwinda et al. 2019). Most research has focused either on lead exposure or on nutritional deficiencies in isolation (Kordas 2017). To date, no integrated study in Indonesia has comprehensively assessed both biological and environmental factors in the same cohort (Córdoba-Gamboa et al. 2023).

This is the first study in a rural, non-industrial Indonesian population to examine the relationship between stunting, blood lead levels, and microminerals, while simultaneously identifying environmental sources of lead exposure (Abdillah 2022; Rodriguez et al. 2024). This study aimed to investigate the association between blood lead levels, essential microminerals (manganese, zinc, and iron), and stunting in children from a non-industrial rural area while identifying environmental lead sources.

To the best of our knowledge, this is the first study conducted in a non-industrial rural region of Central Java, Indonesia, that comprehensively examines the intersection of blood lead levels (BLL), micronutrient status (zinc, manganese, and iron), and environmental sources of lead exposure in relation to child stunting and trace element toxicity. The results demonstrate a concerning public health scenario: more than half of the sampled children (55.2%) presented with elevated BLLs (≥5 μg/dL); normal zinc levels (Zn: 234.9–949.2 μg/dL) were found in 91.4% of subjects; 67.2% had manganese levels above the upper reference range; and iron deficiency (Fe < 40,000 μg/dL) was found in 65.5% of subjects. No statistically significant associations were observed between trace element concentrations (Pb, Mn, Zn, Fe) and height-for-age Z-score (HAZ). These biological findings were further contextualized by the detection of lead contamination in several local environmental matrices, including vegetables (particularly spinach), plant foliage (longan and hairy fruit), household soil, and paint dust.

The high proportion of children with elevated BLLs aligns with earlier findings from other Southeast Asian studies, despite our study being conducted in a rural, non-industrial setting typically presumed to be at lower risk for lead exposure (Yimthiang et al. 2019). According to CDC guidelines, the blood lead reference value is 3.5 μg/dL; blood lead concentrations ≥ 5 μg/dL are considered actionable and are associated with adverse health outcomes, including neurodevelopmental impairment, behavioral issues, and impaired growth (Delgado et al. 2018; Shekhawat et al. 2021). The fact that 32 of 58 children exceeded this threshold is highly concerning and suggests chronic, unrecognized environmental exposure. Stratification by age revealed that children aged 24–59 months had markedly higher BLLs compared to younger toddlers (Yimthiang et al. 2019; Hoang et al. 2021). This supports existing literature identifying increased mobility, greater hand-to-mouth activity, and environmental interaction as critical factors contributing to cumulative lead intake in early childhood (Sharma et al. 2015; Hoffman et al. 2017). However, the absence of a statistically significant relationship between BLL and linear growth (HAZ) in this study mirrors previous mixed findings, where some cohorts showed growth impairment associated with lead, while others found no significant effects (Gleason et al. 2016; Moody et al. 2020; Ahmadi et al. 2022). This discrepancy may reflect differences in exposure dose, chronicity, nutritional status, or genetic susceptibility, and highlights the need for longitudinal follow-up (Muciño-Sandoval et al. 2021; Halabicky et al. 2022; Otavina and Kazakova 2024).

Manganese levels exceeded the safe threshold in 67.2% of children. Although an essential micronutrient, manganese in excess has been increasingly recognized as a neurotoxin (27.28).Elevated Mn levels have been associated with reduced IQ, attention deficit, and behavioral dysregulation, even at subclinical levels (Bjørklund et al. 2017; Rodrigues et al. 2018). The source of excessive Mn in this population is uncertain, but possible contributors include groundwater contamination, high Mn content in local soils, or overuse of iron-containing supplements (Sharma et al. 2021; Chakraborty et al. 2022). Normal zinc levels (Zn: 234.9–949.2 μg/dL) were found in 91.4% of subjects. Several population-based studies have shown that most children have normal whole blood zinc levels, although zinc deficiency remains prevalent, especially in developing countries or in children with chronic conditions (Wang et al. 2015). Studies in China, Canada, and Europe have shown that 50–70% of healthy children fall within the physiological range of Zn levels, with normal levels being the most common finding (Wang et al. 2015).

Iron deficiency (Fe < 40,000 μg/dL) was found in 65.5% of subjects. Although not all studies use Fe units in µg/dL of whole blood, a recent study by Mushi (2023). (Mushi et al. 2023) showed that iron deficiency is very common in young children, particularly in rural and developing areas, with rates approaching or exceeding 65.5% in certain subpopulations. Studies from India and Bangladesh have consistently shown that the prevalence of iron deficiency in children, especially those aged < 5 years, often exceeds 65%, particularly in groups affected by infection, malnutrition, or low socioeconomic status (Sharma et al. 2021; Chakraborty et al. 2022; Gugloth et al. 2022). Although the unit “Fe < 40,000 μg/dL” is rarely used directly in the literature, the prevalence figures are supported both epidemiologically and clinically (Sharma et al. 2021; Chakraborty et al. 2022; Gugloth et al. 2022).

Environmental sampling identified multiple lead exposure pathways. While all household drinking water samples were within acceptable regulatory thresholds, one spinach leaf sample showed lead levels twice the permitted limit (Nag and Cummins 2022). In addition, foliage from longan and hairy fruit trees—commonly found in household gardens—also contained elevated lead concentrations. This likely results from uptake through contaminated soil or the deposition of atmospheric lead particles (Wang et al. 2016; Cao and Bourquin 2020). Most alarmingly, one household soil sample contained lead at 730 ppm—nearly twice the allowable limit of 400 ppm (Obeng-Gyasi et al. 2021; Filippelli et al. 2024).

In parallel, three of six tested paint dust samples were found to exceed the permissible threshold of 90 ppm, with one sample measuring an extreme 6100 ppm. This level of contamination points to the legacy use of lead-based paint, a problem known to persist in many low-resource settings despite formal regulation (Obeng-Gyasi et al. 2021; Ranjbar et al. 2023). These findings collectively refute the assumption that rural areas are inherently safer from environmental toxins and suggest that informal construction practices, agricultural pesticide residues, and poor environmental surveillance may contribute to hidden lead burdens (Rustin et al. 2016; Goumenou et al. 2021).

This study possesses several notable strengths. It is among the first in Indonesia to integrate biological trace element testing and environmental sampling outcomes into a single analytic framework. The use of high-precision ICP-MS for biomonitoring ensures methodological rigor and data accuracy (Laur et al. 2020). Furthermore, by including both environmental and biological assessments, the study provides a more comprehensive understanding of exposure pathways. Nevertheless, limitations must be acknowledged. The cross-sectional design precludes causal inference, and the relatively small sample size and purposive sampling approach limit generalizability. Lastly, no cognitive or neurodevelopmental assessments were conducted, which could have helped quantify the functional impact of trace element imbalances.

This study highlights a critical but underrecognized burden of environmental lead exposure and micronutrient imbalance among children in a rural, non-industrial region of Central Java. More than half of the participants showed elevated blood lead levels; the majority had excessive manganese concentrations, most had normal zinc concentrations, and many were iron deficient. Environmental sources such as contaminated vegetables, foliage, soil, and legacy paint dust were identified as potential contributors. While no significant association was found between trace element concentrations and stunting, the findings underscore the complex interplay of environmental and nutritional factors affecting child health. These results call for urgent public health action, including environmental surveillance, micronutrient screening, and early detection of blood lead levels to identify and reduce exposure risks and improve child health outcomes.

Conflict of interest

The authors have declared that no competing interests exist.

Ethical statements

The authors declared that no clinical trials were used in the present study.

The authors declared that experiments on humans or human tissues were performed for the present study.

The authors declared that no informed consent was obtained from the humans, donors or donors’ representatives participating in the study.

Informed consent from the humans, donors or donors’ representatives: The study protocol received ethical approval from the Universitas Harapan Bangsa Ethics Committee Approval No: B.LPPM-UHB/4303/2021, and written informed consent was obtained from all participating caregivers.

The authors declared that no experiments on animals were performed for the present study.

The authors declared that no commercially available immortalised human and animal cell lines were used in the present study.

Use of AI

No use of AI was reported.

Funding

No funding was reported.

Author contributions

All authors have contributed equally.

Author ORCIDs

Maya Safitri https://orcid.org/0009-0004-0245-5954

Lia Amalia https://orcid.org/0000-0002-0011-1558

Benny Permana https://orcid.org/0000-0002-6588-6557

Dida Achmad Gurnida https://orcid.org/0000-0002-0714-7772

Data availability

All of the data that support the findings of this study are available in the main text.