Third International Seminar on Global Health (3rd ISGH) Technology Transformation in Healthcare for a Better Life ISGH 3 | Vol 3. No. 1 | Oktober 2019 | ISSN: 2715-1948
School of Health Sciences Jenderal Achmad Yani Page 186
Jenderal Sudirman Canal Road – Cimahi 40533 Phone: +62-22-6631622 - 6631624
THE RISK FACTORS OF EXCLUSIVE BREASTFEEDING ON STUNTING AMONG CHILDREN UNDER FIVEIN ONE OF THE CITY IN INDONESIA
Hemi Fitriani*, Achamd Stya R., Poppy Nurdiana [email protected]
Department of Nursing, School of Health Sciences Jenderal Achmad Yani Cimahi, Indonesia ABSTRACT
Background The prevalence of stuntingis significantly increased in Indonesia. It reached to 27,52% in 2016 andit gradually increased to 29,6 % in 2017. The highest prevalence occurred in 2018 as much as 30,8%
especially in West Java. This province exceeds the national rate of the prevalence of stunting that almost reached to 31,1% in 2018. Cimahi had a high prevalence of stunting that reached to 27.78% and 573 stunted children found in the Primary Health Center of Cigugur, Cimahi. One of the risk factors influenced to stunting is exclusive breastfeeding.
Objectives The study aims to determine the correlation between exclusive breastfeeding and stunting.
Methods Case control study design was conducted among mothers who have children at the age between 12- 59 months in the Primary Health Center of Cigugur, Cimahi. Proportional random sampling technique was used to select the participants. A total of 80 samples which divided to 40 mothers of stunted children and 40 mothers of non-stunted children were included in this study. The data were taken from 27th April to 3rd Mei 2019 through observation and questionare. Univariate analysis used frequency distribution while bivariate analysis used chi-square test. Ethical consideration was obtained from The Health Research of Ethics Committee of Institute of Health Science of JenderalAchmadYaniCimahi No. 49/KEPK/V/2019.
Results A total of 67,5% stunting incidence occurred to children who did not breastfeed exclusively. The results shows that exclusive breastfeedingsignificantly gives a crucial impact that prevent stunting (p value : 0,001).
The OR value is 5,476 which means children who did not breastfeed exclusively were more likely to be stunted as much as 5,476 times, than children who breastfeed exclusively.
Conclusions/ ImpartanceBreast milk is the best nutritionalchoice for bone and brain growth and development.
Nurses carry out of stunting prevention by giving an education and health promotion about the advantages of exclusive breastfeeding and its impact to stunting.
Keywords: Exclusive breastfeeding, Case control, Indonesia, Stunting.
INTRODUCTION
Stunting becomes a major public health concern in Indonesia compared to the other health problems. The prevalence of stunting increased in 2016 and it reached to 30,8% in 2018. It is further from the stunting target that is only reached 20%.
As the one of Indonesian’s province, West Java is determined as the highest prevalence of stunting. As much as 15,1% of stunting incidence occurred among children at the age between 0-59 months and it increased to 31,1% (Ministry of Health of the Republic of Indonesia, 2018). Cimahi is one of the industrial cities in West Java with a high prevalence of stunting at the age between 0-59 months which reached to 27,78% in 2017. A total of 573 stunted children found in The Primary Health Center of Cigugur, Cimahi.
Cigugur District has the different population characteristics filled by migrants.Many of them are productive agewith low education level worked as labors and small traders with limited income to Regional Minimum Wage (UMR) of Cimahi. There are many young families lived with more than one child (especially children under five). They prefer to give infant formula milk than breastfeed exclusively.The minimum income with a large number of family members causes low purchasing for infant formula milk. It forces them to give less infant formula than its necessary to save the supply of formula milk without considering the optimalnutritional needs.
Infants (0-6 months) need the best nutrient supply, especially in the right amount of macro and micronutrients to support their brain and bone growth and development. The lower of infant formula milk given to the baby causes the lack of
The Risk Factors of Exclusive Breastfeeding on Stunting Among Children Under Fivein One of The City in Indonesia
Third International Seminar on Global Health (3rd ISGH) Page 187
Vol 3 | No. 1 | October 2019 |
nutrient supply and it continues to developmental disorders.When it is occurred, it will significantly influence their health and it cannot be fixed in the next phase (Soetjiningsih, 2015).
Furthermore, infant malnutrition is highly contributed to the riks factors of stunting.
Exclusive breastfeeding is the best and optimal nutritional choice for every infant. Breast milk contains a higher amount of protein, mineral, and vitamin that support healthy brain and bone growth.
It also contains antibodies that protect the illness and infections by neutralizing bacteria and viruses.
Therefore, it significantly gives a crucial impact for preventing stunting.
The study aims to determine the correlation between exclusive breastfeeding and stunting in The Primary Health Center of Cigugur, Cimahi.
METHODS
Case control study design was conducted among 80 mothers who divided to 40 mothers of stunted children and 40 mothers of non-stunted children.Proportional random sampling technique was used to select the participants. A total of sampleswere selected by unpaired categorical formulas by Dahlan (2010).The data were taken from 27th April to 3rd Mei 2019 in the Primary Health Center of Cigugur, Cimahithrough observation and questionare. The data of stunting was determined by measuring children height with a microtoise.Univariate analysis used frequency distribution while bivariate analysis used chi-square test. Ethical consideration was obtained from The Health Research of Ethics Committee of Institute of Health Science of JenderalAchmadYaniCimahi No.
49/KEPK/V/2019.
RESULTS
The percentage of exclusive breastfeeding in stunted and non-stunted group in RW 13, RW 14, RW 19 in the Primary Health Center of Cigugur, Cimahi can be seen in Table 1,
Table 1. The Frequency Distribution of Exclusive Breastfeeding in Stunted and Non-Stunted
Group in RW 13, RW 14, RW 19 in the Primary Health Center of Cigugur, Cimahi 2019 Stunting Infant
Formula
Eksklusive Breastfeeding
Total
N % N % N %
Stunted 27 67,5 13 32,5 40 100
Non-Stunted 11 27,5 29 72,5 40 100
The Table 1 shows stunting are almost occurred to the baby who did not breastfeed
exclusively. The correlation between exclusive breastfeeding and stunting can be found in Table 2,
Table2.The Correlation between Exclusive Breastfeeding and Stunting among Children under Five in the Primary Health Center of Cigugur, Cimahi 2019
Variable Stunted Non-Stunted P value
OR (CI 95%)
N % N %
Formula Milk Exclusive Breastfeeding
27
13 67,5
32,5 11
28 27,5
72,5 0,00
5,476 (CI 95% : 2,099 – 14,284), Total 40 100 40 100
Table 2 shows that Chi-square statistical test resulted in Continuity Correction test with (p value
= 0.001) pvalue<α (α= 0.05). Therefore, exclusive breastfeeding is significantly related and give the crucial effect to prevent stunting.OR (Odds Ratio) value is 5,476 (CI 95% : 2,099 – 14,284) which means that children who did not breastfeed exclusively were more likely to be stunted as much as 5 times, than children who breastfeed exclusively.
DISCUSSION
There are still a large number of children who did not breastfeed exclusively compared to those who are exclusively breastfed. The reason for the lower exclusive breastfeeding rate in Indonesia is the lack of knowledge of the mothers, family, and community about the importance and the benefit of exclusive breastfeeding. Therefore, mothers are not able to fend off the promotion of infant formula milk and they indirectly can not support exclusive breastfeeding program (MOH, 2011).
The conditions of the people in the Primary Health Center of Cigugur are generally middle to low economic group. The majority of their jobs are labors and hawkers. The level of education is generally middle-low categories.Breastfed mothers revealed that they rarely get and did not actively seek the information about the benefits and methods of exclusive breastfeeding. Therefore,they are not motivated to breastfeed their children exclusively.
They spontaneously give the infant formula milk when having difficulty in breastfeeding.Since infant formula milk is unaffordable, they generally give it less with its necessary that it does not reach the nutritional adequacy of children. They also stated that their babies are fed less than six months for reasons of lack of milk production.
The result shows that exclusive breastfeeding is significantly relatedto stunting. In fact,children
The Risk Factors of Exclusive Breastfeeding on Stunting Among Children Under Fivein One of The City in Indonesia
Third International Seminar on Global Health (3rd ISGH) Page 188
Vol 3 | No. 1 | October 2019 |
who are not exclusively breastfed have a higher risk of stunting as much as five times compared to those who are exclusively breastfed. This study is appropriate with the research of Nurkarimah, et al (2018) which states that there is a correlation between the duration of exclusive breastfeeding and stunting with p 0,000. Larasati, et al (2018) stated that non-exclusive breastfeeding is also related to stunting (OR = 3.23). Therefore, children who are not exclusively breastfed will increase the risk of stunting.
A baby’s bone starts growing and developing after they born. The epiphyseal plate on the long bone which is the center of growth longitudinally becomes actively growing.This process requires macronutrients and micronutrients as the main nutrition for bone formation. The main macronutrients are protein while the main micronutrients are calcium, phosphorus, zinc and vitamin D (Sari, E.M, et al., 2016). Baby needsthe calcium about 140 mg / day and zinc of 0.4 mg / day for bone growth (Wiyono 2016). All of the nutrient supply must be sufficient to support bone growth and development.
Breast milk contains all of the nutrients for proper bone growth and development. It is high in protein, especially containsmore whey protein which is more easily absorbed by the baby's intestine. Whereas,infant formula milk contains more protein casein which is more difficult to digest by the baby's intestine. The quality of breast milk protein is better than formula milk because of its amino acid composition (Boutwell, B. B., Beaver, K. M., &Bames, J. C., 2012). Calcium requirements of children at the aged 0-6 months are close to the amount of calcium contained in breast milk (280 mg / day) with an average milk production of 70 ml / day. The results of a meta-analysis stated that calcium supply from breast milk is sufficient for bone mineralization in infants up to 6 months or 24 months. Zinc contained in colostrum is very high at 280 mg / l while in mature breastmilk is only 3-5 mg / l. Zinc contained in breast milk has high bioavailability, so the absorption of zinc is higher than infant formula milk. Breast milk is the best nutritional choice for bone growth.
Infants who did not breastfeed exclusively are at the risk of deficient protein, calcium, phosphorus and zinc. Moreover, the nutrient supply will not be sufficient for the baby's needs if infant formula milk is not given at the proper amount. Low calcium can result in low mineralization of new bone deposit matrix and osteoblast dysfunction. Calcium deficiency will affect to linear growth if the calcium content in the bones is less than 50% of the normal
content (Sari, et al. 2016). So, children are at the risk of stunting.
Another factor contributed to stunting is infections. The immune system of the infants is underdeveloped, so baby is very susceptible from infection. Breast milk is very beneficial in immunological aspects. It contains many substances in immunity including nucleotides, vitamin A and beta carotene, immunoglobulin A (Ig.A), lactoferrin, lysosimfor 300 times more than infant formula milk, enzymes that protect baby against bacteria (E. coli and salmonella) and viruses, Brochus- AsociatedLympocyte Tissue (BALT) respiratory antibodies, Gut AsociatedLympocyte Tissue (GALT) respiratory tract antibodies, and Mammary AsociatedLympocyte Tissue (MALT) antibodies to the breast, bifidus factors, (MOH RI, 2001). The result of the study suggests that infants who are breastfed exclusively are associated with a reduced risk of acute otitis media, non-specific gastroenteritis, respiratory infections, necrotic enter colitis and Sudden Infant Death Syndrome (Ip, Chung, Raman, Chew, Maqula, Devine, Trichalinos& Lau , 2007).
Low calcium resulted in low mineralization of new bone deposit matrix and osteoblast dysfunction. Calcium deficiency will affect to linear growth if it less than 50% of normal content (Sari, et al. 2016). Likewise, zinc deficiency will be suspectible to infectious disease and growth disorders. It has an important role in the enzyme system that regulates to the process of major metabolism in the body (Dewi, et al. 2017)
The result shows thatsome infants prevent from stunting even they are notexclusively brastfed since the composition of infant formula milk is sufficient and successfully meet their nutritional needs as healthy infants. Moreover, the right way in sterilizing the nipple bottle, preparing clean and hygienic infant formula milk will avoid the bacterial exposurewhich causes diarrhea and other infectious diseases.When baby suffers from diarrhea (more than 4 days) and did not treated appropriately, they will experience nutrient malabsorption and lost good nutrient supply impacted to developmental disorders. Malnutrition children have a low immune system, so they are suspectible to infectious disease such as diarrhea or URI (Upper Respiratory Tract Infection) affected to children’s cognitive development and growth disorder (Dewi, et al.
2018).
CONCLUSION
Exclusive breastfeeding is the best nutritional choice for infant to prevent stunting.Nurses carry
The Risk Factors of Exclusive Breastfeeding on Stunting Among Children Under Fivein One of The City in Indonesia
Third International Seminar on Global Health (3rd ISGH) Page 189
Vol 3 | No. 1 | October 2019 |
out of stunting prevention by giving an education and health promotion about the advantages of exclusive breastfeeding to prevent stunting.
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