Systematic Review: Relationship between Infant and Young Child

Feeding Practices with Stunting in Indonesia

Annisa Yuri Ekaningrum

and Desy Sulistiyorini

STIKES Indonesia Maju, Harapan Street No. 50, Lenteng Agung, South Jakarta, 12610, Indonesia

Keywords: Children, Feeding Practices, Indonesia, Stunting.

Abstract: Stunting affects deficits in cognitive development, more vulnerable to disease, and loss in productivity. One

of main factors is inappropriate breast-feeding and complementary feeding practices. However, none of

studies review about relationship between feeding practices and stunting in children. The aim of this study

was to identify relationship between feeding practices and stunting among children in Indonesia. The

systematic scoping review method was used in this review. The databases were electronic databases including;

Google Scholar and Pubmed. Articles were searched by keywords and used bilinguals Bahasa and English.

The inclusion criteria of studies were focused on relationship between feeding practices and stunting,

published from 2017 to 2021, full text, and research implemented in Indonesia. A total of 1008 papers were

retrieved, but only 18 articles met the inclusion criteria and were included in the analysis. The majority of the

findings revealed that feeding practices have a substantial relationship with incident of stunting for infant and

young children in Indonesia. This includes dietary variety, exclusive breast feeding, the time of introduction

of complementary feeding, high iron feeding, and frequency of feeding. Comprehensive specific and sensitive

nutrition intervention should be implemented equally to tackle stunting in Indonesia.

1 INTRODUCTION

Efforts to reduce child mortality and improve

maternal health have become a global concern

because they are the focus of public health

development which is included in the Sustainable

Development Goals (SDGs). This shows that children

who should receive special attention. After the age of

one year is included in the first 1000 days of life,

children are still in rapid growth characterized by

rapid organ and motor maturity. Bloom revealed that

the growth of brain tissue cells can reach 50% in

children aged 0-4 years old (Cropley, 1994).

Children's brain synapses are like sponges that easily

absorb information and connect with each other when

stimulated. In Indonesia, around 37% or

approximately 9 million children under five are

stunted

(Ministry of Health, 2013). The Basic Health

Research year 2018 data revealed that there were

17.7% of Indonesian children under five experiencing

severe malnutrition and malnutrition, this was

certainly higher than the RPJMN target of 17%

(Ministry of Health, 2018). While the proportion of

children under two years old who are short and very

short was 29.9%, this was certainly higher than the

RPJMN target of 28% and WHO's 20%. Toddler who

experiences stunting will have less optimal cognitive

abilities, causing children more susceptible towards

disease and causing a decrease productivity levels.

Another fact stated that in Bangladesh and Pakistan,

the problem of malnutrition, including short children,

reduces national income (GNP) by 2 percent - 4

percent annually (IFPRI, 2000). In the end, stunting

will broadly inhibit economic growth, increase

poverty and widen inequality. Based on the UNICEF

Conceptual Framework, one of the causes of stunting

in children under two is improper feeding practices.

Research that was conducted by Black et al (2008)

revealed that inappropriate breastfeeding and

complementary feeding practices are the main cause

of malnutrition and death during the first 2 years of

life. If infants and children do not receive food

according to their nutritional needs, then the golden

period will become a critical period that will interrupt

the growth and development of infants and children,

in the present time and later on in the future.

Therefore, the optimal practice of feeding infants and

children become the major concern to support the

development and the growth of the infants and

children. However, studies on the association

Ekaningrum, A. and Sulistiyorini, D.

Systematic Review: Relationship between Infant and Young Child Feeding Practices with Stunting in Indonesia.

DOI: 10.5220/0010756500003235

In Proceedings of the 3rd Inter national Conference on Social Determinants of Health (ICSDH 2021), pages 129-135

ISBN: 978-989-758-542-5

129

between children feeding practices and stunting in

Indonesia are still limited, especially those that use

systematic reviews. This study aimed to analyze the

association between child feeding practices and

stunting from various studies in Indonesia.

2 LITERATURE REVIEW

2.1 Stunting

Stunting is a consequence of insufficient nutritional

intake in an extended period of time due to feeding

that does not match the nutritional needs which leads

to a chronic malnutrition. Stunting arises during the

fetus development in the womb and only observed

when the child age reaches approximately two years

old. Malnutrition at a younger age leads to an increase

in infant and child mortality, causes them to be easily

sick, and causes poor posture as adult

(MCA

Indonesia, 2015). According to the WHO Child

Growth Stunting Standard, stunting is measured by

the index of body length for age or height for age with

a limit (z-score) <-2 SD (WHO, 2010). Many factors

cause stunting in children. Factors that cause stunting

can be caused by direct or indirect factors. The direct

factors of this incident are nutritional intake and the

presence of infectious diseases while the indirect

factors are parenting patterns, health services, food

availability, cultural and economic factors (UNICEF,

1990).

2.2 Feeding Practices

The nutritional needs of infants and children can be

obtained through exclusive breastfeeding and

complementary foods that are appropriate for the age

of the child in terms of quantity, frequency, and

texture of the food. Several studies in Indonesia

revealed that the main factors causing malnutrition

and growth retardation in children under five were

related to low breastfeeding and poor practice of

complementary feeding (Adriani & Kartika, 2013).

At the time of preparing and serving food, hygiene

also needs to be considered such as avoiding food

from dust and animals, cleanliness of eating and

cooking utensils, mothers or family members who

provide food must wash their hands with soap

because unclean and contaminated food can cause

diarrhea or illness, and other infections in children

(Istiany & Rusilanti, 2013).

Poor parenting causes the poor nutritional status

of children under five. If this happens during the

golden age, it will cause the brain to not develop

optimally and it will be difficult to recover. The

results of a study conducted by Sari & Ratnawati

showed a relationship between feeding practices to

toddlers and nutritional status. Feeding practices were

correlated with the quality of food consumption

which in turn will increase nutritional adequacy. The

level of nutritional adequacy is one of the factors that

can affect the nutritional status of toddlers (Sari &

Ratnawati, 2018).

Research conducted by Diana (2006) showed that

mothers who worked as sharecroppers, had daily

activities always take their toddlers to the fields or

fields because there was no other alternative caregiver

so that the time between mother and child was

reduced. The results of observations showed that

children usually do things or play alone without

knowing whether what they are doing was good or

not, while parents only supervise occasionally,

including the lack of time to provide or accompany

children while eating while telling stories or creating

fun and comfortable eating situations for children.

Thus, affecting the eating patterns of mothers of

toddlers. However, the results of this study were

inversely proportional to Martianto et al (2011) which

showed that there was no significant relationship

between nutritional status and parenting. This was

because of the differences in the ages of the children

under five studied, which was 24-60 months, non-

working mom or were housewives, most of whom

were classified as capable or not poor, and the

category of the research area was not food insecure.

Failure in feeding practices can lead to feeding

problems in toddlers and child development in later

periods. The consequences of poor or poor nutrition

in infancy are impaired growth and development of

the brain, muscles, body composition, and metabolic

programming of glucose, fat, and protein. Long-term

impacts can be in the form of low reasoning ability,

educational achievement, immunity, and work

productivity (Naser & Alawar, 2016).

3 METHODS

This study is quantitative research with systematic

review approach. This study was conducted on June

2021. There are five steps in this methods which are

determining topic, searching sources, choosing the

most relevant sources, organizing and analyzing, and

summarizing. Keywords were feeding practices,

stunting, and Indonesia. This literature review

focuses on information about relationship between

feeding practices and stunting in Indonesia. Articles

were searched from the following databases: Google

ICSDH 2021 - International Conference on Social Determinants of Health

130

Scholar and Pubmed. These databases were chosen

because most Indonesian research in Bahasa

Indonesia published in those databases. The inclusion

criteria were Indonesian studies, study design used

correlation and quasi-experimental, and published

between 2017-2021 full text. The articles selection

process is described in figure 1.

Figure 1: Article selection process

4 RESULTS AND DISCUSSION

The majority of studies only assess a single factor and

did not provide a comprehensive view of association

between feeding practices and stunting. Some of the

literature that has been reviewed has differences, this

is because each article uses a measurement theory that

has differences and this causes each article to have to

adjust the characteristics of the respondents used. In

addition, the difference can be seen from the age limit

of the child. The research design that is generally used

to discuss child feeding practices in Indonesia is

cross-sectional.

The majority of the studies revealed no

significance relationship between maternal feeding

practices and incidence of stunting. A cohort and

randomized controlled trial study demonstrated no

significant relationship of infant and young feeding

(IYCF) with improvement in growth of children

under 2 years (Fahmida et al., 2020). Previous studies

also indicated no significant relationship between

feeding practices and incidence of stunting

(Rahmawati & Nurhaeni, 2019). In terms of feeding

practices, previous study showed that mothers did

less responsive feeding practices, such as less

attention to the signs of child hunger, provided food

that is not in accordance with the expected appetite

for children, and either encouraged their children to

eat a great deal or limited their eating (Novitasari &

Wanda, 2020). However, another study show

correlation between nutritional practices and

nutritional status of toddlers in farmer families. It was

emphasized on the study to use local food as strategy

of improving the nutrition for family provided that it

is easily obtained with the more affordable price

(Simanjuntak et al, 2019).

The majority of studies related to child feeding

practices in Indonesia use 8 WHO child feeding

practice indicators such as sustained breastfeeding, the

food introduction, minimum dietary diversity,

minimum meal frequency (MMF), and minimum

acceptable diet (MAD). Continued breastfeeding is

the proportion of mothers who provide continuous

breastfeeding until the children reach the age of 2

years old. The introduction of foods is measured based

on the proportion of infants who begin to introduce

and have given food at the age of 6-9 months.

WHO/UNICEF in its provisions suggest that infants

and children aged 6-23 months receive sufficient

complementary foods provided that they can receive

at least 4 or more than 7 food groups. The 7 food

groups consist of dairy products, eggs, cereals/tubers,

nuts, other protein sources, vegetables, and fruits rich

in vitamin A, also other vegetables and fruits.

Children must meet the Minimum Meal

Frequency (MMF) requirements, namely infants 6-23

months who are given or not breastfed and have

received complementary feeding (soft food/solid

food, including breastfeeding for those who are not

breastfed) must be given with a frequency according

to age and needs. Meanwhile, based on the practice of

feeding infants and children (PMBA) children aged

6-9 months must eat at least 2 times/day, children

aged 9-12 months at least 2 times/day, while children

aged 12-24 months must eat at least 3 times/day.

Meanwhile, the Minimum Acceptable Diet (MAD) is

a blend of minimum dietary diversity (MDD) and

minimum meal frequency (MMF), namely babies

who consume at least 4 of 7 types of food with a

minimum eating frequency according to their age. So

if the MDD and MMF are met, then the MAD is also

fulfilled. Indicators of iron consumption are also

considered by calculating the percentage of children

consuming iron foods at the age of 6 – 23 months in

the form of local and fortified foods. In other studies,

there are also indicators of other feeding practices

such as accuracy of infant age at feeding, frequency

of feeding, amount of food consumed, texture or

Systematic Review: Relationship between Infant and Young Child Feeding Practices with Stunting in Indonesia

131

Table 1: The summary of articles about relationship between feeding practice and stunting in Indonesia

Data

Sources

Authors Subject Design Place Findings

Google

Scholar

Rusmil VK et

Children

aged 12-23

months ol

Cross

sectional

Jatinangor

Primary

Healthcare

There was a relationship between

caregiver’s behavior in child feeding

ractice and stunting

Google

Scholar

Niga MD,

Purnomo W

Children

aged 1-2

years old

Case control Oebobo

Kupang

Primary

Healthcare

There is an association between feeding

practice and hygiene practices with

stunting incident whereas health care

practices have no significant

relationships with stunting

Google

Scholar

Imelda et al. Children

aged 2-5

ears ol

Case control

with

com

arison 1:2

Biromaru

Primary

Healthcare

Complete basic immunization, feeding

practice, low birth weight, and iodize salt

were risk factors of stuntin

Google

Scholar

Susanti E 129 under

five years old

children

Cross

sectional

Gunung

Maddah

Sampang

Village

There were strong correlation between

infant feeding practices and also parent

attachment impact with nutritional status

of under five years old children

Google

Scholar

Febrianita Y,

Fitri A

66 mothers Descriptive

research

Tapung

Kabupaten

Kam

ar.

49,5 % of mothers are classified as

adequate category in feeding practices to

toddlers and is associated with stuntin

Google

Scholar

Lobo et al 137 stunting

toddler

Case control Alak Health

Center of

Kupang City

Mother’s education, parental income,

mother’s knowledge on nutrition, large

family, feeding practice, hygiene and

environmental sanitation practices,

energy adequacy rate and protein

adequacy rate have correlation with

stuntin

Google

Scholar

Hidayat et al Mothers who

had stunting

children

Retrospective

method

Sukamukti

Community

Health Centre

This study revealed that 32% of the

children did not get early initiation of

breastfeeding, 84% did not receive

exclusive breastfeeding, 46% did not

complete breastfeeding until the age of

two years, 34% did not achieve the

minimum dietary diversity (MDD), 36%

did not achieve the minimum meal

frequency (MMF), 56% did not achieve

the minimum acceptable diet (MAD),

and all of respondents consumed iron-

containin

foods.

Google

Scholar

Khaerunnisa

et al

Mothers who

had stunting

toddler

Cross

sectional

East Cimahi

Community

Health Center

More than half of the respondents started

to introduce family food when the child

was 12 months old. The continuous

provision of complementary feeding, the

mother's attitude in the practice of

feeding children was considered good

(73.0%) and 80 % of the respondents

ada

ted their children to famil

food.

Google

Scholar

Tengkawan J

et al

Parents with

children aged

6-12 months

Quasi-

experimental

community-

based study

Three stunting

villages of

Central

Lombok, West

Nusa

Tenggara.

Seminar intervention was found to be

able to improve the practice, while

complete intervention (seminar and

workshop) could enhance both practices

and attitudes significantly.

Google

Scholar

Tanuwijaya

et al

Infants Cross

sectional

Pagelaran

Village,

Pagelaran

District,

Pande

lan

There was no significant relationship

between maternal IYCF knowledge and

nutritional status.

ICSDH 2021 - International Conference on Social Determinants of Health

132

Google

Scholar

Purnama

NLA

Toddlers Cross-

sectional

Posyandu

Anggrek 2,

Mulyorejo

Sub-District,

Surabaya

Results show there is a relationship

between exclusive breastfeeding and

parental feeding behavior with stunting

in children aged 1-3 years

Google

Scholar

Siregar SG Under Five

Years Old

Children

Cross-

sectional

Posyandu of

Sekip Village,

Lubuk Pakam

Subdistrict,

Deli Serdang

enc

There was a relationship between

maternal characteristics of education,

income, knowledge, and parenting

factors about the feeding practice and

health practices with the incidence of

malnutrition in un

er five

ears ol

Google

Scholar

Hendrawati

et al

0-24 months

old children

Retrospective

Method

Sumedang 6,2 % of children did not receive

complementary

breastfeeding when the children aged 6-

8 months, 32,9% of children did not meet

the minimum dietary diversity,

37,0% of children did not achieve the

minimum meal frequency, 55,5% of

children did not achieve the minimum

acceptable diet, and 100% of children

consumed foods containin

iron

Google

Scholar

Sirajuddin et

0-59 months

children

Cross

Sectional

Makassar The significant determinants associated

with stunting were exclusive

breastfeeding, complementary feeding

ractices, and frequency of feeding.

Exclusive breastfeeding is the major

determinant for stunting in toddlers and

therefore should be a priority program to

improve the nutritional status of children

in earl

es of life.

Google

Scholar

Starkweather

C et al

Under age 2

years old

children

Cross

sectional

Rural

Indonesia

Participation in intervention providing

interpersonal communication was

associated with increase knowledge of

feeding practices. On the other side,

knowledge of feeding practices was

correlated to achieving recommended

behavioral practices of minimum meal

frequency, dietary diversity, adequate

diet.

Google

Scholar

Fahmida et al Under 2

years old

Cluster

randomized

cohort trial

Sidoarjo and

Malang

District

The intervention was eﬀective in

improving the feeding practices of

children although it was failed to show

signiﬁcant improvement in linear growth

of children at 18 months of age.

Pubmed Novitasari et

Children

under 5 years

old

Cross

sectional

Depok There was no relationship between

maternal feeding practice and the

incidence of stunting in children in

Depok.

Moreover, most of mothers did non-

responsive feeding practice.

Pubmed Febriana

WR,

Nurhaeni N

Children

aged 6-23

months old

Cross

Sectional

East Jakarta There was no significant association

between IYCF practices and stunting and

its relation with mother and child

characteristics like mother’s age,

mother’s employment status, mother’s

educational level, low birth weight,

sanitation and health behaviors, and

household income.

Systematic Review: Relationship between Infant and Young Child Feeding Practices with Stunting in Indonesia

133

consistency of spent food, food diversity, feeding

methods, personal hygiene (Nurbaiti et al, 2019). This

literature review provides comprehensive

information about the relationship between feeding

practices and stunting. However, it only looks at

Indonesian studies. These findings may not apply to

children from other countries that have the different

characteristics to Indonesia.

5 CONCLUSION

Most studies on child feeding practices in Indonesia

use the WHO IYCF indicators. Some studies add

socio-demographic characteristics and aspects of

personal hygiene. Further research by adding aspects

of feeding rules is needed. Aspects of feeding rules

include schedule, environment, and feeding

procedures. According to the WHO's UNICEF

framework, feeding practices are an immediate factor

in nutritional problems. So that good feeding

practices need to be considered by caregivers,

especially parents. Parents need to pay attention to

proper feeding rules such as not being distracted

while eating, creating a pleasant atmosphere, and

encouraging children to eat alone. This is to minimize

the problem of difficult eating which will have an

impact on the problem of malnutrition.

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