Community and International Nutrition

Nutritional Status and Linear Growth of Indonesian Infants in West Java Are
Determined More by Prenatal Environment than by Postnatal Factors1
Marjanka K. Schmidt,* Siti Muslimatun,* Clive E. West,* **2 Werner Schultink,
Rainer Gross and Joseph G. A. J. Hautvast*
*Division of Human Nutrition and Epidemiology, Wageningen University, The Netherlands; SEAMEO
TROPMED Regional Center for Community Nutrition, University of Indonesia, Jakarta, Indonesia;
**Department of Gastroenterology, University Medical Center Nijmegen, The Netherlands; UNICEF,
New York, NY; and German Agency for Technical Cooperation, Eschborn, Germany.

KEY WORDS:

infants

growth

nutritional status

In Indonesia, many infants and young children have an inadequate nutritional status as reflected by the high prevalence of
underweight and stunting (1,2). Stunting indicates a public
health problem because of its association with an increased risk of
morbidity and mortality, delayed motor and mental development,
and reduced physical capacity (1,3). Most growth faltering, resulting in underweight and stunting, occurs from birth until 2 y
of age but may already start during the gestation period (3).
Prenatal factors, such as maternal nutrition, determine fetal
growth during the gestation period, and thus infant weight and
length at birth. Infant birth weight and length are determinants of future nutritional status as was shown in Bangladeshi
infants who experienced very little catch-up growth after birth
(4). In Indonesian infants, birth weight and length have also
been found to be important determinants of infant growth (5).
During infancy, inadequate intakes of nutrients and frequent
or prolonged episodes of infection may exacerbate the effects of

feeding

morbidity

determinants

fetal and infant growth retardation (1,6). However, the severity

of the effect of morbidity on growth depends on the pathogens
and population involved (7,8). Breast-feeding has been found to
decrease the risk of morbidity and mortality in infants in developing countries (9,10) and morbidity in developed countries
(11). The growth of breast-fed infants differs from that of those
who are formula fed; breast-fed infants usually grow faster during
the first 3 mo of life but more slowly thereafter (12). In addition,
the effects of the duration of breast-feeding and timely introduction of complementary feeding on growth differ among populations (13).
To date, most studies have investigated either the effect of
birth weight and length (4,5) or that of postnatal factors
(1,6,12,13) on growth and nutritional status. In addition, little
information has been published on determinants of growth and
nutritional status of Indonesian infants. We studied a cohort of
Indonesian pregnant women and their newborns until 15 mo of
age, which enabled us to assess the relative effect of prenatal and
postnatal factors on growth and nutritional status of infants.

1
Supported by the Netherlands Organization for Scientific Research-Netherlands Foundation for the Advancement of Tropical Research and the Neys-van
Hoogstraten Foundation, The Netherlands and the German Agency for Technical
Cooperation/South East Asian Ministers of Education Organization, Tropical
Medicine (SEAMEO TROPMED), Indonesia.
2
To whom correspondence should be addressed.
E-mail: Clive.West@staff.nutepi.wau.nl.

SUBJECTS AND METHODS

Study design. Pregnant women from nine rural villages in Leuwiliang subdistrict, Bogor district, West Java, Indonesia were enrolled
in six rounds from November 1997 until May 1998; their infants were

0022-3166/02 $3.00 2002 American Society for Nutritional Sciences.

Manuscript received 5 September 2001. Initial review completed 5 November 2001. Revision accepted 11 April 2002.
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ABSTRACT One of the health problems in Indonesia is the high prevalence of stunting in infants. Determinants
and specifically the relative contribution of prenatal and postnatal factors to growth and nutritional status of
Indonesian infants were investigated. Newborn infants, from women recruited at 18 wk of pregnancy from 9 rural
villages in West Java, Indonesia, were followed until 1215 mo of age. Weight, length, morbidity, breast-feeding
and food intake were assessed monthly. Determinants of length and weight increase and nutritional status reflected
by Z-scores were evaluated using multiple linear regression. Neonatal weight (3.2 0.5 kg) and length (49.7 2.2
cm) were reasonable. However, growth started to falter at 6 7 mo of age, resulting in prevalences of 24% stunting
and 32% underweight at 12 mo of age. The multiple regression models explained 19 41% of the variation in
growth and nutritional status of infants. Neonatal weight ( 0.285) and length ( 0.492) were the strongest
positive predictors of weight-for-age and height-for-age Z-scores, respectively. Fever was negatively associated
with weight increase ( 0.144) and weight-for-age ( 0.142) and weight-for-height Z-scores ( 0.255)
but not with length increase or height-for-age Z-scores. Intake of complementary foods was positively associated
with increases in weight ( 0.190) and length ( 0.179) and nutritional status of infants ( 0.136 0.194). In
conclusion, in this rural population in West Java, neonatal weight and especially length, reflecting the prenatal
environment, are the most important predictors of infant nutritional status. J. Nutr. 132: 22022207, 2002.

GROWTH OF INDONESIAN INFANTS

Breast-feeding and food intake. Together with the morbidity

interview, the mother was asked whether the infant was still breastfed and whether the infant received any other liquid or food in the
14 d preceding the visit. Breast-feeding and food intake data, including food given to the infant before or at the time of starting the
breast-feeding i.e., prelacteal feeding, had been collected at the
postnatal home visit. The type of liquid or food was recorded using a
precoded questionnaire. For breast-feeding status, infants were categorized as exclusively breast-fed, predominantly breast-fed (i.e., receiving breast milk plus water, tea, coffee or fruit juices, but no
artificial milk), complementary fed, or nonbreast-fed (20). Here, we
refer to infants breast-fed exclusively as those infants who were
exclusively breast-fed regardless of whether they received prelacteal
feeding. For data analysis, infant food intake was categorized as
follows, animal products: meat (beef or chicken), liver, egg, fish;
biscuits: biscuit, bread, noodles, porridge (bean or wheat-flour); fruit:
banana and other; rice: rice, rice porridge, rice steamed in banana
leaves (lontong); tempeh: tempeh or tofu (tahu); vegetables: carrot,
dark green leafy vegetables, cabbages, (French) beans, potato and
other; snacks: fried (sweet) potato or cassava (in small quantities not
with the meal), bakso (flour and meat balls), cookies (other than
biscuit), chips, krupuk, agar-agar, candies; milk: milk, infant formula,
fortified infant food; liquids: water, tea and/or coffee with or without
sugar, honey, fruit or vegetable juice.
Data analysis. Data from 318 infants eligible for follow-up were
pooled for analysis irrespective of the treatment that their mothers
had received during pregnancy. Growth, morbidity, iron status and
feeding mode of infants did not differ from 0 to 12 mo of age among
the three treatment groups, although serum retinol concentrations
were improved by vitamin A plus iron supplementation (16,17). In
addition, no differences in growth were found among groups up to 18
mo of age (unpublished data). Therefore we consider that pooling of
the data of all infants to analyze the determinants of growth faltering
is justified. Weight and length were converted into Z-scores using the
NCHS/WHO reference data incorporated in the Epi-Info software
(Epi Info2000 version 1.0.5. CDC, Atlanta). Stunting was defined as
a height-for-age Z-score of less than 2, underweight as weight-forage Z-score less than 2 and wasting as weight-for-height Z-score less
than 2. For analysis, follow-up data of infants were grouped into
monthly age groups of 0 (0 until 0.99 mo, neonatal) to 18 (18 until
18.99 mo). However, we considered that only up to 15 mo of age
there was a reasonable amount of follow-up (anthropometric) data
available for analysis (n 128); therefore, descriptive data are
presented for infants up to that age. For further analysis, we present
the follow-up data up to 12 mo to reduce the risk of selection bias and
to have higher power by having more infants in the analysis. Because
only some of the infants could be reached within 72 h to measure
birth weight and length (16), we took weight and length measured
during mo 1 (neonatal weight and length) as the starting point of our
growth measurements. For infants who had two measurements in mo
1 of life (90%), the means were used.
For the analysis of association of symptoms of morbidity or food
groups with growth, nutritional status or feeding practices and for
multiple linear regression, morbidity symptoms and food intake were
converted into a ratio correcting for compliance with the assessments
as follows: the total number of episodes of a symptom or the total
number of interviews in which a certain food group was reported to be
consumed by the infant from 0 to 12 mo of age was divided by the total
number of assessments this infant had during this follow-up period.
Comparisons of continuous, normally distributed data between
groups were done using t test or ANOVA if correction for other
variables was necessary. Comparisons of continuous, nonnormally
distributed data and categorical data between groups were done using
Mann Whitney U test and 2 test, respectively. Associations of
normally and nonnormally distributed data were evaluated using
Pearsons correlation and Spearman rank correlation, respectively.
For correction of gender in the association between growth and
morbidity or food intake, partial correlation was applied. Determinants of growth and nutritional status of infants were evaluated using
backward multiple linear regression (threshold 0.1). Three types of
variables were considered in the analysis, i.e., prenatal factors such as
those reflecting socioeconomic status (education, work, housing),

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born between February and November 1998. After birth, all eligible
infants were followed up monthly until at least 12 mo of age. Thereafter, infants whose mothers were still willing to participate continued to be measured into childhood until the end of the study period
(November 1999). Growth, morbidity, breast-feeding and food intake
were assessed monthly. In addition, mothers were interviewed at
enrollment for socioeconomic background and pregnancy history, at
delivery for infant food intake and other variables and at 13 mo after
delivery about the use of contraceptives and pregnancy status. Selected anthropometric measurements of women (14) were assessed at
enrollment, near term and 4 mo postpartum. The data presented in
this paper were collected in an intervention trial investigating the
effect of vitamin A and iron supplementation during gestation on
infant growth. The results of the intervention and details of the
study design have been published (14 17). Explanation of the study
was given to the women at enrollment and all women who participated gave written informed consent. The Ministry of Health Indonesia and the Ethical Committees of the Medical Faculty at the
University of Indonesia and Wageningen University approved the
research proposal.
Study population. Of 366 women recruited at 18 wk of pregnancy, 318 infants were eligible for follow-up after birth. Loss of
subjects occurred because of withdrawal from supplementation (n
18), moving outside the research area (n 15), stillbirth or twins
(n 13), or neonatal death (n 2) (14,16). During the follow-up
period from birth to 12 mo, 16 infants moved outside the research
area and 12 infants died. Neonatal weight or length (in mo 1 of life)
and gender ratio did not differ between infants who left the study and
infants who were followed up to 12 mo (n 290). All 318 infants
experienced at least one anthropometric assessment. Infants who
were measured 19 (n 46), 10 13 (n 100) or 14 19 (n 172)
times did not differ with respect to neonatal weight or length, weight
gain or length increase during the first 6 mo of life and gender ratio.
The mean number of measurements was 13.2 3.6.
Assessment of infants. Weight and length of infants were measured and mothers interviewed for morbidity and food intake of their
infants during their monthly visit to their neighborhood health post
(Posyandu). In principle, visits for each health post were planned on
the same date of each month. However, in practice, visits were made
within 1 wk of the planned date. We attempted to reach individual
mothers who were not able to attend by visiting their homes.
Anthropometry. Two pairs of trained field assistants measured
weight and length of infants using standardized methods (18). Weight
was measured to the nearest 50 g using a baby weighing scale (Misaki
baby scale, Japan), which was tared each time before use. Calibration
with a standard weight (5 kg) at regular intervals showed that all
scales were stable and precise. Recumbent length was measured to the
nearest 0.1 cm using a wooden length board (19). Infants were
measured with light clothing. Birth or neonatal weight and length
had been measured by two of the authors (M.K.S. and S.M.) during
a postnatal home visit (16). All field assistants had received training
and were supervised every month by the two authors mentioned
above. Independent measurements performed in random subsample of
5% of the infants showed a technical SD of 44 g and 0.70 cm for
weight and length, respectively (17).
Morbidity. At the time of the anthropometric assessment, the
same field assistants interviewed the caretaker (the mother in all but
2 cases) of the infant about symptoms of morbidity in the 14 d
preceding the visit. More specifically, mothers were asked to recall
the following: diarrhea, defined as 3 stools in 1 d that were more
liquid than usual; fever, mothers evaluation of infants body temperature above normal (hot to the touch; panas); running nose
(pilek), nasal discharge; cough, persistent coughing; difficulty
breathing, breathing with severe noise or wheezing or difficulty inhaling; ear discharge, fluid or pus draining from at least one ear; and
vomiting. Questions were asked in Bahasa Indonesia or in the local
language (Sundanese) if the mother did not understand the term.
First the interviewer asked the mother for any symptoms and then
asked her specifically for each category and for how many days the
infant suffered from that specific symptom. Episodes were defined as
a period of sickness separated by at least 3 d. Mortality of infants was
recorded at a home visit after death had been reported.

2203

SCHMIDT ET AL.

2204

RESULTS
General characteristics of the study population are shown
in Table 1. The number of boys and girls was not different;
27% of the infants were first-borns. Birth weight of infants was
reasonable (Table 2); 6% of the infants had low birth weight
TABLE 1
General characteristics of the cohort of Indonesian newborn
infants and their mothers1
Boy/girl, n
Birth order
Gestational age, wk
Maternal age at enrollment, y
Maternal height at enrollment, cm
Maternal weight at enrollment, kg
Maternal MUAC2 at enrollment, cm
Maternal education, %
Elementary school
Higher education
Occupation of father, %
Daily worker (laborer, farmer, driver)
Monthly worker (government or private employee,
retired)
Trader
Housing, %
Good housing (brick wall, tile roof and cemented
floor)
Poorer housing (wall, roof and/or floor made of
materials with less quality)
1 Data are means SD unless stated otherwise.
2 MUAC, mid-upper arm circumference.

151/167
1.5 1.3
37.8 2.6
24.3 4.6
149.1 4.9
48.9 6.6
24.6 2.4
74.8
25.2
46.5
34.0
19.5
67
33

TABLE 2
Weight, length and growth of Indonesian infants from
birth to 15 mo of age1
Age

72
h2
0 mo3
6 mo
12 mo
15 mo

68
3124
267
248
1285

Period
mo
06
612
1215

2634
223
1175

Weight

Length

kg

cm

3.0 0.3
3.2 0.5
7.3 0.9
8.2 0.9
8.7 0.9

48.5 1.7
49.7 2.2
65.5 2.4
71.7 2.4
74.4 2.5

Weight increase

Length increase

kg

cm

4.1 0.8
1.0 0.5
0.4 0.3

16.0 2.1
6.4 1.2
2.4 1.1

1 Mean SD.
2 Birth weight and length of only those infants who could be

reached for an assessment within 72 h after birth.

3 Neonatal weight and length of all infants who were measured
within 1 mo of age after birth.
4 Length of 1 infant missing.
5 Weight of 2 infants missing.

(2500 g). Most of the increase in length and weight of

infants occurred during the first 6 mo (Table 2). At the
neonatal assessment, only 7% of the infants were stunted, 5%
were underweight and none were wasted. At 6 mo of age,
nutritional status of infants had returned to the same level as
at the neonatal assessment. However, at 12 mo of age, 24%
were stunted, 32% underweight and 4% wasted, and at 15 mo,
these proportions had increased to 32, 40 and 6%, respectively. Growth faltering started at 3 4 mo of age; however,
when compared with neonatal nutritional status, this was 6
to 7 mo of age (Fig. 1). Wasting was less prevalent than
stunting and underweight throughout the period of follow-up.
Boys had greater weight and length than girls from 0 to 15 mo
(data not shown). This difference was due mainly to the
greater birth weight and length of boys, and greater increases
in weight [0.39 (0.20 0.57) kg, mean (95% confidence interval), P 0.0001)] and length [0.7 (0.21.2) cm, P 0.01)]
during the first 6 mo of life. Height-for-age, weight-for-age and
weight-for-height Z-scores from 0 to 15 mo did not differ
between boys and girls. Compared with the 12-mo breast-fed
pooled data set of WHO (12), length and weight of boys and
girls started to falter from the reference curve at 6 7 mo of
age. At 12 mo of age, mean weight-for-age and height-for-age
Z-scores were 1.25 and 1.17 for boys and 1.12 and 1.13
for girls, respectively.
After birth, a large proportion (84%) of the infants received
prelacteal feeding, which in most cases was honey. Some
mothers reported having given water with or without sugar,
coffee, biscuits, bananas or formula milk. A small proportion
(15%) of mothers reported that they discharged part of the first
colostrum. All infants but one were breast-fed after birth and
another mother stopped breast-feeding soon after delivery.
During the first month of life, 80% of the infants were exclusively breast-fed; however, this proportion decreased rapidly
with age (Fig. 2). The mean period of exclusive breast-feeding
was 1.96 1.95 mo. Almost all women continued breastfeeding their infants during the study follow-up (Fig. 2). The

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maternal height and nutritional status (weight, mid-upper arm circumference) during pregnancy and infant neonatal weight and
length; postnatal factors such as duration of breast-feeding, food
practices and morbidity; and covariants such as gender, birth order
and age of the infants. All variables presented in Table 1 were
included and entered as dichotomous or continuous. Occupation of
the father was entered as dichotomous (0 daily worker, 1
monthly worker or trader) variable but was not a significant
determinant in the model. Mid-upper arm circumference of mothers
was not included in any model because it was highly correlated with
maternal weight (r 0.8).
The postnatal variables, prelacteal feeding (0,1), colostrum intake
(0,1) and number of months the infant was exclusively breast-fed,
were included in all models. The period of follow-up (age) was
calculated as the actual age at the 12-mo measurement minus the
actual age at the 0-mo measurement. This age variable was included
as a possible confounder in the models for weight and length increase.
When neonatal weight and length were both included in all models,
neonatal weight was a significant predictor in the models for weight
gain and weight-for-age Z-scores, neonatal length in the models for
length increase and height-for-age Z-scores, and both variables in the
model for weight-for-height Z-scores. Because neonatal weight and
length were highly correlated (r 0.8), models were rerun including
only the significant variable (neonatal weight or length, or both in
the case of weight-for-length). To limit the number of variables and
to avoid collinearity, we selected one variable for morbidity symptoms
and one for food groups to be included in the models. The selection
was based on a comparison of correlation coefficients of each morbidity or food variable with the dependent variable (data not shown).
Fever was most associated with growth and nutritional status of
infants and was therefore included in all models. Of the food groups,
fruit was most associated with weight gain, weight-for-age and heightfor-age Z-scores, biscuits with length increase and snacks with weightfor-height Z-scores; thus, these were included in the respective models. Statistical analysis was carried out with the SPSS software
package (Windows version 7.5.2. SPSS Chicago, IL).

GROWTH OF INDONESIAN INFANTS

small proportion of mothers that breast-fed exclusively or

predominantly after 6 mo postpartum were mostly those who
had returned to exclusive or predominant breast-feeding after
having tried unsuccessfully to introduce food to their infants.
Most infants were first introduced to liquids, fruit (often banana) and biscuits, whereas foods such as rice, vegetables,
tempeh and snacks were introduced at a later age. From 4 mo
of age, intake of foods increased rapidly (data not shown). At
4 mo of age, 15% of the infants did not have a good appetite
as reported by their mothers and this increased gradually to
50% at 12 mo of age.
Prevalence of all reported symptoms of morbidity in infants
increased until 4 5 mo of age and then remained at a similar
level until 12 mo of age (data not shown). The prevalence of
the three most reported symptoms in this period was 60% for
running nose, 45% for fever and 30% for cough. About 10% of
the infants suffered from diarrhea and/or vomiting during the
follow-up period. Prevalence of ear discharge was rare. Morbidity prevalence was not significantly related to season or
gender.
The multiple regression models explained 19 41% of the
variation in growth and nutritional status of infants, with the
models for length increase and height-for-age Z-scores performing the best (Table 3). In each model, neonatal weight
and especially neonatal length were the strongest positive
predictors of nutritional status of infants. These two variables
were also the strongest negative predictors of increases in
weight and length of infants. Prenatal variables such as maternal weight and height at 18 wk of pregnancy and postnatal variables such as fever and intakes of fruit, biscuits or

snacks were of similar strength in predicting increases in

length and weight and nutritional status of infants. Fever was
negatively associated with weight increase and weight-for-age
and weight-for-height Z-scores but not with length increase
and height-for-age Z-scores. Intake of complementary foods
was positively associated with increases in weight and length
and nutritional status of infants (Table 3). Prelacteal feeding,
colostrum intake and number of months the infant was exclusively breast-fed were excluded from all models by the
regression procedure; the last-mentioned was included in the
weight-for-height model although it was not significant
(P 0.059).
Height-for-age, weight-for-age, and weight-for-height Zscores at 12 mo of age were strongly correlated (r 0.897,
0.947 and 0.841, respectively; P 0.01), with those at 15 mo
of age. In addition, models for increases in weight and length
from 0 to 15 mo and nutritional status at 15 mo were similar
to those presented except that more maternal education instead of better housing was a positive predictor in all models.
DISCUSSION
The present study shows that the most important determinants of nutritional status of Indonesian infants in this study
were neonatal weight and length, reflecting the prenatal environment (4,21). Other factors reflecting prenatal environment, such as maternal weight, and postnatal factors, such as
intake of certain complementary food groups and morbidity,
were associated to lesser extents with infant nutritional status.
This suggests that prenatal environment is a more important
determinant of infant nutritional status than postnatal factors.
The negative association between neonatal length and
length increase and between neonatal weight and weight
increase shows that infants who are born short and light can
still catch up to some extent with their longer and heavier
counterparts during y 1 of life. However, they will not achieve
the same weight or length at 12 mo of age as infants born
longer and heavier (22,23); thereafter, the chances of recovery
are small (24,25).
The importance of neonatal length relative to the other
variables in the models for length increase and height-for-age

FIGURE 2 Proportions of Indonesian infants who were exclusively

breast-fed (receiving breast milk only but could or could not have
received prelacteal feeding), predominantly breast-fed (receiving breast
milk plus water, tea, coffee or fruit juices, but no artificial milk),
complementary fed (receiving breast milk plus solid foods) or nonbreast-fed (not receiving any breast milk) at monthly intervals from 0 to
15 mo of age.

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FIGURE 1 Height-for-age, weight-for-age and weight-for-height

Z-scores (bars reflect SEM) of Indonesian infants from 0 to 15 mo of age.
Weight-for-age and height-for-age Z-scores started to decrease significantly (P 0.05) from 3 to 4 mo of age and weight-for-height Z-scores
from 4 to 5 mo of age. Mean weight-for-height Z-scores were higher
(P 0.0001) than weight-for-age and height-for-age Z-scores from 0 to
15 mo of age. Up to 7 mo of age, height-for-age Z-scores were lower
(P 0.01) than weight-for-age Z-scores, whereas the situation was the
reverse (P 0.01) from 9 to 15 mo of age. The number of infants for
whom Z-scores could be calculated (using Epi-info; 2000 software) is
given at the bottom of the figure for each age interval; the numbers
reflect all three Z-scores calculated except that at 0, 1 and 2 mo of age
weight-for-height Z-scores were calculated for 202, 247 and 268 infants, respectively (Epi-info cannot calculate this score for infants who
are shorter than 49 cm); at 0 mo of age, height-for-age Z-score was
calculated for 311 infants (length could not be measured for 1 infant); at
15 mo of age height-for-age Z-scores were calculated for 130 infants
(weight could not be measured for 2 infants).

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SCHMIDT ET AL.

2206

TABLE 3
Regression analysis to explain the influence of prenatal and postnatal determinants on growth
from 0 to 12 mo of age and nutritional status at 12 mo of age of Indonesian infants1
Increase in weight, 012 mo

Increase in length, 012 mo

227

226

Housing (0 poorer housing, 1 good housing)

Maternal height, cm
Maternal weight, kg
Gender (0 boy, 1 girl)
Age (actual age at 12 moactual age at 0 mo)
Neonatal weight, kg
Neonatal length, cm
Fever, number of episodes/number of assessments
Fruit4
Biscuits4

SE

0.215
0.019
0.018
0.467
0.462
0.390

0.626
0.777

0.103
0.011
0.008
0.098
0.169
0.110

0.252
0.237

0.122
0.115
0.151
0.281
0.165
0.222

0.144
0.190

0.039
0.090
0.029
0.000
0.007
0.000

0.014
0.001

SE

0.428
0.086

0.246
0.023

0.091
0.196

0.083
0.000

1.123
1.929

0.433

0.235
0.403

0.054

0.251
0.256

0.435

0.000
0.000

0.000

2.102

0.606

0.179

0.001

Height-for-age Z-score

Weight-for-height Z-score

227

226

226

SE

SE

0.191
0.019
0.019
0.216
0.469

0.100
0.011
0.008
0.095
0.101

0.114
0.124
0.162
0.136
0.285

0.056
0.069
0.021
0.024
0.000

0.158
0.035

0.092
0.009

0.095
0.229

0.087
0.000

0.312

0.172

0.088

0.019

0.198

0.492

0.000

0.000

0.591
0.759

0.244
0.230

0.142
0.194

0.016
0.001

0.596

0.211

0.154

0.005

SE

0.021

0.007

0.195

0.002

0.730
0.147
0.042

0.207
0.043
0.022

0.481
0.459
0.117

0.001
0.001
0.059

0.957

0.229

0.255

0.000

0.634

0.288

0.136

0.029

1 Variables included in the models are explained in the methodology section, variables with dash () are excluded from the model; the percentage
of variation explained by the models (adjusted R2) was 25 and 41% of increases in weight and length from 0 to 12 mo, respectively, and 25% of
weight-for-age, 35% of height-for-age and 19% of weight-for-height Z-scores.
2 Unstandardized coefficient.
3 Standardized coefficient; this reflects the correlation of the dependent and independent variable without considering the unit of both variables,
thus making it possible to compare the strength of association with the dependent variable among the independent variables.
4 Fruit, biscuits and snacks: the number of intake interviews of the food group was reported per number of assessments (as explained in the
methodology section).

Z-scores was greater than that of neonatal weight in the

models for weight increase and weight-for-age Z-scores. This
was shown by the higher relative to the other variables in
the models and the greater percentage of variation explained
by the models including neonatal length. The apparent greater
association of neonatal length with length increase in comparison to neonatal weight with weight increase is probably
due in part to the higher measurement error of neonatal
length. Any measurement error induces a negative association
because the neonatal measure is included in the calculation of
the increase. In addition, fever was associated with weight gain
and weight-for-age Z-scores but not with length increase and
height-for-age Z-scores. Therefore, prenatal environment
seems to play a larger role in the prediction of linear growth
and stunting than in weight gain and underweight. Genetic
background probably plays a limited role in this because Indonesian preschool children from high socioeconomic class
families have been found to have the same growth potential as
an American reference population (26). Although changes
may occur slowly over generations, the underlying causes may
be nutritional (27).

This study contributes to the understanding of the complex

pattern of determinants in infant growth and the relative
contribution of prenatal and postnatal factors; however, there
are two limitations. First, we used neonatal length and weight
instead of birth weight and length. Therefore, the environment during the first days of life of the infants may have
already affected neonatal weight and length. On the other
hand, we did not find an association between feeding practices
in the first days after birth, such as partly discarding colostrum
or prelacteal feeding, and neonatal weight or length of infants.
Second, we can explain only about one third of the variation
in growth and nutritional status of infants during y 1 of life
with our models. This means that there might be other important factors that we did not assess that play a role in infant
growth. In addition, adaptations of the fetus to limitations in
nutrient supply, for example of certain micronutrients, may
not be reflected in neonatal weight and length but may influence later child health (27).
Growth faltering during the second half of infancy is often
seen in Asian populations (5,25). Although stunting was
highly prevalent at 12 and 15 mo of age, the proportion of

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Weight-for-age Z-score
n

Housing (0 lesser housing, 1

good housing)
Maternal height, cm
Maternal weight, kg
Gender (0 male, 1 female)
Neonatal weight, kg
Neonatal length, cm
Exclusively breast-fed, mo
Fever, number of episodes/
number of assessments
Fruit4
Snacks4

b2

GROWTH OF INDONESIAN INFANTS

ACKNOWLEDGMENTS
We are grateful to all participants, field assistants and health
personal of subdistrict Leuwiliang, Bogor for their contribution to this
project.

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stunting in the present study was lower than reported earlier in

Madurese infants (6). The figure at 15 mo could be an underestimation. Because participation after 12 mo of age depended
on the willingness of the mothers to come to the Posyandu for
the monthly measurements, a selection bias could have occurred. Likely the mothers who still attended were more
health conscious and this was reflected in a better nutritional
status of their children.
The positive association between intake of certain complementary foods and growth suggests that part of the growth
faltering, especially in the second half of y 1 of life, was due to
inadequate food intake. Earlier, Kusin et al. (22) reported that
food given to infants might have insufficient energy density,
but also the micronutrient content may have been inadequate
(13,28). In addition, decreased appetite of infants as reported
by mothers in our study may have been due to anorexia as a
result of morbidity or insufficient micronutrient intake (6,29).
Morbidity as reflected by fever indeed had a negative effect on
weight gain and nutritional status of infants, and the period in
which growth started to falter coincided with the period in
which the prevalence of morbidity had increased maximally.
Exclusive breast-feeding for 4 mo (30) did not show an
advantage above complementary or predominantly breastfeeding in terms of growth or morbidity. However, it should be
noted that almost none of the infants were really exclusively
breast-fed and that there was little variation in breast-feeding
practices. It is likely, however, that breast milk intake protected infants from more severe growth faltering (29).
Our study shows that neonatal length is the strongest
predictor of infant nutritional status; therefore, it is very important to ensure that women enter pregnancy in good health
and with adequate nutritional status. However, infancy is still
considered to be a period in which growth and nutritional
status can be improved by reducing morbidity and ensuring
good nutrition.

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