MAKALAH

TREND PROGRAM PEMERINTAH TENTANG STUNTING

Makalah Untuk Memenuhi Tugas Mata Kuliah Keperawatan Anak
Yang Di Bina Oleh Dyah Dwi Astuti, S.Kep, Ns, M.Kep, Sp. Kep. An

Disusun Oleh :

Kelompok 6

1. Andi Safutra Suraya P27220020227

2. Denis Dwi Oktafianingtyas P27220020238
3. Efi Eka Nofitasari P27220020242
4. Eka Yulia Riska Nasution P27220020243
5. Muhammad Adib Sya’bani P27220020257
6. Putri Eriandri P27220020265
7. Rifqi Nurul Aini P27220020269
8. Titah Mustika Wati P27220020274
9. Uswatun Kasanah P27220020276

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLTEKKES KEMENKES SURAKARTA
JURUSAN KEPERAWATAN
PROFESI-NERS
2020
 KATA PENGANTAR

Puji dan syukur kami panjatkan kehadirat Allah SWT yang telah
memberikan berkat, rahmat, nikmat dan hidayah-Nya kepada kami sehingga kami
dapat menyelesaikan penyusunan makalah yang berjudul “Trend Program
Pemerintah Tentang Stunting” tepat pada waktunya. Makalah ini dibuat untuk
memenuhi tugas mata kuliah Keperawatan Anak yang diberikan oleh Ibu Dyah
Dwi Astuti, S.Kep, Ns, M.Kep, Sp. Kep. An untuk mencapai kompetensi yang
diharapkan.Tak lupa pula sholawat dan salam kami haturkan kepada junjungan
Nabi besar Muhammad SAW, yang mana beliau telah membawa umatnya dari
alam yang gelap gulita kepada alam yang terang benderang dan penuh dengan
ilmu pengetahuan.
Kami juga mengucapkan terima kasih kepada teman-teman satu kelompok
yang telah membantu serta dosen yang membimbing kami dalam menyelesaikan
pembuatan makalah ini. Makalah ini disusun agar para pembaca bisa memahami
tentang trend program pemerintah tentang stunting.
Dalam pembuatan makalah ini, penulis menyadari masih terdapat
kekurangan dalam penulisannya. Oleh karena itu, kami meminta kritik dan saran
yang bersifat membangun sehingga dapat menyempurnakan makalah ini baik dari
pembimbing dan pembaca pada pembuatan makalah selanjutnya. Semoga dengan
tersusunnya makalah ini dapat memberikan manfaat pada pembaca umumnya dan
penyusun khususnya.

Surakarta, September 2020

Penulis

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 DAFTAR ISI

SAMPUL .............................................................................................................. i

KATA PENGANTAR .......................................................................................... ii

DAFTAR ISI ........................................................................................................ iii

BAB I PENDAHULUAN ..................................................................................... 1

A. Latar Belakang ................................................................................................. 1

B. Rumusan Masalah ............................................................................................ 3

C. Tujuan .............................................................................................................. 3

BAB II PEMBAHASAN ...................................................................................... 4

BAB III PENUTUP .............................................................................................. 16

A. Kesimpulan ...................................................................................................... 16

B. Saran ................................................................................................................. 16

DAFTAR PUSTAKA ........................................................................................... iv

iii
 BAB I
PENDAHULUAN

A. Latar Belakang
Stunting (pendek) merupakan salah satu masalah gizi didunia (WHO
UNICEF-The World Bank, 2017).Stunting merupakan akibat dari kekurangan
gizi kronik yang terjadi dalam 1000 hari pertama kehidupan anak (WHO,
2017). Anak dibawah lima tahun dikatakan stunting jika sudah diukur
panjang badan menurut umur (PB/U) atau tinggi badan menurut umur (TB/U)
lalu dibandingkan dengan standar baku WHO-MGRS (Multicentre Growth
Reference Study) dan hasilnya berada dibawah -2 Standar Deviasi (SD).
Pada tahun 2016, diperkirakan anak balita yang mengalami stunting
didunia sebanyak 22,9% (155 juta) (WHO, 2017). Jika keadaan ini terus
berlanjut, diperkirakan 127 juta anak dibawah lima tahun mengalami stunting
pada tahun 2025 (WHO, 2017). Menurut WHO jumlah anak balita yang
mengalami stunting di Asia yaitu sebesar 56%, lebih tinggi dibandingkan
Afrika (38%), dan 17,5 % berada di Asia Tenggara (WHO, 2017). Sedangkan
dalam kawasan Asia Tenggara, angka kejadian stunting di Indonesia lebih
tinggi dari negara-negara lain, seperti Myanmar (35%), Philipina (34%) dan
Thailand (16%).
Menurut Tim Nasional Percepatan Penanggulangan Kemiskinan
(TNP2K), stunting disebebkan oleh berbagai faktor seperti pola pengasuhan
yang kurang baik meliputi pemberian makan dalam 2 tahun pertama setelah
kelahiran, masih kurangnya akses terhadap pelayanan kesehatan selama hamil
dan setelah melahirkan, kurangnya akses keluarga ke makanan bergizi, serta
masih terbatasnya akses air bersih dan sanitasi (TNP2K, 2017). Selain itu,
sosial ekonomi juga berpengaruh terhadap dengan kejadian stunting (Branca,
2016).
Pemerintah melakukan program untuk mencegah dan mengurangi
prevalensi kejadian stunting secara langsung (intervensi gizi spesifik) dan
secara tidak langsung (intervensi gizi sensitif).Upaya intervensi gizi spesifik

1
 2

difokuskan pada kelompok 1.000 Hari Pertama Kehidupan (HPK, yaitu ibu
hamil, ibu menyusui, dan anak 0-23 bulan.Intervensi gizi sensitif yang
dilakukan meliputi pada sanitasi dan lingkungan, jaminan kesehatan,
penanggulangan kemiskinan, keluarga berencana, dan pendidikan gizi bagi
semua kalangan. Realisasi dari upaya tersebut melalui pemeriksaan pada ibu
hamil berupa Antenatal Care (ANC) secara terpadu dan menerima standar
pelayanan minimal, Penetapan peraturan pemerintah mengenai Inisiasi
Menyusu Dini (IMD) dan ASI Eksklusif, posyandu. Suatu wilayah
mengalami masalah gizi khususnya stunting jika angka kejadiannya lebih dari
20% (Kemenkes, 2018). Oleh karena itu, perlu dilakukan intervensi secara
spesifik yaitu perbaikan gizi dalam 1000 hari pertama kehidupan, salah
satunya yaitu mendorong pemberian ASI eksklusif (TNP2K, 2017).
Pemberian Air Susu Ibu (ASI) merupakan salah satu faktor pemenuhan
kebutuhan nutrisi bagi baduta, karena ASI memiliki banyak sekali kandungan
hormon, nutrisi, faktor pertumbuhan dan kekebalan, yang diharapkan dapat
menurunkan prevalensi stunting.Program kebijakan pemberian ASI diatur
dalam PP Nomor 33 tahun 2012 pasal 6 dan Undang-Undang Kesehatan
Nomor 36 Tahun 2009 pasal 128 dan Pasal 129, yang menyimpulkan bahwa
setiap Ibu yang melahirkan harus memberikan ASI kepada anak yang
dilahirkannya usia 0-6 bulan. Sejalan dengan itu, pencanangan pemberian
ASI pada baduta semakin digalakkan dengan tujuan menekan peningkatan
prevalensi stunting. Pemerintah dirasa perlu untuk menggalakkan berbagai
program kebijakan kesehatan demi tercapainya penurunan angka baduta
stunting. Salah satunya dengan semakin gencarnya himbauan program
pemberian ASI kepada baduta menjadi salah satu program tercapainya TPB
(Tingkat Pembangunan berkelanjutan) bidang kesehatan.
 3

B. Rumusan Masalah
Berdasarkan latar belakang masalah di atas maka rumusan masalah ini
adalah:
1. Bagaimana analisis jurnal terkait trend program pemerintah tentang
stunting ?
C. Tujuan
Adapun tujuan dalam penulisan makalah ini sebagai berikut.
1. Untuk mengetahui analisis jurnal terkait trend program pemerintah tentang
stunting.
 BAB II
ANALISIS JURNAL

1. Skenario Klinis
Perawat B merupakan mahasiswa ners Poltekkes Kemenkes Surakarta
yang melakukan penelitian di sebuah desa. Perawat B menemukan banyak
kasus balita stunting di daerah tersebut. Masalah yang sering muncul pada
balita di daerah ini adalah kejadian stunting yang cukup tinggi dikarenakan
pemberian ASI yang belum optimum. Setelah membaca beberapa jurnal
penelitian yang menjelaskan bahwa pemberian ASI secara optimum termasuk
intervensi dalam pencegahan stunting. Disini Perawat B ingin mengetahui
apakah ada pengaruh pemberian ASI secara optimum pada kejadian balita
yang mengalami stunting di daerah tersebut.
2. Pertanyaan Klinis
Bagaimana pengaruh optimalisasi ASI terhadap stunting pada balita?
3. Analisis PICOS
Population Balita
Intervention Pemberian ASI
Comparison -
Outcome Kejadian stunting
Study design Metode studi kasus kontrol

4. Strategi searching
Dilakukan pencarian literatur dengan mesin pencari jurnal ilmiah
sciencedirect dengan kata kunci: stunting, kebutuhan gizi, pertumbuhan balita
dan breastfeeding.
5. Evidence (Journal Article)
Dari hasil literature searching diatas, diperoleh jurnal yang relevan yang
berjudul Relationship between breastfeeding duration and undernutrition
conditions among children aged 0-3 Years in Pakistan.

4
 5

6. Literature Review
Peneliti : Batool Syeda, Kingsley Agho, Leigh Wilson, Greesh Kumar Maheshwari,
dan Muhammad Qasim Raza
Judul: Relationship between breastfeeding duration and undernutrition
conditions among children aged 0-3 Years in Pakistan.
Jurnal : International Journal of Pediatrics and Adolescent Medicine
Tahun : 2020
Daring : https://doi.org/10.1016/j.ijpam.2020.01.006
Tujuan: untuk menganalisis apakah ada hubungan antara lama menyusui
dengan stunting.
Metode dan Sampel : Data didapatkan dari Demographic and Health Survey
(DHS) Pakistan tahun 2013-2014. Metode sampling dengan two-staged,
stratified and cluster sampling. Sampel terdiri dari 14.000 rumah tangga yang
terdiri dari 6.944 rumah tangga yang tinggal diperkotaan dan 7.056 rumah
tangga yang tinggal di daerah pedesaan. Pengambilan data dilakukan dengan
pengisian kuisioner dan pengukuran antropometri pada anak.
Intervensi: Pengukuran dilakukan dengan 4 model kuisioner DHS yang
dimodifikasi berisi melek huruf, riwayat antenatal dan postnatal, riwayat
reproduksi, riwayat menyusui dan penyapihan, riwayat penyakit anak, dan
riwayat vaksinasi pada anak. Pengukuran antropometri pada anak dilakukan
dengan menggunakan alat SECA dari UNICEF. Anak dibawah 2 tahun
ditimbang dengan posisi terlentang dan anak berusia 2 tahun atau lebih diukur
dengan berdiri.
Hasil: Durasi menyusui memiliki hubungan yang signifikan dengan stunting
[AOR: 2,43, CI 95% ¼ (1,55, 3,79) untuk anak-anak 2 tahun dan AOR: 4,35,
CI 95% ¼ (2,01, 9,33) untuk anak-anak 3 tahun. Anak-anak yang menyusui
di usia 3 tahun memiliki peluang lebih tinggi terhadap kejadian stunting parah
[AOR: 6,19, CI 95% ¼ (3,31, 11,56)] di banding dengan anak-anak di tahun
kedua [AOR: 2.84, CI 95% ¼ (1.81, 4.46)]. Stunting juga memiliki hubungan
yang signifikan dengan persepsi ukuran kelahiran bayi, pendidikan ibu dan
frekuensi pemeriksaan antenatal ibu selama kehamilan.
 6

Level evidence : V
7. Critical Appraisal Analyzes
a. Analisis
1. Faktor Ibu
Berdasarkan jurnal utama yang diambil, terdapat karakteristik ibu
mengenai stunting pada balita terjadinya yakni ibu bekerja berjumlah
243 (22,6%) dan ibu yang tidak bekerja berjumlah 829 (77,4%).
Kualifikasi pendidikan ibu yakni tidak sekolah berjumlah 584
(54,5%), sekolah dasar (kelas 5) berjumlah 194 (18,1%) dan
pendidikan lebih tinggi berjumlah 295 (27,5). Hal ini sejalan dengan
penelitian Myths (2014) yang berjudul “Belief Surrounding
Complementary Feeding Practices of Infants in India’ bahwa ibu yang
tidak berpendidikan tidak memiliki kesadaran tentang nutrisi anak
yang tepat dan cenderung percaya pada mitos yang berkaitan dengan
pemberian makanan pelengkap yang tidak aman bagi kesehatan anak-
anak. Ibu yang mengalami buta huruf berjumlah 587 (54,8%) dan
tidak buta huruf berjumlah 485 (45,2%). Suami yang bekerja sebagai
petani berjumlah 156 (14,6%) dan pekerjaan selain petani berjumlah
916 (85,4%). Untuk kualifikasi pendidikan suami yakni yang tidak
sekolah berjumlah 338 (31,5%0, sekolah dasar (kelas 5) berjumlah
195 (18,2) dan pendidikan yang lebih tinggi berjumlah 538 (50,3%).
Usia ibu saat hamil sekitar 16-25 tahun sebanyak 342 (31,9%), usia
26-35 tahun sebanyak 550 (51,3%) dan usia 36-50 tahun sebanyak
180 (16,8%). Ibu dengan BMI kurang atau sama dengan 18.5
sebanyak 198 (18.5%) dan lebih dari 18.5 sebanyak 873 (81,5).
Kelahiran anak pertama sebanyak 209 (19,5%), anak ke 2 sampai 4
sebanyak 567 (52,8%) dan anak ke 5 atau lebih sebanyak 296 (27,6%)
dan yang terakhir pada jarak kelahiran anak yakni tidak ada kelahiran
sebelumnya sebanyak 209 (19,6%), < 2 tahun sebanyak 301 (28,1%)
dan > 2 tahun sebanyak 559 (52,3%).
 7

2. Faktor Anak
Pada jurnal utama menyebutkan bahwa pada balita usia 0-3 tahun
yang berjumlah 1072 didapatkan anak laki-laki berjumlah 544
(50,8%) dan anak perempuan 528 (49,2%). Ukuran lahir balita yakni
lahir kecil berjumlah 216 (20.2%), lahir dengan ukuran regular
berjumlah 792 (73,9%) dan ukuran lahir besar berjumlah 64 (5.9%).
Hal ini sejalan dengan penelitian Ettyang G (2016) dengan judul
“Factors Associated With Stunting in Children Under age 2 in the
Cambodia and Kenya 2014” menjelaskan bahwa ukuran kelahiran
adalah prediktor valid dari pertumbuhan pada anak-anak dimana
persepsi ibu tentang ukuran lahir cenderung biar karena ukuran kecil
saat lahir merupakan tanda dari kekurangan nutrisi pada masa
kehamilan yang jika dilanjutkan maka akan menyebabkan stunting
pada anak. Balita yang memiliki riwayat diare sebanyak 323 (30,2%)
dan tidak memiliki riwayat diare berjumlah 749 (69,8%). Selain itu,
balita yang memiliki riwayat demam berjumlah 456 (42,%) dan tidak
memiliki riwayat demam berjumlah 616 (57,4%).

3. Faktor Rumah Tangga

Pada penelitian ini menyebutkan bahwa pada indeks kekayaan
dimana rumah tangga dengan kekayaan miskin berjumlah 456
(42,6%), kekayaan menengah berjumlah 449 (41,8&) dan indek
kekayaan yakni terkaya berjumlah 167 (15,6%). Hal ini sejalan dengan
penelitian Myths (2014) yang berjudul “Belief Surrounding
Complementary Feeding Practices of Infants in India” bahwa ibu yang
tidak memiliki sumber daya untuk menyediakan makanan dengan
jumlah yang cukup dan kualitas makanan tambahan karena
ketidaktahuan atau kemiskinan. Ibu yang menggunakan TV mingguan
berjumlah 711 (66,4%) dan tidak menggunakan TV mingguan
berjumlah 873 (81,4%). Ibu yang menggunakan radio mingguan
berjumlah 199 (18,6%) dan tidak menggunakan berjumlah 873
 8

(81,4%). Ibu yang membaca Koran berjumlah 254 (23,7%) dan tidak
membaca Koran berjumlah 818 (76,3%). Penggunaan sumber air
rumah tangga yang terlindungi berjumlah 458 (42,8%) dan tidak
terlindungi berjumlah 614 (57,3%). Fasilitas toilet di rumah tangga
yang tertutup berjumlah 605 (56,4%) dan tidak tertutup berjumlah 467
(43,6%).
4. Faktor Komunitas
Pada penelitian ini menyebutkan bahwa terdapat faktor komunitas
di mana komunitas yang tinggal di daerah perkotaan berjumlah 316
(29,5%) dan tinggal di daerah pedesaan berjumlah 756 (70,5%).
Daerah demografi Punjab berjumlah 660 (61,6%), Sindh berjumlah
275 (25,6%), KPK berjumlah 117 (10,9%) dan balochistan berjumlah
20 (1,9%).
5. Faktor Layanan Kesehatan
Pada penelitian ini menyebutkan bahwa pemilihan tempat
kesehatan untuk berobat yakni di rumah berjumlah 506 (47,2%) dan
menggunakan fasilitas kesehatan berjumlah 566 (52,8%). Ibu yang
melahirkan secara normal berjumlah 907 (84,6%) dan melahirkan
secara caesarea berjumlah 165 (15,4%). Pada bantuan kesehatan yang
dilakukan oleh tenaga kesehatan professional berjumlah 575 (55,5%),
Dai (TBA) berjumlah 454 (43,8%) dan dilakukan oleh seseorang yang
tidak ahli berjumlah 8 (0,8%). Ibu yang tidak melakukan pemeriksaan
antenatal yakni berjumlah 232 (21,6%), pemeriksaan antenatal yang
dilakukan sebanyak 1 sampai 3 kali berjumlah 425 (39,6%) dan
melakukan pemeriksaan lebih atau sama dengan 4 kali berjumlah 416
(38,8%). Perawatan antenatal yang tepat dapat menjamin
pertumbuhan anak yang sehat. Anak-anak yang ibunya sering
mengunjungi klinik antenatal selama kehamilan dapat menurunkan
kemungkinan kerdil dan wasting di kemudian hari. Hal ini sejalan
dengan penelitian Kuhnt & Vollmer dengan judul “Antenatal Care
and its Implication for Vital and Health Outcomes of Children” bahwa
 9

wanita yang mengunjungi klinik antenatal mendapatkan pendidikan

kesehatan yang berharga tentang nutrisi anak yang tepat dari tenaga
medis untuk membuat pilihan makanan sehat kepada anak-anak
mereka. Selanjutnya, wanita yang tidak mencari perawatan antenatal
umumnya tidak memperhatikan pilihan makanan yang sehat. Riwayat
kunjungan ke pelayanan kesehatan setelah kelahiran berjumlah 664
(61,9%) dan tidak memiliki riwayat kunjungan berjumlah 408
(38,1%).
6. Prevalensi Gizi
Berdasarkan penelitian ini, prevelensi gizi berdasarkan stunting
yaitu sebagian besar kekurangan gizi sebanyak 40% dan nutrisi parah
sebanyak 22,5%. Prevalensi gizi berdasarkan wasting sebagian besar
kekurangan gizi sebanyak 16% dan sebagian besar nutrisi parah
sebanyak 4%. Balita dengan berat badan kurang sebagian besar
kekurangan gizi sebanyak 33% dan balita dengan berat badan kurang
sebagian besar mengalami nutrsi parah sebanyak 12,5%.Korelasi
antara lama menyusui dengan stunting bisa disebabkan karena
keterlambatan pengenalan suplemen makanan untuk diet bayi baik
akibat ketidaksadaran pada sebagian ibu atau kurangnya sumber daya
dalam rumah tangga untuk menyediakan makanan pendamping untuk
bayi. Ini juga bisa karena pengenalan makanan tambahan ke dalam
pola makan anak tertunda dan akibatnya, anak tidak pernah bisa
tumbuh sehat.
b. Pembahasan
Fenomena stunting sudah banyak terjadi pada balita. Hipotesis
Barker dalam Aryastami dalam Tarigan (2017) menjelaskan bahwa efek
stunting berlanjut hingga dewasa dan menjadi faktor penyakit risiko
degeneratif. Sehingga pemerintah mengeluarkan program pencehagan
stunting. Hosain et al. (2017) menyebutkan intervensi yang dapat
dilakukan untuk pencegahan stunting terbagi menjadi 2 cakupan intervensi
gizi, yaitu spesifik dan sensitif. Intervensi gizi spesifik meliputi gizi dan
 10

kesehatan; gizi ibu; optimalisasi pemberian ASI; makanan pendamping;

pencegahan dan manajemen penyakit; serta kedaruratan pangan. Intervensi
gizi sensitif meliputi agrikultur dan ketahanan pangan; keamanan jaringan
social; perkembangan anak usia dini; kesehatan mental ibu; pemberdayaan
wanita; perlindungan anak; pendidikan serta air, sanitasi dan kebersihan.
Gizi merupakan salah satu faktor penting yang menentukan tingkat
kesehatan dan kesejahteraan manusia. Gizi yang baik jika terdapat
keseimbangan dan keserasian antara perkembangan fisik dan
perkembangan mental orang tersebut. Terdapat kaitan yang sangat erat
antara status gizi dan konsumsi makanan. Tingkat status gizi optimal akan
tercapai apabila kebutuhan zat gizi optimal terpenuhi. Dalam mencapai
tumbuh kembang optimal, di dalam Global Strategy for Infant and Young
Child Feeding, WHO/UNICEF merekomendasikan empat hal penting
yang harus dilakukan yaitu: pertama memberikan Air Susu Ibu kepada
bayi segera dalam 30 menit setelah bayi lahir, kedua memberikan hanya
Air Susu Ibu (ASI) saja atau pemberian ASI secara Eksklusif sejak lahir
sampai bayi berusia 6 bulan, ketiga memberikan Makanan Pendamping
Air Susu Ibu (MP-ASI) sejak bayi berusia 6 bulan sampai 24 bulan, dan
keempat meneruskan pemberian ASI sampai anak berusia 24 bulan atau
lebih.
Hasil penelitian yang dilakukan oleh Batool Syeda, Kingsley Agho,
Leigh Wilson, Greesh Kumar Maheshwari, dan Muhammad Qasim Raza
dengan judul “Relationship between breastfeeding duration and
undernutrition conditions among children aged 0-3 Years in Pakistan”
menunjukkan bahwa pemberian ASI pada tahun ke 2 dan ke 3 memiliki
hubungan yang signifikan dengan stunting. Hal tersebut menunjukkan
bahwa pemberian ASI yang optimum dan efektif dapat dilakukan mulai
dari bayi lahir sampai saat usia penyapihan untuk mencegah stunting. Hal
tersebut sejalan dengan peneliti dengan penelitian yang dilakukan oleh
Hosain et al. (2017) dengan judul “Evidence-based approaches to
childhood stunting in low and middle income countries: A systematic
 11

review” yang menyebutkan bahwa intervensi yang dapat dilakukan untuk

pencegahan stunting terbagi menjadi 2 cakupan intervensi gizi, yaitu
spesifik dan sensitif. Intervensi gizi spesifik meliputi gizi dan kesehatan;
gizi ibu; optimalisasi pemberian ASI; makanan pendamping; pencegahan
dan manajemen penyakit; serta kedaruratan pangan. Intervensi gizi sensitif
meliputi agrikultur dan ketahanan pangan; keamanan jaringan social;
perkembangan anak usia dini; kesehatan mental ibu; pemberdayaan
wanita; perlindungan anak; pendidikan serta air, sanitasi dan kebersihan,
yang mana pemberian ASI optimum merupakan salah satu diantaranya.
Aryastami dalam Tarigan (2017) menjelaskan bahwa pemerintah
Indonesia telah berupaya mengadopsi dan mengimplemetasikan intervensi
gizi tersebut dalam upaya pencegahan stunting, pemerintah telah
mengeluarkan berbagai macam kebijakan yang diharapkan dapat
diimplementasikan dengan optimal. Adapun penelitian yang dilakukan di
Indonesia dan menjelaskan bahwa pemberian ASI dapat menjadi salah satu
upaya yang efektif dalam pencegahan stunting antara lain:
Penelitian yang dilakukan oleh Endang Dewi Lestari, Faraissa
Hasanah, Novianto Adi Nugroho tahun 2018 dengan judul “Correlation
between non-exclusive breastfeeding and low birth weight to stunting in
children” menjelaskan bahwa stunting pada anak balita memerlukan
perhatian khusus karena dapat menghambat perkembangan fisik dan
mental anak. Stunting dikaitkan dengan beberapa faktor, salah satunya
adalah pemberian ASI noneksklusif. Penelitian ini dilakukan pada anak
usia 24-59 bulan yang berkunjung ke posyandu dan diambil secara
purposive sampling. Anak yang tergolong stunting dialokasikan pada
kelompok kasus, sedangkan anak dengan status gizi normal dialokasikan
pada kelompok kontrol. Orang tua mengisi kuisioner tentang riwayat
pemberian ASI eksklusif, berat badan lahir anak, pendidikan ibu, dan
status sosial ekonomi keluarga. Hasil Dari 60 subjek, kelompok kontrol
memiliki 30 anak normal dan kelompok kasus 30 anak stunting. Analisis
multivariat dengan uji regresi logistik menunjukkan korelasi yang
 12

signifikan secara statistik antara stunting dan pemberian ASI noneksklusif

(OR disesuaikan untuk ASI eksklusif 0,234; 95% CI 0,061-0,894), serta
berat badan lahir rendah (OR 10,510; 95% CI 1,180 hingga 93,572 Nilai
tersebut mengimplikasikan bahwa pemberian ASI Eksklusif merupakan
salah satu faktor perlindungan terhadap stunting, artinya pemberian ASI
eksklusif mampu menurunkan prevalensi stunting pada balita.
Penelitian lain dilakukan oleh Baroroh Barir, Bhisma Murti, dan
Eti Poncorini Pamungkasari pada tahun 2019 dengan judul “The
Associations between Exclusive Breastfeeding, Complementary Feeding,
and the Risk of Stunting in Children Under Five Years of Age: A Path
Analysis Evidence from Jombang East Java” menjelaskan bahwa stunting
pada anak menjadi masalah kesehatan yang mendapat prioritas dan harus
diutamakan ditangani segera. Perkembangan terlambat, penurunan fungsi
kognitif dan kekebalan tubuh fungsi dan risiko diabetes melitus, jantung
koroner, hipertensi dan obesitas merupakan faktor penyebab efek stunting.
Pengumpulan data dilakukan dengan menggunakan kuesioner dan
dianalisis. Hasil penelitian ini menjelaskan bahwa stunting dipengaruhi
secara langsung dan negatif oleh panjang lahir ≥48 cm, berat badan lahir ≥
2500 g, ASI eksklusif, MPASI tepat waktu, selain itu stunting secara tidak
langsung dipengaruhi oleh keluarga pendapatan, usia ibu, sikap ibu, tinggi
badan> 150 cm, ibu bekerja, ibu pendidikan, dan pengetahuan ibu. Hal ini
berarti penelitian ini secara tersirat juga menjelaskan ASI sebagai salah
satu cara yang cukup efektif untuk mencegah terjadinya stunting.
Penelitian lain dengan judul “The risk factors of exclusive
breastfeeding on stunting among children under fivein one of the city in
Indonesia” yang dilakukan oleh Hemi Fitriani, Achamd Stya R., dan
Poppy Nurdiana pada tahun 2019. Penelitian tersebut menjelaskan bahwa
salah satu faktor risiko yang mempengaruhi stunting adalah ASI eksklusif.
Penelitian ini menggunakan desain studi kasus kontrol dilakukan pada ibu
yang memiliki anak pada usia antara 12- 59 bulan di Puskesmas Cigugur,
Cimahi. Teknik pengambilan sampel acak proporsional dan didapatkan
 13

sebanyak 80 sampel yang terbagi menjadi 40 ibu balita stunting dan 40 ibu
dari anak non-stunting. Data diambil melalui observasi dan kuisioner.
Hasil penelitian ini menjelaskan bahwa sebanyak 67,5% kejadian stunting
terjadi pada anak yang tidak menyusui secara eksklusif, hal tersebut
menunjukkan bahwa pemberian ASI Eksklusif memberikan pengaruh
yang krusial dalam mencegah stunting (p value: 0,001). Nilai OR sebesar
5,476 yang berarti anak yang tidak menyusui secara eksklusif cenderung
mengalami stunting sebanyak 5.476 kali, dibandingkan anak yang
menyusui eksklusif. Sehingga dapat disimpulkan bahwa ASI adalah
pilihan nutrisi terbaik untuk pertumbuhan dan perkembangan tulang dan
otak. Manfaat pemberian ASI Eksklusif ternyata dapat mencegah
terjadinya stunting.

Penelitian lain dengan judul “ASI eksklusif dan berat lahir

berpengaruh terhadap stunting pada balita 2-5 tahun di Kabupaten
Pesawaran” yang dilakukan oleh Apri Sulistianingsih dan Rita Sari pada
tahun 2018. Penelitian tersebut menjelaskan bahwa beberapa faktor yang
mempengaruhi kejadian stunting pada balita diantaranya adalah riwayat
ASI eksklusif dan bayi berat lahir rendah (BBLR). Penelitian ini
merupakan penelitian observasional analitik dengan pendekatan cross-
sectional yang dilaksanakan pada Maret-Mei 2017 di 12 Puskesmas
Kabupaten Pesawaran, Lampung dan jumlah sampel sebanyak 385 sampel.
Hasil penelitian ini menjelaskan bahwa Balita dengan riwayat BBLR
(OR=12,30; CI 95%:3,663-41,299) dan riwayat ASI eksklusif (OR=0,122;
CI 0,075-0,199) berhubungan signifikan dengan kejadian stunting pada
balita 2-5 tahun. Hasil penelitian ini juga menjelaskan riwayat ASI
eksklusif dengan nilai OR=0,108 (CI 95%:0,065-0,180) dan berat lahir
dengan nilai OR=17,063 (CI 95%: 4,892-59,511). Sehingga balita yang
memperoleh ASI eksklusif berisiko 9,3 kali lebih kecil untuk terjadi
stunting dibandingkan balita yang tidak memperoleh ASI eksklusif atau
ASI eksklusif memberikan efek proteksi terhadap terjadinya stunting pada
 14

balita. Sebaliknya, pada berat bayi lahir, ditemukan bahwa balita dengan
riwayat BBLR berisiko 17,063 kali lebih besar untuk mengalami stunting
dibandingkan balita dengan riwayat berat lahir normal. Penelitian ini juga
secara tersirat menggabarkan betapa pentingnya ASI untuk mencegah
stunting.
Hal ini juga sejalan dengan penelitian yang dilakukan oleh
Damayanti, dkk (2016) “Perbedaan Tingkat Kecukupan Zat Gizi Dan
Riwayat Pemberian Asi Eksklusif Pada Balita Stunting dan Non Stunting”.
Penelitian ini menggunakan rancangan cross sectional pada 113 balita di
Kelurahan Kejawan Putih Tambak Kecamatan Mulyorejo Kota Surabaya
yang terdiri dari 27 balita stunting dan 86 balita non stunting. Besar
sampel dihitung dengan perhitungan proporsional sampling. Analisis
perbedaan tingkat kecukupan dan riwayat ASI eksklusif menggunakan uji
Chi Square dan Exact Fisher, analisis perbedaan jumlah asupan
menggunakan uji T-Sampel Bebas dan analisis besar risiko menggunakan
perhitungan Odds Ratio. Hasil penelitian menunjukkan terdapat perbedaan
antara balita stunting dan non stunting dalam riwayat pemberian ASI
eksklusif (p = 0,001). Balita dengan ASI non eksklusif dan balita yang
memiliki tingkat konsumsi inadekuat, memiliki risiko lebih besar untuk
stunting (ASI non eksklusif = 16,5 kali, energi inadekuat = 9,5 kali,
protein inadekuat = 10,6 kali, zinc inadekuat = 7,8 kali, dan zat besi
inadekuat = 3,2 kali). Berdasarkan uji statistik diketahui bahwa ada
perbedaan riwayat pemberian ASI eksklusif antara balita stunting dengan
balita non stunting (p = 0,001). Balita dengan riwayat ASI non eksklusif
lebih berisiko untuk stunting karena hal ini berhubungan dengan kejadian
penyakit infeksi seperti diare yang lebih banyak terjadi pada bayi dibawah
6 bulan yang diberikan makanan selain ASI. Adanya penyakit infeksi
menyebabkan menurunnya nafsu makan, menurunnya penyerapan zat gizi
dan peningkatan katabolisme sehingga zat gizi tidak mencukupi untuk
pertumbuhan.
 15

c. Rekomendasi
Dari beberapa penelitian diatas, maka dapat ditarik kesimpulan
bahwa pemberian ASI yang optimum efektif dalam mencegah stunting.
Pencegahan stunting ini tidak hanya dilakukan oleh satu sektor saja, tetapi
perlu perhatian dan kerja sama dari semua pihak, baik pemerintah dengan
kegiatan lintas sektoral maupun lintas program dan masyarakat pada
umumnya. Hal ini dapat dilakukan dengan meningkatkan kepekaan
sosialnya agar dapat melakukan penanganan masalah gizi dengan benar,
memperhatikan peningkatan pendidikan masyarakat, membuka lapangan
kerja, serta peningkatan keadaan sosial ekonomi masyarakat kearah yang
lebih baik sehingga permasalahan gizi khususnya masalah stunting pada
anak balita dapat segera ditanggulangi. Perawat sebagai salah satu tenaga
kesehatan profesional diharapkan dapat ikut berparsitipasi aktif dalam
melakukan pencegahan stunting dengan memberikan edukasi dan promosi
kesehatan tentang manfaat pemberian ASI yang optimal dan dampaknya
terhadap stunting. Diharapkan ibu juga lebih meningkatkan asupan
makanan terutama makanan sumber zat gizi yang memiliki keterkaitan
dengan pertumbuhan linear pada balita yaitu makanan sumber protein,
zinc, dan zat besi serta lebih memperhatikan pemberian ASI eksklusif dan
MP ASI sesuai dengan usia balita.
 BAB III
PENUTUP
A. Kesimpulan
Stunting adalah kondisi dimana tinggi badan seseorang lebih
pendek dibandingkan tinggi badan orang lain pada umumnya (yang seusia)
yang disebabkan kurangnya asupan gizi yang diterima oleh balita.
Pemerintah indoneia melakukan pencegahan dan pengurangan
prevelensi kejadian stunting secara langsung (intervensi gizi spesifik) dan
secara tidak langsung (intervensi gizi sensitif). Indonesia sudah
menerapkan program pemberian ASI dalam upaya pencegahan stunting.
Pemberian Air Susu Ibu (ASI) merupakan salah satu faktor pemenuhan
kebutuhan nutrisi bagi baduta, karena ASI memiliki banyak sekali
kandungan hormon, nutrisi, faktor pertumbuhan dan kekebalan, yang
diharapkan dapat menurunkan prevalensi stunting.
Dalam berbagai penelitian yang sudah dibahas menyatakan bahwa
pemberian ASI yang optimum dapat mencegah terjadinya kejadian
stunting. Hal tersebut menunjukkan bahwa pemberian ASI yang optimum
dan efektif dapat dilakukan mulai dari bayi lahir sampai saat usia
penyapihan untuk mencegah stunting.

B. Saran
Penulis menyadari akan kekurangan dalam penulisan makalah
diatas dimana masih jauh dari kata sempurna. Penulis akan memperbaiki
makalah tersebut sesuai dengan ketentuan yang ada dan kritik dari
pembaca mengenai trend program pemerintah tentang stunting.

16
 DAFTAR PUSTAKA

Aryastami, N., K., & Tarigan, I. (2017). Kajian kebijakan dan penanggulangan
masalah gizi stunting di Indonesia. Buletin Penelitian Kesehatan, 45 (4):
233 – 240.doi: http://dx.doi.org/10.22435/bpk.v45i4.7465.233-240

Barir, B., Murti, B., & Eti Poncorini Pamungkasari, E., P. (2019). The
associations between exclusive breastfeeding, complementary feeding, and
the risk of stunting in children under five years of age: A path analysis
evidence from Jombang East Java. Journal of Maternal and Child Health,
4(6): 486-498. doi: https://doi.org/10.26911/thejmch.2019.04.06.09

Damayanti, R.A., dkk. (2016). Perbedaan Tingkat Kecukupan Zat Gizi Dan
Riwayat Pemberian Asi Eksklusif Pada Balita Stunting Dan Non Stunting.
Media Gizi Indonesia, 11(1): 61-69

Ettyang G, Sawe Cj. Factors Associated with Stunting in Children Under Age 2 in
the Cambodia and Kenya 2014 demographic and Health Surveys. 2016

Hemi Fitriani, H., Stya A., R., & Nurdiana, P. (2019). The risk factors of
exclusive breastfeeding on stunting Among children under fivein one of
the city in indonesia. Third International Seminar on Global Health, 3(1):
186-189

Hossain M, et al. 2017. Evidence-based approaches to childhood stunting in low

and middle income countries: a systematic review. Arch Dis Child
2017;102:903–909. doi:10.1136/archdischild-2016-311050

Kuhnt J. Vollmer S. Antenatal Care Services and its Implications for Vital and
Health Outcomes of Children : evidence from 193 Surveys in 69 low-
income and middle-income countries. BJM Open 2017 ; 7 (11): e017122
Lestari, E., D., Hasanah, F., & Nugroho, N., A. (2018). Correlation between non-
exclusive breastfeeding and low birth weight to stunting in children.
Paediatrica Indonesiana, 58(3).
doi: http://dx.doi.org/10.14238/pi58.3.2018.123-7

Sabharwal V. Myths and Belief Surrounding Complementary Feeding Practices of

Infants in India. J community Nutr Health 2014 : 3 (1) : 34

Sulistianingsih, A., & Sari, S. (2018). ASI eksklusif dan berat lahir berpengaruh
terhadap stunting pada balita 2-5 tahun di Kabupaten Pesawaran. Jurnal
Gizi Klinik Indonesia, 15(2): 45-51

Syeda B et al., Relationship between breastfeeding duration and undernutrition

conditions among children aged 0-3 Years in Pakistan, International
Journal of Pediatrics and Adolescent Medicine,
https://doi.org/10.1016/j.ijpam.2020.01.006
 International Journal of Pediatrics and Adolescent Medicine xxx (xxxx) xxx

H O S T E D BY Contents lists available at ScienceDirect

International Journal of Pediatrics and

Adolescent Medicine
journal homepage: http://www.elsevier.com/locate/ijpam

Original article

Relationship between breastfeeding duration and undernutrition

conditions among children aged 0e3 Years in Pakistan
Batool Syeda a, c, *, Kingsley Agho a, Leigh Wilson a, b, Greesh Kumar Maheshwari c,
Muhammad Qasim Raza d
a
Western Sydney University, School of Science and Health, Narellan Road, Campbelltown, NSW, 2570, Australia
b
University of Sydney, Faculty of Health Science, 75 East Street, Lidcombe, NSW, 2141, Australia
c
Peoples University of Medical and Health Sciences for Women, Department of Community Medicine, Hospital Road, Nawabshah, 67450, Pakistan
d
Medicine Unit 2, Sir Ganga Ram Hospital, Queens Road, Lahore, 54000, Pakistan

a r t i c l e i n f o a b s t r a c t

Article history: Background: The World Health Organization recommends that a child should be breastfed up to 2 years
Received 15 September 2019 of age as it is essential for proper growth and development but population-based studies around the
Received in revised form world have found conflicting results on the subject. Our study aims to analyze whether there is a rela-
19 January 2020
tionship between the duration of breastfeeding and undernutrition among children aged from birth up
Accepted 21 January 2020
Available online xxx
to 3 years of age in Pakistan.
Methods: A secondary analysis of the Pakistan Demographic and Health Survey 2013-2014 with 1072
children aged 3 years and under was conducted. The relationship between breastfeeding duration and
Keywords:
Breastfeeding duration
undernutrition status was estimated through multiple logistic regression analysis.
Underweight Results: The prevalence of stunting, wasting and underweight were 40.6%, 15.8% and 33.9% respectively,
Stunting while prevalence of severe stunting is at 22.5%; severe wasting at 4.5% and severe underweight at 12.2%
Wasting in children in our study. Odds of being stunted were significantly higher for children in their 3rd year of
Pakistan life [AOR: 4.35, CI 95% ¼ (2.01, 9.33)] compared to children being breastfed in their 2nd year of life [AOR:
2.43, CI 95% ¼ (1.55, 3.79) after being adjusted for maternal, child, demographic and healthcare access
variables. Similarly, children being breastfed in their third year of life were more susceptible to devel-
oping severe stunting [AOR: 6.19, CI 95% ¼ (3.31, 11.56)] in comparison to children in their second year
[AOR: 2.84, CI 95% ¼ (1.81, 4.46)]. There was no significant association between breastfeeding and
wasting/severe wasting, or between breastfeeding and underweight/severe underweight.
Conclusion: Breastfeeding in the 2nd and 3rd year of life was found to have significant relationship with
stunting and severe stunting. Mothers need to be educated about the risks of prolonged breastfeeding to
reduce the burden of undernutrition in the country.
© 2020 Publishing services provided by Elsevier B.V. on behalf of King Faisal Specialist Hospital &
Research Centre (General Organization), Saudi Arabia. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Undernutrition conditions like stunting, wasting and under-
weight children are some of the most important public health is-
sues in less economically developed regions like Southeast Asia and
* Corresponding author. Peoples University of Medical and Health Sciences for
Women, Department of Community Medicine, Hospital Road, Nawabshah, 67450,
Pakistan.
E-mail address: syedabatoolfatima@pumhs.edu.pk (B. Syeda).
Peer review under responsibility of King Faisal Specialist Hospital & Research
Centre (General Organization), Saudi Arabia.
Sub-Saharan Africa [1]. About 45% deaths around the world in
under 5 children can be attributed to undernutrition [[2,3] Stunting
is a relative height to age deficit and is responsible for delayed
development, impaired cognitive function and increased suscepti-
bility to infectious diseases in children. Wasting is severely low
weight for height and can lead to debilitating diseases like protein
energy malnutrition and is also a strong indicator of mortality [4].
Wasting is acute whereas stunting is chronic undernutrition con-
dition. Globally, 149 million children have been reported to be
stunted and another 49.5 million are wasted [5]. Thirty-nine
percent of all stunted children in the world reside in less
economically developed regions of South Asia including Pakistan,

https://doi.org/10.1016/j.ijpam.2020.01.006
2352-6467/© 2020 Publishing services provided by Elsevier B.V. on behalf of King Faisal Specialist Hospital & Research Centre (General Organization), Saudi Arabia. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article as: Syeda B et al., Relationship between breastfeeding duration and undernutrition conditions among children aged
0e3 Years in Pakistan, International Journal of Pediatrics and Adolescent Medicine, https://doi.org/10.1016/j.ijpam.2020.01.006
Downloaded for Anonymous User (n/a) at National Library of Indonesia from ClinicalKey.com/nursing by Elsevier on September 17, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
2 B. Syeda et al. / International Journal of Pediatrics and Adolescent Medicine xxx (xxxx) xxx
India and Bangladesh, which translates to 58 million stunted chil-
dren in the Indian subcontinent alone [5,6]. The 2012-2013 de-
mographic and health survey of Pakistan describes stunting rate at
45%, wasting at 15% and underweight children at 31.5% of under 5
children in the country [7]. These rates are alarming and they prove
that Pakistan is showing no progress and is off track in achieving its
Global Nutrition Targets [8].
The period from birth to second year of life is crucial for optimal
growth and development [9,10]. Deprivation of proper nutrition
during this time may lead to stunting which is why it is the key
period for implementing any intervention strategy for control of
undernutrition [1,11]. The World Health Organization (WHO) rec-
ommends that breastfeeding should be continued up to 2 years as it
aids growth and development by improving both height and
weight, protects against many infectious diseases and also in-
creases chances of survival for the child [12e14] Population based
studies around the world have found conflicting results on the
subject. Many researchers in developing countries have found little
to no association between breastfeeding and undernutrition
[15,16], whereas some studies even found that breastfeeding de-
presses growth if continued after the first year of life [17,18].
Possible explanations for these contradictory results can be effect
modification or uncontrolled confounding, but some researchers
argue that this is because of reverse causality, meaning that it is not
breastfeeding that depresses growth but rather the depressed
growth of the child which encourages the mother’s decision to
continue breastfeeding for longer than usual [19e21].
The literature is full of studies on undernutrition and its relation
to breastfeeding but no research study has ever focused specifically
on the duration of breastfeeding and undernutrition in Pakistan.
This highlights the importance of a country-wide, population-
based study on the subject which can further improve our under-
standing of the relationship between breastfeeding and the various
forms of undernutrition. The study aims to examine the relation-
ship between duration of breastfeeding and undernutrition in the
light of Pakistan demographic and health survey. This will help
policymakers and public health researchers in designing and
implementing appropriate intervention programs which are spe-
cifically tailored to accommodate the needs and requirements of
the country.
2. Methods
2.1. Data source
This study obtained data from the Pakistan Demographic and
Health Survey 2013-14 [7]. It uses a two-staged, stratified, cluster
sampling method. The sample is representative of the 4 provinces
of the country as well as Gilgit Baltistan but excludes FATA, Kashmir
and other restricted areas. A sample size of 14000 households was
established containing 6944 urban households and 7056 rural
households.
Assessment was carried out through four model questionnaires
from measure DHS program which were modified to reflect rele-
vant issues in the country. Sociodemographic information of the
respondents required for this study as well as children eligible for
anthropometric measurement were determined through the
household survey. Complete anthropometric data was available
from 3466 children, measured using SECA scales specially designed
by UNICEF. Children under 2 years were measured by recumbent
length whereas standing length was taken for older children. In-
formation from ever married (15e49 years) was collected through
women’s questionnaire which was used in this study to obtain data
regarding their literacy, antenatal and postnatal history, repro-
ductive history, breastfeeding and weaning history as well as
Please cite this article as: Syeda B et al., Relationship between breastfeeding duration and undernutrition conditions among children aged
0e3 Years in Pakistan, International Journal of Pediatrics and Adolescent Medicine, https://doi.org/10.1016/j.ijpam.2020.01.006
Downloaded for Anonymous User (n/a) at National Library of Indonesia from ClinicalKey.com/nursing by Elsevier on September 17, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
childhood illness and vaccination history [7].
2.2. Dependent variables
Three indicators were examined to categorize children’s nutri-
tion: (i) Underweight (ii) Wasting and (iii) Stunting as the essential
outcomes. Outcome variables were categorized as Class 0 [No
stunting/severe stunting, no wasting/severe wasting, no under-
weight/sever underweight, (>-2SD) (>-3SD) above cut off values].
Class 1 [Stunting/severe stunting, wasting/severe wasting, un-
derweight/severe underweight (<-2SD) (<-3SD) below cut off
values].
2.3. Independent variable
Independent variable is breastfeeding duration, characterized
as: “breastfeeding duration (both exclusive breastfeeding and
supplementary feeding) among children born 3 years prior to the
survey”. Breastfeeding duration was classified into 1st year, 2nd
year and 3rd year of life.
2.4. Other variables
Potential variables and individual factors were also investigated
such as specific characteristics of every child and parent. We
examined education and occupation of the parents, age and gender
of child, mother’s age and her status of marriage, nature and place
of delivery and access to health facilities.
Household wealth index was developed by assessing variables
such as source of drinking water and possession of land or auto-
mobile. Household wealth was estimated by principal components
analysis [22] which was used to classify households into five
quintiles (richest, rich, middle, poor, poorest). Settlement area
(either urban or rural) and geopolitical region were also included in
analysis.
2.5. Statistical analysis
The analysis was performed using Stata version 14.1 survey
commands [23] and was adjusted to control for sampling design,
weights and standard error. In the first stages, frequency counts and
percentages were assessed for designated variables, after which
undernutrition status was calculated i.e. stunting wasting and un-
derweight prevalence in children (0e3 years). Ninety-five percent
confidence intervals were projected using Taylor series lineariza-
tion method.
Logistic regression analysis, adjusted for design and weights,
was used to examine any relationship between duration of
breastfeeding and undernutrition in children less than three years.
First, univariate logistic regression analysis was carried out to
investigate unadjusted odds ratio followed by multinomial logistic
regression analyses using a five-step model as explained in Fig. 1.
Initially, multiple logistic regression was performed on indi-
vidual characteristic variables to assess their relationship with
outcome variables. Subsequently, a stepwise manual backward
deletion analysis was performed and only variables with p value of
less than 0.05 were kept. Afterwards, household variables were
incorporated into these significant variables followed by healthcare
and community level factors. Finally, the independent variable e
breastfeeding duration, was added into the analyses and only var-
iables of significance were retained. Association between duration
of breastfeeding and undernutrition status in children 0e3 years
was calculated using odds ratios (OR) and confidence intervals (CI)
obtained through the multiple regression model.
 B. Syeda et al. / International Journal of Pediatrics and Adolescent Medicine xxx (xxxx) xxx 3

Figure 1. 5-step logistic regression model.

3. Results
3.1. Characteristics of the sample
Demographic characteristics are summarized in Table 1.
Regarding paternal characteristics, fifty percent of fathers had
secondary or higher qualification while 85% had non-farming oc-
cupations. Nearly all women (99.2%) were presently married, 3/4th
were unemployed and more than half were illiterate. More than
80% of women had a BMI in or above normal range. Seventy-four
percent of children were apparently of normal size when born.
Most children had no fever or diarrhoea 24 h preceding the survey.
3.2. Prevalence of undernutrition
Our study revealed that severely stunted and severely wasted
forms of undernutrition were not as prevalent as stunting and
wasting (Fig. 2).
Forty percent children were stunted, around 16% were wasted
and almost 34% were underweight. Twenty-four percent, 4% and
14% had severe forms of stunting, wasting and underweight
respectively. Fig. 2 shows statistical differences between stunting,
wasting, underweight and their severe forms.
3.3. Relationship between breastfeeding duration and
undernutrition
Breastfeeding duration had significant association with stunting
[AOR: 2.43, CI 95% ¼ (1.55, 3.79) for children in their 2nd year of life
and AOR: 4.35, CI 95% ¼ (2.01, 9.33) for children in their 3rd year]
(Fig. 3).
Children breastfeeding in their third year of life had higher odds
of developing severe stunting [AOR: 6.19, CI 95% ¼ (3.31, 11.56)] in
comparison to children in their second year [AOR: 2.84, CI 95% ¼
(1.81, 4.46)] (Fig. 4).
Our study did not find any association between duration of

Please cite this article as: Syeda B et al., Relationship between breastfeeding duration and undernutrition conditions among children aged
0e3 Years in Pakistan, International Journal of Pediatrics and Adolescent Medicine, https://doi.org/10.1016/j.ijpam.2020.01.006
Downloaded for Anonymous User (n/a) at National Library of Indonesia from ClinicalKey.com/nursing by Elsevier on September 17, 2020.
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.
4 B. Syeda et al. / International Journal of Pediatrics and Adolescent Medicine xxx (xxxx) xxx

Table 1 Table 1 (continued )

Characteristics of children aged 0e3 years in Pakistan, 2013-14 (n ¼ 1072).
Characteristic N %
Characteristic N %
Demographic region
Maternal variables Punjab 660 61.6
Employment Sindh 275 25.6
Unemployed 829 77.4 KPK 117 10.9
Employed (past year) 243 22.6 Balochistan 20 1.9
Qualification Health services factors
None 584 54.5 Delivery site
Basic (grade 5) 194 18.1 House 506 47.2
Secondary or higher 295 27.5 Healthcare facility 566 52.8
Literacy Delivery mode
Illiterate 587 54.8 Normal delivery 907 84.6
Literate 485 45.2 C-Section 165 15.4
Husband’s job Delivery assistance
Non farming 916 85.4 Healthcare professional 575 55.5
Farming 156 14.6 Dai (TBA) 454 43.8
Husband’s qualification Unskilled person 8 0.8
None 338 31.5 Number of antenatal check ups
Basic (grade 5) 195 18.2 None 232 21.6
Secondary or higher 538 50.3 1 to 3 425 39.6
Maternal age 4 or more 416 38.8
16e25 years 342 31.9 Postnatal visit history
26e35 years 550 51.3 Positive 664 61.9
36e50 years 180 16.8 Negative 408 38.1
Marriage status
Presently married 1063 99.2
Previously married 9 0.8 breastfeeding and wasting/severe wasting, neither could we
BMI, kg/m2
establish any relationship between breastfeeding duration and
Less or equal to 18.5 198 18.5
Greater than 18.5 873 81.5 underweight/severe underweight. Only severe stunting and
Birth number stunting had significant association with duration of breastfeeding.
1st 209 19.5 They also had significant association with perceived birth size of
2 to 4 567 52.8 baby, maternal education and frequency of antenatal check-ups the
5 or above 296 27.6
mother had during pregnancy. Children who were perceived as
Birth spacing
No prior birth 209 19.6 large at the time of birth were less susceptible to stunting in later
<2 years 301 28.1 life than their counterparts [AOR: 0.20, CI 95% ¼ (0.07, 0.51)].
>2 years 559 52.3 Children perceived as having average size at birth were also less
Child variables
prone to develop severe stunting in comparison to children
Gender
Boy 544 50.8
perceived as small at birth [AOR: 0.54, CI 95% ¼ (0.32, 0.90)].
Girl 528 49.2 Mothers with secondary or higher qualification had decreased odds
Perceived birth size of having stunted children as opposed to uneducated mothers
Small 216 20.2 [AOR: 0.43, CI 95% ¼ (0.25, 0.77)]. On other hand, stunting was also
Regular 792 73.9
uncommon in children whose mothers had 4 antenatal check-ups
Large 64 5.9
Recent diarrhoea history during pregnancy, [AOR: 0.44, CI 95% ¼ (0.23, 0.85)] or severe
Negative 749 69.8 stunting [AOR: 0.45, CI 95% ¼ (0.27, 0.81)] in comparison to
Positive 323 30.2 mothers who had no antenatal checkups.
Fever history (2 weeks)
Negative 616 57.4
Positive 456 42.6
Household factors 4. Discussion
Wealth index
Poorest/poor 456 42.6 Our study observed the relationship between breastfeeding
Middle 449 41.8 duration and undernutrition status among children up to 3 years of
Richest/rich 167 15.6
Mother’s weekly TV use
age in Pakistan. In addition, we also observed other sociodemo-
Positive 711 66.4 graphic factors with any known association to undernutrition. This
Negative 361 33.6 study confirms that breastfeeding duration has a significant asso-
Mother’s weekly radio use ciation with stunting and severe stunting but does not seem to have
Positive 199 18.6
any significant relationship with wasting and severe wasting and
Negative 873 81.4
Mother’s newspaper reading undernutrition/severe undernutrition. Comparable study in
Positive 254 23.7 Botswana also had a similar conclusion [24]. Perceived birth size of
Negative 818 76.3 child, maternal education and antenatal checkup history were also
Water source found to ave significant association with stunting and severe
Not protected 614 57.3
Protected 458 42.8
stunting.
Toilet facilities Other research studies have also established that breastfeeding,
Uncovered 467 43.6 if continued for more than 18 months, leads to an increased sus-
Covered 605 56.4 ceptibility to malnutrition [25,26] further supporting our conclu-
Community variables
sion that breastfeeding duration has a positive association with
Settlement
Urban 316 29.5 stunting, and also that this association increases with age i.e. the
Rural 756 70.5 longer a child is breastfed, the more susceptible it is to stunting.
Children aged 2e3 years were more likely to stunted as well as

Please cite this article as: Syeda B et al., Relationship between breastfeeding duration and undernutrition conditions among children aged
0e3 Years in Pakistan, International Journal of Pediatrics and Adolescent Medicine, https://doi.org/10.1016/j.ijpam.2020.01.006
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Fig. 2. Prevalence of undernutrition status.

severely stunted with increased duration of breastfeeding in com-
parison to breastfeeding during infancy [18]. These findings are also
in line with another study which proves that children being
breastfed in older ages were shorter than their counterparts who
were weaned off early [20].
The correlation between duration of breastfeeding and stunting
may be because of delay in the introduction of supplementary
foods to the baby’s diet either due to unawareness on the mother’s
part, or due to lack of resources in the household to provide com-
plementary foods for the baby. This could also be because intro-
duction of supplementary foods into the child’s diet was delayed
and as a consequence, the child could never develop a healthy
appetite towards complementary feeding. This makes the child
over dependent on breast milk and may also bring about chewing
difficulties both of which may lead to a weak immune system and
impaired growth and development [17, 27]. Contrary to the above
evidence, a few studies have also found prolonged breastfeeding to
be protective against various forms of undernutrition [28,29] while
another found no association between breastfeeding and any form
of undernutrition [30].
A study in Senegal revealed that prolonged breastfeeding
enhanced linear growth however it had no observed effect on being
underweight in children [31]. In contrast, our study observed that
children aged two or three years, who were subjected to longer
durations of breastfeeding had decreased linear height and better
weight for age scores. Furthermore, our study establishes that the
correlation between stunting and breastfeeding duration originates
from the fact that children being breastfed longer had initial low

Fig. 3. Impact of breastfeeding duration on Stunting, Wasting and Underweight in children aged 0e3 years in pakistan (Exposure variables adjusted for individual, Community,
Household and Healthcare services factors).

Please cite this article as: Syeda B et al., Relationship between breastfeeding duration and undernutrition conditions among children aged
0e3 Years in Pakistan, International Journal of Pediatrics and Adolescent Medicine, https://doi.org/10.1016/j.ijpam.2020.01.006
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6 B. Syeda et al. / International Journal of Pediatrics and Adolescent Medicine xxx (xxxx) xxx

Fig. 4. Impact of breastfeeding duration on severe stunting Wasting and severe Underweight in children aged 0e3 years in pakistan (Exposure variables adjusted for individual,
Community, Household and Healthcare services factors).

stunting score which concludes that children did not develop
stunting because they were breastfed longer, rather it was the
child’s sub optimal growth which forced the mother to continue
breastfeeding for longer than usual. Our study did not find any
relationship between breastfeeding duration and wasting/severe
wasting. This is understandable as wasting is an acute malnutrition
condition and manifests only when there is absolute shortage of
food. Children breastfeeding during their 3rd year of life had lower
odds of developing wasting and severe wasting but the association
was insignificant. The lack of association between underweight/
severe underweight can be explained by fact that milk, although
has high nutritive value but has low caloric value, and is not a
suitable as a standalone meal after a certain age. It can also be due
to the fact that weight change in 0e3 year children is greatly
influenced by illness and other behaviour and environmental fac-
tors not explored by this study.
Our study further concludes that undernutrition status has
significant association with perceived birth size, mother’s qualifi-
cation and regularity of antenatal visits at the time of pregnancy.
Other studies have also found that mothers with secondary or
higher qualification had lower odds of having stunted children as
opposed to uneducated or minimally educated mothers [32,33].
This might be explained by the fact that uneducated mothers do not
have awareness about proper childhood nutrition and are also
more likely to believe in myths surrounding complementary
feeding [34] which can be unsafe for the health of their children.
They also may not have resources to provide sufficient quantity and
quality of supplementary food because of ignorance or poverty. Our
study also found a significant relationship between perceived birth
size of baby and stunting. Children perceived as “large” at the time
of their birth were less likely to develop undernutrition conditions
later in life in comparison to children perceived as “small” at birth.
This is in agreement with other studies conducted in Pakistan [35],
Cambodia and Kenya [36] which also conclude that birth size is a
valid predictor of successive growth in children. Mothers percep-
tion of birth size is prone to bias as small size at birth is a sign of
nutrition deprivation in the period of pregnancy which, if
continued, will ultimately lead to stunting in children.
Our study results also found that there is a significant role of
proper antenatal care in warranting healthy growth of the child.
Children whose mothers frequented antenatal clinics during
pregnancy had decreased likelihood of being stunted and severely
stunted later in life. This finding backed by studies in Ethiopia [37],
Nigeria [38] and also a systemic review of 69 less economically
developed countries [39]. This is probably because women who
visit antenatal clinics gain valuable health education regarding
proper child nutrition from medical professionals which equips
them to make healthy food choices for their children. Furthermore,
women who do not seek antenatal care may generally have bad
health seeking behavior or they might not be cared for by their
families enough to seek antenatal care for herself.
Strengths of our study include; 1) Data analyzed in the study
was drawn from nationally representative Pakistan demographic
and Health survey 2012e13, which has large sample size, moreover,
standardized methods were employed to obtain high response rate
and correct measurements and 2) suitable adjustment measure
were taken in investigating the complex sampling design of the
PDHS 2012 - 13. However, the study has some possible limitations
which should be considered when comprehending our results. Due
to its cross-sectional nature, the study is limited in its ability to
establish a causal relationship between the variables. Residual
confounding because of unmeasured variable like food insecurity,
micronutrient consumption cannot be ruled out. Furthermore, a
few variables including breastfeeding duration information was
dependent on a mother’s memory of events which increases the
possibility of recall bias and social desirability bias.

Please cite this article as: Syeda B et al., Relationship between breastfeeding duration and undernutrition conditions among children aged
0e3 Years in Pakistan, International Journal of Pediatrics and Adolescent Medicine, https://doi.org/10.1016/j.ijpam.2020.01.006
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 B. Syeda et al. / International Journal of Pediatrics and Adolescent Medicine xxx (xxxx) xxx
5. Policy implications and conclusions
Although breastfeeding is healthy for the child and the mother,
health care providers need to educate mothers and raise awareness
regarding the consequences of prolonged breastfeeding and facili-
tate them to prevent any harmful outcomes. Any strategy which
enhance mothers’ knowledge and awareness to practice breast-
feeding should be adopted. Additionally, commercial projects
which focus on raising the socio-economic status of people needs
to be developed to reduce the burden of malnutrition in children.
More research needs to be directed to investigate the effect of
breastfeeding duration on health of mother and her nutrition status
to make certain that prolonged breastfeeding has no negative
impact on the health of mother.
Summing up, our study established that the prolonged duration
of breastfeeding in children up to three years of age had significant
association with stunting but not with wasting & underweight. It
also revealed that birth size perception, infrequent antenatal clinic
visits and low literacy level of the mother were considerable factors
associated stunting, wasting and underweight. Utilization of study
results may help in reducing the prevalence of stunting, wasting
and underweight and also put Pakistan back on track to accomplish
WHO global nutrition targets by 2025.
Funding
This research received no funding from any public, private or
nonprofit sector.
Author statement
Dr. Batool Syeda: Substantial contribution to conception and
design, substantial contribution to acquisition of data, substantial
contribution to analysis and interpretation of data, drafting the
article, critically revising the article for important intellectual
content, final approval of the version to be published; Dr. Kingsley
Agho (Supervisor): Substantial contribution to conception and
design, substantial contribution to analysis and interpretation of
data, final approval of the version to be published; Dr. Leigh Wilson
(Co-Supervisor): Substantial contribution to analysis and inter-
pretation of data, drafting the article, final approval of the version
to be published; Dr. Greesh Kumar Maheshwari: Drafting the
article, critically revising the article for important intellectual
content, final approval of the version to be published; Dr.
Muhammad Qasim Raza: Drafting the article, critically revising the
article for important intellectual content, final approval of the
version to be published.
Declaration of competing interest
None.
Acknowledgements
Authors would like to appreciate Measure DHS, ORC Macro,
Calverton, MD, USA for providing the data of PDHS 2012 - 13.
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►► Additional material is
published online only. To view
please visit the journal online
(http://​dx.​doi.​org/​10.​1136/​ nutrition programmes to identify context-specific
archdischild-​2016-​311050).
1 prioritise the implementation of programmes for
Stunting Research Platform,
Nutrition and Clinical Services reducing stunting in low and middle income
Division, ICDDR, Dhaka,
Bangladesh
2
Southampton General Hospital, systematically review the literature published between
Southampton, UK
3 1980 and 2015. Additional articles were identified from
Department of Global Health,
University of Washington,
Seattle, USA
Correspondence to
Dr Muttaquina Hossain,
Nutrition and Clinical Services
Division, International Centre
for Diarrhoeal Disease Research, approach was applied to identify mechanisms
68 Shahid Tajuddin Ahmed
Sarani, Mohakhali, Dhaka 1212, and settings.
Bangladesh;
​muttaquina@​icddrb.​org
Received 18 April 2016
Revised 21 September 2016
Accepted 2 December 2016
Published Online First
3 May 2017
To cite: Hossain M,
Choudhury N, Adib Binte
Abdullah K, et al.
Arch Dis Child
2017;102:903–909.
Evidence-based approaches to childhood
stunting in low and middle income countries:
a systematic review
Muttaquina Hossain,1 Nuzhat Choudhury,1 Khaleda Adib Binte Abdullah,1
Prasenjit Mondal,1 Alan A Jackson,2 Judd Walson,3 Tahmeed Ahmed1
ABSTRACT
Objective We systematically evaluated health and
interventional packages that might help to
countries (LMICs).
Methods Electronic databases were used to
the reference lists and grey literature. Programmes were
identified in which nutrition-specific and nutrition-
sensitive interventions had been implemented for
children under 5 years of age in LMICs. The primary
outcome was a change in stunting prevalence, estimated
as the average annual rate of reduction (AARR). A realist
underpinning programme success in particular contexts
Findings Fourteen programmes, which demonstrated
reductions in stunting, were identified from 19 LMICs.
The AARR varied from 0.6 to 8.4. The interventions
most commonly implemented were nutrition education
and counselling, growth monitoring and promotion,
immunisation, water, sanitation and hygiene, and social
safety nets. A programme was considered to have
effectively reduced stunting when AARR≥3%.
Successful interventions were characterised by a
combination of political commitment, multi-sectoral
collaboration, community engagement, community-
based service delivery platform, and wider programme
coverage and compliance. Even for similar interventions
the outcome could be compromised if the context
differed.
Interpretation For all settings, a combination of
interventions was associated with success when they
included health and nutrition outcomes and social
safety nets. An effective programme for stunting
reduction embraced country-level commitment
together with community engagement and programme
context, reflecting the complex nature of exposures of
relevance.
PROSPERO registration number
CRD42016043772.
INTRODUCTION
Stunting1 is the most common manifestation of
chronic undernutrition during childhood in low
and middle income countries (LMICs). It has been
associated with increased risk of morbidity and
Hossain M, et al. Arch Dis Child 2017;102:903–909. doi:10.1136/archdischild-2016-311050
Original article
What is already known on this topic?
▸ A combination of nutrition-specific and
nutrition-sensitive interventions appears
necessary in order to optimise programmes to
reduce stunting.
What this study adds?
▸ Nutrition education and counselling, growth
monitoring and promotion, immunisation,
water, sanitation and hygiene and social safety
net programmes appear to be the most
commonly included interventions of an effective
package in most low and middle income
countries settings.
▸ Single interventions reduced stunting only in
countries with specific disease burden.
▸ Intervention worked best when country,
community and programme context were taken
into account.
mortality and impacts negatively on both physical
growth and cognitive development; as well as
increased risk of obesity and other metabolic com-
plications in later life. Separately and together these
lead to lower economic productivity, and con-
strained social function.2 Thus, stunting appears a
direct impediment towards achieving the sustain-
able development goals.
The most vulnerable period for the establishment
of lifelong stunting is the first 1000 days from con-
ception. Thereafter, it appears increasingly difficult
to reverse adverse influences ultimately leading to
adults of shorter stature.3 In targeting the first
1000 days, both global movements and regional
programmes have sought to take nutrition interven-
tions to scale by supporting nutrition governance.4
However, these initiatives appear less successful
than anticipated in achieving the desired reduction
in stunting in LMICs.5
Globally, stunting has decreased at approximately
1.8% per year.6 indicating that it will only decrease
by 18% in the next 10 years, failing to achieve the
goal set by the World Health Assembly.7 This is
consistent with data suggesting that scaling up
   903
 Original article
Figure 1 Definition of
nutrition-specific and
nutrition-sensitive interventions and
programmes (adapted from Ruel and
Alderman9).
existing nutrition-specific interventions would reduce stunting
by about 20%.8 A combination of nutrition-specific and
nutrition-sensitive interventions appears necessary in order to
optimise reductions in stunting (figure 1).9
This review sought to identify studies from LMICs where
combined programmatic interventions have been evaluated. It
identifies the programmes and the components of nutrition
interventions in which there had been demonstrable success
leading to a reduction in stunting. In addition, we sought to
determine correlates of success among programmes for particu-
lar contexts and settings by using the realist approach. The
purpose was to provide a synthesis of the available evidence that
could assist policy makers and donors in prioritising the use of
resources for implementation of interventions to prevent and
control stunting in resource limited settings by considering of a
mix of factors for the country, community and programme
contexts.
METHODS
Data sources
A comprehensive search strategy was designed a priori and
applied to electronic bibliographic databases, including Medline
(Pub Med), WHO Regional databases, Google’s Scholar data-
bases and the Cochrane Library with specific key words/con-
cepts: ‘stunting’, ‘linear growth failure’, ‘stunting reduction
programme’, ‘intervention’, ‘approach’ and ‘low and middle
income countries’ (see online supplementary appendix 1). The
search was limited to literature published between 1 January
1980 and 31 March 2015. MeSH headings were used where
available. Published and unpublished references and grey litera-
ture sources were searched electronically and manually.
Study eligibility criteria
This review considered all studies involving human subjects
under 5 years of age (0–59 months), published in the English
language. It had a focus on public health programmes that
implemented nutrition-specific and nutrition-sensitive interven-
tions to reduce stunting, mostly in a community-based setting9
in LMIC’s,10 and where there were data on baseline and
follow-up or end line stunting status. Studies without any com-
ponents of nutrition intervention, individual randomised con-
trolled trials (RCTs) and those in which linear growth or
stunting had not been measured were excluded. The outcome of
904 Hossain M, et al. Arch Dis Child 2017;102:903–909. doi:10.1136/archdischild-2016-311050
interest was changes in stunting prevalence following a pro-
gramme intervention among children under 5 years of age.
The population, intervention, comparators and outcomes
framework
Population Intervention Comparison Outcome
Children aged Nutrition-specific and Programmes other Stunting
between 0 and nutrition-sensitive than nutrition reduction
59 months interventions implemented intervention
either alone or in combination
The reviewers/authors followed ‘Preferred Reporting Items
for Systematic Reviews and Meta-analyses (PRISMA)’ checklist
during this review (see online supplementary appendix 2).11
Titles and abstracts were screened by two authors independently
(MH and KABA). All titles and abstracts from each search were
examined, matched and then the relevant articles were obtained
for review (figure 2). To ensure consistency a calibration exercise
was conducted. The reviewers agreed on the criteria and
applied them to a sample of 20% of the retrieved studies to
demonstrate adequate inter-examiner agreement (κ: 0.70–0.75).
The reviewers read each study independently and any disagree-
ments were resolved through discussion or, where necessary,
through consultation with a third team member (PM).
Data extraction
Two reviewers (MH and KABA) independently extracted both
quantitative and qualitative data on: the number of programme
components implemented, the baseline rate of stunting preva-
lence, the stunting prevalence following the period of the pro-
gramme intervention and the rate of stunting reduction over
time. They used standardised forms, checklists, note taking and
annotation to compile the data from studies employing diverse
interventional packages across multiple settings and geograph-
ical locations. During study selection and data extraction the
reviewers were not blinded to authorship, journal of publication
or the trial results.
Methodological quality assessment
The quality of the individual studies that were included was
assessed by two reviewers (MH and KABA) independently for
both experimental (RCT) and observational (cross-sectional)
studies. The possible risk of bias in RCT was assessed using the

Figure 2 Flow diagram for the
literature search.
Cochrane Collaboration tool12 and quality assessment of cross-
sectional studies was assessed with a modified version of the
Newcastle-Ottawa Scale.13 Judgments as to the possible risk of
bias was rated as ‘high risk’ or ‘low risk’ for the extracted infor-
mation for each of the six domains of RCT (see online
supplementary appendix 3). The scale scores for observational
studies ranged from 0 (lowest grade) to 7 (highest grade).
Observational studies with scores at or above the median (equal
to or greater than 5) were classified as high quality studies (see
online supplementary appendix 4). Risk of bias across studies
was assessed using the approach outlined by the ‘Grading of
Recommendations Assessment Development and Evaluation’
(GRADE) working group.14 The quality of evidence was assessed
as high, moderate and low or very low (see online supplementary
appendix 5), and any disagreement was resolved by discussion or
where necessary by consultation with a third author.
Data analysis
To enable comparisons to be made among the different studies,
the average annual rate of reduction (AARR) was derived, as
described in detail elsewhere.15 For the purpose of our investi-
gation, we considered a programme to be effective if an AARR
for stunting that was equal to or greater than the median
AARR. We further characterised the individual nutrition-related
components of each specific programme to determine which of
Hossain M, et al. Arch Dis Child 2017;102:903–909. doi:10.1136/archdischild-2016-311050
Original article
the components had been implemented in the greater number
of effective programmes in order to provide an indication of the
consistency with which the individual components appeared to
contribute to the reduction in stunting (see online
supplementary appendices 6 and 7). We applied the realist
approach in assessing the programme context and underlying
mechanisms which might explain the programme’s success in
reducing stunting.16 With further discussion and critical review
of the programme evaluation reports and grey literature we
identified several contextual factors of probable relevance.
These were themed for the different underlying contexts into
broad key concepts or connections, which were considered to
capture the likely mechanism(s) behind successful programme
outcome (stunting reduction) (figure 3).
Protocol and registration
A full protocol for the study was completed by the authors
prior to commencement of the study (see online supplementary
appendix 8) and can be accessed at http://www.crd.york.
ac.uk/PROSPERO/display_record.asp?ID=CRD42016043772.
Registration no: CRD42016043772.
Role of the funding source
The funding institution had no role in the design and develop-
ment, data extraction, analysis and interpretation of the data, or
905
 Original article
Figure 3 Realist review framework.
preparation, review, or approval of the paper. The correspond-
ing author had full access to all the data in the study and had
final responsibility for the decision to submit for publication.
RESULTS
Identification and selection of the literature
An initial search combining all key words yielded the titles of
6267 articles. The full text of 111 papers were screened and
assessed for eligibility after removal of duplicates (based on
author name, article title, year of publication and journal name)
and clearly unrelated articles. A further 27 papers were identified
from reference lists and the grey literature. After removal of ineli-
gible studies, 18 papers were included in the review (figure 2). In
this way, 14 programmes were identified in 19 LMICs where
nutrition-specific approaches had been implemented, either
alone or in combination with nutrition-sensitive interventions, to
reduce stunting.
Description of included studies and risk of bias assessment
All but one of the studies were cross-sectional. Most studies tar-
geted children under 5 years of age living in poor households
from rural areas. The programmes were implemented between
1986 and 2010, from countries in Asia, Latin America and
Africa. None of the programmes enabled comparison with a
true control area in which there had been no intervention.
Included studies generated evidence of moderate quality (11 out
of 17 included observational studies and 1 RCT) with low risk
of bias (see online supplementary appendices 3–5).
Nutrition intervention programme and stunting reduction
The effect of the different interventions in reducing stunting
varied widely across the studies, with decreases in the AARR of
stunting ranging from 0.6 to 8.4 (median 3) percentage points
per year. Programmes with AARR of stunting of at least 3
(median AARR) from baseline were considered to have been
effective. We identified seven effective programmes. In Asia,
programmes in Bangladesh and Vietnam achieved AARR of
stunting of 4.5%. In Latin America, Brazil demonstrated the
highest AARR of 8.4%. The Millennium Villages programme in
nine sub-Saharan countries achieved AARR of 7%. For success-
ful programmes, both nutrition-specific and nutrition-sensitive
interventions were combined. These were found in three out of
seven programmes with interventions that included nutrition
education and counselling, immunisation, growth monitoring
and promotion (GMP), water, sanitation and hygiene (WASH)
and social safety net (SSN) interventions (see online
supplementary appendices 6 and 7). Programmes to prevent and
treat malaria were implemented only in African countries
906
(Malawi, Niger and sub-Saharan Africa) where there was high
malaria prevalence. The majority of SSN programmes were
implemented in Latin American countries and targeted poor
beneficiaries. The AARR in these countries varied widely
(between 2.2% and 6.7%), even when the individual compo-
nents for the intervention appeared similar (nutrition education
and counselling, vitamin A supplementation, immunisation,
WASH, food security and SSN). Programmes which recruited
younger children (0–36 months) from poor rural households
and which were implemented in areas with no other health pro-
grammes (Bangladesh, Peru and sub-Saharan Africa) reduced
stunting more effectively than others (Ethiopia, Haiti, India,
Malawi and Mexico) (table 1).
Contextual factors behind programme outcome
A realist approach was used to examine contextual factors
which were considered to be the drivers for successful pro-
gramme outcome (reduction of stunting). We identified four key
concepts underpinning the connection between programme
intervention and outcome. This analysis suggests that a stunting
reduction programme becomes effective (AARR of stunting at
least 3%) where there is an evidence of strong political commit-
ment, multi-sectoral collaboration between government, non-
government, national and international organisation, active
community engagement, and where the programme is delivered
through community-based platforms with high coverage and
compliance (≥5 out of 7 programme). These underlying factors
were clearly identified in five of seven programmes in which
stunting was effectively reduced (table 2).
DISCUSSION
Summary of evidence
This systematic review identifies that in order to achieve success
with interventions designed to reduce stunting in LMICs
requires a combination of factors and components which
together provide a suitable context. Nutrition education and
counselling, GMP, immunisation, WASH, and SSN programmes
were the components most frequently included in the interven-
tion packages. The programmes appear most successful where
strong political commitment and multi-sectoral collaboration
between government, non-government, national and inter-
national organisations exist and where programmes are deliv-
ered through community service delivery platforms with active
community engagement.
Although nutrition is necessary, interventions that focus solely
on nutrition are likely to be insufficient in themselves for many
of the global contexts where there is the need to reduce stunt-
ing. This review has shown that in most settings a combination
Hossain M, et al. Arch Dis Child 2017;102:903–909. doi:10.1136/archdischild-2016-311050
 Table 1 Nutrition intervention/programmes in low and middle income countries
Geographic Study population and Time Effective
region Country Author, year Programme name Study design setting period Programme components AARR programme

Asia Bangladesh Smith et al17 Strengthening household ability Cross-sectional Children 6–24 months, 2006–2010 Nutrition education and counselling; GMP; Vit A and IFS; 4.5 Yes
to respond to development surveys poorest household immunisation; HFP, access to local health facilities;
opportunities (Shouhardo) sanitation; women empowerment; PFSA; SSN
Bangladesh Arifeen et al18 Integrated management of Cluster Rural children 0–59 months 2000–2007 Nutrition education and counselling; GMP; IMCI 2.9 No
childhood illness (IMCI) randomised trial
programme
Cambodia Ikeda et al19 National nutrition programme Cross-sectional Children 0–59 months 2000–2010 IYCF; MNP; IMCI; parental education; HFP; WASH; 1.03 No
surveys reduction of maternal tobacco use
India Haddad et al20 Integrated child development Cross-sectional Children 6–24 months, 2006–2012 Nutrition education and counselling; IYCF; Vit A and IFS; 2.2 No
services programme surveys poorest household immunisation; IMCI; FF and FS; deworming; PFSA; SSN;
HFP; women empowerment, child psychosocial stimulation;
community kitchen and garden; telemedicine; WASH;
Nepal Bilukha et al21 The vita-mix-it distribution Pre–post design Bhutanese children 2007–2010 Nutrition education and counselling; MNP; FS; GMP; 4 Yes
programme 6–59 months, Nepal immunisation; deworming
refugee camps
Vietnam Khan et al22 National childhood malnutrition Cross-sectional Children 0–59 months 1990–2004 Immunisation; IMCI; PFSA; HFP; WASH 4.3 Yes
control programme surveys
Latin America Brazil Lima et al23; National health and nutrition Cross-sectional Children 0–59 months, poor 1986–2006 PFSA; SSN; IMCI; parental education; WASH; HFP 8.4 Yes

Hossain M, et al. Arch Dis Child 2017;102:903–909. doi:10.1136/archdischild-2016-311050

Monteiro et al24; programme surveys household
Victora et al25
Haiti Ayoya et al26 National health and nutrition Cross-sectional Children 0–59 months, poor 2006–2012 IYCF; Vit A and IFS; IMCI, immunisation; IMCI; FF; SSN; 1.05 No
programme surveys household HFP; WASH
Mexico Rivera et al27; Oportunidades programme Cross-sectional Children 0–24 months, poor 1988–2006 Nutrition education and counselling; immunisation, GMP; 2.9 No
Leroy et al28 surveys household FS and FF; SSN, women empowerment
Peru Lechtig et al29 The good start in life Before-and-after Rural poor children 2000–2004 Nutrition education and counselling; GMP; IYCF; Vit A and 4.3 Yes
programme design 0–36 months IFS; immunisation; FF; WASH, child psychosocial stimulation
Africa Ethiopia Fenn et al30 The child caring practices Cross-sectional Children 6–36 months, poor 2004–2009 Nutrition education and counselling; IYCF; MNP; IMCI; 2.42 No
project surveys household immunisations; SSN; HFP
Malawi Kalimbira et al31 Integrated community-based Cross-sectional Rural children 6–59 months, 1996–2005 Nutrition education and counselling; Vit A and IFS; FF; 2.4 No
micronutrient and health surveys poor household deworming; malaria prevention and treatment; WASH; HIV
programme testing and referral
Niger Amouzou et al32 Child survival programme Cross-sectional Children 0–59 months, poor 1998–2009 Malaria prevention and treatment 3.3 Yes
surveys household
33
Sub-Saharan Remans et al ; Millennium village Cross-sectional Rural children 0–24 months, 2006–2009 Nutrition education and counselling; GMP; IYCF; Vit A and 6.7 Yes
Africa Pronyk et al34 surveys poor household IFS; MNP; immunisations; IMCI; PFSA; access to local
healthcare; WASH; telemedicine; malaria prevention and
treatment, SSN
AARR, average annual rate of reduction; FF, food fortification; FS, food supplementation; GMP, child growth monitoring and promotion; HFP, health and family planning services; IYCF, infant and young child feeding; MNP, multiple micronutrient powder;
PFSA, Poverty and food security alleviation; SSN, Social safety net; Vit A and IFS, vitamin A and iron-folic acid supplementation; WASH, water, sanitation and hygiene.
Original article

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Table 2 Key concepts/connections linked to programme context and outcome

Key concepts/ Derived from following No. of implemented No. of effective
connections context/theme Programme implemented in LMIC’s programmes programme (≥3 AARR)

Country level Economic growth Bangladesh, India, Brazil, Mexico, Cambodia 6 2

Strong political will
Budget allocation
Multi-sectoral collaboration
Community level Community engagement
Programme level Community-based delivery platform
Wider programme coverage
Programme compliance
Presence of other health/nutrition
programme
Other Social media involvement
Environment (natural calamity,
disease outbreak, etc)
AARR, average rate of reduction; LMICs, low and middle income countries.
Bangladesh, India, Nepal, Vietnam, Brazil, Haiti, Malawi, 10 6
Niger, Peru, sub-Saharan Africa
India, Vietnam, Haiti, Ethiopia, Niger, sub-Saharan Africa 6 3
Bangladesh, Cambodia, India, Nepal, Vietnam, Haiti, Peru, 10 5
Malawi, Niger, Sub-Saharan Africa
Bangladesh, India, Nepal, Haiti, Peru, Ethiopia, Malawi, 10 5
Niger, Sub-Saharan Africa
Bangladesh, India, Nepal, Haiti, Peru, Ethiopia, Malawi, 10 5
Niger, Sub-Saharan Africa
Bangladesh, India, Nepal, Vietnam, Brazil, Mexico, Cambodia, 9 5
Malawi, Niger, Sub-Saharan Africa
Bangladesh, India, Nepal, Vietnam, Brazil, Mexico, Cambodia, 9 5
Malawi, Niger, Sub-Saharan Africa
India, Nepal, Mexico, Ethiopia 4 1
Bangladesh, India, Niger 3 1
Bangladesh, Brazil, Ethiopia, Sub-Saharan Africa 4 3

of nutrition-specific and nutrition-sensitive approaches is
needed for best effect. Even though combined interventional
packages result in the greatest reductions in stunting (4.3–8.4
AARR), there is not necessarily a fixed combination of interven-
tions that consistently demonstrate greatest benefit in all con-
texts. Thus, for Bangladesh, Peru and nine sub-Saharan African
countries there was effective reduction of stunting with nutrition
education and counselling, vitamin supplementation, immunisa-
tion, WASH, food security and SSN programmes. However, the
same combinations of interventions were not similarly effective
in Ethiopia, Haiti, India, Malawi or Mexico.20 26 28 30 31 The
difference may be explained by the need for more secure target-
ing of younger children from rural household, and also the
effects of other programmes or interventions in either the same
or a neighbouring community. It is clear that in addition to geo-
graphical location, the organisation, administration and delivery
of the intervention, as well as the population being targeted has
an effect on the overall effectiveness of the intervention.
However, there may be some settings in which a dominant risk
factor accounts for much of the population attributable fraction
of stunting and where a simple intervention can have profound
impact. For example, malaria prevention and treatment has
shown significant benefit in reducing stunting in regions with
high malarial burden.32–34
The available evidence would not support the suggestion that
any one single intervention or fixed combination of interven-
tions is likely to achieve universal success across all settings in
assuring consistent reductions in stunting. It also became clear
during our analysis that when there was a seeming difference in
the effect of individual components, it was likely that the
context for other related intervention components had changed,
altering the overall balance of possible beneficial mechanisms.
The evidence supports the suggestion that programme managers
and policy makers should identify and implement context spe-
cific intervention packages by addressing all three connections
(country, community and programme) to achieve effective stunt-
ing reduction. At country level, Government’s strong political
commitment and multi-sectoral collaboration between national
and international agencies provides a high level supportive
framework for the formulation and coordination of appropriate
908
policies,35 leading to the design and implementation of suitable
large scale nutrition-related programmes. At the community
level, community engagement enables better community-based
service delivery with wider coverage and beneficiary compli-
ance, enabling programme level interventions to achieve greater
degrees of stunting reduction.36 This review supports the
acknowledgement by WHO that programmes addressing the
contextual factors achieved better reductions in stunting, more
quickly.37
Strengths and weaknesses of this review
There are several important strengths to this analysis. The
review was carried out systematically using established PRISMA
and GRADE guidelines. A realist approach was adopted in
evaluating underlying factors which could account for the mech-
anistic basis underlying programme success. This approach
further helped to structure the evidence to inform recommenda-
tions on stunting reduction in different programmes employing
diverse interventional packages across multiple settings and
geographies. Standardised methods were used to calculate the
AARR for all countries.
The review does have limitations. We included studies pub-
lished in peer-reviewed journals and may have missed important
unpublished data as a result of publication bias. Studies pub-
lished in languages other than English were not included, which
may have resulted in language bias. Finally, because many pro-
grammes combined interventions, it was not possible to attri-
bute the level of stunting reduction directly to the effect of any
single intervention.
CONCLUSION AND RECOMMENDATION
Programmes that combine nutrition-specific and nutrition-
sensitive interventions, particularly those with strong health
access and safety net components, appear to be most effective in
reducing stunting in LMICs. Given the complex nature of these
diverse intervention packages, strong political commitment,
multi-sectoral collaboration, community-based service delivery
platforms and wider programme coverage and compliance are
all likely critical components of effective stunting reduction pro-
grammes. Programme managers and policy makers should
Hossain M, et al. Arch Dis Child 2017;102:903–909. doi:10.1136/archdischild-2016-311050

consider specific contextual factors in order to determine the
most suitable combination of interventions while planning and
implementing programmes to combat stunting.
Acknowledgements This research study was funded by core donors who provide
unrestricted support to ICDDR for its operations and research. Current donors
providing unrestricted support include: Government of the People’s Republic of
Bangladesh; Global Affairs Canada (GAC); Swedish International Development
Cooperation Agency (Sida) and the Department for International Development (UK
Aid). We gratefully acknowledge these donors for their support and commitment to
ICDDR’s research efforts. AAJ acknowledges support from NIHR Southampton
Biomedical Research Centre.
Contributors MH and TA conceptualised the paper. MH contributed to overall
coordination, collating of data sources, data analysis, tables and figures. TA and NC
provided overall statistical and data analysis advice. MH, KABA and PM undertook
the systematic review of published studies searches and abstraction. MH, TA, JW and
AAJ provided input into the overall estimation process. All the authors reviewed and
provided input to the manuscript. The authors alone are responsible for the views
expressed in this article and they do not necessarily represent the views, decisions,
or policies of the institutions with which they are affiliated.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Open Access This is an Open Access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited and the use is non-commercial. See: http://creativecommons.org/
licenses/by-nc/4.0/
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 http://dx.doi.org/10.22435/bpk.v45i4.7465.233-240
Kajian Kebijakan dan Penanggulangan Masalah Gizi Stunting di Indonesia ... (Ni Ketut Aryastami, dan Ingan Tarigan )

Kajian Kebijakan dan Penanggulangan Masalah Gizi Stunting di Indonesia

POLICY ANALYSIS ON STUNTING PREVENTION IN INDONESIA

Ni Ketut Aryastami1, dan Ingan Tarigan2

Puslitbang Humaniora dan Manajemen Kesehatan, 2Puslitbang Sumber Daya dan Pelayanan
1

Kesehatan, Badan Litbang Kementerian Kesehatan RI

Jl. Percetakan Negara 29 Jakarta 10560, Indonesia
E-mail: aryastami@hotmail.com

Submitted : 25-8-2017, Revised : 11-9-2017, Revised : 19-9-2017, Accepted : 23-10-2017

Abstract
Stunting prevalence in Indonesia has been almost stagnant at 37% from year 2007 to 2013. With the cut-
off point greater than 20%, WHO classified Indonesia has a public health problem. The purpose of this
review is to analyze policy related problems and gaps that could be filled as a policy option. Policy analysis
was conducted through searching and analyzing legal documents, policy as well as programs following
the policy formulation. Finally, round table discussion inviting experts was conducted to construct a
recommendation. Stunting prevalence has barely reducing within the last ten year which was only 4%
from 1992 to 2013, though programs and budget allocation has been made, even scaling up nutrition is
mentioned in Presidential Regulation no.42/2013 through National Movement of First Thousand Days
of Life. Stunting has a long term effect that bring about non communicable diseases causing economic
burden, although stunting can be corrected. Serious integrated effort should be taken into account at
all levels as a policy recommendation. Mothers or future brides should be given information of healthy
pregnancy and nutrition. Exclusive breast feeding should be done mandatory to healthy delivery mothers.
In addition, proper complementary feeding should be well understood by mothers and health workers.

Keywords: stunting, policy analysis, Indonesia

Abstrak
Prevalensi stunting di Indonesia memiliki angka cukup stagnan dari tahun 2007 hingga 2013. WHO
menetapkan batasan masalah gizi tidak lebih dari 20%, sehingga dengan demikian Indonesia termasuk
dalam negara yang memiliki masalah kesehatan masyarakat. Tujuan kajian ini adalah untuk mengkaji
kebijakan dan kesenjangan yang dapat dipecahkan melalui opsi kebijakan melalui analisis dokumen
legal dan literatur lainnya serta program yang telah dikembangkan. Kemudian dilakukan forum diskusi
dengan melibatkan pakar dalam menyusun hasil sebagai opsi kebijakan. Penurunan angka stunting
hanya mencapai 4% antara tahun 1992 hingga 2013. Perpres no. 42/2013 telah menetapkan Gerakan
Nasional Seribu Hari Pertama Kehidupan dalam upaya meningkatkan status gizi balita yang diikuti oleh
pengembangan program termasuk anggarannya. Stunting memiliki risiko panjang yakni PTM pada usia
dewasa, walaupun masih dapat dikoreksi pada usia dini. Upaya penurunan masalah gizi harus ditangani
secara lintas sektoral di semua lini. Ibu dan calon pengantin harus dibekali dengan pengetahuan cukup
tentang gizi dan kehamilan, ASI Eksklusif pada ibu bersalin yang sehat. Selanjutnya MPASI harus
dipahami oleh para ibu dan tenaga kesehatan secara optimal.

Kata kunci: stunting, policy analysis, Indonesia

233
 Buletin Penelitian Kesehatan, Vol. 45, No. 4, Desember 2017: 233 - 240
PENDAHULUAN
Stunting merupakan masalah gizi kronis
yang disebabkan oleh multi-faktorial dan bersifat
antar generasi. Di Indonesia masyarakat sering
menganggap tumbuh pendek sebagai faktor
keturunan. Persepsi yang salah di masyarakat
membuat masalah ini tidak mudah diturunkan
dan membutuhkan upaya besar dari pemerintah
dan berbagai sektor terkait. Hasil studi
membuktikan bahwa pengaruh faktor keturunan
hanya berkontribusi sebesar 15%, sementara
unsur terbesar adalah terkait masalah asupan
zat gizi, hormon pertumbuhan dan terjadinya
penyakit infeksi berulang.1,2 Variabel lain dalam
pertumbuhan stunting yang belum banyak disebut
adalah pengaruh paparan asap rokok maupun polusi
asap juga berpengaruh terhadap pertumbuhan
stunting.3
Periode 1000 hari pertama kehidupan
(1000 HPK) merupakan simpul kritis sebagai awal
terjadinya pertumbuhan Stunting, yang sebaliknya
berdampak jangka panjang hingga berulang dalam
siklus kehidupan. Kurang gizi sebagai penyebab
langsung, khususnya pada balita berdampak jangka
pendek meningkatnya morbiditas. Bila masalah ini
bersifat kronis, maka akan mempengaruhi fungsi
kognitif yakni tingkat kecerdasan yang rendah dan
berdampak pada kualitas sumberdaya manusia.
Pada kondisi berulang (dalam siklus kehidupan)
maka anak yang mengalami kurang gizi diawal
kehidupan (periode 1000 HPK) memiliki risiko
penyakit tidak menular pada usia dewasa.4,5
Stunting merupakan masalah kesehatan
masyarakat yang harus ditangani secara serius.
Hasil-hasil Riskesdas menunjukkan, besaran
masalah Stunting yang relatif stagnant sekitar 37%
sejak tahun 2007 hingga 2013 Dari 33 provinsi
yang ada di Indonesia, lebih dari separuhnya
memiliki angka prevalensi diatas rata-rata nasional.
Kesenjangan prevalens Stunting antar provinsi
yang masih lebar antara DIY (22,5%) dan NTT
(58,4%) menunjukkan adanya ketimpangan dan
pembangunan yang tidak merata.6
Prevalensi BBLR menurut Riskesdas
11,1% (2010) dan 10,2% (2013); Proporsi lahir
pendek (<48 cm) sebesar 20,2% (2013). Proporsi
pemberian ASI secara ekslusif selama enam bulan
masih rendah (15,3%). Dari penelitian terdahulu
dinyatakan bahwa ada hubungan yang signifikan
kejadian stunting dengan berat badan lahir7
dan pemberian ASI serta pemberian makanan
234
pendamping ASI yang tidak optimal.8,9
Pertumbuhan Stunting yang terjadi pada
usia dini dapat berlanjut dan berisiko untuk tumbuh
pendek pada usia remaja. Anak yang tumbuh
pendek pada usia dini (0-2 tahun) dan tetap pendek
pada usia 4-6 tahun memiliki risiko 27 kali untuk
tetap pendek sebelum memasuki usia pubertas;
sebaliknya anak yang tumbuh normal pada usia
dini dapat mengalami growth faltering pada usia
4-6 tahun memiliki risiko 14 kali tumbuh pendek
pada usia pra-pubertas.10 Oleh karena itu, intervensi
untuk mencegah pertumbuhan Stunting masih tetap
dibutuhkan bahkan setelah melampaui 1000 HPK.
Fenomena tersebut diatas menarik untuk
dikaji mengingat masalah Stunting memiliki
dampak yang cukup serius; antara lain, jangka
pendek terkait dengan morbiditas dan mortalitas
pada bayi/Balita, jangka menengah terkait dengan
intelektualitas dan kemampuan kognitif yang
rendah, dan jangka panjang terkait dengan kualitas
sumberdaya manusia dan masalah penyakit
degeneratif di usia dewasa.
BAHAN DAN METODE
Analisis kajian dilakukan melalui review
literatur terkait masalah gizi, pertumbuhan dan
outcomenya yakni tumbuh dibawah kurva standar
anthropometri WHO (<-2 standar deviasi).
Kecenderungan pertumbuhan stunting (pendek)
dipelajari dari berbagai literatur dan hasil-hasil
studi sebelumnya yang terkompilasi dari berbagai
survey sejak tahun 1992 (Survey Vitamin A) hingga
Riskesdas 2013.
Literatur review dilakukan dari berbagai
sudut pandang; teori dan jurnal untuk mempelajari
determinan dan faktor risiko terkait variabel
outcome (stunting). Kajian hasil analisis data
Riskesdas 2013 merupakan salah satu informasi
berbasis masyarakat yang digunakan dalam
menganalisis determinan terkait kejadian .
Informasi terkait kebijakan dan program diperoleh
dari sektor-sektor terkait antara lain Bappenas dan
Kementerian Kesehatan. Kebijakan global terkait
gizi diperoleh dengan cara mengunduh dari situs-
situs dunia (WHO, Unicef, dll) melalui teknologi
internet.
Penyusunan draft kajian dilakukan bersama
team peneliti melalui berbagai diskusi, presentasi,
konsultasi dengan pakar. Hasil kajian selanjutnya
dipresentasikan dan didiskusikan melalui seminar
terbuka di Badan Litbangkes dengan melibatkan
 Kajian Kebijakan dan Penanggulangan Masalah Gizi Stunting di Indonesia ... (Ni Ketut Aryastami, dan Ingan Tarigan )
pembahas dari Universitas Indonesia, Direktorat
Bina Gizi Kementerian Kesehatan, Bappenas,
wartawan. Seminar juga dihadiri oleh mahasiswa,
peneliti dan organisasi lainnya yang bergerak
dibidang penanggulangan masalah gizi.
Round Table Discussion (RTD) dilakukan
untuk memaparkan hasil studi dan mendapatkan
pandangan dari para stake holders dan pakar
terkait solusi dan rekomendasi yang mungkin
dikembangkan untuk perencanaan dimasa yang
akan datang.
HASIL
Kebijakan Penanggulangan Stunting
Upaya percepatan perbaikan gizi merupakan
upaya Global, tidak saja untuk Indonesia, melainkan
semua negara yang memiliki masalah gizi stunting.
Upaya ini diinisiasi oleh World Health Assembly
2012.11 Adapun target yang telah ditetapkan dalam
upaya penurunan prevalensi stunting antara lain:
menurunnya prevalensi stunting, wasting dan
dan mencegah terjadinya overweight pada balita,
menurunkan prevalensi anemia pada wanita usia
subur, menurunkan prevalensi bayi berat lahir
rendah (BBLR), meningkatkan cakupan ASI
eksklusif. Sebagai negara anggota PBB dengan
prevalensi stunting yang tinggi turut berupaya dan
berkomitmen dalam upaya percepatan perbaikan
gizi ‘scaling up nutrition (SUN)’ masyarakat.
Upaya tersebut tidak terlepas dari rencana jangka
panjang, menengah dan jangka pendek dengan
mengacu kepada undang-undang yang telah
ditetapkan oleh Badan Legislatif.
Undang-Undang nomor 17/2007 tentang
Rencana Pembangunan Jangka Panjang (2005-
2025) menyebutkan, pembangunan pangan dan
perbaikan gizi dilaksanakan secara lintas sektor
meliputi produksi, pengolahan, distribusi, hingga
konsumsi pangan dengan kandungan gizi yang
cukup, seimbang, serta terjamin keamanannya.
Selanjutnya, Undang-Undang Kesehatan nomor
36 tahun 2009 tentang Kesehatan menyebutkan,
arah perbaikan gizi adalah meningkatnya mutu gizi
perorangan dan masyarakat melalui, perbaikan
pola konsumsi makanan yang sesuai dengan gizi
seimbang; perbaikan perilaku sadar gizi, aktivitas
fisik, dan kesehatan; peningkatan akses dan mutu
pelayanan gizi yang sesuai dengan kemajuan
ilmu dan teknologi; dan peningkatan sistem
kewaspadaan pangan dan gizi. Sejalan dengan
kedua undang-undang tersebut, terbit Undang-
Undang tentang Pangan nomor 18 tahun 2012 yang
menetapkan kebijakan di bidang pangan untuk
perbaikan status gizi masyarakat. Pemerintah
dan Pemerintah Daerah menyusun Rencana Aksi
Pangan dan Gizi setiap 5 (lima) tahun.
Dari ketiga undang-undang tersebut
selanjutnya diterbitkan Perpres N0. 5/ 2010 tentang
Rencana Pembangunan Jangka Menengah (2010-
2014) menyebutkan, arah Pembangunan Pangan
dan Gizi yaitu meningkatkan ketahanan pangan dan
status kesehatan dan gizi masyarakat. Selanjutnya,
Inpres No. 3/2010 menegaskan tentang penyusunan
Rencana Aksi Nasional Pangan dan Gizi (RAN-
PG) 2011-2015 dan Rencana Aksi Daerah Pangan
dan Gizi (RAD-PG) 2011-2015 di 33 provinsi.
Peraturan Presiden nomor 42/2013 tentang
Gerakan Nasional Perbaikan Gizi diterbitkan untuk
mendukung upaya penggalangan partisipasi dan
kepedulian pemangku kepentingan secara terencana
dan terkoordinir untuk percepatan perbaikan gizi
dalam 1000 hari pertama kehidupan (1000 HPK).
Dengan demikian, instrumen pendukung kebijakan
dalam percepatan perbaikan gizi sudah cukup
lengkap, dan membutuhkan upaya implementasi
yang terorganisir dan dapat diterapkan disetiap
tingkatan oleh setiap elemen yang terlibat. Dengan
terbitnya Perpres ini, dibutuhkan upaya yang
lebih konkrit, fokus pada 1000 HPK dan integrasi
kegiatan secara lintas program (upaya spesifik)
maupun lintas sektoral (upaya sensitif) oleh semua
stakes holders.
Masalah Balita Stunting di Indonesia
Prevalensi Balita stunting di Indonesia
cukup tinggi. Distribusinyapun tidak merata,
antara desa kota maupun antar provinsi. Hasil-
hasil survey yang pernah dilakukan di Indonesia
dari tahun 1992 hingga 2013, atau selama sekitar
20 tahun, penurunan prevalensi stunting hanya
sebesar 4%. Bahkan proporsi sekitar 37% tampak
stagnan dari tahun 2006 hingga 20136. Tabel 1
memberikan gambaran prevalensi secara lebih
spesifik berdasarkan hasil survey.
Menurut hasil Riset Kesehatan Dasar 2013,
kesenjangan antar provinsi tampak cukup lebar,
yakni proporsi 20% (Yogyakarta) hingga 48%
(NTT). Stunting sebagai masalah gizi yang bersifat
kronis tidak dapat dipisahkan dengan masalah gizi
kurang secara umum. Masalah gizi kurang (BB/U
<-2 SD) menurut data Riskesdas menunjukkan
proporsi yang cukup stagnan, yaitu 18,4% (2007);
17,9% (2010); dan 19,6% (2013). Masalah stunting
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tidak hanya terkait dengan faktor asupan gizi, tetapi di Indonesia yang cukup tinggi, yaitu 10,2%
faktor lain seperti pola asuh, penyakit infeksi dan (2010) dan 11,1% (2013). Riskesdas 2013 juga
kesehatan lingkungan. menunjukkan tingginya proporsi dan kesenjangan
Keterlambatan pertumbuhan fisik (growth bayi yang lahir pendek (<48 cm), yaitu 28,7%
faltering) bayi di Indonesia sudah mulai tampak (NTT) dan 9,6% (Bali), dengan rata-rata nasional
pada usia 3-6 bulan12). Pertumbuhan bayi lahir sebesar 20,2%. Selanjutnya proporsi bayi yang
hingga usia 3 bulan tampak sesuai dengan kurva lahir BBLR (<2500 gram) dan pendek (<48 cm)
pertumbuhan WHO-Anthro. Meskipun tampak nasional sebesar 4,3%, dan tertinggi di Papua
ada penurunan prevalensi stunting sebesar 5% (7,6%).
antara tahun 1989 dan 2005, hasil-hasil Riskesdas
menunjukkan, prevalensinya tampak hampir Masalah efek sisa dalam pertumbuhan
stagnan sebesar 37% hingga tahun 2013. Hasil penelitian longitudinal data Indo-
nesian Family Life Survey (IFLS) menunjukkan
Tabel 1. Prevalensi Balita Pendek / Stunted di perubahan Z-score pertumbuhan pada usia dini
Indonesia hingga usia pra-pubertas; pendek pada usia dini dan
STUNTING tidak berhasil mengejar (catch up) pertumbuhannya
SURVEI
(≤ -2SD) pada usia Balita sebanyak 77% akan tetap pendek
Suvita (Survei Nasional Vit. A), Tahun 1992 41,4 pada usia pra-pubertas. Sebaliknya, anak yang
(15 Provinsi) pendek pada usia dini dan berhasil mengejar
IBT (Indonesia Bagian Timur), Tahun 1991 44,5 pertumbuhannya pada usia Balita, sebanyak
(4 Provinsi)
84% akan tumbuh normal pada usia pra-pubertas
SKIA (Survei Kesehatan Ibu dan Anak) 45,9
(Aryastami, 2015). Oleh karena itu upaya perbaikan
Nasional Tahun 1995
dan intervensi untuk mencegah stunting tetap
JPS (Jaring Pengaman Sosial) 43,8
dibutuhkan pada usia balita. Untuk lebih jelasnya,
Survei masalah gizi di 7 Provinsi 36,3
(Puslitbang gizi 2006)
perubahan pertumbuhan (pengukuran melalui
Riskesdas 2007 (Badan Litbangkes) 36,8
Z-score pertumbuhan) pada usia dini hingga usia
pra-pubertas tampak seperti dalam tabel 3.
Riskesdas 2010 (Badan Litbangkes) 35,6
Riskesdas 2013 (Badan Litbangkes) 37
Tabel 3. Perubahan Z-score Pertumbuhan Anak
Hasil analisis mendalam terhadap data
Usia Dini hingga Usia Pra-opubertas
Riskesdas dan hasil studi kohort di Kota Bogor
Karakteristik Persen TB/U (Z-score) Usia 7-9 tahun
untuk pertumbuhan anak hingga usia 24 bulan Pertumbuhan <-2 SD ≥-2 SD Total
ditunjukkan dalam tabel 2. (n=301) (%) (%)
02N – 46N 10,1 89,9 138
Tabel 2. Proporsi Pertumbuhan Stunting pada Usia 02P – 46P 77,1 22,9 70
Dini
02N – 46P 59,5 40,5 42
USIA PROPORSI (%) SUMBER DATA
02P – 46N 15,7 84,3 51
6 bulan 22,4
TOTAL 33,6 66,4 301
1 tahun 27,3 Studi Kohort Tumbuh Kem-
bang Bogor, 2015 (n=220)
Keterangan:
2 tahun 36,1
• 02 dan 46 = kelompok umur usia 0-2 dan 4-6 tahun
3 tahun 40,9
• N = pertumbuhan normal P = pertumbuhan pendek
0-11 bulan 20,2 Riskesdas 2013 (n=14.956)
12-23 bulan 40,4 Riskesdas 2010 (n=3.024)
Gangguan pertumbuhan dapat berawal
0-23 bulan 32,9 Riskesdas 2013 (n=30.933)
dari dalam kandungan. Janin yang tumbuh dalam
kandungan ibu yang mengalami kurang gizi kronis
Terdapat hubungan pertumbuhan stunting (KEK) akan beradaptasi dengan lingkungannya.
dengan bayi berat lahir rendah (BBLR). Stunting Penyesuaian pertumbuhan janin tersebut
berhubungan dengan pengaruh gizi dalam siklus menyebabkan pertumbuhan yang tidak optimal atau
kehidupan yang berulang dari generasi ke generasi. retardasi yang dikenal dengan istilah intra uterine
Hasil Riskesdas menunjukkan, prevalensi BBLR growth retardation (IUGR).13

236
 Kajian Kebijakan dan Penanggulangan Masalah Gizi Stunting di Indonesia ... (Ni Ketut Aryastami, dan Ingan Tarigan )
Anemia ibu hamil juga sering dihubungkan
dengan kelahiran prematur dan BBLR. Selain
pengaruh KEK pada kehamilan, hasil Riskesdas
2013 menunjukkan proporsi ibu hamil dengan
anemia di Indonesia mencapai 37,1%. Kondisi
ini tentunya akan memperparah resiko BBLR
dan pertumbuhan stunting pasca lahir. Berbagai
program telah dikembangkan untuk menjaga
kesehatan ibu hamil dan janin, diantaranya adalah
pemberian tablet tambah darah (TTD). Sayangnya,
hasil Riskesdas 2013 kembali menunjukkan
bahwa cakupan konsumsi TTD pada ibu hamil
hanya mencapai 33,2%, atau dengan kata lain,
hanya 1 dari 3 ibu hamil mengkonsumsi cukup
tablet tambah darah. Hasil studi kohort di Bogor
menunjukkan, pertambahan berat badan ibu selama
kehamilan <9,1 kg mencapai 22,7%. Studi ini juga
menunjukkan, pada ibu hamil dengan usia kurang
dari 20 tahun proporsi pertambahan berat badannya
semakin rendah pada usia kehamilan yang semakin
tua; artinya, terjadi perebutan zat gizi antara ibu
dan janin yang dikandungnya, sehingga bayi akan
mengalah dan tumbuh tidak optimal.
Hasil-hasil Riskesdas menunjukkan, status
kesehatan reproduksi di Indonesia masih rendah.
Bila hal ini dihubungkan dengan masalah gizi
dalam lingkaran kehidupan, maka sangat beralasan
bila masalah stunting sulit untuk diturunkan dan
stagnan selama periode 2007 hingga 2013. Pendek
merupakan kondisi yang tidak dapat diperbaiki lagi
ketika usia sudah dewasa. Pertumbuhan mengalami
puncak pertumbuhannya pada usia remaja (pada
wanita usia 10-12 tahun pada laki-laki usia 12-14
tahun). Pertumbuhan setelah usia tersebut masih
terjadi, tetapi melambat dan hampir terhenti setelah
melampaui usia 20 tahun. Tinggi badan kurang dari
150 cm pada ibu hamil berisiko untuk melahirkan
anak BBLR terkait plasenta dan pinggul ibu yang
kecil.
Selanjutnya, kurang energi kronik tampak
sudah memiliki proporsi tinggi pada WUS yang
tidak hamil; sementara pada ibu hamil proporsinya
hampir mencapai 40%. Demikian juga dengan
proporsi anemia (Tabel 4).
Tabel 4. Status Kesehatan Reporoduksi di Indonesia
(Riskesdas 2013)
Karakteristik
Ibu Hamil Wanita Usia Subur
(%) (%)
Pendek (< 150 cm) 31,3 NA
KEK (IMT <18,5) 38,5 46,6
Risiko KEK (LILA 24,2 20,8
<23,5 cm)
Anemia 37,1 19
Masalah retain effect (efek sisa) dapat
berlanjut dari dalam kandungan hingga posnatal,
bahkan hingga usia dewasa. Hipotesis Barker
tentang fetal programming menyatakan,
konsekuensi masalah gizi didalam kandungan
dapat berlanjut hingga dewasa, yang dapat menjadi
faktor risiko penyakit .
degeneratif.14 Penelitian melalui hewan
coba menunjukkan, resistensi insulin sebagai pre-
disposing faktor terjadinyua penyakit degeneratif
akibat gangguan pertumbuhan sel organ yang
belum mencapai puncaknya ketika lahir.15
Efek sisa pertumbuhan anak pada usia dini
terbawa hingga usia pra-pubertas. Peluang kejar
tumbuh melampaui usia dini masih ada meskipun
kecil. Ada hubungan kondisi pertumbuhan (berat
badan lahir, status sosial ekonomi) usia dini
terhadap pertumbuhan pada anak usia 9 tahun.16
Anak yang tumbuh normal dan mampu mengejar
pertumbuhannya setelah usia dini 80% tumbuh
normal pada usia pra-pubertas.
Tingginya masalah stunting di Indonesia
tidak semata-mata karena faktor BBLR yang
memiliki prevalensi sebesar 10,2%, tetapi panjang
badan lahir yang tidak optimal (<48 cm) yang
mencapai 20,2%. Pendek pada usia dini berisiko
4,5 kali stunting pada usia 4-6 tahun dan 3,8 kali
pada usia pra-pubertas.
Tabel 5. Efek Sisa Pertumbuhan Usia Dini terhadap
Usia Pra-pubertas
TB/U (Z-score) TB/U (Z-score) <-2 SD
Usia 0-2 tahun Usia 4-6 tahun Usia 7-9 tahun
(n=301) Usia 4-6 tahun Usia 7-9 tahun
• Pendek 62,5 61,4
• Normal 26,9 29,5
OR 4,51 3,79
95% CI (2,74-7,43) (2,29-6,28)
p 0,000 0,000
Sumber : Aryastami, 2015
Selanjutnya, dibandingkan dengan mereka
yang tumbuh normal pada usia dini hingga usia
pra-pubertas, risiko pertumbuhan pendek pada
usia dini dan tetap pendek pada usia 4-6 tahun
berisiko 27 kali untuk tumbuh pendek pada usia
pra-pubertas dan pertumbuhan normal pada usia
dini dan pendek pada usia 4-6 tahun berisio 14 kali
pendek pada usia pra-pubertas. Bila pencegahan
stunting pada periode emas tidak terkejar, maka
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 Buletin Penelitian Kesehatan, Vol. 45, No. 4, Desember 2017: 233 - 240
pencegahan stunting pra-pubertas tetap harus
dioptimalkan hingga usia 5 tahun.
PEMBAHASAN
Di Indonesia, kebijakan Scaling up Nutri-
tion telah diterjemahkan kedalam Gerakan Nasio-
nal Seribu Hari Pertama Kehidupan. Mengingat
masalah gizi merupakan masalah yang memiliki
variabel multi faktorial, maka implementasinyapun
membutuhkan keterlibatan lintas sektor. Studi
mengenai keberhasilan implementasi kebijakan
penurunan masalah gizi melalui berbagai metode
(sistematik review, kuantitative riset, semi kualitatif
interview, analisis pohon masalah) menunjukkan
bahwa implementasi kebijakan penurunan masalah
gizi secara global tidak mudah. Setidaknya terdapat
delapan kelemahan variabel yang masih menjadi
kendala, antara lain: masalah koordinasi yang sulit,
strategi yang tidak cukup kuat, minat yang kurang
dari stake holders, jaringan antar stake holders
yang tidak kuat, masih lemahnya power dalam
merekat kebijakan, struktur dalam kolaborasi yang
tidak sama, sumberdaya manusia yang terbatas,
tidak terjaminnya ketersediaan anggaran.17
Sebagai negara anggota Perserikatan
Bangsa- Bangsa, Indonesia telah berkomitmen
untuk turut menurunkan prevalensi stunting
yang masih menjadi masalah dalam kesehatan
Masyarakat. Terbitnya Perpres no. 42/2013
merupakan salah satu strategi dalam SUN dengan
melibatkan lintas sektor. Perpres ini menjadi penting
seperti telah disebutkan dalam berbagai dokumen
dan penelitian bahwa stunting berhubungan dengan
kemiskinan, pendidikan rendah, beban penyakit,
pemberdayaan perempuan yang masih rendah.18,19
Prevalensi stunting yang cukup stagnan
selama lebih dari lima tahun di Indonesia tidak
sejalan dengan pertumbuhan ekonomi dan
pembangunan yang semakin membaik. Secara
teoritis kemiskinan dituduhkan sebagai penyebab
mendasar masalah gizi.20 Studi di Bangladesh
menunjukkan hubungan kemiskinan dengan
masalah gizi kurang dan buruk ditemukan pada
ibu yang buta huruf, pendapatan rumah tangga
yang rendah, memiliki saudara kandung yang lebih
banyak, memiliki akses pada media yang lebih
rendah, asupan gizi yang lebih buruk, serta sanitasi
dan kesehatan lingkungan yang lebih rendah.21
Namun demikian, kesenjangan pembangunan
antar wilayah di Indonesia tampaknya berpengaruh
terhadap disparitas prevalensi stunting yang
238
cukup lebar. Hasil studi di Ghana menyebutkan,
kemiskinan dan karakteristik wilayah sebagai
penyebab kesenjangan dalam masalah gizi pada
anak balita.22 Namun demikian, hasil studi dari
negara-negara miskin dan sedang berkembang
membuktikan bahwa tidak ada hubungan antara
laju pertumbuhan ekonomi dengan masalah
gizi kurang pada usia dini.23 Dengan demikian
dibutuhkan upaya yang serius dalam penangan
masalah gizi stunting pada usia dini bahkan dalam
1000 hari pertama kehidupan sebagai periode emas
dalam pencegahan pertumbuhan stunting.24,25
Pertumbuhan tidak optimal dalam masa
janin dan atau selama periode 1000 HPK memiliki
dampak jangka panjang. Bila faktor eksternal
(setelah lahir) tidak mendukung, pertumbuhan
stunting dapat menjadi permanen sebagai remaja
pendek. Hasil-hasil penelitian menunjukkan
bahwa mereka yang memiliki ukuran lebih
kecil atau stunting ketika lahir, secara biologis
memiliki ukuran yang berbeda dari mereka yang
lahir dengan ukuran lebih besar.26-28 Masalah
pertumbuhan stunting sering tidak disadari oleh
masyarakat karena tidak adanya indikasi ‘instan’
seperti penyakit. Tumbuh pendek seringkali
dianggap sebagai pengaruh genetik, padahal
faktor genetik hanya menjelaskan 15% variasi
dibandingkan faktor gizi.29 Efek sisa pertumbuhan
dapat menjadi predisposing terjadinya penyakit
kronik pada usia dewasa; upaya memperbaiki
lingkungan pertumbuhan masa janin dapat
sekaligus mengurangi risiko penyakit degeneratif
diusia dewasa.30,31 Oleh karena itu, penanggulangan
masalah stunting harus dimulai jauh sebelum
seorang anak dilahirkan (periode 100 HPK) dan
bahkan sejak masa remaja untuk dapat memutus
rantai stunting dalam siklus kehidupan.
KESIMPULAN
Untuk mencegah masalah stunting
dibutuhkan upaya yang bersifat holistik dan saling
terintegrasi. Peraturan Presiden Nomor 42 Tahun
2013 harus disikapi dengan koordinasi yang kuat
di tingkat pusat dan aturan main dan teknis yang
jelas di tingkat provinsi, kabupaten/kota, hingga
pelaksana ujung tombak. Diseminasi informasi
dan advocacy perlu dilakukan oleh unit teknis
kepada stake holders lintas sektor dan pemangku
kepentingan lain pada tingkatan yang sama. Untuk
jajaran struktural kebawahnya perlu dilakukan
knowledge transfer dan edukasi agar mampu
 Kajian Kebijakan dan Penanggulangan Masalah Gizi Stunting di Indonesia ... (Ni Ketut Aryastami, dan Ingan Tarigan )
menjelaskan dan melakukan pemberdayaan dalam
meningkatkan status gizi masyarakat.
Selanjutnya, perlu penguatan sistem agar
1000 HPK dapat menjadi bagian dari budaya
dan kehidupan sosial di masyarakat (misal: ibu
merasa malu bila tidak memberikan ASI secara
eksklusif kepada bayinya). Selanjutnya, informasi
mengenai ASI eksklusif, untung-ruginya menyusui
bayi sendiri hingga menjadi donor ASI dapat
dikembangkan melalui kelas ibu hamil. Dengan
demikian, motivasi ibu untuk menyusui bayinya
muncul karena kesadaran, bukan karena dipaksa.
Pengetahuan ibu sebelum kehamilan atau
sebelum menjadi pengantin (calon pengantin)
merupakan target strategis yang paling
memungkinkan untuk memberikan daya ungkit.
Kursus singkat menjelang perkawinan harus
dijadikan prasyarat untuk memperoleh surat nikah.
Intervensi ini dapat menjadi bekal ibu sebelum
hamil agar menjaga kehamilannya sejak dini,
dimana tumbuh kembang kognitif janin terbentuk
pada trimester pertama kehamilan. Status gizi dan
kesehatan ibu hamil yang optimal akan melahirkan
bayi yang sehat. Bayi yang lahir sehat dan dirawat
dengan benar melalui pemberian ASI eksklusif,
pola asuh sehat dengan memberikan imunisasi
yang lengkap, mendapatkan makanan pendamping
ASI (MPASI) yang berkualitas dengan kuantitas
yang cukup dan periode yang tepat.
Generasi yang tumbuh optimal alias tidak
stunting memiliki tingkat kecerdasan yang lebih
baik, akan memberikan daya saing yang baik
dibidang pembangunan dan ekonomi. Disamping
itu, pertumbuhan optimal dapat mengurangi
beban terhadap risiko penyakit degeneratif
sebagai dampak sisa yang terbawa dari dalam
kandungan. Penyakit degeneratif seperti diabetes,
hipertensi, jantung, ginjal merupakan penyakit
yang membutuhkan biaya pengobatan tinggi.
Dengan demikian, bila pertumbuhan stunting dapat
dicegah, maka diharapkan pertumbuhan ekonomi
bisa lebih baik, tanpa dibebani oleh biaya-biaya
pengobatan terhadap penyakit degeneratif.
UCAPAN TERIMA KASIH
Ucapan terimakasih disampaikan kepada
Pusat Humaniora dan Manajemen Kesehatan,
Badan Litbang Kesehatan yang telah memberikan
kesempatan kepada penulis untuk melakukan
kajian ini. Terimakasih kepada Prof. dr. Endang
L. Achadi, MPH, Dr.PH dan Dr. Triono, MSc
selaku team pakar. Akhirnya, terimakasih kepada
Dr. Atmarita, MPH sebagai tim peneliti yang telah
memberikan banyak masukan dalam penulisan
kajian ini.
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 Paediatrica Indonesiana
p-ISSN 0030-9311; e-ISSN 2338-476X; Vol.58, No.3(2018). p. 123-7; doi: http://dx.doi.org/10.14238/pi58.3.2018.123-7
Correlation between non-exclusive breastfeeding and
low birth weight to stunting in children
Endang Dewi Lestari, Faraissa Hasanah, Novianto Adi Nugroho
Abstract
Background Indonesia is ranked fifth in the world for the problem
of stunting. Stunting in children under the age of five requires
special attention, due to its inhibiting effect on children’s physical
and mental development. Stunting has been associated with several
factors, one of which is non-exclusive breastfeeding.
Objective To determine the correlations between non-exclusive
breastfeeding and low birth weight to stunting in children aged
2-5 years.
Methods This case-control study was conducted in October to
November 2016 in multiple integrated health service clinics (po-
syandu) in Sangkrah, Surakarta, Central Java, Indonesia. Subjects
were children aged 24-59 months who visited the posyandu and
were included by purposive sampling. Children classified as stunted
were allocated to the case group, whereas the children classified
with normal nutritional status were allocated to the control group.
Parents filled questionnaires on history of exclusive breastfeeding,
child’s birth weight, maternal education, and family socio-economic
status.
Results Of the 60 subjects, the control group had 30 normal
children and the case group had 30 stunted children. Multivariate
analysis by logistical regression test revealed statistically significant
correlations between stunting and non-exclusive breastfeeding
(adjusted OR for exclusive breastfeeding 0.234; 95%CI 0.061 to
0.894), as well as low birth weight (adjusted OR 10.510; 95%CI
1.180 to 93.572) This value implies that exclusive breastfeeding is
a protecting factor against stunting, which means exclusive breast-
feeding is able to decrease the prevalence of stunting in children
under the age of five.
Conclusion In children aged 2-5 years, the histories of non-exclu-
sive breastfeeding and low birth weights are significantly correlated
sith stunting. [Paediatr Indones. 2018;58:123-7; doi: http://
dx.doi.org/10.14238/pi58.3.2018.123-7].
Keywords: exclusive breastfeeding; stunting;
children 24-59 months
Original Article
S
tunting is a chronic nutritional deficiency
caused by inadequate nutritional intake
for an extended period, due to improper
feeding. Chronic nutritional deficiency will
influence the body length.1,2 Stunting is defined as
a Z-score of <-2 SD for body height to age ratio
(BH/A) or body length to age ratio (BL/A), according
to the World Health Organization (WHO) Child
Growth Standard.3 Indonesia is currently one of
117 countries worldwide with three highly prevalent
nutritional problems in toddlers: stunting, wasting, and
overweight, as reported in the 2014 Global Nutrition
Report of Indonesia.4,5 The Indonesian Ministry of
Health 2013 Basic Health Data (Riskesdas) reported a
37.2% prevalence of stunting in children under the age
of five in Indonesia, which had increased compared
to 2007 (36.8%), and 2010 (35.6%).4
Stunting in children under the age of five
requires special attention due to inhibiting effects
on physical and mental development. Stunting at
early ages can increase the risk of mortality and
morbidity, as well as suboptimal body posture as
adults. 1 The WHO/UNICEF global strategy on
From the Department of Child Health, Sebelas Maret University Medical
School/Dr. Moewardi Hospital, Surakarta, Central Java, Indonesia.
Reprint request to: Endang D. Lestari. Department of Child Health,
Sebelas Maret University Medical School/Dr. Moewardi Hospital. Kolonel
Sutarto Street, No. 132, Jebres, Surakarta, Central Java 57126, Indonesia.
Tel. +628122659230. Email: endang_t@yahoo.com.
Paediatr Indones, Vol. 58, No. 3, May 2018 • 123
 Endang Dewi Lestari et al.: Correlation between non-exclusive breastfeeding and low birth weight to stunting
feeding infants and young children recommends
four important points to achieve optimal growth and
development: early breastfeeding initiation (EBI) in
the first 30 minutes of life, exclusive breastfeeding
for the first 6 months of life, giving complementary
food accompanied by breastfeeding at 6-24 months
of age, and continuous breastfeeding for 2 years or
more.6,7 Growth and development during infancy
requires balanced nutrition, as the toddler’s intestinal
system is still in the process of maturing. Breast milk
contains numerous factors that meet the nutritional
needs of infants according to their age.8 Also, breast
milk also contains immunological substances that
can prevent infections in infants. Yet, the latest data
have shown that exclusive breastfeeding behavior in
the first 6 months of life remains inappropriately with
the recommendation.5-7 The 2015 WHO/UNICEF
Data on Infant and Young Child Feeding showed that
only 39% of babies in developing countries received
exclusive breastfeeding from 0-5 months.6 Hence,
we aimed to determine the correlation between non-
exclusive breastfeeding and the incidence of stunting
in children aged 2-5 years.
Methods
This observational analytic study with a case-control
approach was done in October – November 2016 to
analyze for a relationship between a history of exclusive
breastfeeding and stunting in children aged 2-5 years.
Subjects were patients aged 24-59 months at multiple
integrated health service clinics (posyandu) under the
auspices of the primary health care integrated service
unit in Sangkrah, Surakarta, Central Java, Indonesia.
Children’s nutritional status was assessed by way of
body height/age (BH/A) index. Stunted children
were allocated to the case group and children without
stunting were allocated to the control group. Subjects’
parents provided written informed consent. Children
with infection or other chronic conditions at the time
of the study were excluded.
Sixty children were included by purposive
sampling, to which the rule of thumb was applied,
resulting in 30 subjects per group.9 Data on exclusive
breastfeeding, birth weight, maternal education, and
socio-economic status based on Surakarta's minimum
wage were collected using questionnaires. Low socio-
124 • Paediatr Indones, Vol. 58, No. 3, May 2018
economic level was defined as family income of less
than the minimum regional wage of Surakarta in 2016,
which was rounded up to Rp 1,400,000. Education
level was defined as the length of education less than
9 years and higher than 9 years. Body height was
measured three times, using a microtoise with 0.1cm
accuracy, and mean values were calculated. The
measurements were conducted on the same day or
within three days at most of the interview.
The dependent variable of this study was stunted
nutritional status, while the independent variable
was the history of exclusive breastfeeding. External
variables were the maternal educational status, socio-
economic status, and history of low birth weight.
Chi-square test was used for bivariate analysis
and logistical regression test was used for multivariate
analysis, using statistical product and service solution
(SPSS) 24.0 for Mac, with significance of P<0.05.
The Research Ethics Committee of Sebelas Maret
University Medical School, Surakarta, approved this
case control study.
Results
Table 1 shows that the case group had a rather balanced
sex ratio, with 15 children of each sex. The control
group consisted of 14 boys (46.7%) and 16 girls (53.7%).
The independent variable of exclusive breastfeeding
was differentiated into exclusively breastfed or not
exclusively breastfed. In the case group, 17 children
(56.7%) were exclusively breastfed, while 13 children
(43.3%) were not exclusively breastfed in other words,
they receved infant formula or complementary foods. In
the control group, 26 children (86.7%) were exclusively
breastfed, and 4 children (13.3%) were not exclusively
breastfed. There were 6 children in the case group and
one in the control group who did not receive breast
milk the first day of life.
Low birth weight was defined as birth weight <
2500 grams. The case group had 9 children (30%)
with a history of low birth weight and 21 children
(70%) with normal birth weight. In the control group,
1 child (3.3%) had a history of low birth weight, while
29 children (96.7%) had normal birth weight.
Maternal education was classified as either low
(less than 9 years) or high (more than 9 years). In
the case group, 10 subjects (33.3%) had low, while
 Endang Dewi Lestari et al.: Correlation between non-exclusive breastfeeding and low birth weight to stunting

20 (66.7%) had high maternal educational status. In Multivariate analysis by logistical regression test
the control group, 14 subjects (46.7%) had low and 16 similarly revealed statistically significant correlations
(53.3%) had high maternal educational status. between stunting and non-exclusive breastfeeding
Socio-economic status was classified as low (adjusted OR for exclusive breastfeeding 0.234;
(< IDR 1400000 monthly income) or high (> IDR P=0.034), as well as low birth weight (adjusted OR
1400000 monthly income). In the case group, 21 10.510; P=0.035) (Table 3).
children (70.0%) had low and 9 children (30.0%)
had high socio-economic status. In the control group, Table 3. Multivariate analysis
24 children (83.3%) had low and 6 children (16.6%) Variables Adj OR P value 95%CI
had high socio-economic status. Overall, 45 children Eclusive breastfeeding 0.234 0.034 0.061 to 0.894
(75%) had parents with low socio-economic status Low birth weight 10.510 0.035 1.180 to 93.572
and 15 children (25.5%) had parents with high socio-
economic status (Table 1).
Discussion
Table 1. Characteristics of subjects
Characteristics Case group Control group
There was a significant relationship between non-
(n=30) (n=30) exclusive breastfeeding and stunting in children
Sex, n (%) aged 24-59 months. More children with normal
Male 15 (50.0) 14 (46.7) nutritional status received exclusive breastfeeding
Female 15 (50.0) 16 (53.3)
(86.7%) than stunted children (56.7%). Bivariate
Exclusive breastfeeding, n (%) analysis showed that exclusive breastfeeding was a
Yes 17 (56.7) 26 (86.7)
No 13 (43.3) 4 (13.3) protective factor against stunting, with OR 0.201.
Birth weight, n (%) Furthermore, multivariate analysis revealed that
Low 9 (30.0) 1 (3.3) exclusive breastfeeding was still a protective factor,
Normal 21 (70.0) 29 (96.7) with OR 0.234 (95%CI 0.061 to 0.894). A 2010
Maternal education, n (%) study in Banda Aceh similarly reported that stunting
Low 10 (33.3) 14 (46.7)
High 20 (66.7) 16 (53.3)
in children under the age of five was associated with
Socio-economic status, n (%)
non-exclusive breastfeeding, with a 5 times higher risk
Low 21 (70.0) 24 (83.3) of stunting than children under five who had received
High 9 (30.0) 6 (16.6) exclusive breastfeeding.10
According to interviews, most mothers gave
their children formula in addition to breast milk. Their
Table 2 shows the bivariate statistical analysis reasons variations in breast milk production, infant lack
results. Chi-square test revealed that stunting had of appetite for breast milk, and maternal work outside
significant correlations with non-exclusive breastfeeding the home. Feeding of formula and breast milk can satisfy
(OR for exclusive breastfeeding: 0.201; P=0.010) and the nutritional requirements of the child, but formula
low birth weight (OR 12.429; P=0.006). There were lacks antibodies. As such, the child would be prone to
no significant correlations between stunting and sex diseases.11 Breast milk contains numerous immunological
(P=0.796), maternal education (P=0.292), or socio- substances not found in formula, such as immunoglobins
economic status (P=0.371). that can prevent disease, secretory substances that can

Table 2. Bivariate statistical analysis

Variables OR 95%CI P value
Sex 0.875 0.318 to 2.410 0.796
Exclusive breastfeeding 0.201 0.056 to 0.721 0.010
Maternal education 1.750 0.616 to 4.97 0.292
Low birth weight 12.429 1.461 to 105.737 0.006
Socio-economic status 1.714 0.371 to 5.621 0.523

Paediatr Indones, Vol. 58, No. 3, May 2018 • 125

 Endang Dewi Lestari et al.: Correlation between non-exclusive breastfeeding and low birth weight to stunting
neutralize pathogenic E. coli and multiple viruses of the
digestive track, as well as lactoferrin, an immunological
substance that binds iron from the digestive track and
has bactericidal properties.12 Breast milk also contains
a 65:35 ratio of whey to casein, while formula has a
ratio of 20:80. As such, proteins and other substances
in breast milk tend to be more easily absorbed compared
to formula milk.12
More children with history of low birth weight
were in the case group than in the control group. We
found that history of low birth weight increased the risk
of stunting more than 12 times compared to those with
normal birth weight. A Zimbabwe study also found that
more infants with history of low birth weight (41.4%)
experienced stunting.13 The effect of birth weight on
stunting happens in the first 6 months of life, then
decreases until the age of 24 months. As such, if infants
can catch up in their growth in the first 6 months
of life, there is a higher chance for them to achieve
normal body height.14 Infants with history of low birth
weight have been shown to have growth retardation
in utero, both acutely and chronically. Hence, these
children are prone to infections such as diarrhea and
lower respiratory tract infections, as well as increased
probability of icterus, anemia, chronic lung problems,
exhaustion, and loss of appetite compared to children
with normal birth weight.15 In our study, 70% of those
in the case group had a history of normal birth weight.
This may have been due to inadequate nutrition in
these otherwise normal infants, which caused growth
faltering (failure to thrive).16
We found no significant relationship between
socio-economic status and stunting (P=0.371). Low
socio-economic status was noted in 70% of the case
group, and 83.3% of the control group. In contrast,
a study in the North Moluccas reported a significant
relationship between stunting/severe stunting and low
socio-economic status in children aged 0-59 months.17
The food consumed by low income families is less
varied and lower in quantity, particularly in terms of
nutrition required for childhood growth, such as sources
of protein, minerals, and vitamins. As such, there is a
higher risk of malnutrition in these children.18 The
contrasting results in our study may have been due to
different socio-economic measurements.
Low parental education level, of both fathers and
mothers, may increase the risk of stunting, but we did
not find this to be the case in our study. We found no
126 • Paediatr Indones, Vol. 58, No. 3, May 2018
significant relationship between stunting and maternal
educational level (P=0.292). Similarly, Nasikhah
(2012) in East Semarang reported that bivariate and
multivariate analyses revealed no statistical significance
between stunting and maternal educational level.19
This finding may have been due to the mothers with
high educational status giving their infants formula,
because they work outside home and cannot breastfeed
their children. Working mothers have less time for their
children, perhaps leading to malnutrition in a later stage
and influencing growth and development.20
In conclusion, there is a significant relationship
between non-exclusive breastfeeding and stunting.
Breastfeeding may be a protective factor against
stunting in children under the age of five. Low birth
weight infant also have a significant relationship
with stunting. Further study should include not yet
investigated variables, a larger sample size, and larger
population coverage.
In light of our findings, we suggest that health
workers, promote breastfeeding to mothers during
pregnancy and after delivery. Mothers should be
informed of the recommended practice of breastfeeding
from childbirth to the age of 6 months, and about
factors affecting the nutritional status of children
aged 24-59 months, specifically to prevent stunting. In
addition, expecting and new mothers should educate
themselves on the nutritional requirements of infants,
and early detection of stunting, so that they can lower
the risk in their toddlers.
Conflict of Interest
None declared.
Funding Acknowledgment
The authors received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
References
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Paediatr Indones, Vol. 58, No. 3, May 2018 • 127
Journal of Maternal and Child Health (2019), 4(6): 486-498
https://doi.org/10.26911/thejmch.2019.04.06.09

The Associations between Exclusive Breastfeeding,

Complementary Feeding, and the Risk of Stunting
in Children Under Five Years of Age: A Path
Analysis Evidence from Jombang East Java

Baroroh Barir1), Bhisma Murti2), Eti Poncorini Pamungkasari3)

1)MastersProgram in Nutrition, Universitas Sebelas Maret

2)MastersProgram in Public Health, Universitas Sebelas Maret
3)Faculty of Medicine, Universitas Sebelas Maret

ABSTRACT

Background: Stunting in children becomes a health problem that gets priority and must be
addressed immediately. Delayed development, a decrease in cognitive function and immune
function and the risk of diabetes mellitus, coronary heart disease, hypertension and obesity are the
effects of stunting. This study aimed to analyze the determinants of stunting in children aged 2-3
years in Jombang, East Java.
Subjects and Method: This was an analytic observational study with case control design. The
study was carried out at Plandaan and Kabuh community health centers, Jombang, East Java, from
March to April 2019. A sample of 200 children aged 2-3 years old was selected by fixed disease
sampling. The dependent variable was stunting. The independent variables were maternal age,
maternal height, maternal attitudes, maternal occupation, birth length, infant birth weight,
exclusive breastfeeding, breastfeeding, family income, mother's education, and mother's know-
ledge. The data collection was done using questionnaires and analyzed with path analysis.
Results: Stunting was directly and negatively affected by birth length ≥ 48 cm (b= -2.37; 95% CI=
-3.25 to -1.50; p <0.001), infant birth weight ≥ 2500 g (b= -1.43; 95% CI= -2.53 to -0.32; p= 0.011),
exclusive breastfeeding (b= -1.09; 95% CI= -1.90 to -0.28; p= 0.008), and timely complementary
feeding (b= -1.09; 95% CI= -1.94 to -0.24; p= 0.012). Stunting was indirectly affected by family
income, maternal age, maternal attitude, maternal height >150 cm, employed mother, maternal
education, and maternal knowledge.
Conclusion: Stunting is directly and negatively affected by birth length ≥48 cm, birth weight ≥
2500 g, exclusive breastfeeding, timely complementary feeding. It was indirectly affected by family
income, maternal age, attitude, maternal height >150 cm, employment, education, and knowledge.

Keywords: stunting, determinants, path analysis

Correspondence:
Baroroh Barir. Masters Program in Nutrition, Universitas Sebelas Maret, Jl. Ir. Sutami No. 36 A,
Surakarta 57126, Central Java. Email:barorohbarir5@gmail.com.Mobile: +6281331940865.

BACKGROUND pays attention to stunting in children under

One of the goals in the health sector, the
Sustainable Development Goals (SDGs)
mentions the target of community nutri-
tion, namely in 2030, ending all forms of
malnutrition, including achieving the inter-
national target of 2025 for reducing
stunting and wasting for children under five
(Ministry of Health, 2015). The government
the age of 2-3, one of which is through the
national and international nutrition move-
ment, namely the Scaling Up Nutrition
(SUN) movement (Singh, 2016). Stunting
events in the world are estimated at around
22.2% of children under five. The results of
basic health research (2018) in Indonesia,
in 2013 around 37.2% of children under five

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 Barir et al./ The Associations between Exclusive Breastfeeding
were stunting and dropped to 30.8% with
the fifth largest prevalence of stunting.
Stunting will have an impact on the level of
intelligence and be more vulnerable to
disease and increase poverty and widen
inequality (Kusumawati et al., 2015).
Stunting is influenced by low mater-
nal education factors, height <145 cm, age
<20 years and ≥ 35 years, lack of know-
ledge and negative maternal attitudes.
Armstrong et al (2011) stated that the level
of education caused stunting because of the
lack of the ability of mothers to receive
information about nutrition. Other factors
were maternal height <150 cm due to
pathological conditions such as deficiency
of plant hormones and increased chances of
inheriting these genes so that children grow
into stunting (Onis and Branca, 2016).
Huda et al. (2017) explained that the
lack of maternal knowledge related to
health behavior and environmental hygiene
had an effect on the occurrence of infec-
tious diseases as well as mothers who work-
ed at risk of having stunting children
because of the lack of maternal attention to
children's nutritional needs. Akram et al
(2018) also explained that stunting is
affected by the administration of MP-ASI
too early.
SUBJECTS AND METHOD
1. Study Design
This was an analytic observational study
with case control design. The study was
conducted at Plandaan and Kabuh commu-
nity health centers, Jombang, East Java,
from March to April 2019.
2. Population and Samples
The source population in this study was
from all stunting children aged 2-3 years at
Plandaan and Kabuh community health
centers, Jombang, East Java. A sample of
200 children aged 2-3 years old was
selected by fixed disease sampling.
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3. Study Variables
The dependent variable was stunting. The
independent variables were maternal age
during pregnancy, maternal height, atti-
tude, employment status, birth length, birth
weight, exclusive breastfeeding, comple-
mentary feeding, family income, maternal
education, and maternal knowledge.
4. Operational Definition of variables
Stunting. Stunting was the value of calcu-
lating height for children aged 2 - 3 years
according to age which is expressed by
standard deviation, in which the value of Z-
score <- 2 SD, measured by microtoise.
Maternal age. Maternal age was age
based on date of birth on birth certificate
when retrieving data in years, measured by
questionnaire.
Maternal height. Maternal height was
height based on anthropometric measure-
ments, measured by microtoise.
Birth length. Birth length was the length
measured after birth and recorded in the
maternal and child health book.
Birth weight. Birth weight was a measure
of a child's weight weighed shortly after
birth and recorded in maternal and child
health book.
Exclusive breastfeeding. Exclusive
breastfeeding was breastfeeding without
the addition of any food or drink to children
from birth to age 6 months. It was mea-
sured by questionnaire.
Family income. Family income was the
average amount of fixed and side income
from the family head, mother and other
family members in the last 1 month. It was
measured by questionnaire.
Maternal education. Maternal education
was the last formal education attained by
mother. It was measured by questionnaire.
Maternal knowledge. Maternal knowledge
was maternal ability to answer questions
about good nutrition for pregnant women.
It was measured by questionnaire.
487
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https://doi.org/10.26911/thejmch.2019.04.06.09
Maternal attitude. Maternal attitude was
the response of the beliefs held by pregnant
women to nutritional intake that must be
consumed and fulfilled, during pregnancy
in the form of positive or negative response.
It was measured by a questionnaire.
Maternal occupation. Maternal occupa-
tion was a form of activity carried out by
the subjects to earn income. It was mea-
sured by a questionnaire.
5. Data Analysis
Univariate analysis was performed to see
the frequency distribution and the per-
centage of the characteristics of the study
subjects. Bivariate analysis was conducted
to study the relationship between stunting
and independent variables using chi-
square. Multivariate analysis carried out
using path analysis run on Stata 13. Step of
of path analysis was model specification,
model identification, model fit, parameter
estimation, and model re-specification.
6. Research Ethics
Research ethics included informed consent,
anonymity, confidentiality, and research
ethics. Research ethics was obtained from
Faculty of Medicine, Universitas Sebelas
Maret, Surakarta with number 114/ UN27.-
06/KEPK/2019.
RESULTS
1. Sample Characteristics
The study subject was 200 children aged 2-
3 years old in Jombang, East Java. Sample
characteristic was described in Table 1.
Table 1 shows that almost all of 155
subjects or 87.5% had birth lengths ≥ 48
cm, birth weight ≥2,500 g (87.5%), exclu-
sive breastfeeding (61.0%), timely comple-
mentary feeding was 136 children (68.0%).
As many as 159 mothers (79.5%) were at
healthy reproductive age (<20 or >35 years
old). Half of the study subjects had low
income (50.5%). Mostly (93.5%) of mater-
nal height was >150 cm.
488
2. Bivariate Analysis
Bivariate analysis was used to see the
correlation between independent variables
of maternal age, maternal height, maternal
attitude, maternal occupation, birth length,
infant birth weight, exclusive breastfeeding,
breastfeeding, family income, maternal
education and knowledge of mothers with
dependent variable stunting based on the
results in Table 2.
Table 2 shows the results of bivariate
analysis. Table 2 shows that birth length ≥
48 cm (OR = 0.07; p <0.001), birth weight
≥ 2500 g (OR = 0.14; p <0.001), exclusive
breastfeeding (OR = 0.22; p <0.001), timely
complementary feeding (OR= 0.35; p=
0.002), family income (OR= 0.05; p=
0.041), positive attitude (OR= 0.33; p=
0.001) reduced the risk of stunting.
Age at high risk of pregnancy (OR =
0.76; p = 0.500), working outside the home
(OR = 1.13; p = 0.722), good maternal
knowledge (OR= 0.90; p = 0.743), high
maternal education (OR= 1.00; p = 1,000),
maternal height >150 cm was statistically
not significant with stunting.
3. Path Analysis
Figure 1 shows the structural model after
estimation using STATA and shows the
suitability of the path analysis model as
follows:
Table 3 shows that there was a direct
and negative influence on birth weight on
stunting, and the effect was statistically
significant. Children who were born at
gram 2500 grams had logods for stunting
of 1.43 units lower than those with birth
weight <2500 grams (b = -1.43; 95% CI -
2.53 to -0.32; p = 0.011). There was a direct
and negative influence on birth length on
stunting, and the effect was statistically
significant. Children whose birth length ≥
48 cm had a logodd for stunting of 2.37
units lower than children with birth length
<48 cm (b = -2.37; CI 95% -3.25 to -1.50; p
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 Barir et al./ The Associations between Exclusive Breastfeeding

<0.001). There was a direct and negative stunting 1.09 units (b= -1.09; 95% CI= -
effect of timely complementary feeding on 1.90 to -0.28; p= 0.008). There was an
stunting. Timely complementary feeding indirect and positive effect of family income
reduced logodd of stunting 1.09 units (b= - on stunting through infant birth. Children
1.09; 95% CI= -1.94 to -0.24; p= 0.012). with high family income had logodd to
There was a direct and negative effect of experience normal birth weight of 1.01 units
exclusive breastfeeding on stunting. Exclu- higher than low family income (b= 1.01;
sive breastfeeding decreased logodd of 95% CI= 0.08 to 1.95; p= 0.033).
Table1. Subjects Characteristics
Characteristics Frequency (n) Percentage (%)
Birth Body Length
< 48 cm 45 22.5
≥ 48 cm 155 87.5
Infant Birth Weight
< 2500 gram 25 12.5
≥ 2500 gram 175 87.5
Exclusive breastfeeding
No 78 39.0
Yes 122 61.0
Complementary feeding
Not on time 64 32.0
On time 136 68.0
Stunting
No Stunting 150 75.0
Stunting 50 25.0
Maternal Age
≥ 20-35 years 159 79.5
< 20 years or > 35 years 41 20.5
Maternal education
Low (<Senior high school) 112 56.0
High (≥Senior high school) 88 44.0
Maternal occupation
Working at home 140 70.0
Working outside the house 60 30.0
Family Income
Low (< Rp 1,800,000) 101 50.5
High (≥Rp 1,800,000) 99 49.5
Maternal height
<150 cm 13 6.5
>150 cm 187 93.5
Attitude
Negative 69 34.5
Positive 131 65.5
Maternal knowledge
Poor 92 46.0
Good 108 54.0

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Table2. BivariateAnalysis
Stunting
Total
Independent Variables No Yes OR p
N % N % N %
Birth height
< 48 cm 15 33.3 30 66.7 45 100 0.07 <0.001
≥ 48 cm 135 87.1 20 12.9 155 100
Birth weight
< 2500 g 9 36.0 16 64.0 25 100 0.14 <0.001
≥ 2500 g 141 80.6 34 19.4 175 100
Exclusive breastfeeding
No 45 57.7 33 42.3 78 100 0.22 <0.001
Yes 105 86.1 17 13.9 122 100
Complementary feeding
Late 39 60.9 25 39.1 64 100 0.35 0.002
Timely 111 81.6 25 18.4 136 100
Family Income
Low (<Rp 1,800,000) 68 68.7 31 31.3 99 100 0.051 0.041
High (≥Rp 1,800,000) 82 81.2 19 18.8 101 100
Maternal Age
Healthy Reproduction Age 113 73.9 40 26.1 153 100 0.76 0.500
High Risk Age 37 78.7 10 26.1 47 100
Maternal Attitude
Negative 42 60.9 27 39.1 69 100
Positive 108 82.4 23 17.6 131 100 0.33 0.001
Occupation
At home 106 75.6 34 24.3 140 100
Outside of home 44 73.3 16 26.7 60 100 1.13 0.722
Knowledge
Poor 68 73.9 24 26.1 92 100
Good 82 75.9 26 24.1 108 100 0.90 0.743
Education
Low (< SHS) 84 75 28 25.0 112 100 1000 1000
High (≥ SHS) 66 75.0 22 25.0 88 100
Maternal Height
< 150 cm 30 71.4 12 28.6 42 100 0.79 0.548
> 150 cm 120 75.9 38 24.1 158 100

There was an indirect and negative complementary feeding and exclusive

effect of maternal age on stunting through
infant birth weight, and the effect was
statistically significant. Children of maternal
age who were at high risk of having logodd
to experience a normal baby's birth weight
are 1.10 units lower than the age of mothers
who had healthy reproductions (b= -1.10;
95% CI= -2.00 to -0.19; p= 0.018). There
was an indirect and positive influence of the
mother's attitude towards stunting through
breastfeeding, and the effect was statistically
significant. Children with positive maternal
attitudes had logodd to experience timely
complementary feeding of 0.79 units higher
than negative maternal attitude (b= 0.79;
95% CI= 0.17 to 1.40; p= 0.012). Children
with positive maternal attitude had logodd
for experience exclusive breastfeeding of
0.75 units higher than negative maternal

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 Barir et al./ The Associations between Exclusive Breastfeeding

attitude (b= 0.75; 95% CI= 0.14 to 1.34; p= 0.014).

Figure 1. Structural Model of Path Analysis

Table 3. The results of path analysis

95%
Dependent
IndependentVariabel b Lower Upper p
Variable
Limit Limit
Direct Effect
Stunting  Birth weight (≥ 2500 gram) -1.43 -2.53 -0.32 0.011
 Birth length (≥48 cm) -2.37 -3.25 -1.50 <0.001
 Timely complementary feeding -1.09 -1.94 -0.24 0.012
 Exclusive breastfeeding -1.09 -1.90 -0.28 0.008
Indirect Effect
Birth weight  Family Income (≥Rp 1,800,000) 1.01 0.08 1.95 0.033
Maternal age (<20 or ≥35 year old -1.10 -2.00 -0.19 0.018
Timely comple-  Maternal attitude (positive) 0.79 0.17 1.40 0.012
mentary feeding
Exclusive  Maternal attitude (positive) 0.75 0.14 1.34 0.014
breastfeeding
Family Income  working outside of house 0.70 0.09 1.32 0.025
Attitude  good knowledge 1.41 0.79 1.32 <0.001
Occupation  Education (≥Senior high school) 0.79 0.02 1.25 0.041
Knowledge  Education (≥Senior high school) 0.79 0.21 1.36 0.007
Birth length Maternal height (> 150 cm) 1.87 0.70 3.04 0.007
N Observation = 200
Log likehood=-10009
AIC=2063.25
BIC= 2135.81

There was an indirect and positive income, and the effect was statistically
effect of work on stunting through family significant. Children with mothers who

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work outside the home have logodd to
experience high family income of 0.70 units
higher than maternal work in the home (b=
0.70; CI 95%= 0.09 to 1.32; p= 0.025).
There was an indirect and positive effect of
knowledge on stunting through attitudes,
and the effect was statistically significant.
Children with positive maternal attitudes
had logodd to experience good maternal
knowledge of 1.41 units higher than nega-
tive attitudes (b= 1.41; 95% CI= 0.79 to
1.32; p <0.001).
There was an indirect and positive
effect of education on stunting through
work and knowledge. Children with high
maternal education had logodd to expe-
rience working mothers outside the home
by 0.79 units higher than low maternal
education (b= 0.79; 95% CI= 0.02 to 1.25;
p= 0.041) and children with high maternal
education had logodd to experience know-
ledge women with a total of 0.79 units were
higher than low maternal education (b=
0.79; 95% CI= 0.21 to 1.36; p= 0.007).
There was an indirect and positive effect of
maternal height on stunting through birth
length, and the effect was statistically
significant. Children with maternal height
>150 cm had logodds to experience birth
length >48 cm at 1.87 units higher than
maternal height <150 cm (b = 1.87; CI 95%
0.70 to 3.04; p = 0.007).
DISCUSSION
1. The effect of infant birth weight on
stunting in children aged 2-3 years
The results showed that there was a signi-
ficant effect of infant birth weight on the
incidence of stunting. Birth weight is one of
the determinants of stunting factors
(Rahayu et al., 2018). Low birth weight
influenced the growth and development of
a baby that was slower than the baby born
with normal weight.
492
Infants with low birth weight since
the womb had experienced inter-uterine
inter-growth retardation and could con-
tinue until the next age after birth that is
experiencing slower growth and develop-
ment than those born to normal, and had
an impact on failure to grow and develop
according to age. Based on studies con-
ducted, it was shown that low birth weight
babies had a risk of 10.51 times for stunting
compared to normal birth weight (Lestari et
al., 2018).
2. The effect of birth length on stunt-
ing in children aged 2-3 years
The results showed that there was a signi-
ficant effect between birth length on the
incidence of stunting. Stunting reflects the
inability to achieve optimal growth caused
by health status and / or suboptimal nutri-
tional status (Rahmadi, 2016). Short birth
length will have an impact on the child's
height in early childhood and adulthood
(Dorelien, 2016).
Short-born body lengths have a 2.4
times risk for stunting at ages 6-12 months
compared to children who have normal
birth lengths (Rahayu, 2011). Rahmawati et
al (2018) explained that body length ≥ 48
cm had a risk of 0.90 times for not expe-
riencing stunting compared to birth length
<48 cm.
3. The effect of complementary feed-
ing on stunting in children aged 2-
3 years
The results showed that there was a signi-
ficant influence between timely comple-
mentary feeding on stunting. Timely com-
plementary feeding was one of the factors
that influence the incidence of stunting
(Ministry of Republic of Indonesia, 2012).
Akram et al. (2018) explained that stunting
is influenced by the administration of
complementary feeding too early (infants
less than 6 months) and the occurrence of
infectious diseases (diarrhea). Giving food
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 Barir et al./ The Associations between Exclusive Breastfeeding
and drinks other than breast milk in infants
aged 0-6 months caused babies to expe-
rience digestive disorders one of which was
diarrhea and if the treatment was not good
it can lead to stunting in children.
According to Uwiringiyimana et al.
(2019) explained that the timely comple-
mentary feeding reduces the incidence of
stunting. Giving complementary feeding by
giving zinc supplements has the possibility
of 1.89 to increase body weight seen from
the z-score compared to those not given
supplements.
4. The effect of exclusive breastfeed-
ing on stunting in children aged 2-
3 years
The results showed that there was a signi-
ficant effect between exclusive breastfeed-
ing on the incidence of stunting. Failure of
growth after birth is a reflection of exclusive
breastfeeding that is less precise and causes
stunting (Rahmadi, 2016). The effort to
reduce the incidence of stunting is to
optimize exclusive breastfeeding for 6
months.
Proper exclusive breastfeeding can
provide protection against gastrointestinal
infections that can cause nutritional deple-
tion that causes stunting (Kramer and
Kakuma, 2012). Lestari et al. (2018)
explained that exclusive breastfeeding can
reduce the incidence of stunting which has
a 0.23 times probability of not stunting
compared to those who are not given
exclusive breastfeeding.
5. The effect of family income on
stunting in children aged 2-3 years
The results showed that there was a
significant effect between family income on
the incidence of stunting.
Family income during pregnancy
increases development in children through
the birth weight of the child, thereby
reducing the incidence of stunting (Conant
et al., 2017). Families with high income
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have the ability to meet nutritional needs
and choose good health services for
children so that they will prevent infectious
diseases that cause stunting.
Nshimyiryo et al. (2019) explained
that family income has an important role in
providing an effect on the welfare and
health-oriented standard of living, thereby
reducing the possibility of stunting.
6. The effect of maternal age on
stunting in children aged 2-3 years
The results showed that there was a
significant influence between the age of the
mother during pregnancy on the incidence
of stunting. According to Jiang (2015),
pregnant women over the age of 35 have a
risk of giving birth to stunting children 2.74
times compared to mothers who give birth
at the age of 25-35 years.
Asiyah et al. (2010) also explained
that pregnancies with a gestational age of
20-35 years are a safe period because of the
maturity of the reproductive and mental
organs for pregnancy and childbirth. A
study conducted by Fall et al. (2015)
showed that children from mothers less
than 19 years old have higher risk of
experiencing impaired growth so that they
are quite short in age at 2 years by 30-40%.
7. The effect of maternal attitude on
stunting in children aged 2-3 years
The results showed that there was a signi-
ficant effect between maternal attitudes
toward the incidence of stunting through
complementary feeding and exclusive
breastfeeding. According to Mardewi et al
(2016), a positive attitude is one of the
determinants of factors that influence
exclusive breastfeeding.
The results of the study of Astuti and
Isroni (2013) showed that there was a rela-
tionship between attitude and exclusive
breastfeeding behavior. Mothers with posi-
tive attitudes towards exclusive breastfeed-
ing have the possibility to give exclusive
493
Journal of Maternal and Child Health (2019), 4(6): 486-498
https://doi.org/10.26911/thejmch.2019.04.06.09
breastfeeding compared to mothers who
are negative (Vijayalakshmi et al., 2015).
Kismul et al. (2018) exclusive breastfeeding
can reduce stunting because the calcium
content in breast milk is more efficiently
absorbed. Indicators that need to be con-
sidered in the administration of comple-
mentary feeding are the age of giving com-
plementary feeding, the type of comple-
mentary feeding, the frequency of comple-
mentary feeding, the portion complemen-
tary feeding, and the provision of comple-
mentary feeding in early stages (Lestari,
2014). Tessema (2013) explained that
mother's positive attitude towards comple-
mentary feeding provides an important role
for fulfilling infant nutrition and is able to
stimulate eating skills and self-confidence
in infants.
8. The effect of maternal occupation
on stunting in children aged 2-3
years
The results showed that there was a signi-
ficant effect between the occupation of
mothers on the incidence of stunting.
Mardiyanti and Kurniawati (2014) explain
that highly educated women are usually
busy with activities outside the home
because of work, but by working, mothers
are able to increase family income so that
the tendency to meet family food needs is
better. The higher the family income, the
mother tends to switch to formula milk so
that the mother no longer gives ASI to her
baby (Susiloretni, 2014). Illahi (2017)
explains that mothers who work outside the
home can cause children to be poorly cared
for so that the pattern of parenting will be
affected and fulfill the child's nutritional
needs thereby increasing the chances of
stunting.
9. The effect of knowledge on stunt-
ing in children aged 2-3 years
The results showed that there was a signi-
ficant effect between maternal knowledge
494
on the incidence of stunting. Kamiyaet al
(2018) explained that negative maternal
attitudes related to food had an effect on
negative maternal actions and behaviors
which had an impact on children's nutri-
tional problems, one of which was stunting.
According to Zainudin (2014), poor
nutrition knowledge of mothers is influ-
enced by the attitude of lack of care about
nutrition, so that it will have an impact on
the growth and development of their
children. Based on the results of the study,
it was found that there was a direct influ-
ence on birth length, infant birth weight,
exclusive breastfeeding and MP-ASI and
was directly influenced by family income,
maternal age, maternal attitudes, maternal
height, occupation, education, and
knowledge.
10. The effect of maternal education
on stunting in children aged 2-3
years
The results showed that there was a signi-
ficant influence between education on the
incidence of stunting through work and
knowledge. Alfianrisa et al (2017) explained
that high education is related to the occu-
pation of mothers outside the home,
thereby reducing exclusive breastfeeding
and increasing the risk of stunting. Accord-
ing to Garti et al (2018) mothers who work
at home can apply more time to provide the
best parenting style and mothers can focus
more on caring for children and influencing
better child development. Mothers who
work outside the home have 5.38 times the
risk of stunting compared to housewives.
Maternal education is useful in receiving
information about nutrition and external
health problems so that the mother is able
to choose and serve food for the family and
reduce the incidence of stunting (Makoka
and Masibo, 2015).
A study conducted by Abuya et al
(2015) shows that low education <high
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 Barir et al./ The Associations between Exclusive Breastfeeding
school had a risk of 1.28 times the occur-
rence of stunting compared to children
whose mothers are highly educated.
11. The effect of maternal height on
stunting in children aged 2-3
years
The results showed that there was a
significant effect between maternal height
on the incidence of stunting in children
aged 2-3 years. The determinant of the
factors that influence birth length is one of
them is maternal height (Addo et al., 2013).
According to Sinha et al (2018) birth
length is influenced by maternal height
because it is based on biological aspects
associated with internal factors, namely
factors from the mother (genetic factors) so
that it is associated with the incidence of
stunting. The results of the study are in line
with the study conducted by Indriyani et al
(2018) showing that mothers with <150 cm
maternal height had a risk of 1.39 times to
have children with birth length <48 cm
thus increasing the risk of stunting.
Based on the results of the study, it
can be concluded that there was a direct
influence of birth length, infant birth
weight, exclusive breastfeeding and MP-
ASI and is directly influenced by family
income, maternal age, maternal attitudes,
maternal height, occupation, education and
knowledge.
AUTHOR CONTRIBUTION
Baroroh Barir was the main author who
played a role in collecting and processing
the data. Bhisma Murti and Eti Poncorini
Pamungkasari examined the framework of
research concepts and methodologies.
FUNDING AND SPONSORSHIP
This study was self-funded.
e-ISSN: 2549-0257
CONFLICT OF INTEREST
There is no conflict of interest.
ACKNOWLEDGMENT
We would like to thank Bhisma Murti and
Eti Poncorini Pamungkasari who reviewed
this study. We also thank the public health
centers for helping with the study and the
participating mothers and children who
were willing to be the subjects.
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 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

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

hemi.ftrn@yahoo.com

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 Cigugur District has the different population

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.
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

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
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 Eksklusive Total
Formula Breastfeeding
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
Third International Seminar on Global Health (3rd ISGH)
Vol 3 | No. 1 | October 2019 |
Children Under Fivein One of The City in Indonesia
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 OR
N % N % value (CI 95%)
Formula Milk 27 67,5 11 27,5 5,476
(CI 95% :
0,00 2,099 –
Exclusive
Breastfeeding 13 32,5 28 72,5 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
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 The Risk Factors of Exclusive Breastfeeding on Stunting Among
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
Third International Seminar on Global Health (3rd ISGH)
Vol 3 | No. 1 | October 2019 |
Children Under Fivein One of The City in Indonesia
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
Page 188
 The Risk Factors of Exclusive Breastfeeding on Stunting Among
out of stunting prevention by giving an education
and health promotion about the advantages of
exclusive breastfeeding to prevent stunting.
REFERENCES
Anggraini, Y. (2013). Pengaruh Demografi Dan
Sosioekonomi Pada Kejadian Kekurangan
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Provinsi Lampung. Jurnal Kesehatan. Vol.
IV.No.2.
Boutwell, B. B., Beaver, K. M., &Bames, J. C.
(2012) Role of breastfeeding in childhood
cognitive development: a propensity score
matching analysis. Journal of Paediatrics and
Child Health. 48(9):840-5. doi: 10.1111/j.1440-
1754.2012.02547.x.
Budijanto, D.(2018). Situasi Balita Pendek
(Stunting) di Indonesia. Jakarta : Kementrian
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Dahlan, M. S. (2010). Besar Sampel Dan Cara
Pengambilan Sampel dalam Penelitian
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Dewi, E. K., et al.(2017). Hubungan Tingkat
Kecukupan Zat Besi Dan Seng Dengan Kejadian
Stunting Pada Balita 6-23 Bulan. Jurnal
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Masyarakat-Universitas Airlangga.
Dewi, N. T., et al.(2018). Hubungan Berat Badan
Lahir Rendah Dan Penyakit Infeksi Dengan
Kejadian Stunting Pada Baduta Di Desa Maron
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Ip, S., Chung, M., Raman, G., Chew, P., Maqula,
N., Devine, D., rikalinos, T., & Lau, J. (2007).
Breastfeeding and maternal and infant health
outcomes in developed countries. Evid Rep
Technol Assess. 153: 1-186.
Kementrian kesehatan RI.2018.
BukuSakuPemantauan Status Gizi 2017. Jakarta
Larasati D.A, et al. (2018).Hubungan Antara
Kehamilan Remaja Dan Riwayat Pemberian ASI
Dengan Kejadian Stunting Pada Balita Di
Wilayah Kerja Puskesmas Pujon Kabupaten
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Surabaya : Universitas Airlangga.
Nurkarimah, et al. (2018).hubungan durasi
pemberian ASI esklusif dengan kejadian
stunting pada anak. Jurnal Fakultas
Kepewrawatan vol. 5.Pekan Baru.
Sari,E.M, et al. (2016). Asupan Protein, Kalsium
Dan FosforPadaAnak Stunting Dan Tidak
Stunting Usia 24-59 Bulan. Jurnal Gizi Klinik
Indonesia.Vol 12.No. 4. Jurusan Minat Umum
Gizi Dan Kesehatan, Program S2 Ilmu
Kesehatan Masyarakat, Dan Fakultas
Kedokteran Universitas Gajah Mada
Yogyakarta.
Soetjiningsih.(2015).Tumbuh Kembang Anak Ed.
2.Jakarta: Buku Kedokteran EGC.
WHO.(2017).Stunted Growth and
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Wiyono, S.(2016).Epidemiologi Gizi (Konsep dan
Aplikasi). Jakarta : CV.Sagung
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 Apri Sulistianingsih, dkk: ASI eksklusif dan berat lahir berpengaruh terhadap stunting pada balita 2-5 tahun di Kabupaten Pesawaran
Jurnal Gizi Klinik Indonesia
Vol 15 No 2 - Oktober 2018 (45-51)
ISSN 1693-900X (Print), ISSN 2502-4140 (Online)
Online sejak Januari 2016 di https://jurnal.ugm.ac.id/jgki

ASI eksklusif dan berat lahir berpengaruh terhadap stunting pada

balita 2-5 tahun di Kabupaten Pesawaran
Exclusive breastfeeding and birth weight have an effect on stunting in children 2-5 years in Pesawaran Regency
Apri Sulistianingsih1, Rita Sari2

1
Program Studi DIII Kebidanan STIKes Muhammadiyah Pringsewu
2
Program Studi Ners STIKes Muhammadiyah Pringsewu

ABSTRACT
Background: Stunting cases in infants in Indonesia continue to be a maternal and child health problem. Stunting cases in Pesawaran
District increase every year. Some of the factors that influence the incidence of stunting in children include the history of exclusive
breastfeeding and low birth weight (LBW). Objective: This study aims to determine the effect of exclusive breastfeeding and birth
weight on stunting in children 2-5 years cases in the Pesawaran District. Method: This research used observational analytics
with a cross-sectional approach. This research was conducted in March-May 2017 in 12 Puskesmas on Pesawaran Lampung
District. The number of samples was 385 samples. The variables studied in this study were the incidence of stunting, history of
LBW and history of exclusive breastfeeding. Analysis and present data using the Chi-Square test and multiple logistic regression.
Results: Children with a history of LBW (OR=12.30; 95% CI:3.663-41.299) and exclusive breastfeeding history (OR=0.122;
95% CI:0.075-0.199) were significantly associated with the incidence of stunting. The multivariate analysis explained the history
of exclusive breastfeeding with OR=0.108 (CI 95%: 0.065-0.180) and birth weight with OR=17.063 (CI 95%: 4.892-59.511).
Conclusion: Children with exclusively breastfeeding 9.3 times less risk for stunting than children non-exclusive breastfeeding or
exclusive breastfeeding provides a protective effect against stunting in children 2-5 years. Children with an LBW history had a
risk of 17.063 times greater for stunting than children with normal birth weight.

KEY WORDS: exclusive breastfeeding; LBW; stunting

ABSTRAK
Latar belakang: Kasus stunting pada balita di Indonesia masih menjadi masalah kesehatan ibu dan anak. Kasus stunting di
Kabupaten Pesawaran meningkat setiap tahunnya. Beberapa faktor yang mempengaruhi kejadian stunting pada balita diantaranya
adalah riwayat ASI eksklusif dan bayi berat lahir rendah (BBLR). Tujuan: Penelitian ini bertujuan untuk mengetahui pengaruh
ASI eksklusif dan berat lahir terhadap stunting pada balita 2-5 tahun di Kabupaten Pesawaran. Metode: Penelitian observasional
analitik dengan pendekatan cross-sectional yang dilaksanakan pada Maret-Mei 2017 di 12 Puskesmas Kabupaten Pesawaran
Lampung dan jumlah sampel sebanyak 385 sampel. Variabel yang diteliti adalah kejadian stunting, riwayat BBLR, dan riwayat ASI
eksklusif. Analisis data menggunakan uji Chi-Square dan regresi logistik ganda. Hasil: Balita dengan riwayat BBLR (OR=12,30;
CI 95%:3,663-41,299) dan riwayat ASI eksklusif (OR=0,122; CI 0,075-0,199) berhubungan signifikan dengan kejadian stunting
pada balita 2-5 tahun. Demikian juga dengan hasil analisis multivariat yaitu riwayat ASI eksklusif dengan nilai OR=0,108 (CI 95%:
0,065-0,180) dan berat lahir dengan nilai OR=17,063 (CI 95%: 4,892-59,511). Simpulan: Balita yang memperoleh ASI eksklusif
berisiko 9,3 kali lebih kecil untuk terjadi stunting dibandingkan balita yang tidak memperoleh ASI eksklusif atau ASI eksklusif
memberikan efek proteksi terhadap terjadinya stunting pada balita. Sebaliknya, pada berat bayi lahir, ditemukan bahwa balita dengan
riwayat BBLR berisiko 17,063 kali lebih besar untuk mengalami stunting dibandingkan balita dengan riwayat berat lahir normal.

KATA KUNCI: ASI eksklusif; BBLR; stunting

Korespondensi: Apri Sulistianingsih, STIKes Muhammadiyah Pringsewu, Jl. Makam KH. Ghalib No.112, Pringsewu Utara, Kec. Pringsewu, Kabupaten Pringsewu,
Lampung 35373, Indonesia, Telp. 0822-8021-9225, e-mail: sulistianingsih.apri@gmail.com

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Jurnal Gizi Klinik Indonesia, Vol. 15, No. 2, Oktober 2018: 45-51

PENDAHULUAN memengaruhi terjadinya stunting. Tingkat keparahan

stunting menunjukkan kecenderungan menurun pada
Secara global, diperkirakan 26% balita mengalami
anak yang diberikan ASI eksklusif (10).
stunting (1). Menurut data riset kesehatan dasar
Kabupaten Pesawaran merupakan kabupaten yang
(Riskesdas) tahun 2013, kasus balita pendek (stunting)
tergolong baru karena diresmikan pada tahun 2007.
di Indonesia sebesar 37,2% sedangkan prevalensi di
Selama 10 tahun pemerintahan, belum banyak penelitian
Provinsi Lampung yaitu sebesar 42,6% (2). Bahkan,
terkait dengan faktor penyebab stunting di Kabupaten
prevalensi balita pendek di Kabupaten Pesawaran
Pesawaran, terutama yang berkaitan dengan BBLR dan
mencapai 50,81%. Menurut laporan pemantauan status
ASI eksklusif. Padahal prevalensi balita stunting cukup
gizi (PSG) tahun 2015, kejadian balita pendek di
tinggi dan meningkat setiap tahunnya. Berdasarkan
Kabupaten Pesawaran sebesar 24,4% yang mengalami
data tersebut menunjukkan bahwa prevalensi stunting
peningkatan menjadi 26,7% pada tahun 2016 dan 35,5%
di Kabupaten Pesawaran masih menjadi masalah.
pada tahun 2017 (3-5).
Dengan demikian, tujuan dari penelitian ini adalah untuk
Balita pendek (stunting) merupakan suatu kondisi
menganalisis pengaruh faktor ASI eksklusif dan berat
kekurangan gizi kronis yang dimulai sejak 1000
lahir terhadap kejadian stunting pada balita 2-5 tahun di
hari pertama kehidupan (1). Pada kajian penelitian
Kabupaten Pesawaran.
sebelumnya, bayi berat lahir rendah (BBLR), riwayat air
susu ibu (ASI) eksklusif, dan prematuritas merupakan
faktor yang berhubungan dengan stunting di Indonesia BAHAN DAN METODE
(1,6). Dampak dari stunting dapat mempengaruhi
Penelitian ini adalah penelitian kuantitatif
keterlambatan dalam berpikir dan perkembangan pada
observasional analitik dengan pendekatan cross-sectional
masa balita hingga berdampak pada masa dewasa dengan
yang dilaksanakan pada bulan Maret-Mei 2017 di 12
membatasi kapasitas kerja karena berkurangnya massa
Puskesmas Kabupaten Pesawaran Lampung. Populasi
otot dan meningkatkan risiko obstetri pada wanita (7).
penelitian ini adalah pasangan ibu dan anak balita yang
Berat lahir berpengaruh terhadap pertumbuhan
berada di 12 wilayah Puskesmas Pesawaran. Besar sampel
dan perkembangan di masa yang akan datang (8). Kasus
ditentukan dengan menggunakan rumus uji beda dua
BBLR di Indonesia mencapai 10% (2) sedangkan
proporsi yang diperoleh sebanyak 385 sampel. Metode
di Kabupaten Pesawaran, BBLR pada tahun 2016
sampling yang digunakan adalah proportional cluster
sebanyak 7,9% (8). Bayi dengan BBLR akan mengalami
sampling untuk 12 Puskesmas. Setiap puskesmas diambil
gangguan pertumbuhan karena risiko komplikasi pada
datanya sesuai dengan jumlah balita yang terdaftar di
masa kelahirannya. Hasil kajian pada studi sebelumnya
wilayah kerja Puskesmas Pesawaran kemudian jumlah
menjelaskan bahwa anak-anak dengan berat badan lebih
balita tersebut dibagi sesuai dengan jumlah sampel yaitu
dari 3000 gram berisiko lebih rendah untuk menjadi
385 subjek. Kriteria inklusi yang ditetapkan pada penelitian
stunting (OR=0,25; CI 95%:0,11-0,54) (7). Penelitian
ini adalah ibu dan balita usia 2-5 tahun yang berada di 12
menunjukkan bahwa bayi BBLR memiliki cadangan gizi
wilayah Puskesmas Pesawaran dan bersedia menjadi subjek
mikro untuk pertumbuhan yang rendah seperti vitamin A,
penelitian. Sementara itu, kriteria eksklusi pada penelitian
seng, dan zat besi sehingga sangat bergantung pada ASI
ini adalah balita dengan riwayat cacat bawaan dan menderita
untuk menutupi kekurangan gizi (9). Namun, di sisi lain
penyakit serius pada saat penelitian.
ternyata cakupan ASI di Indonesia masih rendah. Data
Variabel yang diteliti adalah kejadian stunting pada
saat ini menunjukkan bahwa hanya 27,1% penduduk
balita sebagai variabel dependen serta riwayat BBLR
Indonesia yang menyusui secara eksklusif. Persentase
dan riwayat ASI eksklusif sebagai variabel independen.
cakupan pemberian ASI eksklusif di Kabupaten
Variabel stunting merupakan hasil pengukuran tinggi
Pesawaran tahun 2016 masih rendah yaitu 49,7%. Hasil
badan menurut umur (TB/U) yaitu apabila nilai z score
studi sebelumnya menyatakan bahwa durasi menyusui
kurang dari -2 (z score TB/U< -2 SD) sedangkan nilai
dan durasi pemberian ASI eksklusif secara signifikan

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 Apri Sulistianingsih, dkk: ASI eksklusif dan berat lahir berpengaruh terhadap stunting pada balita 2-5 tahun di Kabupaten Pesawaran

z score lebih dari atau sama dengan -2 (z score TB/ menentukan status gizi dilakukan sebanyak 1 kali
U≥ -2 SD) dikategorikan normal (1). Variabel riwayat pengukuran. Analisis data menggunakan uji Chi-Square
BBLR diketahui dari catatan riwayat persalinan di buku dan regresi logistik ganda.
Kesehatan Ibu dan Anak (KIA) dengan kategori BBLR
jika berat badan lahir kurang dari 2.500 gram (1). Variabel HASIL
riwayat ASI eksklusif diketahui melalui wawancara
Karakteristik responden pada Tabel 1 menunjukkan
individu menggunakan kuesioner Riset Kesehatan
bahwa sebagian besar pendidikan orang tua responden
Dasar (2013). Bayi yang tidak diberikan makanan atau
tergolong berpendidikan menengah/tinggi (65%) dan
minuman selain ASI sejak lahir sampai dengan usia
penghasilan di atas Upah Minimum Regional (UMR)
6 bulan maka dikategorikan ASI eksklusif sedangkan
(57,7%). Lebih lanjut, mayoritas responden tidak
apabila bayi diberikan makanan sebelum mulai disusui
diberikan makanan prelaktal (53,5%). Namun, mayoritas
atau diberikan makanan selain ASI sebelum usia 6 bulan
usia awal pemberian makanan selain ASI yaitu kurang dari
maka dikategorikan tidak ASI eksklusif (2).
6 bulan (66,7%) dengan jenis makanan yang pertama kali
Proses penelitian diawali dengan melakukan
diberikan setelah ASI yang terbanyak secara berurutan
survei catatan balita di puskesmas dan desa termasuk
adalah bubur nasi (23,1%); bubur formula (21,0%);
data balita yang tidak aktif di posyandu, kemudian
pisang dihaluskan (19,5%); dan lain-lain (19,0%).
peneliti melakukan sampling sesuai teknik yang telah
Berdasarkan hasil penelitian pada Tabel 2 diketahui
ditentukan. Peneliti memberikan penjelasan kepada
bahwa dari 385 balita di 12 Puskesmas Kabupaten
subjek penelitian tentang tata cara dan etika penelitian
Pesawaran ditemukan balita pendek (stunting) sebanyak
kemudian dilanjutkan dengan penandatangan surat
46% sedangkan balita normal sebanyak 54%. Sebagian
kesediaan menjadi responden. Proses pengambilan data
besar balita tidak mendapatkan ASI eksklusif (66,2%)
dilakukan oleh peneliti beserta enumerator. Enumerator
sedangkan balita yang memiliki riwayat ASI eksklusif
merupakan bidan puskesmas yang bertugas di wilayah
hanya 33,8%. Mayoritas balita memiliki berat lahir
binaan dengan minimal pendidikan diploma tiga.
normal (92,2%) sedangkan sejumlah kecil balita memiliki
Wawancara dan pengukuran tinggi badan anak untuk
riwayat BBLR (7,8%). Tabel 2 juga menunjukkan adanya
hubungan antara riwayat ASI eksklusif dan berat lahir
Tabel 1. Karakteritik responden dengan kejadian stunting pada balita. Balita dengan
riwayat ASI eksklusif berhubungan signifikan dengan
Variabel n %
Pendidikan orang tua kejadian stunting (p<0,001; OR=0,122; CI 95%: 0,075-
Dasar (SD/SMP) 127 33,0 0,199). Demikian juga balita dengan riwayat BBLR
Menengah/tinggi 258 67,0 (p<0,001; OR=12,30; CI 95%: 3,663-41,299).
Penghasilan orang tua Hasil analisis pada Tabel 3 menunjukkan
<UMR 198 51,4 permodelan uji regresi ganda yaitu hasil riwayat ASI
≥UMR 187 48,6
eksklusif dengan nilai OR=0,108 (CI 95%: 0,065-
Makanan prelaktal
Ya 179 46,5 0,180) dan berat lahir dengan nilai OR=17,063 (CI
Tidak 206 53,5 95%: 4,892-59,511). Hal ini menjelaskan bahwa balita
Usia mulai diberikan makanan selain ASI yang memperoleh ASI eksklusif berisiko 9,3 kali lebih
< 6 bulan 225 66,2 kecil untuk terjadinya stunting dibandingkan balita yang
≥ 6 bulan 130 33,8
tidak memperoleh ASI eksklusif atau ASI eksklusif
Jenis makanan selain ASI yang pertama kali diberikan
memberikan efek proteksi terhadap terjadinya stunting
Susu formula 67 17,4
Bubur formula 81 21,0 pada balita. Sebaliknya pada berat lahir, ditemukan bahwa
Pisang dihaluskan 75 19,5 balita dengan riwayat BBLR berisiko 17,063 kali lebih
Bubur nasi 89 23,1 besar untuk mengalami stunting dibandingkan balita
Lain-lain 73 19,0 dengan riwayat berat lahir normal.

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Jurnal Gizi Klinik Indonesia, Vol. 15, No. 2, Oktober 2018: 45-51

Tabel 2. Hubungan riwayat ASI eksklusif dan berat lahir dengan stunting pada balita 2-5
tahun di Kabupaten Pesawaran

Status gizi
Total OR
Variabel Normal Stunting p
(CI 95%)
n % n % n %
Riwayat ASI eksklusif
ASI eksklusif 29 22,3 101 77,7 130 33,8 <0,001 0,122
Tidak eksklusif 179 70,2 76 29,8 225 66,2 (0,075-0,199)
Total 208 54,0 177 46,0 385 100
Berat lahir
Normal 205 57,7 150 42,3 355 92,2 <0,001 12,300
BBLR 3 10,0 27 90,0 30 7,8 (3,663-41,299)
Total 208 54,0 177 46,0 385 100

Tabel 3. Analisis multivariat pengaruh riwayat ASI eksklusif dan berat lahir terhadap stunting
pada balita 2-5 tahun di Kabupaten Pesawaran

Variabel Koef ß SE (ß) p POR*Adj (CI 95%)

I. Model awal dan akhir
Riwayat ASI eksklusif -2,222 0,260 <0,001 0,108 0,065-0,180
Berat lahir 2,837 0,637 <0,001 17,063 4,892-59,511
Konstanta 1,142 0,213 <0,001

BAHASAN balita yang tidak rutin ke Posyandu di wilayah kerja

12 Puskesmas Kabupaten Pesawaran untuk mengukur
Hasil penelitian ini menunjukkan bahwa kejadian
tinggi badan dan berat badan. Menurut Buku Kesehatan
stunting pada balita di Kabupaten Pesawaran masih tinggi
Ibu dan Anak (KIA), pemantauan status gizi balita dapat
yaitu sebesar 46% dari 385 balita yang menjadi subjek
dilihat dari pertumbuhan berat badan menurut umur,
penelitian. Hasil ini masih lebih tinggi dibandingkan
berat badan menurut tinggi badan, dan tinggi badan
laporan Riskesdas (2013) di Provinsi Lampung yaitu
menurut umur. Pemantauan ini sebaiknya dilakukan
42,6% dan laporan Pemantauan Status Gizi (PSG) di
setiap bulan dan dituliskan di dalam buku KIA. Namun
Kabupaten Pesawaran tahun 2017 yaitu 35,5% (2,8).
pada kenyataannya, kader Posyandu hanya rutin mencatat
Stunting merupakan kasus pada balita yang memiliki tinggi
pemantauan berat badan menurut umur, sedangkan kurva
badan dibandingkan usia dengan nilai z-skor kurang dari
pemantauan tinggi badan menurut umur dan berat badan
dua standar deviasi (<2 SD) di bawah median (11). Tinggi
menurut umur belum menjadi agenda rutin pencatatan.
badan menurut umur diketahui sebagai salah satu indikator
Oleh karena itu, kasus stunting belum dapat dideteksi
pertumbuhan pada masa balita. Tinggi badan menurut umur
secara dini, padahal pada buku KIA telah terdapat kurva
juga dapat menggambarkan kecukupan nutrisi pada masa
pemantauan yang terbagi berdasarkan umur 0-6 bulan,
balita. Balita yang tidak terpenuhi kebutuhan nutrisinya
6 bulan-2 tahun, dan 2-5 tahun yang seharusnya rutin
dapat berpengaruh terhadap pertumbuhan, perkembangan,
dicatat setiap bulan (12).
dan kecerdasan. Apabila kondisi ini terus berlanjut maka
Kasus riwayat BBLR pada penelitian ini ditemukan
akan berdampak pada daya saing yang rendah pada masa
sebanyak 7,8%. Prevalensi ini hampir sama dengan
dewasa. Kejadian stunting juga berkaitan dengan beberapa
prevalensi di tingkat Provinsi Lampung yaitu 8% dan
faktor diantaranya adalah berat lahir, usia ibu, dan cakupan
lebih rendah dari prevalensi nasional yaitu 10%. Faktor
ASI eksklusif (7).
risiko BBLR di Indonesia diantarnya adalah faktor
Tingginya kejadian stunting pada penelitian
lingkungan (paparan asap rokok dan tempat tinggal),
ini karena peneliti juga melakukan penelitian pada

48
 Apri Sulistianingsih, dkk: ASI eksklusif dan berat lahir berpengaruh terhadap stunting pada balita 2-5 tahun di Kabupaten Pesawaran
sosiodemografi (usia dan sosio-ekonomi), dan faktor ibu
(anemia, plasenta abnormal, status gizi ibu, pemeriksaan
antenatal, pre-eklampsia, paritas, dan komplikasi pada
kehamilan). Anemia dan status gizi menjadi faktor
dominan yang mempengaruhi BBLR (11).
Pada penelitian ini diketahui adanya riwayat ASI
eksklusif pada balita sebanyak 33,2%. Cakupan pemberian
ASI eksklusif secara nasional di Indonesia hanya 27,1%
(13). Rendahnya cakupan ASI eksklusif berdampak pada
masih tingginya kasus malnutrisi di Indonesia. Hasil
penelitian ini menunjukkan bahwa riwayat BBLR dan dan
riwayat ASI eksklusif berpengaruh signifikan terhadap
kejadian stunting di Kabupaten Pesawaran Lampung.
Bayi berat lahir rendah merupakan faktor predisposisi
pencapaian pertumbuhan setelah lahir. Bayi berat lahir
rendah berhubungan dengan kelahiran prematur dan atau
Intrauterine Growth Restriction (IUGR). Hasil studi
membuktikan bahwa BBLR menjadi penentu utama
terjadinya stunting (1). Retardasi pertumbuhan dini
bersamaan dengan perkembangan kognitif yang kurang
optimal dan terhambatnya pertumbuhan organ internal
dapat mengakibatkan kemampuan kognitif yang rendah
dan meningkatkan risiko penyakit kronis di kemudian
hari (14).
Hasil penelitian ini didukung oleh studi di Amazon
yang menunjukkan bahwa BBLR merupakan faktor
determinan terjadinya stunting pada anak di bawah 5
tahun, kemudian disusul dengan riwayat infeksi kronis
seperti diare (15). Selain itu, penelitian di Iran juga
menjelaskan bahwa kasus BBLR dapat meningkatkan
kejadian stunting pada balita (7). Bayi dengan BBLR
akan mengalami gangguan pertumbuhan sejak awal
kehidupannya. Stunting pada anak-anak, khususnya dalam
2 tahun pertama kehidupan memiliki efek jangka panjang
pada tinggi badan saat dewasa, pencapaian sekolah,
pendapatan, hingga kecenderungan penyakit kronis saat
dewasa (16). Studi di Afrika juga menunjukkan bahwa
balita yang mengalami stunting, akan berisiko mengalami
gangguan ekonomi, gangguan reproduksi, dan penurunan
kognitif pada masa dewasa (17).
Hasil analisis penelitian ini menunjukkan bahwa
balita dengan riwayat ASI eksklusif dapat menurunkan
risiko menjadi stunting sampai 9,3 kali lebih kecil
dibandingkan pada balita tanpa riwayat ASI eksklusif.
Pemberian ASI eksklusif bersifat protektif terhadap
kejadian stunting. Namun, pada jangka pendek, ASI
eksklusif memberikan perlindungan pada infeksi diare
dan pernapasan (18) yang telah banyak bukti bahwa
infeksi berkepanjangan menyebabkan balita stunting.
Pada jangka panjang, ASI eksklusif memberikan
perlindungan terhadap penyakit tidak menular seperti
diabetes, tekanan darah, dan kolestrol serta obesitas (19).
Menyusui adalah cara terbaik dalam menyediakan
makanan yang ideal untuk pertumbuhan dan
perkembangan bayi. Lebih dari dua pertiga angka
kematian pada balita terkait dengan praktik pemberian
makan yang tidak tepat selama tahun pertama kehidupan.
Hasil studi pada Empowered Action Group (EAG) States
di India menyatakan bahwa pemberian ASI eksklusif
merupakan faktor utama yang mempengaruhi status
gizi anak. Dengan demikian, intervensi tunggal yang
paling hemat biaya untuk mengurangi kematian bayi di
negara-negara berkembang adalah promosi pemberian
ASI eksklusif (10).
Lebih lanjut, pemberian ASI dipengaruhi oleh
faktor keluarga dan motivasi ibu. Sebagian besar kasus
menunjukkan bahwa ibu yang menyusui juga mengalami
kondisi kurang gizi, yang mengakibatkan rendahnya
produksi ASI dan pada akhirnya dilakukan pengenalan
makanan pendamping ASI (MP-ASI) kepada bayi
sebelum berusia 6 bulan. Beberapa kajian penelitian juga
menyatakan bahwa berat badan lahir, status menyusui,
usia ibu, besar keluarga, status sosial ekonomi, dan urutan
kelahiran berhubungan dengan kejadian stunting pada
anak (7,10,20). Hasil penelitian lain juga menyebutkan
bahwa stunting secara signifikan terkait dengan status
ekonomi miskin (21). Temuan ini sesuai dengan hipotesis
umum bahwa kemiskinan mengarah pada asupan gizi
yang kurang pada kehamilan yang dapat menyebabkan
BBLR. Sementara itu, BBLR juga menyebabkan
komplikasi pada masa kelahiran yang mengganggu
pertumbuhan dan perkembangan sehingga menyebabkan
stunting (15).
Keterbatasan dan kelemahan pada penelitian
ini terletak pada desain penelitian cross-sectional
yang kurang mampu untuk menjelaskan secara tepat
hubungan riwayat ASI eksklusif dan BBLR dengan
kejadian stunting. Penelitian ini tidak menganalisis faktor
49
Jurnal Gizi Klinik Indonesia, Vol. 15, No. 2, Oktober 2018: 45-51
sosiodemografi yang menjadi latar belakang terjadinya
kasus stunting. Penghasilan yang rendah cenderung
memiliki variasi makan yang monoton seperti nabati,
sayuran, dan buah yang mungkin terbatas dibandingkan
dengan rumah tangga berpenghasilan lebih tinggi (20).
Peneliti juga tidak melakukan eksplorasi terhadap pola
makan yang merupakan faktor langsung penyebab
kejadian stunting. Oleh karena itu, peneliti kemudian
melakukan penggalian data tentang BBLR menggunakan
riwayat kelahiran dalam buku KIA. Pada riwayat
ASI eksklusif, peneliti melakukan pengkajian dengan
menanyakan riwayat pemberian ASI termasuk makanan
prelaktal, pendamping ASI, pemberian makanan lain, dan
usia mulai diberikan makanan pendamping ASI.
Hasil dari studi ini membuktikan bahwa riwayat
BBLR dan tidak memberikan ASI eksklusif merupakan
faktor risiko stunting di Kabupaten Pesawaran.
Menurut temuan peneliti, mengurangi kasus stunting
membutuhkan upaya yang berkelanjutan, dimulai dari
mendiagnosis dan mengobati ibu dan anak sejak masa
prakonsepsi dan peningkatan praktik pemberian ASI
eksklusif di antara ibu dan keluarga. Hasil penelitian ini
dapat menjadi pertimbangan bagi pemegang kebijakan
untuk meningkatkan intervensi dalam promosi ASI
eksklusif dan meningkatkan cakupan ASI eksklusif di
Kabupaten Pesawaran. Selain itu, perlu peningkatan
promosi kehamilan sehat sejak masa prakonsepsi untuk
mencegah kasus BBLR yang dapat berisiko terhadap
morbiditas dan mortalitas anak serta dampak jangka
panjang stunting yang merugikan hingga masa dewasa.
Perlu dilakukan penelitian lanjut untuk program
intervensi penatalaksanaan kasus stunting berdasarkan
hasil temuan ini dengan meningkatkan promosi ASI dan
pencegahan BBLR.
SIMPULAN DAN SARAN
Penelitian ini menemukan bahwa riwayat ASI
eksklusif dan BBLR adalah faktor yang berpengaruh
terhadap terjadinya stunting pada balita usia 2-5 tahun.
Dengan demikian, perlu implementasi program intervensi
pencegahan kasus stunting melalui promosi kehamilan
sehat dan ASI eksklusif serta intervensi kuratif pada kasus
stunting untuk mencegah morbiditas balita di Kabupaten
Pesawaran.
50
UCAPAN TERIMA KASIH
Penulis menyampaikan ucapan terima kasih
kepada Kementrian Riset dan Teknologi Pendidikan
tinggi yang telah mendukung terlaksananya penelitian
ini melalui program hibah dosen.
Pernyataan konflik kepentingan
Tidak ada konflik kepentingan dalam penelitian ini.
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2017. Jakarta: Kemenkes RI; 2017.
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2016. Jakarta: Kemenkes RI; 2016.
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factors at birth for stunting at 24 months of age in rural
Indonesia. Paediatrica Indonesiana [series online] 2016
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https://paediatricaindonesiana.org/index.php/paediatrica-
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Determinants of stunting in school-aged children of Tehran,
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JFL, Serra-Majem L. Factors associated with stunting among
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Mozambique. Nutrient 2017;9(5). doi: 10.3390/nu9050491.
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its impact on nutritional status of child in EAG States. J Stat
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11. Danaei G, Andrews KG, Sudfeld CR, Fink G, McCoy DC,
Fawzi WW, et al. Risk factors for childhood stunting in
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pmed.1002164.
 Apri Sulistianingsih, dkk: ASI eksklusif dan berat lahir berpengaruh terhadap stunting pada balita 2-5 tahun di Kabupaten Pesawaran
12. Kemenkes RI. Buku kesehatan ibu dan anak. Jakarta:
Kemenkes RI; 2015.
13. Kemenkes RI. Demographic and health survey 2012.
Jakarta: Kemenkes RI; 2012.
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Maternal and child undernutrition: consequences for adult
health and human capital. Lancet 2008;371(9609):340-57.
doi: 10.1016/S0140-6736(07)61692-4.
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Cardoso MA. Factors associated with stunting and
overweight in Amazonian children: a population-based,
cross-sectional study. Public Health Nutr 2014;17(3):551-
60. doi: 10.1017/S1368980013000190
16. Ali Z, Saaka M, Adams A, Kamwininaang SK, Abizari
AA. The effect of maternal and child factors on stunting,
wasting and underweight among preschool children In
Northern Ghana. BMC Nutrition 2017;3:31. doi: 10.1186/
s40795-017-0154-2
17. Visser J. The effect of childhood stunting on adult life
[Thesis]. [series online] 2016 [cited 2 Aug 2017]. Available
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fa311e8752632244263515dcf027813560c7.pdf
18. Horta Bl, Victora Cg. Short-term effects of breastfeeding:
a systematic review on the benefits of breastfeeding on
diarrhoea and pneumonia mortality. World Heal Organ
[series online] 2013;1–54. Available From: URL: https://
www.who.int/maternal_child_adolescent/documents/
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19. Horta BL, Victoria CG, WHO. Long-term effects of
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who.int/iris/handle/10665/79198
20. Fenske N, Burns J, Hothorn T, Rehfuess Ea. Understanding
child stunting in India: a comprehensive analysis
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PLoS One 2013;8(11):e78692. doi: 10.1371/journal.
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51
 PERBEDAAN TINGKAT KECUKUPAN ZAT GIZI DAN RIWAYAT
PEMBERIAN ASI EKSKLUSIF PADA BALITA STUNTING DAN NON
STUNTING
Retty Anisa Damayanti1, Lailatul Muniroh2, Farapti3
1Program Studi S1 Ilmu Gizi, Fakultas Kesehatan Masyarakat, Universitas Airlangga, Surabaya
2Departemen Gizi Kesehatan, Fakultas Kesehatan Masyarakat, Universitas Airlangga, Surabaya

Email: rettydamayanti@gmail.com

ABSTRAK
Stunting merupakan proses akumulatif dari kurangnya asupan zat-zat gizi dalam jangka panjang. Tujuan dari penelitian
ini adalah untuk menganalisis perbedaan tingkat kecukupan zat gizi dan riwayat pemberian ASI (Air Susu Ibu)
eksklusif pada balita stunting dan non stunting. Penelitian ini menggunakan rancangan cross sectional pada 113 balita
di Kelurahan Kejawan Putih Tambak Kecamatan Mulyorejo Kota Surabaya yang terdiri dari 27 balita stunting dan
86 balita non stunting. Besar sampel dihitung dengan perhitungan proporsional sampling. Analisis perbedaan tingkat
kecukupan dan riwayat ASI eksklusif menggunakan uji Chi Square dan Exact Fisher, analisis perbedaan jumlah asupan
menggunakan uji T-Sampel Bebas dan analisis besar risiko menggunakan perhitungan Odds Ratio. Hasil penelitian
menunjukkan terdapat perbedaan antara balita stunting dan non stunting dalam jumlah konsumsi energi, protein, zinc,
dan zat besi (p = 0,000). Terdapat perbedaan pula pada tingkat kecukupan energi (p = 0,000), protein (p = 0,042), zinc
(p = 0,000), dan zat besi (p=0,009) serta perbedaan riwayat pemberian ASI eksklusif (p = 0,001). Balita dengan ASI
non eksklusif dan balita yang memiliki tingkat konsumsi inadekuat, memiliki risiko lebih besar untuk stunting (ASI
non eksklusif = 16,5 kali, energi inadekuat = 9,5 kali, protein inadekuat = 10,6 kali, zinc inadekuat = 7,8 kali, dan
zat besi inadekuat = 3,2 kali). Saran yang dapat diberikan, diharapkan ibu lebih meningkatkan asupan makanan pada
balita terutama makanan sumber protein, zinc dan zat besi serta diharapkan ibu lebih memperhatikan pemberian ASI
eksklusif dan MP ASI sesuai dengan usia balita.

Kata kunci: ASI eksklusif, balita, stunting, tingkat kecukupan zat gizi

ABSTRACT
Stunting is an accumulative process of inadequacy number of nutrients in a long period of time. The purpose of
this research was to analyse the difference of nutrients adequacy and the history of exclusive breastfeeding between
stunting and non stunting toddler. This cross sectional research was done in 113 toddler who is categorized to 27
stunting toddler and 86 non stunting toddler at Kejawan Putih Tambak village, Surabaya. The number of sample was
calculated with proportional sampling. To compare the nutrients adequacy and the history of exclusive breastfeeding,
Chi-square test and Exact Fisher were used, to compare amount of intake, Independent T-test and Odds Ratio were
calculated. As a result, there was a difference in energy, protein, zinc and iron consumption, and there was also a
difference in history of exclusive breastfeeding between stunting and non-stunting toddler (p = 0.000), Non stunting
toddler have a higher intake of energy, protein, zinc, and iron than stunting toddler. Toddler with non exclusive
breastfeeding have a higher risk to be stunting than toddler with exclusive breastfeeding, and toddler who have
inadequate energy, protein, zinc, and iron intake have a higher risk to be stunting than toddler with adequate energy,
protein, zinc and iron intake (non-exclusive breastfeeding = 16.5 times, inadequate energy = 4.84 times, inadequate
protein = 3.4 times, inadequate zinc = 3.72 times, inadequate iron = 2.36 times). Advice that can be given is that
mother should increase food intake of toddler, especially food that contain protein, zinc, and iron and mother should
give also more attention to the exclusive breastfeeding and complementary feeding which is suitable with the toddler’s
age.

Keywords: exclusive breastfeeding, toddler, stunting, nutrient adequacy

61
62 Media Gizi Indonesia, Vol. 11, No. 1 Januari–Juni 2016: hlm. 61–69
PENDAHULUAN
Stunting adalah gangguan pertumbuhan
linier yang tidak sesuai dengan umur yang
mengindikasikan kejadian jangka panjang
serta merupakan dampak akumulatif dari
ketidakcukupan konsumsi zat gizi, kondisi
kesehatan yang buruk dan pengasuhan yang tidak
memadai (Aridiyah, et al., 2015). Faktor penyebab
langsung dari stunting adalah asupan makanan
tidak adekuat, karakteristik balita meliputi usia,
jenis kelamin, berat badan lahir dan pajang badan
lahir serta adanya penyakit infeksi yang berulang.
Faktor penyebab tidak langsung dari stunting
adalah ketersediaan pangan, pola pengasuhan
serta jangkauan dan mutu pelayanan kesehatan
masyarakat (Shrimpton, 2006).
Pemenuhan gizi pada masa balita akan
menentukan berbagai aspek kehidupan di masa
depan. Stunting pada balita akan berdampak pada
nilai sekolah yang rendah, tinggi badan yang lebih
pendek, dan kurangnya kemampuan motorik pada
usia sekolah serta produktivitas yang rendah dan
risiko terjadinya penyakit degeneratif pada usia
dewasa (Hoddinott, et al., 2013)
Kekurangan energi pada seseorang
merupakan indikasi kekurangan zat gizi lain.
Apabila kondisi ini dibiarkan dalam jangka waktu
lama, maka akan mengakibatkan penurunan
berat badan. Penurunan berat badan selanjutnya
akan menyebabkan keadaan gizi kurang yang
mengakibatkan terhambatnya proses pertumbuhan
tinggi badan (Almatsier, 2009). Kekurangan
protein menyebabkan retardasi pertumbuhan dan
kematangan tulang karena protein adalah zat gizi
yang essensial dalam pertumbuhan. Meskipun
asupan energi cukup, apabila asupan protein kurang
maka akan menghambat pertumbuhan pada balita
(Oktarina dan Sudiarti, 2013). Pada defisiensi zinc,
efek metabolit GH (Growth Hormone) dihambat
sehingga sintesis dan sekresi IGF-1 (Insulin
Like Growth Factor 1) berkurang. Berkurangnya
sekresi IGF-1 menyebabkan stunting (Adriani
dan Wirjatmadi, 2012). Defisiensi zat besi dapat
menyebabkan gangguan pada sistem kekebalan
tubuh.
Balita yang sering mengalami sakit akan
berpengaruh pada pertumbuhannya karena adanya
sakit akan diikuti nafsu makan menurun (Malde,
et al., 2010). Pemberian ASI eksklusif dapat
menurunkan risiko kejadian stunting karena ASI
mengandung antibodi dan kandungan kalsium
pada ASI mempunyai bioavailabilitas yang tinggi
sehingga dapat diserap dengan optimal terutama
dalam fungsi pembentukan tulang (Almatsier,
2009).
Berdasarkan hasil Riset Kesehatan Dasar
(Riskesdas) prevalensi stunting di Indonesia
adalah 36,8% (2007), 35,6% (2010), dan 37,2%
(2013). Di Jawa Timur, prevalensi stunting
menunjukkan kecenderungan adanya penurunan
yaitu 34,8% (2007), 35,8% (2010), dan 26,1%
(2015). Untuk Kota Surabaya, prevalensi stunting
tahun 2015 adalah 19,3%. Kecamatan Mulyorejo
merupakan wilayah Kota Surabaya yang prevalensi
stuntingnya cenderung mengalami peningkatan
yaitu 12,13% (2013), 15,6% (2014), dan 18,7%
(2014).
Kelurahan Kejawan Putih Tambak yaitu salah
satu kelurahan di wilayah Kecamatan Mulyorejo
dipilih sebagai lokasi penelitian karena adanya
peningkatan prevalensi stunting setiap tahun
yaitu 12,7% (2013), 14,2% (2014), dan 20%
(2015). Prevalensi stunting di Kelurahan Kejawan
Putih Tambak pada tahun 2015, lebih tinggi dari
prevalensi stunting di Kota Surabaya.
Usia 2 – 5 tahun merupakan usia rawan
terjadinya kurang gizi karena pada usia ini ASI
sudah tidak diberikan sehingga zat gizi yang
diterima oleh balita hanya berasal dari diet saja.
Pada usia ini, balita sudah mampu memilih
makanan sendiri, pendidikan gizi ibu yang kurang
menyebabkan balita memilih makanan yang miskin
zat gizi sehingga terjadi kondisi kekurangan zat
gizi (Sunarti dan Nugrohowati, 2013).
Cakupan pemberian ASI eksklusif di
Kelurahan Kejawan Putih Tambak paling rendah
dibandingkan kelurahan lainnya di Kecamatan
Mulyorejo yaitu 60% (2013), 76% (2014) dan
80% (2015), serta prevalensi stunting yang paling
tinggi yang mengindikasikan adanya kondisi
kekurangan gizi kronis. Oleh karena itu, tujuan
dari penelitian ini adalah menganalisis perbedaan,
tingkat kecukupan zat gizi terutama zat gizi yang
berhubungan dengan pertumbuhan linear yaitu
protein, zinc, dan zat besi serta perbedaan riwayat
pemberian ASI eksklusif antara balita stunting dan
 Retty Anisa Damayanti, dkk., Perbedaan Tingkat Kecukupan Zat Gizi…
non stunting usia 2-5 tahun di Kelurahan Kejawan
Putih Tambak Surabaya
METODE
Jenis penelitian ini merupakan penelitian
observasional dengan menggunakan desain
penelitian cross sectional. Penelitian dilaksanakan
pada bulan Februari-Mei tahun 2016 di Kelurahan
Kejawan Putih Tambak Kecamatan Mulyorejo,
Kota Surabaya.
Sampel penelitian adalah 113 balita berusia
2–5 tahun yang terdiri dari 27 balita stunting dan
86 balita non stunting. Besar sampel masing-
masing kelompok ditentukan dengan perhitungan
proportional sampling dengan rumus n/N × T
(n = besar sampel masing-masing kelompok, N =
besar populasi, T = besar sampel total) (Amanda,
2014).
Variabel dalam penelitian ini adalah
karakteristik balita (usia, jenis kelamin, berat
badan lahir, dan panjang badan lahir), tingkat
kecukupan (energi, protein, zinc, dan zat besi),
jumlah konsumsi (energi, protein, zinc dan zat
besi), pola asuh (riwayat pemberian ASI eksklusif
dan Makanan Pendamping ASI/MP ASI) serta
status gizi Tinggi Badan menurut Umur (TB/U).
Berat badan lahir dikategorikan menjadi
BBLR dan normal sedangkan panjang badan lahir
dikategorikan pendek dan normal. Balita masuk
dalam kategori BBLR (Berat Badan Lahir Rendah)
jika memiliki berat badan lahir kurang dari 2500
gram sedangkan kategori panjang badan lahir
kategori pendek jika balita memiliki panjang badan
lahir kurang dari 48 cm (Ngaisyah, 2016)
Tingkat kecukupan energi dan zat gizi
dikategorikan menjadi adekuat dan inadekuat.
Menurut Gibson (2005), tingkat kecukupan energi,
protein, dan zinc dikatakan adekuat jika ≥ 77%
AKG (Angka Kecukupan Gizi). AKG energi untuk
balita usia 2–3 tahun adalah 1125 kkal/hari, AKG
protein 26 gr/hari dan AKG zat besi 8mg/hari.
Untuk balita usia 4–5 tahun, AKG energi adalah
1600 kalori/hari. AKG protein 35 gr/hari dan AKG
zat besi 9 mg/hari. Untuk tingkat kecukupan zinc
63
Tabel 1. Besar Sampel masing-masing Kelompok
Kelompok Besar Populasi Besar Sampel
Stunting 45 45/186 × 113 = 27
Non stunting 141 141/186 × 113 = 86
Total 186 113
dihitung dengan AKG yang dikonversikan dengan
EAR (Estimated Average Requirements). AKG zinc
balita usia 2-3 tahun adalah 4 mg/hari dengan EAR
1,2, setelah dikonversikan menjadi 3,3 mg/hari.
AKG zinc balita usia 4–5 tahun adalah 45mg/hari
dengan EAR 1,2, setelah dikonversikan menjadi
4,16 mg/hari. Konversi dilakukan dengan cara
membagi angka AKG dengan angka EAR. Tingkat
kecukupan zinc masuk dalam kategori adekuat jika
≥ 3,3 mg pada balita usia 2–3 tahun dan ≥ 4,16 mg
pada balita usia 4–5 tahun.
Peneliti melakukan pengukuran antropometri
dengan indikator TB/U. Balita dengan z-score
<-2SD termasuk dalam kelompok stunting
sedangkan balita dengan z-score ≥-2SD
termasuk dalam kelompok non stunting, z-score
dihitung dengan menggunakan software WHO-
Anthro. Selanjutnya, ibu diwawancarai dengan
menggunakan kuisioner dan form food recall
2 × 24 hours.
Untuk menganalisis perbedaan tingkat
kecukupan energi, protein, zinc, dan zat besi serta
riwayat pemberian ASI antara balita stunting
dan non stunting menggunakan uji Chi Square
2 × 2 karena skala data adalah nominal, jika tidak
memenuhi syarat maka digunakan uji Exact Fisher
(Pahlevi, 2012). Untuk menganalisis perbedaan
jumlah konsumsi energi, protein, zinc, dan zat
besi antara balita stunting dan non stunting
menggunakan Uji-T Sampel bebas karena skala
data adalah rasio, jika data tidak berdistribusi
normal menggunakan uji Mann Whitney, dan untuk
uji normalitas menggunakan uji Kolmogorov-
Smirnov (Suiraoka, 2011). Analisis besar risiko
menggunakan perhitungan OR (Odds Ratio) karena
perhitungan OR digunakan untuk penelitian dengan
desain cross sectional (Lestari, et al., 2014).
64 Media Gizi Indonesia, Vol. 11, No. 1 Januari–Juni 2016: hlm. 61–69

HASIL DAN PEMBAHASAN Balita BBLR cenderung mengalami stunting

Karakteristik Balita
Karakteristik balita merupakan faktor
penyebab langsung dari kejadian stunting.
Karakteristik balita yang diteliti dalam penelitian
ini adalah usia, jenis kelamin, berat badan lahir dan
panjang badan lahir.
Berdasarkan tabel 2, pada balita usia 24–59
bulan Kelurahan Kejawan Putih Tambak Surabaya,
balita stunting paling banyak ditemukan pada
kelompok usia 36–47 bulan yaitu sebesar 31,4%.
Hal ini sejalan dengan penelitian Bahmat (2015)
di Nusa Tenggara yang menyimpulkan bahwa
balita stunting paling banyak pada usia 36–47
bulan. Hal tersebut disebabkan karena mulai tahun
kedua kehidupan, laju pertumbuhan melambat
dan terjadi perubahan bentuk tubuh balita menjadi
lebih berotot.
Stunting lebih banyak terjadi pada balita
berjenis kelamin laki-laki yaitu 25,0%, sedang
pada balita perempuan sebesar 22,6%. Hal ini
sesuai dengan penelitian Roscha, et al. (2013) yang
menganalisis data Riskesdas menyatakan bahwa
balita stunting lebih banyak berjenis kelamin laki-
laki (39,5%).
Lebih banyaknya prevalensi stunting pada
balita laki-laki disebabkan karena laki-laki lebih
berisiko untuk mengalami kekurangan gizi akibat
lebih banyaknya kebutuhan energi protein pada
laki-laki. Jenis kelamin menentukan besar kecilnya
kebutuhan energi protein seseorang (Bahmat,
2010).
yaitu sebesar 83,3%. Berdasarkan nilai Odds Ratio
dapat dinyatakan bahwa balita dengan riwayat
BBLR memiliki risiko stunting 19,3 kali lebih
besar dibandingkan dengan balita dengan riwayat
berat badan lahir normal. Hal ini sejalan dengan
penelitian Adel (2014) pada balita usia 1–2 tahun
di Libya yang menyimpulkan bahwa berat badan
lahir rendah mempengaruhi kejadian stunting pada
anak usia 1–2 tahun (p < 0,05, OR = 1,58). Balita
BBLR lebih berisiko untuk menjadi stunting karena
balita BBLR memiliki kerentanan yang lebih
tinggi terhadap penyakit infeksi, seperti diare dan
infeksi saluran pernafasan bawah serta peningkatan
risiko komplikasi termasuk sleep apnea, ikterus,
anemia, gangguan paru-paru kronis, kelelahan,
dan hilangnya nafsu makan dibandingkan dengan
anak-anak dengan berat badan lahir yang normal
sehingga mengakibatkan pertumbuhan fisik yang
tidak optimal (Rahman, et al., 2016).
Proporsi balita dengan riwayat panjang badan
lahir pendek lebih banyak pada kelompok stunting
yaitu sebesar 43,8% dan pada anak yang lahir
dengan panjang badan normal sebesar 20,6%.
Balita dengan riwayat panjang badan lahir
pendek memiliki risiko stunting 2,9 kali lebih
besar dibandingkan dengan balita dengan riwayat
panjang badan lahir normal. Hal ini sejalan dengan
penelitian Meilyasari dan Isnawati (2014) yang
menyimpulkan bahwa panjang badan lahir pendek
memiliki pengaruh paling besar dengan kejadian
stunting. Menurut Meilyasari dan Isnawati
(2014), balita dengan riwayat panjang badan lahir

Tabel 2. Karakteristik Balita

Stunting Non stunting Total

Variabel OR
n % n % N %
Usia
24–35 8 19,0 34 81,0 42 100
36–47 11 31,4 24 68,6 35 100 1,9
48–59 8 22,2 28 77,8 36 100
Jenis Kelamin
Laki-laki 15 25,0 45 75,0 60 100 1,1
Perempuan 12 22,6 41 77,4 53 100
Berat Badan Lahir
BBLR 5 83,3 1 16,7 6 100 19,3
Normal 22 20,6 85 79,4 107 100
Panjang Badan Lahir
Pendek 7 43,8 9 56,2 16 100 2,9
Normal 20 20,6 77 79,4 97 100
 Retty Anisa Damayanti, dkk., Perbedaan Tingkat Kecukupan Zat Gizi…
pendek merupakan indikasi terjadinya kekurangan
pemenuhan zat gizi ibu selama kehamilan dan
indikasi adanya gangguan pertumbuhan dalam
uterus yang menyebabkan pertumbuhan linear
menjadi tidak optimal. Kekurangan gizi sejak
dalam kandungan berpengaruh terhadap organ
dan pertumbuhan janin. Bayi yang mengalami
kekurangan gizi selama masa kehamilan masih
dapat diperbaiki dengan asupan yang baik sehingga
dapat melakukan tumbuh kejar sesuai dengan
perkembangannya. Namun, apabila intervensinya
terlambat dapat mengalami gagal tumbuh.
Tingkat Kecukupan Energi dan Zat Gizi
Asupan makan yang tidak adekuat merupakan
penyebab langsung terjadinya stunting pada
balita. Kurangnya asupan energi dan protein
menjadi penyebab gagal tumbuh telah banyak
diketahui. Kurangnya beberapa mikronutrien
juga berpengaruh terhadap terjadinya retardasi
pertumbuhan linear. Kekurangan mikronutrien
dapat terjadi karena rendahnya asupan bahan
makanan sumber mikronutrien tersebut dalam
konsumsi balita sehari-hari serta disebabkan
karena bioavailabilitas yang rendah (Mikhail,
et al., 2013).
Asupan makanan yang diteliti dalam penelitian
ini terdiri dari tingkat kecukupan serta jumlah
konsumsi energi dan zat gizi lainnya yaitu protein,
zinc, dan zat besi. Hasil penelitian menunjukkan
bahwa proporsi balita yang memiliki tingkat
kecukupan energi, protein, zinc, dan zat besi
inadekuat lebih banyak pada kelompok stunting
dibandingkan kelompok non stunting. Hasil
Tabel 3. Perbedaan Tingkat Kecukupan Zat Gizi
Stunting
Variabel
n %
Tingkat kecukupan energi
Inadekuat 18 54,5
Adekuat 9 11,2
Tingkat kecukupan protein
Inadekuat 3 75,0
Adekuat 24 22,0
Tingkat kecukupan zinc
Inadekuat 12 60,0
Adekuat 15 16,1
Tingkat kecukupan zat besi
Inadekuat 16 37,2
Adekuat 11 15,7
65
penelitian juga menunjukkan bahwa tingkat asupan
energi, protein, zinc dan zat besi yang inadekuat
akan meningkatkan risiko terjadinya stunting pada
balita.
Hasil penelitian menunjukkan bahwa
proporsi balita yang memiliki tingkat kecukupan
energi inadekuat lebih banyak pada kelompok
stunting (54,5%) dan balita yang memiliki tingkat
kecukupan energi inadekuat memiliki risiko
stunting 9,5 kali lebih besar dibandingkan dengan
balita yang memiliki tingkat kecukupan energi
adekuat. Hal ini sejalan dengan penelitian Oktarina
dan Sudiarti (2013) yang menyebutkan bahwa
balita dengan asupan energi rendah mempunyai
risiko 1,28 kali lebih besar untuk mengalami
stunting dibandingkan dengan balita yang memiliki
tingkat kecukupan energi cukup.
Proporsi balita yang memiliki tingkat
kecukupan protein inadekuat lebih banyak pada
kelompok stunting (75%) dan dapat diketahui pula
bahwa balita yang memiliki tingkat kecukupan
protein inadekuat memiliki risiko stunting 10,6
kali lebih besar dibandingkan dengan balita yang
memiliki tingkat kecukupan protein adekuat.
Penelitian oleh Nungo (2012) pada balita usia 1–5
tahun di Kenya dan Hidayati, et al. (2010) pada
balita usia 1-3 tahun di Surakarta menyimpulkan
bahwa balita yang memiliki tingkat kecukupan
protein tidak adekuat mempunyai risiko 3,46 kali
akan menjadi stunting dibandingkan dengan balita
dengan asupan protein adekuat.
Kecukupan protein hanya bisa terpenuhi jika
asupan energi tercukupi. Apabila asupan energi
kurang, asupan protein akan digunakan untuk
Non Stunting
P-value OR
n %
15 45,5 0,000 9,5
71 88,8
1 25,0 0,042 10,6
85 78,0
8 40,0 0,000 7,8
78 83,9
27 62,8 0,009 3,2
59 84,3
66 Media Gizi Indonesia, Vol. 11, No. 1 Januari–Juni 2016: hlm. 61–69
memenuhi kebutuhan energi. Pertumbuhan balita
membutuhkan tambahan protein. Ketidakcukupan
asupan protein dapat menghambat laju
pertumbuhan (Adriani dan Wirjatmadi, 2012).
Pertumbuhan pada balita akan meningkatkan
jumlah total protein dalam tubuh sehingga
membutuhkan protein lebih besar daripada orang
dewasa. Protein memegang peranan esensial
dalam mengangkut zat-zat gizi dari saluran cerna.
Kekurangan protein akan mengganggu berbagai
proses dalam tubuh dan menurunkan daya tahan
tubuh terhadap penyakit (Almatsier, 2009).
Kuantitas dan kualitas protein yang
dikonsumsi mempengaruhi kadar plasma Insulin
Like Growth Factor I (IGF-I) yang merupakan
mediator hormon pertumbuhan. Protein juga
mempengaruhi pertumbuhan matriks tulang yang
memiliki peran penting dalam pembentukan tulang
(Mikhail, et al., 2013).
Proporsi balita yang memiliki tingkat
kecukupan zinc inadekuat lebih banyak pada
kelompok stunting (60%) dan balita yang memiliki
tingkat kecukupan zinc inadekuat memiliki risiko
stunting 7,8 kali lebih besar dibandingkan dengan
balita yang memiliki tingkat kecukupan zinc
adekuat. Hal ini sejalan dengan penelitian Gibson,
et al. (2007) yang menyimpulkan bahwa defisiensi
zinc menghambat pertumbuhan linear pada anak
usia 6-13 tahun di NE Thailand. Arsenault, et al.
(2008) pada penelitiannya juga menyimpulkan
bahwa balita yang menerima suplementasi zinc
memiliki pertumbuhan yang lebih baik karena
konsumsi zinc dapat menstimulasi nafsu makan,
meningkatkan asupan energi serta meningkatkan
massa bebas lemak pada tubuh.
Zinc berfungsi dalam pembentukan antibodi,
berperan dalam fungsi indera pengecap dan
hormon pertumbuhan. Kekurangan zinc dapat
mengakibatkan hipogeusia atau penurunan nafsu
Tabel 4. Perbedaan Jumlah Konsumsi Zat Gizi
Kelompok
Variabel Stunting
mean ± SD
Energi (kkal) 847,6 ± 224,12
Protein (gr) 37,8 ± 14,6
Zinc (mg) 3,8 ± 1,6
Zat besi (mg) 5,4 ± 3,5
makan dan hiposmia atau kehilangan indra bau
(Almatsier, 2009). Zinc berperan dalam proses
pertumbuhan dan perkembangan pada balita,
zinc membantu melawan infeksi dan membantu
kerja hormon pertumbuhan. Pada defisiensi zinc,
kerja dari hormon pertumbuhan akan dihambat
(Aridiyah, et al., 2015).
Proporsi balita yang memiliki tingkat
kecukupan zat besi inadekuat lebih banyak pada
kelompok stunting (37,2%) dan balita yang
memiliki tingkat kecukupan zat besi inadekuat
memiliki risiko stunting 3,2 kali lebih besar
dibandingkan dengan balita yang memiliki tingkat
kecukupan zat besi adekuat.
Penelitian Hidayati, et al. (2010)
menyimpulkan bahwa asupan zat besi inadekuat
meningkatkan risiko stunting 3,46 kali lebih besar
pada balita. Balita dengan defisiensi zat besi
akan mengalami penurunan terhadap kekebalan
tubuh sehingga memiliki risiko lebih besar
untuk mengalami penyakit terutama penyakit
infeksi. Adanya penyakit infeksi dan anoreksia
akan menghambat pertumbuhan linear karena
menurunkan intake makanan, mengganggu
absorpsi zat gizi, dan menyebabkan hilangnya
zat gizi (Mikhail, et al., 2013). Berdasarkan hasil
penelitian diketahui bahwa balita non stunting
memiliki jumlah rata-rata konsumsi energi, protein,
zinc dan zat besi yang lebih tinggi dibandingkan
dengan balita stunting.
Berdasarkan uji statistik juga diketahui ada
perbedaan jumlah konsumsi energi, protein, zink,
dan zat besi antara balita stunting dan non stunting
di Kelurahan Kejawan Putih Tambak Surabaya.
Hal ini sejalan dengan penelitian yang dilakukan
oleh Suiraoka, et al. (2011) pada balita usia 2-5
tahun di Denpasar yang menyimpulkan bahwa ada
perbedaan bermakna jumlah rata-rata konsumsi
energi dan protein per hari pada kelompok balita
Non Stunting P-value
mean ± SD
1.116,2 ± 196,4 0,000
51,9 ± 11,0 0,000
5,7 ± 1,7 0,000
8,5 ± 3,5 0,000
 Retty Anisa Damayanti, dkk., Perbedaan Tingkat Kecukupan Zat Gizi…
normal dan kelompok balita stunting dengan
jumlah rata-rata konsumsi energi dan protein balita
non stunting lebih tinggi dibandingkan dengan
balita stunting. Penelitian ini juga sejalan dengan
penelitian Hidayati, et al. (2010) pada balita usia
1-3 tahun di wilayah perkotaan kumuh Surakarta
yang menyimpulkan bahwa kekurangan asupan
zinc dan zat besi pada balita menyebabkan balita
mempunyai risiko lebih besar terhadap kejadian
stunting.
Riwayat Pemberian ASI dan MP ASI
Pola asuh merupakan faktor tidak langsung
yang mempengaruhi terjadinya stunting pada
balita. Pola asuh yang diteliti dalam penelitian
ini adalah riwayat pemberian ASI eksklusif
dan riwayat usia pertama pemberian MP ASI.
Pemberian ASI dikatakan eksklusif jika balita
hanya mendapatkan ASI saja tanpa tambahan
makanan atau minuman apapun mulai dari lahir
sampai usia 6 bulan (Zogara, et al., 2014).
Pada penelitian, diketahui ada 16 balita
yang tidak pernah mendapatkan ASI dengan
alasan ASI tidak bisa keluar dan ibu sakit pada
saat melahirkan. Proporsi balita yang tidak
mendapatkan ASI non eksklusif lebih banyak
pada kelompok stunting. Berdasarkan uji statistik
diketahui bahwa ada perbedaan riwayat pemberian
ASI eksklusif antara balita stunting dengan balita
non stunting (p = 0,001). Balita dengan riwayat
mendapatkan ASI non eksklusif memiliki risiko
stunting 16,5 kali lebih besar dibandingkan balita
dengan riwayat mendapatkan ASI eksklusif. Hal
ini sejalan dengan penelitian Lestari, et al. (2014)
di Aceh yang menyimpulkan bahwa bayi dengan
ASI non eksklusif memiliki risiko lebih besar
untuk mengalami stunting (OR = 6,54).
Balita dengan riwayat ASI non eksklusif lebih
berisiko untuk stunting karena hal ini berhubungan
Tabel 5. Riwayat Pemberian ASI Eksklusif dan MP ASI
Stunting
Variabel
n %
Riwayat Pemberian ASI
Non Eksklusif 17 29,8
Eksklusif 1 2,5
Usia Pemberian MP ASI (bulan)
<6 25 34,2
≥6 2 5
67
dengan kejadian penyakit infeksi seperti diare
yang lebih banyak terjadi pada bayi dibawah 6
bulan yang diberikan makanan selain ASI. Adanya
penyakit infeksi menyebabkan menurunnya nafsu
makan, menurunnya penyerapan zat gizi dan
peningkatan katabolisme sehingga zat gizi tidak
mencukupi untuk pertumbuhan (Lestari, et al.,
2014).
Sebagian besar balita memiliki riwayat
mendapatkan MP ASI terlalu dini (<6 bulan).
Proporsi balita yang mendapatkan MP ASI
dini lebih besar pada kelompok balita stunting.
Berdasarkan uji statistik diketahui bahwa ada
perbedaan usia pemberian MP ASI balita stunting
dengan balita non stunting (p = 0,000). Balita
dengan riwayat mendapatkan MP ASI dini memiliki
risiko stunting 9,9 kali lebih besar dibandingkan
dengan balita dengan riwayat mendapatkan MP
ASI non dini. Hal ini sesuai dengan penelitian
Aridiyah, et al. (2015) pada balita di Jember yang
menyimpulkan bahwa pemberian ASI eksklusif
dan usia pertama pemberian MP ASI merupakan
faktor yang berhubungan dengan kejadian stunting
pada balita. Pemberian makanan terlalu dini dapat
mengganggu pemberian ASI eksklusif serta
menjadikan bayi rentan terhadap penyakit karena
enzim pencernaan pada bayi belum mencapai
jumlah yang cukup untuk mencerna makanan kasar
sampai usia 6 bulan. Kebersihan yang kurang pada
pemberian MP ASI juga berisiko mengakibatkan
diare (Zogara, et al., 2014).
KESIMPULAN DAN SARAN
Kesimpulan yang bisa diambil dari penelitian
ini adalah balita dengan riwayat BBLR dan/
panjang badan lahir pendek memiliki risiko
lebih besar untuk mengalami stunting. Terdapat
perbedaan tingkat kecukupan energi, protein, zinc,
Non stunting Total
P-value OR
n % N %
40 70,2 57 100 0,001 16,5
39 97,5 40 100
48 65,8 73 100
0,000 9,9
38 95 40 100
68 Media Gizi Indonesia, Vol. 11, No. 1 Januari–Juni 2016: hlm. 61–69
dan zat besi pada balita stunting dan non stunting
di Kelurahan Kejawan Putih Tambak Surabaya
di mana balita yang memiliki tingkat kecukupan
energi, protein, zinc, dan zat besi inadekuat
memiliki risiko lebih besar untuk stunting (energi
inadekuat = 9,5 kali, protein inadekuat = 10.6 kali,
zinc inadekuat = 7,8 kali, zat besi inadekuat = 3,2
kali). Terdapat perbedaan riwayat pemberian ASI
pada balita stunting dan non stunting dimana balita
yang mendapatkan ASI non eksklusif memiliki
risiko 16,5 kali lebih besar untuk stunting.
Saran yang dapat diberikan, diharapkan ibu
lebih meningkatkan asupan makanan terutama
makanan sumber zat gizi yang memiliki keterkaitan
dengan pertumbuhan linear pada balita yaitu
makanan sumber protein, zinc, dan zat besi serta
diharapkan ibu lebih memperhatikan pemberian
ASI eksklusif dan MP ASI sesuai dengan usia
balita.
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