Low birth weight was the most dominant predictor associated with stunting among children aged 12–23 months in Indonesia

Stunting is associated with the higher incidence of degenerative diseases in the later stages of life [1]. Globally, it is estimated that 26% of toddlers are stunted. Results from the National Basic Health Survey (Riskesdas) 2010 showed that the prevalence of stunting among toddlers and infants was 35.6% with a higher prevalence rate among infants aged 12–23 months (40.4%). The prevalence of stunting ranged from 22.5% in Yogyakarta to 58.4% in East Nusa Tenggara (NTT). This disparity may be caused by the unequal economic development in both provinces [2].

One of the most prominent risk factor for stunting is low birth weight (LBW). LBW is defined as birth weight less than 2500 g. Aside from genetic reasons, LBW is also an indication of premature birth or Intra Uterine Growth Retardation or IUGR [3].

Global statistics reveal that 3.5 million child deaths caused by malnutrition occur annually. Non-exclusive breast feeding is the suspected cause of 1.4 million child deaths and up to 10% of the illnesses among children. Malnutrition is generally expressed as stunted growth and thinness, as a result of IUGR during the mother’s pregnancy in addition to improper care after birth [4].

The disparities of the stunting prevalence in Indonesia were obviously related to the underlying economic determinants between the more developed western and less-developed eastern part of Indonesia. However, other important factors such as birth weight, feeding practices, illness during the first 2 years of life and accessibility of health programs intervention are closely related to stunting.

Current data shows that only 15.3% of Indonesian infants were exclusively breastfed in the first 6 months of their life [2]. Achievements of universal coverage of optimal breast feeding in addition to appropriate complementary feeding practices would reduce more than 15% of the mortality among children under 5 years of age [5, 6]. In addition, neonatal illness is another determinant of children’s nutritional status.

The objective of this study is to analyze the impact of low birth weight, feeding practices and neonatal illness on the likelihood of stunting among Indonesian infants.

The total number of subjects was 3,368 infants of age 12–23 month. As much as 344 subjects were excluded from the analysis due to missing information and/or outliers resulting in 3,024 subjects available for the data analysis.

In our study, we found that LBW, gender (boys) and history of neonatal illness and poverty are independently related to stunting among infants in Indonesia. Low birth weight is a predisposing factor to growth attainment after birth. LBW is related to preterm delivery, IUGR or both. In developing countries, like Indonesia, the risks are more often associated with IUGR [9–11]. Several studies have shown that most of infants born with low weight in Indonesia had IUGR [3, 12]. Previous study by Karima et.al, showed a significant relationship between a mother’s nutritional status, weights gained during pregnancy, iron intake and the age of gestation with the incidence of LBW [13]. Evidence suggests that poor early growth retardation coincides with sub-optimal cognitive development and the inhibited growth of internal organs may result in a low cognitive ability and increase risks for chronic diseases in later life [14]. A study in Zimbabwe found that growth of the LBW babies are well behind the growth of normal weight babies and significant length differences were apparent at 12 months of age [15]. Intra uterine growth restriction and/or erratic growth during the first 2 years of life can lead to a lower economic productivity in adult-hood. According to Victora: “Poor fetal growth or stunting in the first 2 years of life leads to irreversible damage, including shorter adult height, lower attained schooling, reduced adult income, and decreased their offspring birth weight” [14]. In addition, stunting as stated by Pojda, is a powerful predictor of infant growth and survival [16].

Breast feeding frequency in addition to good quality breast milk given to infants until the age of 6 months is expected to prevent growth faltering. Appropriate complementary feeding including quality, variety and diversity after the exclusive breast-feeding would further support the growth of an infant. Appropriateness is defined as the correct type of food (semi solid to solid, that includes protein sources), balanced nutrients composition (energy, protein, vitamins and minerals), proper food preparation practices, as well as proper child care [17].

However, growth deficits since birth seem to significantly increases the risk of stunting up until 2 years of life and to contribute to a short stature as well as increasing the risk of developing chronic diseases later in life. A study from Guatemala showed that when the median length of new born babies was 2 cm (−1 SD) shorter than the standard reference, this difference increases to 9 cm (−2 to −2.7 SD) by the time the baby reaches 2 years of age [18].

In our study, boys have 1.28 times higher risk to be stunted compared to girls. Our finding differs from Kramer et.al who reported that the relative risks of IUGR is 1.19 in girls relative to boys [9]. A previous study using data from Indonesia reports a similar result as ours. Data from some surveys showed that the prevalence of stunting among preschool children was higher for boys compared to girls. The prevalence of stunting among preschool children in Indonesia in 1990 and 2001 for boys was 47.0 and 46.6%, while for girls the prevalence was ranged from 41.9 to 45.5% [10, 19]. Similarly, relative risk of stunting in boys was 1.65 compare to girls in Kolkata, India [20].

Our analysis showed that after controlling for food given, there was a significant association between neonatal illness and stunting. Infection is an important determinant of infant nutritional status. A study indicated that severe malnutrition is related to high prevalence or incidence of diarrhea [21]. Infectious diseases have an adverse metabolic effect that may influence the amount of food consumed and result in a lower nutritional state [22]. A child who experiences infection may have a higher metabolic rate and therefore need a higher food intake. At the same time, infants have a lower appetite and loose nutrients because of diarrhea and vomiting. Semba in his study in Indonesia found that there was an association between mortality and a history of diarrhea among children less than 5 years of age [23]. A further study mentioned that the risk of stunting is increased when the infants had repeated or prolonged episodes of diarrhea [22].

Colostrum given and pre-lacteal feeding have no significant contribution to stunting. This analysis reveals that infants who were either given colostrum or pre-lacteal feeding are at no risk of being stunted. Exclusive breast feeding until the age of 6 months has no association with stunting either. Meta-analysis showed that the protective effect of breastfeeding may due to confounding with socio-economic status. Women who are higher in socio-economic status maybe more nutrition-conscious [7]. Along similar lines, the absence of an association in our study between early complementary feeding and stunting may be a reflection of the higher consciousness of mothers toward nutrition.

Low prevalence on exclusive breast-feeding was due to habitual in older time or by older people such as the grandmother by giving breast milk to infants until the age of 4 months as much as possible. The quality of breast milk given is not an important for the mothers. Thus, the nutrients needed by the infants come mostly from complementary foods. In most of the cases, the mothers breastfeeding are undernourished themselves, resulting in low production of breast milk and earlier introduction of complementary foods. Other possible explanations may be that in developing countries, the age of introduction of complementary foods is not associated with stunting, as shown by a study in rural Ethiopia [23].

In our study, stunting is significantly associated with poor economic status. This finding is in accordance with the common hypothesis that poverty leads to LBW and prolonged stunting, independently of other variables [24]. Nevertheless although socio-economic status is associated with risk factors of health, the pathways through which it affects health outcomes remain to be explored [25].

We showed in our study that LBW, gender (boys), history of neonatal illness and poverty were factors related to stunting among children aged 12–23 months in Indonesia. Among the variables, LBW was the most important and dominant risk factor.