Factors Influencing Nutritional Status Changes in Wasting Toddlers

in the Working Area of Serpong Sub-District Health Center: A

Retrospective Cohort Study

Aulia Vania Andini and Ony Linda

Department of Public Health, Faculty of Health Sciences, University of Muhammadiyah Prof. Dr. Hamka, Jakarta, Indonesia

Keywords: Nutritional Status, Toddlers, Wasting.

Abstract: The main issue worldwide is wasting, which contributes to 45% of deaths in children under five years of age.

In 2022, South Tangerang achieved 100% intervention for wasting toddler through a supplementary feeding

program. Despite this, some toddlers still require additional supplementary feeding recovery (PMT) because

their nutritional status remains unchanged. This study analyzed the factors affecting nutritional changes in

wasting toddlers. The cohort study involved 46 wasting children in Serpong Districts who received PMT

recovery during a three-month period. The secondary data required were anthropometric measurements of

toddlers and history of infectious diseases during PMT-P consumption and can be found in the KIA Book.

The primary data in this study included the characteristics of mothers and toddlers, the suitability of toddlers

for consuming supplementary food recovery (PMT-P), and the history of infectious diseases in toddlers during

the period of supplementary food recovery. Statistical analyses were performed using the chi-square test. The

findings indicated a significant relationship between mother’s education (p = 0.014; RR = 13,462),

supplementary feeding recovery (p = 0.002; RR = 11,500), history of infections (p = 0.003; RR = 8,143), and

improvement in nutritional status in the Serpong Sub-District Health Centre. Many toddlers still have poor

nutrition.

1 INTRODUCTION

Wasting is a major nutritional concern worldwide.

Data from the World Health Organization (WHO)

indicate that in 2020, there will be 56.2%, or

approximately 13.6 million, of children wasting in

Southeast Asia, with a prevalence rate of 14.5%.

Children aged 5 years with malnutrition have

weakened long-term immune responses during

development (World Health Organization, 2021).

Based on the findings of the Indonesian

Nutritional Status Survey (SSGI) in 2022, the

prevalence of wasting in 2022 is 7.7%, and the

province of Banten has a prevalence of wasting above

the national average of 7.9%. According to these

percentages, the target of the 2024 National Medium-

Term Development Plan (RPJMN) of 7% has not yet

been achieved (Presidential Regulation of the

Republic of Indonesia Number 18, 2020). The 2022

SSGI results for wasting among toddlers in Banten

Province and 4.9% in South Tangerang City indicate

that each child needs monitoring and assessment of

nutritional status to ensure optimal growth, which

involves comparing a child's weight and height

(Ministry of Health of Indonesia, 2020).

One of the Sustainable Development Goals

(SDGs), which is the second goal, is to address

hunger and all forms of malnutrition by 2030 and

achieve food security. To achieve the SDG target, the

government tackled stunting and wasting priority.

According to Minister of Health Regulation Number

39 of 2016 in the Guidelines for the Implementation

of the Healthy Indonesia Program with a Family

Approach, one of the efforts being made is the

implementation of the Supplementary Feeding

(PMT) program for toddlers. The Supplementary

Feeding Program (PMT) aims to address insufficient

food intake. It also aims to prevent the occurrence of

diseases that may arise owing to nutritional

deficiencies. The supplementary food recovery

provided to address nutritional issues was given for a

duration of 90 days (Ministry of Health of Indonesia,

2017)

In Banten province, 43.5% received PMT and

74.9% benefited from the PMT program. In 2022,

232

Andini, A. V. and Linda, O.

Factors Inﬂuencing Nutritional Status Changes in Wasting Toddlers in the Working Area of Serpong Sub-District Health Center: A Retrospective Cohort Study.

DOI: 10.5220/0012920000004564

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 5th International Conference on Social Determinants of Health (ICSDH 2023), pages 232-239

ISBN: 978-989-758-727-6; ISSN: 2975-8297

South Tangerang City became one of cities that

provided 100% intervention for wasting toddlers

through the Supplementary Feeding Recovery

Program (PMT-P).

Previous research, which was tested using

Pearson’s product-moment correlation with a p-value

of 0.037 (p < 0.05), showed that there was a

connection between compliance consumption of

PMT-P by toddlers and changes in nutritional status

(Adelasanti & Rakhma, 2018). The utilization of the

Supplementary Feeding Program (PMT) is

influenced by the taste of the biscuits consumed.

Taste is a sensory response to gustatory nerve

stimulation (Setiawan 2018).

According to the United Nations Children's Fund

(UNICEF), inadequate food intake and infectious

diseases are direct causes of malnutrition, while

socio-economic factors are indirect causes. Food

intake and infection significantly affect the nutritional

status. Imbalanced diets weaken the immune system,

causing symptoms such as nausea, vomiting, and

reduced appetite, thereby affecting nutrition (Linda

and Huriah, 2018). Weak immunity leads to illness

and appetite loss, resulting in poor nutrition (Rosha et

al., 2020). Other studies have also shown that the

majority of undernourished toddlers are females

(Sekar et al., 2020).

Mothers play crucial roles in the growth and

development of their children. Age, education, and

occupation are factors that influence a mother's

ability to effectively fulfill her role in optimal child

growth. As seen in previous research by Wubante

(2017) in Ethiopia, mothers above 34 years of age had

a lower risk of having undernourished children (0.29

times), whereas those aged 20–34 years had a slightly

higher risk (0.59 times). Older mothers generally

have a lower risk, likely because of their better child-

rearing experience.

Another study reported that 73.3% of

mothers had completed high school education,

implying that higher parental education leads to better

health knowledge and proper supplementary feeding

practices (Solo et al., 2017). A mother's occupation

also affects child growth; those who do not work have

more time at home to monitor and control their child's

intake (Fauzia et al., 2019).

In a preliminary study conducted in the

working area of the Lengkong Karya Community

Health Center, Serpong Sub-District, two out of four

toddlers who completed the Supplementary Feeding

Recovery Program (PMT-P) did not experience

improved nutritional status. Therefore, this study

aimed to analyze factors that may contribute to

changes in the nutritional status of toddlers.

2 METHODS

This study is an observational study using a

retrospective cohort design (looked at backwards

events) to see the factors associated with changes in

the nutritional status of toddlers within the past 3

months, namely in January–March 2023.

Measurement of independent variables and

characteristics of toddlers and mothers, namely

history of disease and suitability in the

implementation of supplementary food recovery,

using a questionnaire as a research instrument. The

dependent variable was the change in the nutritional

status of toddlers according to the anthropometric

index weight for height (WHZ).

The sampling technique used in this study was

total sampling or saturated sampling of 46 toddlers.

This study was conducted in the working area of the

Serpong Sub-District Community Health Center in

South Tangerang City, which consists of seven health

centers: Ciater Health Center, Lengkong Wetan

Health Center, Serpong 1 Health Center, Serpong 2

Health Center, Rawa Buntu Health Center, and Rawa

Mekar Jaya Health Center.

Data collection uses secondary and primary data.

The secondary data required were anthropometric

measurements of toddlers and history of infectious

diseases during PMT-P consumption. The secondary

data in this study can be found in the Kesehatan Ibu

dan Anak (KIA) book. The primary data in this study

included the characteristics of mothers and toddlers,

the suitability of toddlers in consuming

Supplementary Food Recovery (PMT-P), and the

history of infectious diseases of toddlers during the

period of supplementary food recovery using a

questionnaire as a research instrument. Data were

analyzed using the chi-squared test with statistical

software.

Consuming Supplementary Food Recovery

(PMT-P) is categorized as "appropriate" and "not

appropriate." It is considered "appropriate" when the

respondent's score is 4, while it is considered "not

appropriate" if the respondent's score is <4. After

conducting validity and reliability tests for the

supplementary food recovery variable, a Cronbach's

alpha value of 0.720 was obtained. The variable

"History of Infection" is categorized into "Ever" and

"Never." It was categorized as "ever" when the

respondent's score was ≥ 1. On the other hand, it fell

under the category of ‘never’ when the respondent's

score was 0. After conducting validity and reliability

tests for the History of Infection variable, Cronbach's

alpha value of 0.762 was obtained.

Factors Inﬂuencing Nutritional Status Changes in Wasting Toddlers in the Working Area of Serpong Sub-District Health Center: A

Retrospective Cohort Study

233

3 RESULT

Respondents’ characteristic show in Table 1. the

majority of wasting toddlers in the Serpong Sub-

district Primary Health Care Work Area were aged

between 12 and 59 months, totaling 38 toddlers

(approximately 82.6 %). Female respondents

accounted for approximately 52.2% of the total

respondents.

Table 1: Respondent Characteristic.

Variable n %

Children Characteristics

Children A

6-11 Months 8 17,4

12-59 Months 38 82,6

Children Gende

Female 24 52,2

Male 22 47,8

Mother’s Characteristics

Mother age

>34 years 25 54,3

≥ 19 – 34 years 21 45,7

Mother’s Education

Not finished elemtary

school

8 17,4

Elementary – Junior high

school

15 32,6

Senior High School 14 30,4

Graduated (D3, S1, S2,) 9 19,6

Mother’s Occupation

Housewife 36 78,3

Private Employee 5 10,9

Entrepreneur 5 10,9

In terms of mothers' ages among wasting toddlers,

most were >34 years (54.3%) and ≥ 19–34 years

(45.7%). In terms of education, 20 mothers completed

high school (32%), while 8 had higher education

(17.4%). Most mothers (78.3%) who took care of

wasting toddlers in the Serpong Sub-district Primary

Health Care Work Area were housewives.

Distribution of Respondents Based on The

Criteria of Supplementary Recovery Feeding (PMT-

P) show in Table 2. For those questions, a score of 1

was assigned if the answers met the criteria. That

receives a score of 1 if the answers are "Toddler

Biscuits," "60 or 90 Packets," "3 Months," "8 or 12

Pieces," "Child Only," and "Yes."

Table 2: Distribution of Respondents Based on the Criteria

of Supplementary Recovery Feeding (PMT-P).

Question

Answers

n %

Supplementary Food Recovery (PMT-P)

What types of supplementary

foods does the toddler receive?

Toddler Biscuits

46 100

Milk

0 0

Other

0 0

How many biscuits does the

toddler receive in one month?

60 or 90

34 73,9

Less than 60 or less than 90

12 26,1

More than 60 or more than

0 0

How long has the child been

receiving supplementary feeding

(PMT-P)?

3 months

29 63,0

More than 3 months

17 37,0

Less than 3 months

0 0

How many pieces of biscuit are

consumed in one meal?

8 or 12

23 50

Less than 8 or less than 12

19 41,3

More than 8 or more than

4 8,7

Who consumes the supplementary

feeding?

Child only

25 54,3

Family / Friends

11 23,9

Other

10 21,7

Is the provided supplementary

feeding (PMT-P) completely

consumed by the child?

Yes

17 37,0

29 63,0

Then, the scores are composite and categorized as

"appropriate" and "not appropriate." PMT-P is

considered "appropriate" if the respondent has a total

score of 6. It is considered "not appropriate" if the

respondent has a total score of <6. The data

processing results based on the PMT-P categories are

as follows:

Table 3: Category of Supplementary Recovery Feeding

(PMT-P).

Cate

Variable n %

Supplementary Food Recovery

Appropriate 15 32,6

Not A

riate 31 67,4

The majority of toddlers still do not meet the proper

consumption of supplementary feeding recovery

(PMT-P), totaling 31 toddlers, or about 67.4%, while

the toddlers who meet the proper consumption of

PMT-P are 15 toddlers, or about 32.6%.

ICSDH 2023 - The International Conference on Social Determinants of Health

234

Tabel 4: Distribution of Respondents Based On The Criteria

of Infectious Diseases.

Question Answer

Yes No

n % n %

Has the child been diagnosed

with Pulmonary Tuberculosis

(TB) by a doctor in the past 3

months?

5 10,9 41 89,1

Has the child ever been

diagnosed with lung

inflammation (Pneumonia),

with or without a chest X-ray,

by a healthcare professional

(

Doctor/Nurse/Midwife

)

5 10,9 41 89,1

Has the child experienced

symptoms of high fever, cough,

and difficult

breathin

5 10,9 41 89,1

Has the child been diagnosed

with Acute Respiratory

Infection (ARI) by a healthcare

professional

(Doctor/Nurse/Midwife) in the

ast 3 months?

7 15,2 39 84,8

Has the child experienced fever,

cough for less than 2 weeks,

runny/stuffy nose, and sore

throat? (By fever, we mean an

increase in the child's body

temperature)

7 15,2 39 84,8

Has the child been diagnosed

with diarrhea by a healthcare

professional

(Doctor/Nurse/Midwife) in the

ast 3 months?

29 63,0 17 37,0

Has the child experienced

passing stool with a watery or

loose consistency, having bowel

movements more than 3 times a

day? (Symptoms like having 3-

6 bowel movements a day, loose

or water

stool

)

29 63,0 17 37,0

The results indicated that most respondents

answered "yes" when asked about their history of

illness. This was most prominent in questions related

to diarrhea, where 29 toddlers (approximately 63.0

%) responded affirmatively. On the other hand, the

fewest "no" responses regarding illness history were

for questions about TB and pneumonia, with 41

toddlers (approximately 81.9 %) responding

negatively.

Then, the respondents' answers were composite-

scored and grouped into "ever" and "never." A history

of infectious diseases is considered "ever" if the

respondent's score is >0 and "never" if the score is >0.

The data processing results based on the categories of

infectious disease history are as follows:

Table 5: Category of Infectious Diseases.

Cate

Variabel n %

History Of Infectious Diseases

Never 22 47,8

Ever 24 52,2

In this study, the majority of toddlers experienced

infections, totaling 24 toddlers (52.2 %) who had

never had a history of infection.

Figure 1. Change in Z-Score Based On WHZ Among 3

Months.

Based on Figure 1, the z-score change graph

indicates that there was an improvement in the

toddlers z-score over the three month period. In the

first month, it decreased from -2.38 SD to -2 SD in

the second month. Then, it increased again to -1.78

SD in the third month

Table 6: Category of Toddlers Changes in Nutritional

Status.

Variable n %

Changes in Nutritional Status

Goo

20 43,5

Not Goo

26 56,5

In this study, a change in nutritional status is

considered “good” when the final nutritional status

shows an improvement to normal nutritional status,

whereas it is considered “not good” if the final

nutritional status still wasting or indicates a decline to

severe malnutrition

As shown in Table 6, the majority of toddlers

experienced a deterioration in their nutritional status,

with 26 respondents (56.5 %) showing a decline.

Meanwhile, 20 toddlers (approximately 43.5%)

showed improvement in their nutritional status.

-2,38

-2

-1,78

-7

-2

Bulan Ke-1 Bulan Ke-2 Bulan Ke-3

Changes in nutrional status among 3

months

1st Month 2nd Month 3rd

Factors Inﬂuencing Nutritional Status Changes in Wasting Toddlers in the Working Area of Serpong Sub-District Health Center: A

Retrospective Cohort Study

235

Table 7: Distribution of Respondents Based on Toddler

Gender with Changes in Toddler Nutritional Status.

Gender

Change in Nutritional

Status

(95%

CI)

value

Goo

Not Goo

n % n

Female

12 50,0 12

50,0

1,750

(0,537-

5,701)

0,526

Male

8 36,4 14

63,6

The bivariate results of the child's gender with

changes in nutritional status show that more

improvements were observed in nutritional status

among female toddlers (50.0%) compared to male

toddlers (36.4%). However, this study indicated that

there was no relationship between sex and changes in

nutritional status (p = 0.526). These findings align

with those of a previous study that also found no

significant association between sex and changes in

nutritional status (Hasyim and Saputri, 2022).

There is a distinct proportion of nutritional status,

where more females experience a change in wasting

than males (Anita, 2018). This study deviates from

this theory, as female sex does not always correlate

with poor nutritional status, as changes in nutritional

status are influenced by multiple factors, such as the

child's history of infectious diseases.

Table 8: Mothers Characteristics with Changes in Toddler

Nutritional Status.

Variable

Change in Nutritional

Status

(95%

CI)

P value

Goo

Not Goo

n % n

Mother Age

At Risk

13 65,0 12

46,2

2,167

(0,653-

7,190)

0,330

Not At Risk

7 35,0 14

53,8

Mother

Education

High 7 87,5 1 12,5 13,462

(1,429-

121,47)

0,014

Low 13 34,3 25 65,8

Mother

Occupation

Not

Working

16 44,4 20 55,6

1,200

(0,288-

4,993)

1,000

Bivariate results showed no relationship between

maternal age and changes in children's nutritional

status (p = 0.330). This is consistent with a study by

Martiana (2018) that found no significant association

between maternal age and changes in children's

nutritional status (P-value = 0.362) (Martiana, 2018).

Older or more mature mothers have better

childcare experiences than younger mothers do

(Wubante, 2017). The results of this study contradict

this theory. Maternal age is an indirect factor

influencing children's nutritional status; however, in

this study, the majority of mothers were relatively

young (22 years), which means that they might not

have sufficient information and knowledge about

nutrition during pregnancy and after childbirth.

Furthermore, in this study, mothers with a higher

education background have children with a

significantly better rate of improvement in the

nutritional status (87.5%) was observed. The

calculation of Relative Risk (RR) values showed that

respondents with higher education were 13 times

more likely to experience positive changes in

nutritional status. The research findings indicated a

relationship between maternal education and changes

in children's nutritional status (P = 0.014). These

results are consistent with those of a study by Zaqiah

(2019), who also found a significant connection

between maternal education history and changes in

nutritional status (P-value = 0.014). However, this

study contradicts the findings of Amanda (2020),

which indicated no relationship between education

and changes in nutritional status (P = 2.000).

This study showed that mothers with higher

education are better equipped to understand the health

and nutrition of their children. This helps them make

good choices about adding extra food that can make

their children healthier (Solo et al., 2017). Moms with

more education are also aware of balanced nutrition

and can pick the right food for their families (Martina

2018). However, in this study, most mothers had less

education, and more of them saw their children's

nutrition as deteriorating. Moms with more education

often learn good nutrition in seminars, so they know

how to better feed their children. Moms that study

more are usually better for their children at picking

the right food.

Table 8 shows that there was no relationship

between employment and undernutrition status

changes in toddlers (p = 1.000). These findings align

with those of a previous study that found no

significant association between employment and

changes in nutritional status (0.279) (Yunis, 2018).

However, this contradicts the findings of Fauzia

(2019), who suggested a significant relationship

between maternal employment and changes in

nutritional status (p = 0.001).

Moms who do not work have more time to take

care of their children and watch them grow so that

they can control what they eat (Fauzia et al., 2019).

However, this study obtained a different result. In this

ICSDH 2023 - The International Conference on Social Determinants of Health

236

study, most mothers who did not work did not study

much. Even though they have more free time with

their children, many use phones and tablets more and

do not know much about feeding their children

correctly. This lack of knowledge means that they did

not pay sufficient attention to what their children

needed to eat.

Table 9: Distribution of Respondents Based on

Supplementary Feeding Recovery (PMT-P) with Changes

in Toddler Nutritional Status.

PMT-P

Change in Nutritional

Status

(95%

CI)

value

Goo

Not Goo

n % n

Appropriate

12 80,0 3

20,0

11,500

(2,568-

51,502)

0,002

Not

Appropriate

8 25,8 23

74,2

This study showed a relationship between

providing recovery supplementary feeding and

changes in the nutritional status of toddlers (P =

0.002). The Relative Risk (RR) calculation results

indicated that compliance with PMT-P increased the

likelihood of toddlers experiencing positive changes

in nutritional status by 11 times. These findings align

with those of a study that reported a significant

association between PMT-P and changes in

nutritional status (p = 0.037) (Adelasanti, 2018).

This study contradicts the findings of Nurfatimah

and Rakhma (2017), who found no correlation

between PMT and changes in nutritional status

among undernourished toddlers in the Sukoharjo

Regency (p = 0.340). They suggested that when

mothers become tired of PMT, they may not attempt

to modify it into other foods, as taught during

counseling (Nurfatimah et al., 2017). This study

aligns with the theory that supplementary foods serve

as nutritious additions to the main diet of the target

group, thereby fulfilling their nutritional needs. If

implemented according to recommendations aimed at

meeting the energy and protein requirements of

malnourished toddlers, PMT programs can improve

children's nutritional status (Kementerian Kesehatan

RI, 2017).

In this study, many mothers mentioned that their

children did not like the taste of biscuits and became

bored with them, so they did not eat enough food

daily. In addition, some mothers did not know that the

PMT-P should only be given to their children and

should not be shared with family or friends. Others

did not try to change PMT-P to avoid boredom. A few

months later, even though the PMT-P could replace

one main meal, skipping the meal was skipped. Moms

that do not meet the PMT-P criteria may not

understand how they help their children with nutrition

(Adelasanti & Rakhma, 2018).

Toddlers who do not fully follow PMT-P still

improve their nutrition if they eat other foods such as

sweet bread. Despite not fully adhering to PMT-P,

their weight increased because they preferred snacks

and formula milk. Moms provide other foods because

they can afford them. On the other hand, toddlers who

strictly follow PMT-P but have worsening nutrition

might have other issues like past illnesses. Some are

still recovering from TB and lost weight due to recent

diarrhea.

Table 10: Distribution of Respondents Based on History of

Infectious Diseases with Changes in Toddler Nutritional

Status.

History Of

Infectious

Diseases

Chan

e in Nutritional Status

(95%

CI)

value

Goo

Not Goo

n % n

Never

15 68,2 7

31,8

8,143

(2,148-

30,863)

0,003

Ever

5 20,8 19

79,2

As shown in Table 10, there was a relationship

between a history of infectious disease and changes

in nutritional status (p = 0.003; RR = 8,143). This is

consistent with previous research findings that more

toddlers who have never been infected with infectious

diseases experience a better nutritional status than

those who have been infected (Sri, 2018). This is

further supported by earlier studies, such as that of

Nengsi (2017), who reported a connection between

infectious diseases and changes in nutritional status

(p = 0.046).

This study aligns with Carolin's research (2020),

suggesting that infectious diseases can increase the

likelihood of toddlers experiencing undernutrition.

Some toddlers in this study were still undergoing

treatment for infectious diseases including

tuberculosis (TB). The most common infectious

disease experienced by the children in this study was

diarrhea. This can be attributed to some mothers' lack

of awareness of their children’s hygiene, such as

allowing their children to handle food with dirty

hands. Some caregivers who assisted during the study

also mentioned that there were mothers who let their

children's clothes and bodies remain dirty and did not

bathe them for several days. The impact of infectious

diseases on child growth includes weight loss due to

reduced appetite, leading to reluctance to consume

food.

Factors Inﬂuencing Nutritional Status Changes in Wasting Toddlers in the Working Area of Serpong Sub-District Health Center: A

Retrospective Cohort Study

237

4 CONCLUSIONS

After performing the study around 46 toddlers in the

Serpong Sub-district Community Health Center area,

it can be concluded that the mother’s education (p =

0.014; RR = 13,462), supplementary feeding

recovery (p = 0.002; RR = 11,500), history of

infections (p = 0.003; RR = 8,143) are related to

changes in wasting among the toddlers in the same

area of South Tangerang city. However, the study did

not find a significant link between the child's gender

(p = 0.413), mother's age (p = 0.330), and mother's

job (p = 1.000) and changes in wasting. This suggests

that mothers need a way to learn more about balanced

child nutrition and that they should be eager to learn

and apply better eating habits to help their children

grow healthy.

ACKNOWLEDGEMENTS

Praise and gratitude to Allah SWT submitted by me

for blessings and bounty, such as ideas, great health,

and good people around me, so that I finally finished

my graduating paper. Without it, I would not have

been able to write an acknowledgment of my paper.

We are grateful to the Serpong Sub-District Health

Centre and Universitas Muhammadiyah and Prof. Dr.

HAMKA (UHAMKA), who contributed to the

completion of this study.

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