See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/343570929

ICASH-A017 THE COMPARISON OF DIARRHEA INCIDENCE BETWEEN 0-6

MONTHS OLD INFANTS WHO WERE EXCLUSIVELY BREASTFED, NON-
EXCLUSIVELY BREASTFED AND GIVEN MILK FORMULA IN CIREBON CIT....

Conference Paper · July 2019

CITATIONS READS

0 111

3 authors, including:

Witri Pratiwi Ahmad Fariz Malvi Zamzam Zein

Universitas Swadaya Gunung Jati Universitas Swadaya Gunung Jati
19 PUBLICATIONS 9 CITATIONS 34 PUBLICATIONS 110 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Witri Pratiwi on 11 August 2020.

The user has requested enhancement of the downloaded file.

 Proceedings of International Conference on Applied Science and Health
(No. 4, 2019)
Science for the mankind: Translating research results into policy and practices

ICASH-A017
THE COMPARISON OF DIARRHEA INCIDENCE BETWEEN 0-6
MONTHS OLD INFANTS WHO WERE EXCLUSIVELY BREASTFED,
NON-EXCLUSIVELY BREASTFED AND GIVEN MILK FORMULA IN
CIREBON CITY, INDONESIA
Dewi Sukmawati*, Witri Pratiwi, Ahmad Fariz Malvi
Faculty of Medicine, Universitas Swadaya Gunung Jati, Cirebon, Indonesia
*Corresponding author’s email: sukmawi98@gmail.com

ABSTRACT

Background: Infant diarrhea is one of the major health issues in Indonesia due to its high incidence
and mortality. In 2015, the mortality rate of diarrhea and gastroenteritis in infants under one year in
hospitals in Cirebon was 21%. Inappropriate infant feeding practice is one of the risk factors of
diarrhea in infants. WHO recommends that every infant should get exclusive breastfeeding during the
first 6 months of life and continued breastfeeding until 24 months of age. The aim of this study is to find
out the difference in diarrhea incidence between 0-6 months old infants who were exclusively breastfed,
non-exclusively breastfed, and given infant milk formula.
Methods: This was an observational study with cross-sectional design. A total of 89 infants aged 0-6
months old were recruited by purposive sampling. The primary data were obtained using
questionnaires that were filled by the mother or caregiver of the infants. The data were analyzed using
the Chi-Square test and Prevalence Ratio was calculated.
Results: The Chi-Square test showed a significant difference in diarrhea incidence between 0-6 months
old infants who were exclusively breastfed, non-exclusively breastfed and infant milk formula
(p=0,028). Infants who were not breastfed have 4 times higher risk of diarrhea (PR=4.145; CI95%=
1.198-14.400) compared to infants who were breastfed. Infants who were not exclusively breastfed has
3 times higher risk of diarrhea incidence compared to the infants receiving exclusive breastfeeding
(RP=3.286; CI95%=1.144-9.434)
Conclusion: Proper breastfeeding practice can decrease diarrhea incidence in infants aged 0-6
months. Mothers should be encouraged to exclusively breastfeed her baby during the first 6 months of
life.

Keywords: Diarrhea, breastfeeding, infant milk formula, infant feeding practice

INTRODUCTION
Diarrhea is a condition of abnormal bowel movement, loose or liquid stools with abnormal defecation
frequency. Diarrhea in neonates is indicated by defecation frequency more than 4 times. While for
infants, diarrhea happens if defecation frequency is more than 3 times [1,2]. Diarrhea in infants has still
become an important health problem in developing countries, including Indonesia because of the high
incidence and mortality [3]. Inappropriate and late treatment of the diarrhea infant can lead to severe
dehydration condition dan cause death [2].

In 2017, the World Health Organization (WHO) stated that diarrhea was the second cause of death in
children under 5 years. Every year, there are around 1.7 billion cases of diarrhea with a mortality rate
of 525.000 children under 5 years [4]. The high incidence of diarrhea in children under 5 years are

141
 Proceedings of International Conference on Applied Science and Health
(No. 4, 2019)
Science for the mankind: Translating research results into policy and practices

caused by immature immunity so the infectious agents can spread easily [2]. Indonesian Basic Health
Research in 2013 reported that the period prevalence rate of diarrhea for all age group is 3,5% and
children under 5 years has the highest prevalence of diarrhea. The diarrhea incidence of children under
5 years in West Java is 7,9% and babies under 1 year old is 7% [4].

Infant mortality under one year in hospitals in Cirebon was 21% caused by diarrhea and gastroenteritis.
The incidence of acute diarrhea in Cirebon in 2015 was a disease with the highest morbidity (1.90%)
of 46,464 total new case visits to community health centers. The incidence of diarrhea in the Kesunean
Health Center in Cirebon City in 2016 became the second most common disease after Upper
Respiratory Tract Infection (URTI) with 7.4% of cases experienced by infants under one year.
Inappropriate feeding in infants 0-6 months such as formula feeding and early infant food
complimentary can be contributing factors of high diarrhea incidence in babies[5]. Infant formula is
formulated in order to give an infant nutrition that can fulfill their needs. But the composition of infant
formula can not replace breast milk for example the role of maintaining the immune system,
bacteriostatic, anti allergic and psychosocial[6]. WHO recommend that every infant should get early
initiation of breastfeeding, exclusive breastfeeding during the first 6 months of life and continued
breastfeeding until 24 months of age [5]. Indonesian Basic Health Research in 2018 reported that
Exclusive breastfeeding coverage in Indonesia is 37.3%, and in West Java is 36% while the target of
exclusive breastfeeding is 75% [4]. Breastfeeding is an unequalled way of providing ideal nutrition for
babies healthy growth and development. Breast milk is a safe and clean feeding for babies and contains
important antibodies, especially in colostrum which is very important for babies immunity [6]. The aim
of this research is to find out the differences of diarrhea incidence between 0-6 months old infants who
were exclusively breastfed, non-exclusively breastfed and infant milk formula.

METHODS
This was a Cross Sectional observational study conducted during December 2018 until February 2019
with 89 infants 0-6 months old who attended Monthly Maternal and Child Health Service of Kesunean
Community Health Center, Cirebon City, West Java, Indonesia. The samples were collected by
purposive sampling technique and the sample size was calculated using the Isaac and Michael table.
The mother or caregiver of babies was given a questionnaire to collect the data about infant diarrhea
incidence and feeding practices. The questionnaire was adapted and validated from the correlation
between exclusive breastfeeding and the incidence of diarrhea and risk factors in infants aged 6-12
months in the village of Bendungan, Cilegon in 2010 by Istianingrum Yurilla[7].The feeding practice
was divided into three groups: exclusively breastfed, non-exclusively breastfed and infant milk formula.
The inclucion criteria were babies 0-6 month old in Kesunean health center. The exclusion criteria
were babies with Rotavirus immunization history.

SPSS version 24 for windows was used to analyse the data. Analysis of Chi-square test and prevalence
ratio with 95% confidence interval were used to test the hypotheses. Chi square test was used to analyze
the comparison of the incidence of diarrhea in infants 0-6 months with nutrition between infants who
were given exclusive breastfeeding, non-exclusive breastfeeding and formula milk. Prevalence ratio
test with 95% confidence interval was used to find out the odds of diarrhea incidence between the
groups of infant feeding practice.
Diarrheal Incidence
Diarrheal incidence is defined as the incidence of diarrhea event that experienced by the infant during
their life. Diarrhea in neonates is indicated by defecation frequency more than 4 times. While for infants,
diarrhea happens if defecation frequency is more than 3 times. Diarrheal frequency is categorized into
never and ever.

142
 Proceedings of International Conference on Applied Science and Health
(No. 4, 2019)
Science for the mankind: Translating research results into policy and practices

Infant Feeding Practices

The infant Feeding Practice is categorized into exclusive breastfed, non-exclusive breastfed and infant
milk formula. Exclusively breastfed refers to infant only get breastfed without adding and or replacing
with other foods or drinks except vitamins or drugs. Non-exclusive breast fed refers to infant get
breastfed with the addition of formula milk or other foods. Infant milk formula refers to infant only get
milk that formulated for infants without breast fed or other foods.

Ethical clearance approval No. 50/EC/FK/XI/2018 was obtained from Ethical Committe of the faculity
of Medicine Swadaya Gunung Jati University on 19th November 2018. The mother of the baby
explained about this study, purpose and confidence. If the respondent allows then sign on the informed
consent sheet.

RESULTS
Characteristic of respondents
Most of the babies in this study were >2-3 months old (21.3%), followed by >1-2 months old (20.2%),
>3-4 months old, >4-5 months old, and >5-6 months old (15.7%) and 0-1 months old (11.2%) There
was also more male than female infans with 47 males (52.8%) and 42 females (47.2%). Most of the
mothers were housewife (89.9%) and as a worker (10.1%).

Table 1. Characteristics of Respondents

Characteristics Amount (n) Percentages (%)

Age of infants
0-1 months old 10 11.2
>1-2 months old 18 20.2
>2-3 months old 19 21.3
>3-4 months old 14 15.7
>4-5 months old 14 15.7
>5-6 months old 14 15.7
Gender of infants
Female 42 47.2
Male 47 52.8
Mother’s Job
Housewife 80 89.9
Worker 9 10.1

Univariate analysis
The most of the babies were exclusively breastfed (59.6%), followed by non- exclusively breastfed
(25.8%) and infant milk formula (14.6%). About 21.3% of the babies ever experienced diarrhea.

143
 Proceedings of International Conference on Applied Science and Health
(No. 4, 2019)
Science for the mankind: Translating research results into policy and practices

Table 2. Infant Feeding Practice and Diarrhea Incidence

Variable Amount (n) Percentages (%)

Infant Feeding Practice
Exclusive breastfed 53 59.6
Infant milk formula 13 14.6
Non-excusive breastfed 23 25.8
Diarrhea Incidence
Never diarrhea 70 78.7
Ever diarrhea 19 21.3

Bivariate analysis
The comparison of diarrhea incidence between babies who were exclusively breastfed, non- exclusively
breastfed and infant milk formula was analyzed by Chi-square test using significance level p<0.05.

Table 3. The Comparison of Diarrhea Incidence Between the Groups of Infant Feeding Practice
Diarrhea Incidence
Infant Feeding
Never Ever P-Value
Practice % % Total %
diarrhea diarrhea
Infant milk
7 53.8 6 46.2 13 100
formula
Non-exclusive
17 73.9 6 26.1 23 100
breastfeeding
Exclusive 0.028
46 86.8 7 13.2 53 100
breastfeeding
Total 70 78.7 19 21.3 89 100

Chi-square test analysis showed significant differences of diarrhea incidence between the three groups
(p=0.028). The highest diarrhea incidence was in the group of babies who got infant milk formula
(46.2%). The lowest diarrhea incidence was in the group of babies who got exclusive breastfeeding
(86.8%).

Table 4. The Prevalence Ratio of Diarrhea Incidence Between the Groups of Infant Feeding Practice
95% CI for
Diarrhea Incidence RP
Exp(B)
No
Never Ever Lower Uper
Total
diarrhea diarrhea
1. Non-exclusive breastfeeding 17 6 23
Exclusive breastfeeding 46 7 53 2.319 0.682 7.889
Total 63 13 76
2. Infant milk formula 7 6 13
Exclusive breastfeeding 46 7 53 5.633 1.461 21.718
Total 53 13 66
3. Infant milk formula 7 6 13
Non-exclusive breastfeeding 17 6 23 2.429 0.579 10.185
Total 24 12 36

144
 Proceedings of International Conference on Applied Science and Health
(No. 4, 2019)
Science for the mankind: Translating research results into policy and practices

Table 4. shows that the babies who got non-exclusive breastfeeding has 2 times higher risk of diarrhea
incidence compared to the babies who got exclusive breastfeeding (RP=2.319). Babies who got infant
milk formula has 5 times higher risk of diarrhea incidence compared to the babies who got exclusive
breastfeeding (RP=5.633). Babies who got infant milk formula has 2 times higher risk of diarrhea
incidence compared to the babies who got non-exclusive breastfeeding (RP=2.429).

The Table 5 below show the prevalence ratio of the group of babies who never got breastfeeding (infant
milk formula) and babies who got breastfeeding, either exclusively or not.

Table 5. The Prevalence Ratio of Diarrhea Incidence Between the Babies Who Never Got
Breastfeeding and Got Breastfeeding

95% CI for
Diarrhea Incidence RP
Exp(B)
Never Ever Lower Uper
Total
diarrhea diarrhea
Never got breastfeeding 7 6 13
Got breastfeeding 63 13 76 4.154 1.198 14.400
Total 70 19 89

Babies who never got breastfeeding have 4 times higher risk of diarrhea incidence compared to the
babies who got breastfeeding, either exclusively or not (RP=4.154).

The Table 6 below show the prevalence ratio of the group of babies who got exclusive breastfeeding
and babies who not exclusive breastfeeding (non- exclusive breastfeeding and infant milk formula) .

Table 6. The Prevalence Ratio of Diarrhea Incidence Between the Babies Who Not Exclusive
Breastfeeding and Exclusive Breastfeeding

95% CI for
Diarrhea Incidence RP
Exp(B)
Never Ever Lower Uper
Total
diarrhea diarrhea
Not exclusive breastfeeding 12 24 36
Exclusive breastfeeding 7 46 53 3.286 1.144 9.434
Total 19 70 89

Babies who not exclusive breastfeeding have 3 times higher risk of diarrhea incidence compared to the
babies who got exclusive breastfeeding (RP=3.286).

DISCUSSION
Diarrhea in infants is often caused by infection because babies are born with an imperfect immune state
[2,5]. Breast milk can protect babies from infections that cause diarrhea. This is because breast milk
contains immunological and bioactive components that work to provide passive immune defense from
the mother to the baby[6].

This study showed there was a significant difference between infants 0-6 months who were given
exclusively breast-fed, non-exclusive breastfed, and infant milk formula with the incidence of diarrhea.
This finding were associated with the Maki research in 2017 with a significant difference between
exclusive breastfeeding and formula milk on the incidence of diarrhea in infants aged 6-12 months in
the Ranotana Weru health center areas with the Mann-Whitney test with p value = 0.010 [8]. The

145
 Proceedings of International Conference on Applied Science and Health
(No. 4, 2019)
Science for the mankind: Translating research results into policy and practices

difference with this study was respondents aged 6-12 months and did not observe non-exclusive
breastfeeding variables.

Infant formula has no content that plays a role in body immunity, such as sIgA (seceretory
imunoglobulin A) that have a role in the protection of the digestive tract mucosa which can inhibit the
proliferation of pathogens in the gastrointestinal tract [6], and formula milk does not contain lactase
which is intended to increase lactose intolerance which causes feces or stool to be more fluid [2,9].
Based on the results showed that the chance of diarrhea in infants from 0-6 months who were only given
by infant milk formula was 4 times greater than breastfed, was 5 times more at risk of diarrhea than
those given exclusive breast-fed and 2 times at higher risk for diarrhea than those with non-exclusively
breast-fed. A similar finding was also observed in a study in Community Health Center Teupin Raya
Regency, Pidiebahwa, the incidence of diarrhea in infants aged of 0-6 months who were given by infant
milk formula was 3 times more at risk than not given formula milk with Odds Ratio of 3.667 (CI =
1.52-11.00) [10].

World Health Organization (WHO) recommends that the for a mom must give exclusive breastfeeding
until the babies 6 months old and complementary feeding begins at 6 months of the age[5]. This is
because the digestive system of infants less than 6 months old is still not yet mature and digestive
enzymes such as stomach acid (HCl), amylase, maltase, sukrase, and lipase have not worked perfectly
so that it can cause diarrhea [2,11,12]. The results showed that infants who were given non-exclusive
breastfeeding were 2 times is higher got risk for diarrhea compared to those who were given exclusively
breast-fed. Associated with the Sentan’s research in 2018 with exclusive breast-fed related significantly
to reporting in the work areas of Banjarangkan II of Health Center in Klungkung Regency with the chi
square test p = 0.005 was obtained, while non-exclusive breastfed status increased until 4 times from
0-6 months with OR = 4.129 (CI = 1.542-11.05) [13].

The results showed that infants from 0-6 months who weren’t given non-exclusive breastfed and infant
milk formula had a 3 times higher got the risk of diarrhea than those given exclusive breastfeeding.
This is in accordance with Banerjee's 2019 study that exclusive breastfeeding greatly reduced the
incidence of diarrhea in the city of Kolkata, India with an Odds Ratio of 0.12 (CI = 0.03-0.4) [14].
Supported by Hanieh's research in 2015 in the North Vietnam stated that Exclusive breastfeeding
reduced the odds of inpatient admission for diarrheal illness by more than 60% (OR 0.37, 95% CI 0.15
to 0.88) [15]. In addition breast milk contains lactoferrin which increases bactericidal activity sIgA
against causative bacteria such as Escherichia coli and some Salmonella. The mucin content in the
breast milk can also inhibit the adhesion of Escherichia coli and rotavirus [6,16].

The limitation of this study was only analyzed infant feeding practice, it did not consider other risk
factors for diarrhea, such as the habit of washing caregivers' hands, cleaning milk bottles and cutlery,
and water used to thin formula milk. For the future studies can used consider other factors that cause
diarrhea, such as the habit of washing caregivers' hands, cleaning milk bottles and cutlery, and water
used to disolve formula milk.
CONCLUSION
Exclusively breastfed, non-exclusively breastfed and infant milk formula showed a significantly
differences with diarrhea incidence 0-6 months old infants. Breastfeeding practice can decrease diarrhea
incidence in 0-6 months old infants. The mother is encouraged to breastfeed her baby exclusively during
the first 6 months of life. The Primary Health Care improve public promotion and education activities
regarding importance of exclusive breastfeeding to decrease diarrhea incidence in infants 0-6 months
old.

146
 Proceedings of International Conference on Applied Science and Health
(No. 4, 2019)
Science for the mankind: Translating research results into policy and practices

CONFLICT OF INTEREST
The authors declare no conflict of interest.

REFERENCES
1. Motamed F, Kazemi N, Nabavizadeh R. Assessment of Chronic Diarrhea in Early Infancy in Tehran Tertiary Care Center ; Tehran-
Iran. 2015;3:45–50.
2. Melorose J, Perroy R, Careas S. Nelson Textbook of Paediatrics. Vol. 1, Statewide Agricultural Land Use Baseline. 2015. 23-49
p.
3. Kementerian Kesehatan RI. Situasi Diare di Indonesia (Diarrhea Situation in Indonesia). Vol. 2, Buletin jendela data & informasi
kesehatan. 2011. 1-44 p.
4. Depkes RI. Riset Kesehatan Dasar (Indonesian Basic Health Research). Jakarta: Badan Penelitian dan pengembangan Kesehatan
Kementrian Kesehatan RI; 2013.
5. Sankar MJ, Sinha B, Chowdhury R, Bhandari N, Taneja S, Martines J, et al. Optimal breastfeeding practices and infant and child
mortality : a systematic review and meta-analysis. 2015;3–13.
6. Aldy OS, Lubis BM, Sianturi P, Azlin E, Tjipta GD. Dampak Proteksi Air Susu Ibu Terhadap Infeksi (Impact of Mother's Milk
Protection Against Infection). Sari Pediatri. 2016;
7. Istianingrum Y. Hubungan antara Pemberian ASI Eksklusif dengan Kejadian Diare dan Faktor-Faktor Risiko pada Bayi Berusia
6-12 Bulan di Kelurahan Bendungan Kecamatan Cilegon (The Correlation between Exclusive Breastfeeding and The Incidence of
Diarrhea and Risk Factors in Infants Aged 6-12 Months in The Village of Bendungan, Cilegon). Jakarta; Fakultas Kedokteran
Universitas Islam Negeri Syarif Hidayatullah; 2010
8. Maki F, Umboh A, Yudi A. Perbedaan Pemberian Asi Eksklusif dan Susu Formula Terhadap Kejadian Diare pada Bayi Usia 6-12
Bulan di Wilayah Kerja Puskesmas Ranotana Weru (Differences in Exclusive Breastfeeding and Formula Milk for Diarrhea in
Babies 6-12 Months in Ranotana Weru Health Center). Vol. 5, eJournal Keperawatan (eKp). 2017.
9. Wicaksono MA. Intoleransi Laktosa (Lactose Intolerance). Mandala Heal. 2014;7.
10. Maulidar., Iskandar. Hubungan Pemberian Susu Formula dengan Kejadian Diare pada Bayi Usia 0-6 Bulan (Correlation formula
milk feeding with the incidence of diarrhea in infants 0-6 months). Jurnal AcTion: Aceh Nutrition Journal 2016;1(2):73–77.
11. Heryanto E. Faktor-Faktor yang Berhubungan dengan Pemberian Makanan Pendamping ASI Dini (Factors Associated with
Giving Early Complementary Feeding). J Ilmu Kesehatan. 2017;2(2):141–152. Oloruntoba EO, Folarin TB, Ayede AI. Hygiene
and sanitation risk factors of diarrhoeal disease among under-five children in Ibadan , Nigeria. African Health Sciences
2014;14(4):1001-1011.
12. Agedew E. Early Initiation of Complementary Feeding and Associated Factors among 6 Months to 2 Years Young Children, in
Kamba Woreda, South West Ethiopia: A Community –Based Cross - Sectional Study. J Nutr Food Sci [Internet]. 2014;04:1–74.
Available from: https://www.omicsonline.org/open-access/early-initiation-of-complementary-feeding-and-associated-factors-
among-months-to-years-young-children-in-kamba-woreda-south-west-ethiopia-a-community-based-cross-sectional-study-2155-
9600.1000314.php?aid=32548.
13. Sentana K, Adyana I, Subanada I. Hubungan Pemberian ASI Eksklusif dengan Kejadian Diare pada Bayi (Correlation of Exclusive
Breastfeeding with Diarrhea in Infants). E-Jurnal Med DOAJ. 2018;7.
14. Banerjee N, Chakraborty A, Lahiri A, Biswas K. Exclusive breast feeding reduces diarrhoeal episodes among children : results
from a cross-sectional study among the mothers of under-five children in Kolkata. Int J Community Med Public Heal. 2019;6:733–
7.
15. Hanieh S, Ha TT, Simpson JA, Thuy TT, Khuong NC, Thoang DD, et al. Exclusive breast feeding in early infancy reduces the
risk of inpatient admission for diarrhea and suspected pneumonia in rural Vietnam : a prospective cohort study. BMC Public Health.
2015;1–10.
16. Martin C, Ling P, Blackburn G. Review of Infant Feeding : Key Features of Breast Milk and Infant Formula. MDPI. 2016;8:1–11.

147

View publication stats