Supplementary Infant Feeding in Developing Countries

Transcription

1 Weaning: Why, What, and When?, edited by A. Ballabriga and J. Rey. Nestlf Nutrition, Vevey/Raven Press, New York c 97 Supplementary Infant Feeding in Developing Countries Ashfaq Ahmad Department of Child Health, Khyber Medical College, Peshawar, Pakistan About 00 B.C. Hippocrates said, "The physician must know and must bear great pains to know what man is in relation to food and drink and habits generally and the relation of each to each individual." Successful feeding of human infants has been accomplished for millions of years. This helps to explain the survival of the human species, which is so versatile in its ability to utilize food of many kinds. Human beings eat what they can find in their environments, generally following patterns set by their ancestors. These patterns of feeding are enmeshed in the culture where the infant was born and where its parents have lived. The cultural setting of infant feeding practices have a direct effect on the health status of the growing child. Unfortunately, in many developing countries like Pakistan, grave misconceptions are prevalent in the community regarding infant feeding; this, along with increased incidence of bottle feeding, contributes to a very high mortality and morbidity from diarrheal diseases and malnutrition. An Eastern Mediterranean Region Organization (EMRO) collaborative study on infant feeding and weaning practices was conducted simultaneously in six different locations covering all four provinces of Pakistan. The aims and objectives of this study were (a) to assess the nutritional status of infants, (b) to determine the feeding patterns and weaning practices, and (c) to evaluate the adequacy of supplements offered to the infants and to find possible reasons for deficiencies. METHODOLOGY The task in each province was allotted to a provincial coordinator and a team of field workers, trained by the provincial coordinators. Field work was carried out from September 90 to August 9. Four rural and two urban slum samples were selected. The infants included were studied according to a standard World Health Organization questionnaire, which consisted of identification data, and information 'Designed for this study, EM/NUTA/9, December 9. 97

2 9 SUPPLEMENTARY INFANT FEEDING about the family, breast feeding, the child, supplements fed to the child, and factors affecting supplementary feeding. The completed questionnaires were returned to the provincial coordinators and were checked for gross discrepancies. In addition to the questionnaires, % of the food samples were biochemically analyzed in provincial laboratories of known repute. SAMPLE CHARACTERISTICS A total of,50 infants were studied; 35 were under of age;,, and 5 between and, and, and and, respectively. Of the sample, 5.% infants belonged to nuclear families, and the remaining came from extended family systems. According to the information obtained, only.% of the mothers and 39.% of the fathers were educated. Education was defined as the ability of the individual to read and write simple sentences. Only.% had what can be regarded as an adequate monthly income of 00 rupees or more. Only 3.% of the infants were born in hospital; the rest were born at home. PREVALENCE AND DURATION OF BREASTFEEDING The study showed that only 3.3% of the infants had never been breast-fed. Of the remaining 9.7%, some 7.% were totally weaned at the time of interview. Table shows the duration of breast-feeding in infants who were not breast-fed at the time of interview. Table shows the reasons for stopping breast-feeding these infants. Insufficient milk and another pregnancy accounted for.7% and 9.% of the cases, respectively; 5.% of mothers stopped breast-feeding because of ill health. Only.% had to do so because of work. Information regarding the pattern of breast-feeding showed that 9.% fed infants on demand and.% did so according to a specific schedule. The Protein Advisory Group of the United Nations has suggested the following definition for weaning foods: "Processed, protein-rich foods to serve as supplementary food for breast-fed infants after of age. As a rule such products should not be recommended for infants below of age''. Most commercial foods do not satisfy the above definition and, because of ignorance, are used as a substitute for breast milk for children under of age, which is extremely hazardous. Some of the available commercial products have good protein and other nutrient contents but are beyond the purchasing power of most people. The majority Handbook of human nutritional requirements. WHO monograph, Series no.. Geneva: WHO, 97.

3 SUPPLEMENTARY INFANT FEEDING 99 TABLE. Duration of breast-feeding in infants who were no longer breast-fed at the time of interview Up to Northwest Frontier Province (rural) Punjab (urban slum) Total (.7%) 3 5 (33.33%) 9 3 (.5%) (3.9%) TABLE. Reasons for stopping breast-feeding Work Insufficient milk III health Any other/none (pregnancy) Northwest Frontier Province (rural) Punjab (urban slum) (.0%) (.73%) 3 55 (5.3%) 5 50 (9.5%) of parents do not understand the proper use of such products, and therefore there is a high risk of contamination and underfeeding. In Pakistan, as in other developing countries, bottle-fed commercial baby foods have become a status symbol. Although through the efforts of the medical profession the advertising of these foods in the public media has been curbed, they are still in vogue. However the figures from our study sample are encouraging. Only 3.3% of the infants were never breast-fed, and only.% received commercial baby foods. INTRODUCTION OF SUPPLEMENTARY FOODS INTO INFANT'S DIET Table 3 gives the age at which mothers felt that supplementation of the infant's diet should be made. It covers the ages of to and there is a wide variety of opinions. Table lists information about the reasons given for starting supplementary feeding. Of this group 3.% of mothers had started supplementing

4 0 SUPPLEMENTARY INFANT FEEDING TABLE 3. Age at which mothers felt that supplements should be started Up to Northwest Frontier Province (rural) Punjab (urban slum) (5.9%) (.3%) (5.%) i (%) 7 (5.9%) TABLE. Reasons given for starting supplementary ifeeding Lactation failure Age of baby Another pregnancy Hungry baby Medical advice/other Northwest Frontier Province (rural) Punjab (urban slum) (.7%) (3.5%) 7 3 (5.%) 3 79 (9.0%) 5 5 (5.5%) the infant's dietary intake before of age, while 7.0% had not given any supplement at. Table 5 shows the types of supplementary foods given to infants. Only 9.7% used a portion of the regular family diet as supplement;.% used diets especially prepared for infants, and.% used commercially prepared foods. Mostly buffalo and cow's milk was used. In 3% of the cases, it was boiled, but in 7% it was consumed unboiled. The milk was sometimes diluted (Table ). As mentioned above, some mothers preferred to use a portion of the regular family diet, whereas others used foods specifically prepared for the infants. These were mostly a combination of rice, mammalian milk, sugar, pulses, vegetables, and other cereals. The most commonly used among these were dalia (porridge), kichri (a preparation made from rice, pulses, and oil), sagoo dana (semolina pudding), firny (rice and milk pudding), and different forms of tea, which include green tea with cardamom and sugar, milk replacing the aqueous portion in some cases. Fruits were not very commonly used, but among them banana seemed to be

5 SUPPLEMENTARY INFANT FEEDING TABLE 5. Supplements given to infants Milk Buffaloi Cow Goat Other Portion of regular family diet Specially cooked for infants Biscuit toffees Commercially prepared food Northwest Frontier Province (rural) Punjab (urban slum) TABLE. Supplementary feeding with mammalian milk Not idiluted 0% 50% Diluted 75% 5% Total Northwest Frontier Province (rural) Punjab (urban slum) the most popular. Boiled vegetables, depending upon the season, were also used. Tuberous vegetables like potatoes were the commonest. Although most mothers felt that eggs and meat are beneficial for the infants, these were rarely used because of economic limitations. Foods such as biscuits, toffees etc, available from local shops, were among the supplements used to stave off the hunger of the infants. ADEQUACY OF THE SUPPLEMENTS This was assessed from the dietary information provided by the mother (recall method) and by the actual weighing of food samples. Obvious drawbacks exist in both methods (Table 7). Most mothers did not weigh the food before or after it was cooked. In rural areas, people by and large utilize foods grown on their farms,

6 SUPPLEMENTARY INFANT FEEDING TABLE 7. Range of daily calorie and protein intakes from breast milk and supplements Calorie intake (kcal) < ,000,000-,0 >,0 Protein intake (g) <5 5- > hence the need for weighing is not felt. Though the weighing of food with the assistance of trained investigators may secure comparatively accurate information, biases in this technique may still appear. The presence of an investigator may introduce the prestige bias, the household either exaggerating the amount of food consumed or changing the pattern in favor of more expensive foods. The ambiguity is further enhanced when the food is converted to its energy and nutrient values. The food conversion tables used are not always applicable because they do not provide any information about numerous locally made food items. An accurate way of determining nutrient intake is biochemical analysis, but it is a difficult and expensive process and was done only in a small number (%) of cases in this study. According to the criteria laid down by WHO 3 for the present study, 9.% of children to of age were consuming adequate calories and.7% had an adequate protein intake. In the to age group there was an adequate protein and calorie intake in 0.% and 9.9% of the sample, respectively. Of children between and of age, 5.9% had adequate calorie and 53.9% adequate protein intake (Table ). Such high figures of inadequate supplementation outnumber the clinically obvious cases of protein energy malnutrition. (Most of the nutritional surveys in India show more or less similar results with minor variations attributable to location.) 3 "An intake of proteins less than g/day, derived partly from breast milk and partly from a predominently cereal-based supplement for children between and of age, may be considered inadequate. A calorie intake of less than,000 calories for children between and years of age may be considered inadequate." (These criteria were designed specifically for this study, EM/ NUTR/9 December 9.)

7 SUPPLEMENTARY INFANT FEEDING 3 TABLE. flange of daily calorie and protein intakes from supplements Calorie intake (kcal) < ,000,000-,0 >,0 Protein intake (g) Less than 5g 5- Above 90 (0.%) 5 (3.%) 5 (.%) (.37%) (5.%) (.%) (.0%) (.0%) (7.%) 7 (3.7%) (.33%) (.%) (.93%) (9.35%) (3.3%) 33 (.%) 3 37 (3.9%) 7 (9.3%) (.7%) 7 (7.%) 5 (9.55%) 3 5 (9.7%) 93 (3.9%) 9 (.7%) 3 (5.5%) (.%) 33 (.09%) (.%) 5 (7.3%) 5 (9.7%) (0.00%) 3 (50.%) 5 In general, prolonged breast-feeding was the rule in all regions. Usually this started within or 3 days of delivery and continued into the second or third year or even longer. Breast-feeding was usually given on demand and not according to any time schedule. Pregnancy was the most common cause for stopping breast-feeding. Children were weaned from the breast by to. Supplements were usually started around to of age, and these were milk and/or cereal food in the form of cooked rice, wheat, or millet either as rotis or soft cooked as porridges prepared with broken cereals. In certain communities processed milk products such as infant milk powder and condensed milk were used, in dilutions far in excess of the recommended levels. DEFICIENCIES IN THE CURRENT SUPPLEMENT The supplements offered to the infants were deficient both in calorie and protein content, particularly between and of age, but also between and. To combat the deficiencies with locally available food resources would require a full-scale nutrition program. Although many cereals, seeds, vegetables, fruits, and cheap commercial products are available, their introduction as weaning supplements would be hazardous without prior evaluation. An alternative approach

8 SUPPLEMENTARY INFANT FEEDING would be to prepare cheap weaning diets from locally available resources and arrange for their distribution to families through government agencies. These diets can be fortified with essential nutrients. The causes of inadequacy of supplements and of the consequent malnutrition are multifactorial and almost the same in most developing countries. Ecological, cultural, and demographic processes all contribute, but the low productivity of agricultural products has the most important share. This can be attributed to low per unit land production resulting from poor irrigation and improper use of fertilizers, new seeds, and pesticides. Wastage of various kinds of foods occurs on farms, as well as during transportation and storage. Poverty remains the prime cause of malnutrition and underlies most other factors. The very low income of most families in relation to food prices is reflected in the fact that they spend almost all of their income on food items. Nutritional problems are aggravated in urban situations because food has to be bought rather than grown and because expensive commercial foods are promoted by mass advertisements. Cultural factors complicate the problems still further. The largest share of the family diet goes to the adult males, and very little and low-quality food remains for the growing children and the females, who may be pregnant or lactating. In recent times the most deleterious effect of modernization has been the switch from breast- to bottle-feeding. Although the incidence of breast-feeding in the sample is very satisfactory, the high incidence of malnutrition signifies the operation of other important factors. We found that.3% of the family diets were adequate in proteins, calories, and other nutrients, both qualitatively and quantitatively. We feel that supplements can be improved by better intrafamilial distribution of foods if they are used in specified amounts, concentrations, and combinations. For this purpose a nutrition education program is necessary for maternal guidance through mother-child health centers, social workers, school teachers, community workers, and the public media. In most cases this would allow for good growth if the food were given in combination with the mother's milk.