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Infant feeding practices and the development of malnutrition in rural Gambia
University of Cambridge and Medical Research Council, Dunn Nutritional Laboratory, Cambridge, England
When Professor Fujimaki invited me to present this lecture, he wrote the following: "In an affluent society like ours, malnutrition sounds like a story far from reality. We would like you to let us know exactly what things really are like!" In this paper I will discuss just one small African village, called Keneba, in the Gambia. I hope to convince you that the malnutrition that kills or severely inhibits the development of the majority of Gambian children in the second or third year of their lives has its beginnings with the undernutrition of the mother. I will also illustrate that the elimination of malnutrition necessitates a whole multiplicity of approaches because of the diverse health hazards affecting the mother and her child.
Of the many countries in Africa, the Gambia, on the bulge of West Africa, is one of the smallest. The country is only about 30 kilometers wide and 600 kilometers long, straddling the River Gambia (Fig. 1). Most Gambians live in small villages, and the one in Fig. 2 is typical. The streets are completely unpaved; there is neither sanitation nor drainage. The houses are made of mud bricks and have roofs of corrugated metal or grass.
The women are the main work-force in the village and, apart from cooking, they are also largely responsible for the growing and harvesting of the staple food and cash crops (Fig. 3). The major cash crop and the main source of dietary protein for the villagers is groundnut. These are grown using traditional techniques; there is little modern agricultural technology. The main dietary staples are cereals: rice, millet, sorghum, and maize.
This rapid description of the village is what a tourist or any casual visitor would see. Reality is, however, much more harsh. A study published in 1973 by McGregor showed that by the age of five years, 50 per cent of the babies born alive have died. Subsequently, we have shown that by two years, two-thirds of surviving children would also be considered malnourished by international standards. These are not unusual statistics. Similar values have been obtained in many parts of Africa where careful assessments have been made.
Growth Faltering and Malnutrition
The main type of frank malnutrition is marasmus (Fig. 4); the swollen, edematous form of protein-energy malnutrition is very rare in Keneba. The age when marasmus becomes a serious clinical problem is one to two years, but for every child who reaches this sad state, there are many more who are seriously underweight. Figure 5 shows the percentage expected weight and height of the children, on the basis of WHO standards, at different ages. Between one and three years, the average child is only 75 per cent of this standard; two-thirds would be defined as undernourished, being less than 80 per cent of weight for age. In the past, most nutritional-aid schemes have concentrated almost exclusively on such one- to three-year-old children. The aim has been to prevent them from becoming so ill that they need hospital treatment, but clearly a more ideal approach would be to attack the problem earlier- at its very start. In a special survey we showed that, although at birth babies tend to be small, on average 2.9 kg, for the first two months they do well and show growth catch-up. From the third month on, however, this good progress falters, and from four months on, the percentage weight for age begins to fall progressively (Fig. 6).
At two to three months, the only real source of food is breast-milk. If there is a dietary deficiency affecting growth at this age, it must be associated with breastfeeding. I must emphasize that all Gambian women breast feed their babies for up to two years; the problem is not caused by the women's stopping breastfeeding, but by a possible defect in the quantity and quality of milk they are able to produce.
How much breast milk does a baby need at different ages? No one knows with certainty, but it is possible to make some estimate from WHO/FAD estimates for energy needs. Figure 7 shows the energy needs of an average-weight child during the first 12 months of life, and also of children who are 20 per cent below and 20 per cent above this average weight. Using these data, it can be calculated by simple mathematics approximately how much milk a child needs. Human milk contains about 69 kcals/100 ml. If one multiplies the weight of the child by his energy needs/kg, then, by the composition factor, an estimate of the milk needed can be derived. Figure 8 shows the theoretical range of milk requirements thus calculated for average, small, and large children at different ages. But how do these theoretical needs fit with actual consumption?
Figure 8 also shows the range of human milk consumption in Keneba. Milk intakes do not rise with age by the amount they theoretically should, and only up to two-three months (the shaded area in the figure) do needs and consumption overlap. From Fig. 6 it can be seen that it was only at this time that growth performance matched the international standards. These results are not unique to the Gambia. Figure 9 shows the Gambian results compared to those obtained by a number of workers in the Ivory Coast, Mexico, and Zaire (Congo).
There could be a number of reasons why milk outputs decrease. One possibility might be a lack of breast stimulation from the suckling child, but this is unlikely. Gambian mothers feed their children at least 14 times each day; furthermore, plasma prolactin-the hormone that stimulates milk production in response to the baby's feeding-is maintained at high levels for many months. A more likely reason is that the mother's diet is not sufficient to provide the nutrients in her milk to promote adequate growth of her infant beyond the first three months.
FIG. 1. Map of the Gambia Showing Keneba and Surrounding Villages
FIG. 5. Mean Percentage Weight and Height for Age of Village Children between Three Months and Three Years
FIG. 6. Mean Percentage Weight for Age during Early Infancy
FIG. 7. Range of Dietary Energy Needs during Infancy According to WHO/FAD (1973)
How much food does a lactating mother need? WHO/FAD have suggested 2,200 kcals for a non-lactating woman, and 2,750 for a lactating one. These theoretical estimates fit in well with the amounts people eat in the industrialized countries, but the evidence is that Gambian women eat much less. By weighing all of the food eaten by a mother, we obtained the data in Fig 10. Intakes at all times of the year were always well below the WHO/FAD estimated requirements, but particularly so in August and September.
These Gambian results are very similar to those previously reported in a number of other countries, for example in India and the lowlands of New Guinea. These low intakes, however, are not always due to lack of food. In fact, the weight of food eaten by the Gambian mothers was little different from that found in a parallel study being carried out in the United Kingdom. The real difference is in the energy and nutrient concentrations of the foods. The Gambian foods, on average, contain much more water. This is why there is such a big difference in energy intake
Local Weaning Foods
Because of the short-fall in breast-milk relative to needs, the mothers introduce supplementary feeding early, although they continue to breast-feed. This begins at about three months, and by five months of age, 80 per cent of the children are receiving other foods in addition to breast-milk, as shown in Fig. 11.
This supplementary food has many defects, however; in a number of ways the nutrient content is no substitute for breast-milk. Energy, calcium, and vitamin contents are particularly low, but perhaps more importantly, the gruel fed is made up from water that is contaminated by potentially pathogenic animal and human fecal coliforms. Gross bacteriological contamination is especially a problem in the rainy season. The food becomes contaminated in a number of other ways. A microbiologist lived with our team for a year, sampling and analyzing the infants' food at different stages of preparation and storage. His work showed that even with freshly prepared food, up to one-third would be condemned as microbiologically unfit for human consumption by international standards, and particularly during the rainy months (see the accompanying table). Food kept for an hour or two before being eaten was even worse.
FIG. 8. Human Milk Intakes to Satisfy Energy Requirements in Fig. 7
FIG. 9. Mean Milk Intakes in Various Developing Countries
FIG. 10. Food Energy Intake of Lactating Keneba Women According to Season (1977)
FIG. 11. Age of Introduction of Weaning Foods
FIG. 12. Pattern of Diarhoeal Diseases and Rainfall
Percentage of Food Samples Containing Unacceptable Levels of One or More Pathogens According to Season
|Time after preparation (in hours)||Wet season: June-Oct.||Dry season: Nov.-May|
|0 - 1||34.9(43)||6.3(73)|
|1 - 2||52.6(19)||30.8(13)|
|4 - 6||57.8(38)||46.3(41 )|
Figures in parentheses are the actual numbers of samples studied.
As shown in Fig. 12, this food and water contamination is associated with a rise in the incidence of diarrhoeal diseases. In some months of the year the average child has diarrhoea most of the time.
The combination of insufficient human milk and nutritionally poor and contaminated weaning foods drastically retards child growth in the Gambia, and all too frequently results in frank malnutrition. There is no simple solution to the problem; many approaches and improvements are necessary, many types of expertise must be brought together and integrated. It is this sort of integrated, practical research that the UN University fosters.
Reading List of Recent Relevant Publications on Nutrition
Barrell, R.A.E., and M.G.M. Rowland, "infant Foods as a Potential Source of Diarrhoeal Illness in Rural West Africa." Trans. Roy. Soc. Trop. Med. Hyg., 73: 85 - 90(1979)
---- "The Relationship between Rainfall and Well Water Pollution in a West African (Gambian) Village." J. Hyg. (Cambridge). In press.
Cole, T.J., and J.M. Parkin, "Infection and Its Effect on the Growth of Young Children: A Comparison of the Gambia and Uganda." Trans. Roy. Soc. Trop. Med Hyg., 71: 196 - 198 (1977).
Patterson, S., J. Parry, T.H.J. Matthews, R.R. Dourmashkin, D.A.J. Tyrrell, R.G. Whitehead, and M.G.M. Rowland, "Viruses and Gastroenteritis." Lancet 2: 451, 1975.
Paul, A.A., A.M. Prentice, M.A. Hutton, E.M. Muller, and R.G. Whitehead, "Factors Affecting Breast Milk Intake in Rural Gambian Infants," Eleventh International Congress of Nutrition, Rio de Janeiro, Brazil, 27 August-1 September, 1978.
Paul , A. A., E.M. Muller, and R.G. Whitehead, "The Quantitative Effects of Maternal Dietary Energy Intake on Pregnancy and Lactation in Rural Gambian Women." Trans. Roy. Soc Trop. Men Hyg., in press.
Rowland, M.G.M. "Malnutrition: Prevention or Cure." J. Trop. Pediat, in press.
Rowland, M.G.M., A.A. Paul, A.M. Prentice, E.M. Muller, M.A. Hutton, R.A.E. Barrell, and R.G. Whitehead, "Seasonal Aspects of Factors Relating to Infant Growth in a Rural Gambian Village." Seasonal Dimensions to Rural Poverty, IDS, in press.
Rowland, M.G.M., T.J. Cole, and R.G. Whitehead, "A Quantitative Study into the Role of Infection in Determining Nutritional Status in Gambian Village Children." Brit J. Nutr., 37: 441- 450 (1977).
Rowland, M,G.M., and J.P.K. McCollum, "Malnutrition and Gastroenteritis in the Gambia " Trans. Roy. Soc. Trop. Med Hyg., 71: 199 203(1977).
Rowland, M.G.M., R.A.E. Barrell, and R.G. Whitehead, "Bacterial Contamination in Traditional Gambian Weaning Foods." Lancet 1: 1 36 - 1 38 (1978).
Rowland, M.G.M., T.J. Cole, and R.G. Whitehead, "Protein-Energy Malnutrition." Trans. Roy. Soc. Trop. Med. Hyg., 72: 550 - 551 (1978).
Rowland, M.G.M., H. Davies, S. Patterson, R.R. Dourmashkins, D.A.J. Tyrrell, T. H.J. Matthews, J. Parry, J. Hall, and H.E. Larson, "Viruses and Diarrhoea in West Africa and London: A collaborative study." Trans Roy Soc. Trop. Med Hyg., 72: 95 - 98, (1978).
Rowland, M.G.M., and R.A.E. Barrell, "Ecological Factors in Gastroenteritis." Ann. Haman Biol., in press.
Rowland, M.G.M., and T.J. Cole, "The Effect of Early Glucose Electrolyte Therapy on Diarrhoea and Growth in Rural Gambian Village Children." J. Trop. Pediat., in press.
Rowland, M.G.M., and A.A. Paul, "Factors Affecting Lactation Capacity: Implications for developing countries." Nutrition Foundation (U.K.) Monograph Series, in press.
Tully, M. "Nursing with a Research Unit in Africa." Nursing Times, 1978, pp. 401 - 405.
Whitehead, R.G. "The Infant-Food Industry." Lancet ii: 1192 - 1194, 1 976.
---"Some Quantitative Considerations of Importance to the Improvement of the Nutritional Status of Rural Children." Proc. Roy. Soc., London, B. 199: 49 - 60,1977.
Whitehead, R.G., M.G.M. Rowland, and T.J. Cole, "Infection, Nutrition, and Growth in a Rural African Environment." Proc. Nutr. Soc. (U.K.), 35: 369 - 375 (1976).
Whitehead, R.G., W.A. Coward, P.G. Lunn, and l.H.E. Rutishauser, "A Comparison of the Pathogenesis of Protein-Energy Malnutrition in Uganda and The Gambia." Trans. Roy. Soc. Trop. Med. Hyg., 71: 189 - 195 (1977).
Whitehead, R.G., M.G.M. Rowland, M.A. Hutton, A.M. Prentice, E.M. Muller, and A.A. Paul, "Factors Influencing Lactation Performance in Rural Gambian Mothers." Lancet ii: 178 - 181, 1978.
Whitehead R.G. "Infant Feeding in the Developing World." Core Journals in Pediatrics, 1: A-3-A7 (1977).
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