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Timely and appropriate complementary feeding of the breast-fed Infant-an overview
Nevin S. Scrimshaw and Barbara A. Underwood
International Nutrition Program, Department of Nutrition and Food Science Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
"Breast is Best," but for how long? The time factor is all important. Failure to know the time when breast-feeding alone is not enough and appropriate weaning foods must be introduced contributes to much of the morbidity and mortality among infants and young children in developing countries. Among lower socio-economic groups, the normal growth and development of exclusively breast-fed infants during the early months of life soon give way to subtle growth failure, increased susceptibility to infection, and varying degrees of protein-energy malnutrition.
Breast-feeding alone does not assure adequate nutrition for the first full year, and usually not beyond the first six months even under favourable circumstances. Under the adverse conditions so usual in underprivileged developing countries, many infants show evidence even earlier of a faltering rate of weight gain or other consequences of under-nutrition because appropriate complementary feeding is not given when needed. This may occur as early as three to four months in infants of some populations (1-11), or as late as five to six months in others (12-18). The variations are due primarily to differences in the health, nutrition, and life-style of the mother, all of which may affect milk production, and to the overall burden on the infant from diarrhoeal, respiratory, and other infectious diseases.
For the great majority of infants and young children who will receive the benefits of breast-feeding during the early months of life, the focus of primary health care, nutrition education, preventive medicine, and public health programmes should be on the weaning period. This critical transitional period commences with the need to introduce food to complement breast milk and ends when the child is fully consuming the family diet. The mother must understand when and how properly to complement breast milk during this period. She must have available to her explicit options for doing so that are practical, effective, and suited to existing resources and overall family responsibilities.
With modernization, development, and opportunities or necessity for women to work outside of the home, the trend in developing countries is toward earlier weaning. This is most pronounced among families migrating to, or already living in, urban areas. Even in urban settings, however, most infants in these societies continue to receive the advantages of breast milk in the early post-partum months. Only a relatively small number are artificially fed from birth.
In unfavourable environmental circumstances, children who are bottle-fed from birth or weaned early often develop malnutrition of the marasmic type at a relatively early age and have a higher frequency of illness and death than do comparable breast-fed infants. Unlike the substitutes for breast milk given to more privileged children of these same regions and to those in the industrialized countries, those given to less privileged children are usually grossly deficient in quantity as well as in nutritional and sanitary quality.
INAPPROPRIATE WEANING PRODUCTS
The problem of inappropriate and inadequate weaning foods is not new and not unique to the Third World. In the past century in the US and Europe, inadequate weaning practices were associated with mortality rates of infants and young children that exceeded those in most developing countries today. Mothers traditionally have used sugar water, barley water, rice water, corn starch, and other cereal gruels and paps with unfortunate consequences. With the diffusion of nutrition knowledge and sometimes also with the availability of better weaning foods and various public health measures, the situation has improved in most developing countries, as judged by a steady fall in infant and preschool child mortality rates over the past several decades. One obstacle to this improvement in infant survival has been the increased availability of nursing bottles and rubber nipples that encourage the use of thin, watery preparations and that are almost impossible to sterilize under the conditions of most Third World homes.
With feeding and sanitary practices varying so greatly from one population to another, it is necessary to avoid generalizations. The dangers of bottles lie mainly in the fact that they are often filled with nutritionally inadequate and unsanitary weaning foods or non-foods, and in their potential interference with breast-feeding. Recently, the availability and promotion of commercial formulas specifically designed for infant feeding have become risk factors for some populations. These formulas have often simply replaced unhygienic and nutritionally deficient mixtures in the bottle, but at a higher cost. When mothers use these commercial products without adequate resources to purchase them in sufficient quantity, or the facilities to prepare them properly, the effect on the infant may be no better than that with the bottle-feeding of inadequate traditional foods. The connotation of status associated with the use of bottles and proprietary foods among some marginal groups can also encourage premature introduction of breast-milk substitutes.
THE IMPORTANCE OF COMPLEMENTARY FOODS
Most developing country infants are breast-fed during the first critical months of life (19). They become malnourished later because of inadequate complementary feeding practices. It follows, then, that for these infants, improvement in growth and development and reduction of morbidity and mortality do not depend on persuading mothers to initiate breast-feeding. Rather, they demand measures that will increase the lactation capacity of mothers and the practicality of their continuing breast-feeding, assure appropriate complementary feeding, and lead to an eventual fitting termination of the weaning process. This requires programmes that improve the nutrition of the mother and ensure her effectiveness in managing the weaning period. The goal should be to provide mothers with the means to determine when the nutrition of their children requires improvement as well as with practical ways to provide complementary foods either from readily available local sources, or, if appropriate, properly prepared processed weaning foods. These programmes must take into account the life-styles, needs, resources, and desires of the mother. The risk that complementary feeding will reduce breast-milk output or shorten the duration of lactation requires further investigation to determine the best way of providing safe and nutritious complementary foods so as to be supportive of continued breast-feeding.
THE IMPORTANCE OF TIMING OF INTRODUCTION OF COMPLEMENTARY FOODS
Authorities agree that the greatest benefit from breast-feeding occurs in the first two to three months after birth when breast milk is generally adequate as the sole source of food and when its anti-infective properties (20) and sanitary nature greatly reduce the risk of infection.
The need for complementary feeding can be made readily apparent to the mother through a programme of periodic weighing and her maintenance of a weight chart for her child (21-23). There is no universally applicable time for starting complementary feeding. It depends on a number of biological and social factors that differ from one population and family to another. Included among the factors are availability of complementary foods of adequate nutritional content and density, the potential for their hygienic preparation, the nature of the family diet that the child shares, the economic status of the family, the contraceptive effect of lactation, and specific family and community obligations and opportunities of the mother.
NON-BREAST-FEEDERS AND EARLY WEANING
Mothers who cannot breast-feed, who are unable to continue to do so for medical reasons, who really do not have sufficient milk, whose work or life circumstances make continued breast-feeding impractical, or who choose not to breast-feed, require special consideration. For such mothers, the availability of a nutritious, safe substitute can be life-saving for the baby. In some situations this may be a substitute lactating mother or some form of locally available animal milk; in others, it may be a commercially produced infant formula. However, proprietary products for feeding such infants can, and should, be made available in ways that do not discourage breast-feeding for mothers who are willing and able to do so. To prohibit production of such products, however, would in some instances force a return to the use of traditional cereal or starchy gruels as breast-milk subsitutes with disastrous consequences for the health and survival of the infant.
Under some circumstances, the benefits to the family of gainful employment of the mother exceed those of continued breast-feeding. There can be no doubt, however, that influential educational and community leaders, and public health authorities should exert maximum efforts to facilitate breast-feeding during at least the early months of life. The important question is, therefore, how best to help a mother recognize when complementary feeding is needed and how best she can use available alternatives with minimal compromise to her health, her lactation performance, the health of her infant, and the well-being of the family as a whole.
It should be noted that both historically (24, 25) and currently (26), early weaning and extensive bottle-feeding are practiced in some populations without either the availability or the promotion of artificial formulas. The role of demand on the part of the mother for breast-milk substitutes even without such stimulation, and her right to make such a demand, are often overlooked. In many populations commercial infant foods have tended to replace indigenous mixtures of poor sanitary quality and nutritional value with a product that, if used as directed, would be far better. Unfortunately, economic and sanitary conditions as well as lack of knowledge among poor populations in developing countries make it likely that over-diluted and insufficient commercial formulas will be offered to the infant and that they will become a probable cause of diarrhoeal and other infections.
The approach to correcting the misuse of complementary foods is two pronged: (a) to encourage and provide support systems that favour the choice to breast-feed, and (b) where breast-feeding is not chosen, to try to improve the artificial feeding by attention to the quantity, nutrient density, and sanitary characteristics of the food as it is given to the child. Experience with modern infant formulas in the industrialized countries demonstrates that when quantity, quality, and sanitation are adequate, the results, as judged by growth, morbidity, and mortality need not be different from those observed among exclusively breast-fed infants (27-29). A strong return to breast-feeding is now evident in North America, and in Scandinavian and other European countries despite the availability and promotion of nutritionally adequate and safe products for bottle-feeding. Thus, there is reason for optimism regarding the potential for an improvement of infant-feeding practices that will accelerate the already falling infant and preschool child mortality rates in most developing countries.
In other words, the challenge to those truly concerned about reducing the present deplorable global prevalence of childhood malnutrition is to assist mothers to become more self-reliant in the knowledge needed to make informed decisions, and in their opportunities for arriving at those decisions that will provide the best child-rearing possible under the circumstances. The mother's decision is a personal one to be respected as a right, not to be usurped by civil authorities, legislation, or patronizing attitudes of others. Restrictions that discriminate against the poor mother contribute to the multiple factors enmeshing her and her family in an all-encompassing web of continuing deprivation.
From this brief analysis, the following conclusions emerge.
1. Two major problems are associated with infant-feeding practices in developing countries. Recent attention tends to focus only on the second.
2. These problems require different approaches, and exclusive attention to the second can exacerbate the first.
3. Dialogue and co-operation in improving infant-feeding practices are essential and must involve community leaders, health professionals, educators, and, where appropriate, government officials and representatives of industry.
1. R.G. Whitehead, ''The Infant-Food Industry," Lancet, ii: pp. 1192-1194, 1976.
2 A. Chavez, C. Martinez, and H. Bourges, "Role of Lactation in the Nutrition of Low Socio-Economic Groups," Ecol. Food Mitr;. 4: pp. 159-169,1975.
3. P.S. Venkatachalam, T.P. Susheela, and Parvathi Rau, "Effect of Nutritional Supplementation during Early Infancy on Growth of Infants," J. Trop. Pediat., 13: pp. 70-76, 1967.
4. R. Tripp, "Farmers and Traders: Some Economic Determinants of Nutritional Status in Northern Ghana," J. Trop. Pediat., in press.
5. J.C. Waterlow, "Adequacy of Breast-Feeding," Lancet, ii: pp. 897-898, 1979.
6. J.C. Waterlow and A.M. Thomson, "Observations on the Adequacy of Breast-Feeding,' Lancet, ii: pp. 238-242, 1979
7. M.G.M. Rowland, R.A.E. Barrell, and R.G. Whitehead, "Bacterial Contamination in Traditional Gambian Weaning Foods," Lancet, i: pp. 136-138, 1978.
8. P.S. Venkatachalam, "A Study of the Diet, Nutrition and Health of the People of the Chimbu Area," Territory of Papua and New Guinea, Dept. of Public Health Monograph, 4: pp. 1-90, 1962.
9. L.J. Mata, The Children of Santa Marķa Cauque: A Prospective Field Study of Health and Growth (MIT Press, Cambridge, Massachusetts, 1978).
10. K.J. Kimmance, "Failure to Thrive and Lactation in Jordanian Viliages in 1970," J. Trop. Pediat. Environ. Child Hlth., 18: pp. 313-316, 1972.
11. L.T. Tie, O.K. Lian, T.W. Liong-Ong, and C.S. Rose, "Health, Development, and Nutritional Survey of Preschool Children in Central Java," Am. J. Clin. Nutr., 20: pp. 1 260- 1 266, 1 967.
12. R.M. Herriott, A.M. Hsueh, and R. Aitchison, "Influence of Maternal Diet on Offspring. Growth, Behavior, Feed Efficiency and Susceptibility [Human)," Final Report on AID/CSD 2944 (contract with the Johns Hopkins University, 1 978).
13. A.K. Lebshtein and A.M. El Bahay, "The Extent of Breast and Bottle Feeding of Children in Cairo and Its Effect on Their Growth," J. Egypt. Publ. Hlth. Assoc., Ll: p. 246. 1976.
14. E. Lauber and M Reinhardt, "Studies on the Quality of Breast Milk during 23 Months of Lactation in a Rural Community of the Ivory Coast," Am. J. Clin. Nutr., 32: pp. 1159-1173, 1979.
15 C. Gopalan, "Studies on Lactation in Poor Indian Communities J. Trop. Pediat., 4: pp. 87-97, 1958.
16. A.A. Kanawati, D.S. McLaren, and 1. Abu-Javvdeh, "Failure to Thrive in Lebanon. 1. Experience with some simple somatic measurements," Acta Paediat. Scand.. 60: pp. 309-316, 1971.
17. K.Y. Lee, S. Band, and D.J. Yun, "Dietary Survey of Weanling Infants in South Korea," J. Amer. Dietet. Assoc.. 43: pp. 457-461, 1963.
18. R. Rajelakshmi, ''Reproductive Performance of Poor Indian Women on a Low Plane of Nutrition," Trop. Geogr. Med.. 23: pp. 117-125, 1971.
19. World Hlth. Org., "Collaborative Study on Breast-feeding- Methods and Main Results of the First Phase of the Study," Preliminary Report, WHO MCH/79.3, 1979.
20. R.K. Chandra, ''Immunological Aspects of Human Milk," Nutr. Rev., 36: 265-272, 1978.
21. J.E. Rodde, D. Ismail, and R. Sutrisno, "Mothers as Weight Watchers: The Road to Child Health in the Village," Environ. Child Hith., 21: pp. 295-297, 1975.
22. World Hlth. Org., "A Growth Chart for International Use in Maternal and Child Health Care." (WHO, Geneva, 1978), pp. 1-38.
23. D. Morley, Paedriatic Priorities in the Developing World ((Butterworth & Co. Ltd., London, 1973),ch, 7.
24. W.J. Howarth, "The Influence of Feeding on the Mortality of Infants," Lancet, ii: pp. 210-213, 1905.
25. W.H. Davis, "Statistical Comparison of the Mortality of Breast-Fed and Bottle-Fed Infants,' Am. J. Dis. Childr., 5: pp. 234247, 1913.
26. F. Mardones-Santander, "History of Breast-Feeding in Chile," Food and Nutrition Bulletin of the UN University World Hunger Programme, 1 (4): pp. 15-22, 1979.
27. F. Adebonojo, "Artificial vs. Breast-feeding: Relation to Infant Health in a Middle Class American Community," Clin. Pediat., 11: p. 25,1972.
28. Research Sub-Committee, South-East England Faculty, Royal College of General Practitioners, "The Influence of Breast-feeding on the incidence of Infectious Illness during the First Year of Life," Practitioner, 209: p. 356, 1972.
29. D. Wheatley, "Incidence and Treatment of Infantile Gastroenteritis in General Practice," Arch. Dis. Childh., 43: pp. 53-57, 1968.
Food and Nutrition Bulletin, vol. 1. no. 4 (August 1979), p. 13.
In the first paragraph under the heading "The Role of the Agencies of the UN System and Others Dealing with Cooperation and/or Financing of Nutrition Programmes " the sentence "They do not lack the mandate to respond to governments' requests, but generally do not have trained staff," misrepresented the author's intention. The statement in the original paper by Abraham Horwitz, of which the article in the Bulletin was an abridgement, read:
We do not believe that the agencies lack the mandate to respond to governments' requests. What they may not have on their staffs they can obtain from the world's pool of knowledge and experience.
The staff of the Food and Nutrition Bulletin regrets the error.
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