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The duration of breast-feeding adequacy in a rural area of Bangladesh
Rafiqul Huda Chaudhury
Bangladesh Institute of Development Studies, Dhaka, Bangladesh
Breast-feeding not only is important as a source of calories and essential nutrients, but it also provides the infant with relative immunity against many types of infections and promotes bonding between mother and infant. The cessation of breast-feeding exposes the infant to a wide range of health risks. However, the adequacy of breast-milk for the nutritional needs of a child is limited to the early months of life. Sole breast-feeding by poorly nourished mothers will lead to a worsening nutritional status and growth faltering before or soon after six months and render a child more susceptible to infection (1, 2).
The poor nutritional situation of children is related to other aspects of physical quality of life, particularly those of infant and preschool mortality. Infant and preschool mortality rates on the one hand and the nutritional status of children on the other are positively correlated, and the direction of causality runs from malnutrition to disease and subsequent deaths of children (31. In rural Bangladesh during the mid-1970s, deaths in the first year were found to be 131 per 1,000 live births, and for the age group one to four years old, 28.4 per 1,000 population. These rates were based on vital registration of a population of 263,000 in some rural areas of Bangladesh 14).
This study employs data from a rural area of Bangladesh to examine the relationship of prolonged breast-feeding to total nutrient intake of the young child. It is assumed that, beyond four to six months, the longer a child goes without complementary food, the worse the total dietary intake is likely to be. Breast-feeding in rural Bangladesh is almost universal, and it commonly extends beyond the second year of life and sometimes as long as four years (5, 6). Therefore, a rural area of Bangladesh provides an ideal setting to test the hypothesis proposed in this study.
MATERIALS AND METHODS
Data in this study were collected from 572 members of 108 households in the village of Muyiarchar, approximately 220 miles north-east of Dhaka, in the Sylhet district. The sample included 50 per cent of the village households selected from various socio-economic groups. classified on the basis of landholdings and income. There were 93 children in the age group seven months to four years. Of these, 41 and 52 were in the age groups seven months to two years and three to four years, respectively. Those under seven months were exluded from purview of the analysis on the assumption that breast milk is adequate to meet the nutrient needs of infants during the early months of life. The data collected included consumption of rice, wheat, fish, milk, meat, pulses, eggs, vegetables, and fruits per person per day and the sources and costs of food consumed. The data were collected for each member of the household once a month over a period of one year by 24-hour recall interview. Mothers provided the information on food consumption by children. Interviewers were locally recruited and were mostly teachers from a nearby elementary school.
Individual food intake was converted into nutrient intake by employing the Indian Food Composition Table (7). Unfortunately, the actual milk production of lactating mothers was not measured. However, Brown and co" workers 16), in a longitudinal study of the actual amount of breastmilk being ingested by infants in a similar area of Bangladesh, found very little change during the first two years of life. On the basis of data on actual milk production by Brown et al., we have added 750 calories to the requirement of mothers who have children one year old or under and 550 calories to that of mothers who have children between the ages of one and two years. Assuming an 80 per cent efficiency of conversion of food energy to milk, the children are actually receiving from breast milk an average of 600 and 440 calories per day per child, respectively.
The caloric needs of a child seven months to four years old are computed according to age- and sex-specific recommendations of the 1973 FAO/WHO report (method A) (8; the 1984 FAO/WHO/UNU Protein Energy Requirement Report has not yet been published; however, for this age group, the calorie requirements do not differ significantly from those of 1973) in order to ensure comparability of the findings of the present study with those of others (9-11) conducted in Bangladesh. Age- and sex specific recommendations were adopted both to allow for full potential growth of a child and to provide extra calories to compensate for losses caused by infections and parastic diseases widely prevalent in rural Bangladesh. For comparison purposes caloric needs are also computed on the basis of the 1973 FAO/WHO report (method B) utilizing the mean weights reported from another study in a rural Bangladesh population (9).
Multiple classification analysis (MCA) 112) was used for the analysis of data. The technique provides a mean value of the dependent variable for each subclass of the independent variable and a deviation from the grand mean that are adjusted simultaneously for the effects of all other variables considered and their intercorrelations.
Age and Caloric Adequacy Ratio
The overall nutritional situation of the children in the study village looks very bleak, particularly when the energy needs of a child are calculated by method A. According to this method, the intake of a child in the age group seven months to four years, on average, falls 34 per cent short of the calorie requirement (table 1). However, this situation changes when the energy needs are calculated by method B, which shows that a child in this age range consumes, on average, 11 per cent more calories than the requirement (table 2).
TABLE 1. Unadjusted and Adjusted Deviations in Mean Caloric Adequacy Ratio by Age of Children (Seven Months to Four Years): Method A
|Deviation from Grand Mean||F-Value|
|7 to 11 mo||7||103.56||37.46||66.74|
|1 to<2yr||12||52.17||- 13.93||10.98||45.27**|
|2 to < 3 yr||22||60.42||- 5.68||1.47|
|3 to < 4 yr||52||66.68||0.58||-12.14|
* Adjusted deviation from grand mean, adjusted for variables
(i) age, (ii) per capita expenditure on food, (iii) number of
children below adult ages, (iv) education of father, and (v)
education of mother.
** Significant at .001 Ievel.
TABLE 2. Unadjusted and Adjusted Deviations in Mean Caloric Adequacy Ratio by Age of Children (Seven Months to Four Years): Method B
|Deviation from Grand Mean||F-Value|
|7 to 11 mo||7||167.27||56.08||106.95|
|1 to < 2 yr||12||101.84||- 9.30||33 57||52.33* *|
|2 to < 3 yr||22||122.22||11.08||22.08|
|3 to < 4 yr||52||101.05||- 10.09||- 31.48|
* Adjusted for all variables listed in footnote of table 1.
** Significant at .001 Ievel.
Table 1 shows the unadjusted and adjusted relationship between age and caloric adequacy by method A. Data according to unadjusted series confirm the natural history of nutritional development as reflected by a deterioration relative to calorie intake after the second half of the first year of life, with a rise after 24 months. An infant of 7 to 11 months can usually satisfy calorie requirements. However, after the first 11 months of life, the caloric adequacy ratio of a child drops sharply to as low as 52 per cent for children between age one and two. In other words, a child less than two years old can satisfy only half of the estimated calorie requirements for a well nourished child of this age and undoubtedly can survive on this intake only because of small size for age. Caloric adequacy ratios of the two older subgroups (two to less than three and three to four years) of children are slightly improved.
The above findings are unadjusted for the effect of other variables that may be related to calorie intake and therefore to the caloric adequacy ratio of children. The calorie intake of children is likely to vary with the educational and economic background of their parents and number of young children in the family. For example, education of the father and mother may have positive effects on calorie intake of children because those parents with higher education are more responsive to the needs of children. Similarly, the greater the per capita expenditure on food, the higher would be the expected calorie intake of children. On the other hand, an increase in the number of young children in the family may have a negative effect on the nutrient intake of children. Therefore, these variables need to be controlled while determining the net relationship between age and caloric adequacy ratio for children.
Multiple classification analysis (MCA) is used to examine the independent effects of age on the caloric adequacy ratio by adjusting for the effects of other predictor variables. The numbers shown under the unadjusted and adjusted columns in table 1 are expressed as deviations from the grand mean. For example, 66, the top of column 5 in table 1, means that infants in the age category 7 to 11 months have a 66 per cent higher caloric adequacy ratio than the average.
The relationship between age and caloric adequacy ratio is changed from slightly irregular positive to a consistently inverse pattern when adjustment is made for the effect of other variables (table 1, column 5). Control for variation in per capita expenditure on food possibly played a significant role in accounting for changing the magnitude of relationships between age and caloric adequacy ratio from unadjusted to adjusted series. It explained nearly 20 per cent of the total variance of caloric adequacy ratio over and above that which can be explained by other predictors. (The independent effect of per capita expenditure on food is measured by rerunning the programme, omitting the predictor in question from the analysis, and observing the decrease in total explained sum of squares.) According to the adjusted series, the caloric intake is at least 33 per cent higher than the age-calculated requirement during the 7-to-1 1-month age period, and then it tapers off dramatically, satisfying only 77 per cent of the requirement at less than two years, and continuing to decline thereafter.
The pattern of relationship between age and caloric adequacy ratio as obtained under adjusted series by method A (table 1) closely corresponds to that of the pattern obtained by method B (table 2), even though the dietary adequacy of children calculated by the former is lower than the latter. The findings obtained by methods A and B clearly demonstrate declining caloric adequacy with age, and a child fails to meet caloric requirements beyond the second year of life when adjustment is made for the effect of other variables. These findings again confirm that once breast milk is no longer adequate as a sole source of dietary energy, complementary feeding tends to be inadequate.
Intake of Complementary Food and Caloric Adequacy Ratio
Table 3 provides data on the caloric adequacy ratio for children seven months to two years old by level of calories obtained from complementary food, i.e., other than breast milk. We have omitted those under seven months old from purview of the analysis on the assumption that breast milk is adequate to meet the nutrient needs of infants during the early months of life. The table shows that after six months of age, those children who obtain less than 65 per cent of calories from complementary foods are calorically worse off than those who receive more than 65 per cent of calories from such foods, according to both the unadjusted and adjusted series, and this difference is statistically significant. An almost identical result emerges even when we measure the caloric need of a child according to age-sex average weight-specific recommendations of the 1973 FAD/WHO Report (8), i.e., under method B (see table 4). These findings indicate that after six months of age those children who are more dependent on breast milk but less on solid food are nutritionally in a worse state than those who received adequate solid food along with breast milk.
Caloric Adequacy Ratio at Different Ages by Percentage of Calories Obtained from Complementary Food Intake
The overall relationship between intake of complementary food and the caloric adequacy ratio of children as observed above also holds true when we control for age of the children. Table 5 presents data on the caloric adequacy ratio and percentage of calories obtained from complementary food at different ages by method A. The table indicates that calorie intake falls significantly short of requirements for those breast-fed children who receive a lower proportion (65 per cent or less) of their calories from complementary food even during the second half of the first year of life. However, calorie requirements for children 7 to 11 months old are well met when sufficient solid food is introduced along with breast-feeding. This finding, though based on a small number of cases, clearly demonstrates that, even during the second part of the first year of life, breast-feeding by poorty nourished Bangladeshi mothers is not enough to meet suggested calorie requirements (based on age-specific need) of an infant. Complementary solid food must also be introduced.
TABLE 3. Unadjusted and Adjusted Deviations in Mean Caloric Adequacy Ratios by Proportion of Calories Obtained from Complementary Food by Children Seven Months to Two Years of Age: Method A
|Deviation from Grand Mean||F-Value|
|< 65||12||53.59||- 11.98||- 15.87||18.66* *|
* Adjusted for all variables listed in footnote of table 1,
** Significant at .001 level
TABLE 4. Unadjusted and Adjusted Deviations in Mean Caloric Adequacy Ratios* by Proportion of Calories Obtained from Complementary Food by Children Seven Months to Two Years of Age: Method B
|Deviation from Grand Mean||F-Value|
|< 65||12||95||- 29.05||- 29.35||35.82* * *|
* Caloric need (based on age-sex average weight) divided by
actual calorie intake multiplied by 100.
** Adjusted for all the variables listed in footnote of table 1.
*** Significant at .0001 Ievel.
TABLE 5. Caloric Adequacy of Children at Different Ages (Seven Months to Three Years) by Percentage of Calories Obtained from Complementary Food: Method A
Calories from Complementary Food (%)
|7 to 11 mo||3||125.92||10.47||4||86.78||13.34||3.55*|
|1 to < 2 yr||6||69.05||8.41||6||35.28||15.29||4.33**|
|2 to < 3 yr||20||62.36||10.10||2||40.88||3.4||0.35*|
|1 to < 3 yr||26||63.90||10.00||8||36.88||13.25||6.02**|
* Significant at less than .05 level.
** Significant at less than .01 Ievel.
TABLE 6. Caloric Adequacy Ratio* of Children at Different Ages (Seven Months to Three Years) by Percentage of Calories Obtained from Complementary Food: Method B
Calories from Complementary Food (%)
|7 to 11 mo||3||203.32||16.92||4||140.13||21.54||3.55**|
|1 to < 2 yr||6||134.78||16.28||6||68.89||29.90||4.32***|
|2 to < 3 yr||20||126.19||18.36||2||82.49||2.78||3.19**|
* Calorie need (based on age- and sex-average weightl divided
by actual caloric intake multiplied by 100.
** Significant at .05 level.
*** Significant at .01 level.
The importance of solid food in meeting the caloric need of a breast-fed child is verified even when we assess the requirement of a child according to weight-specific instead of age-specific recommendations of the 1973 FAD/WHO report (see table 6). Data in table 6 show that after 11 months the calorie intake falls significantly below requirements for those breast-fed children who receive a lower proportion (65 per cent) or less) of their calories from complementary food.
DISCUSSION, CONCLUSION, AND POLICY IMPLICATIONS
The findings in this study demonstrate the inadequate calorie intakes of young children in rural Bangladesh in comparison with well-nourished children of the same age. The condition of a child worsens particularly beyond the second year of life whether requirement estimates are based on age or weight. This drastic calorie deprivation may be attributed to the diminished role of breast-feeding to meet the caloric needs of a growing child without sufficient intake of complementary solid food. The importance of solid food is also underscored by the finding that breastfed infants, particularly in the second six months of life by method A and the first year of life by method B, fail to receive adequate calories from breast milk, as judged by estimated requirements, unless they receive sufficient solid food along with it. These findings, though based on a small number of cases, reinforce the need for designing nutritional education programmes that emphasize the timely introduction of solid food along with breast milk to ensure the caloric adequacy of infant diets. This will also require changes in patterns of intrafamilial distribution of food that favour the adult and elderly over young children.
The paper was written while the author was a special UNU-UNICEF Fellow in the International Food and Nutrition Program at the Massachusetts Institute of Technology. He is now Visiting Fellow at the Population Studies and Training Center at Brown University in Rhode Island. The findings presented here are part of a major study on "Determinants of Intra-familial Distribution of Food and Nutrient Intake in Rural Bangladesh." The financial support received from UNICEF to analyse the data of the present study and the fellowship from Brown University are gratefully acknowledged. The author is grateful to Professor Nevin Scrimshaw at MIT, Professor Richard Jolly and Dr. Hossein Ghassemi of UNICEF, and Professor Paul Streeten of Boston University for intellectual and moral support. Professor Scrimshaw deserves special thanks for his valuable comments on earlier versions of this paper. The author is solely responsible for any errors remaining.
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