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Feeding from the family pot for prevention of malnutrition

B. N. S. Walia, S. K. Gambhir, D. Kumar, and S. P. S. Bhatia
Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India

The following article on the use of foods from the "family pot" for the rehabilitation of malnourished children supports the conviction of many health workers that, in principle, this is the most practical approach to the prevention of malnutrition among pre-school children, even in impoverished families The small shifts in food distribution within the family that are required with this approach are of negligible significance for the other family members, but of critical importance for the young child. The problem in the past has been the lack of a means of persuading a mother of the need to feed her child more, particularly when she is already breast-feeding. This obstacle can be overcome if the mother can monitor the chid's growth and learn that a failure to gain weight from one weighing time to another means that more food is necessary. If there is evidence of disease, medical attention may also be indicated.

Of course, the implementation of this approach is subject to cultural variation in the suitability of foods being used by the other members of the family. For reasons which include high fibre content, strong seasoning, and low nutrient density, some foods will not be appropriate for infants and young children. Also, the phrase "family pot" may well apply to some cultures, but in others there is no single pot, but rather a variety of foods, some of which are always suitable for the young child. If cultural variations are taken into account, the concept advanced by this article should be universally applicable.

* * *

INTRODUCTION

Governments and voluntary organizations have employed a number of strategies for the prevention and treatment of malnutrition. In India, the Integrated Child Development Services Scheme [1], the Supplement Nutrition Programme [2], the Applied Nutrition Programme [3], and the Midday Meal Programme [4] are some of the schemes that have been implemented for several years. Similar programmes for nutrition supplementation of pre-school children have been tried in different developing countries [5, 6]. Some of the approaches tested include:
- creation of Nutrition Rehabilitation Centres;
- distribution of food at Community Feeding Centres;
- delivery of pre-packaged nutrition supplements by community health workers;
- distribution of powdered milk, bulgar wheat, and corn soya oil in Well-Baby Clinics and MCH Centres.

A review of several nutrition supplement programmes conducted under the aegis of the United Nations International Children's Emergency Fund (UNICEF) showed that most of these interventions had met with only limited success and were not cost effective.

The most disappointing aspect of such programmes was that after the programme no residual impact on the subjects' health or food habits could be demonstrated. Other aspects that have been the subject of criticism are an inability to substantiate nutritional change attributable to programmes, the limited coverage of the malnourished population, and the relatively ineffectual screening and targeting criteria employed [7].

Discussing the prevention and treatment of malnutrition, Morley states that the family pot would provide the ideal food for a child [8]. Although pediatricians and nutrition textbooks have advocated that a child over the age of six months be fed something from the rest of the family's food supply, this approach has not been used for the treatment of children suffering from malnutrition.

The purpose of the present study was to test whether it was possible (a) to utilize existing family resources for the prevention and treatment of malnutrition and (b) to avoid some of the problems and difficulties encountered in the existing programmes.

MATERIAL AND METHODS

The study was conducted in four villages in the Kharar Community Block of the Ropar District of Punjab, India, situated at 13 to 18 km from Chandigarh. The total population of the villages was 5,742 in March 1980.

TABLE 1. Impact of nutrition education on the nutritional status of malnourished children (n = 533)

Children under six years of age numbered 661; 533 of these (299 males and 234 females) were followed for a period of two years. In the vast majority of cases, the mothers could provide the exact date of birth of the child according to the Indian calendar; for the remaining mothers, the local events calendar approach was used to arrive at the date of birth. Children were weighed with a portable beam scale with a sensitivity of 50 gm. The nutritional status of children was graded by comparison with the Harvard Standards [9], the fiftieth percentile being regarded as 100 per cent according to the classification system proposed by the Indian Academy of Pediatrics.

Children were visited at home by a health worker every fortnight from 1 March 1980 to 28 February 1982. In March 1980, 452 /85 per cent) were graded as normal or grade 1; 81 (15 per cent) were graded as having either grade 2 or grade 3 malnutrition. Of these 81 children, 76 comprised the sample for this study.

ln September 1980, a nutritional demonstration programme was initiated. The 76 children were visited at home three times a week for two weeks and then once a fortnight for four fortnights. During visits the health worker informed a mother that the low weight of a child could be corrected with food cooked for the rest of the family. In the presence of the mother she broke a baked chappati into small pieces and mashed it into a half cup of cooked pulses (legume gruel). These ingredients form the staple diet of the population in rural areas of Punjab. The health worker then fed the mashed chappati to the child by hand and encouraged the mother to do the same. The procedure was repeated on every visit. No other food supplement was supplied nor were any other nutrition education messages offered. The mothers were gradually encouraged to take over the feeding of their children. Fortnightly visits were continued, and weights were recorded every month and charted on the WHO "Road to Health Cards" developed by Morley [8] .

TABLE 2. Improvement in nutritional status after feeding from family pot (n = 76)

RESULTS

As table 1 shows, 76 children (14.2 per cent) were found to be suffering from grade 2 or grade 3 malnutrition at the beginning of the study; six months after the initiation of nutrition demonstrations, this figure had fallen to 5.63 per cent. The prevalence dropped further to 3.75 per cent by December 1981.

The prevalence of grade 3 malnutrition cases dropped from 2 per cent to 0.19 per cent during the same period. All children were weighed again in February 1982. The prevalence of grade 2 and grade 3 malnutrition cases was found to be 1.88 per cent (ten children) and 0.19 per cent (one child) respectively.

Table 2 shows that 89.4 per cent of the subjects improved their nutritional status by one or more grades.

Table 3 shows that 10 (90.9 per cent) of 11 subjects with grade 3 malnutrition and 58 (89.2 per cent) of 65 subjects with grade 2 malnutrition improved with the approach employed.

TABLE 3. Number of subjects who improved in relation to initial nutritional status (n = 76)

Discussion

In the study population 14.26 per cent of children were found to be suffering from grade 2 or grade 3 malnutrition. Within six months this figure had dropped to 5.63 per cent, and within the next 12 months, i.e. by February 1982, only 2.06 per cent of the children in the population had grade 2 or grade 3 malnutrition. This finding strongly suggests that although the nutrition demonstrations ceased after ten demonstrations, the subjects continued to gain weight and to improve their nutritional status as a result of improvements in feeding practices.

That the children continued to gain weight after the demonstrations had stopped and that the malnutrition prevalence rate continued to decline for several months show that feeding from the "family pot" had been adopted as a family habit.

Table 3 shows that the approach was as effective in subjects with grade 3 malnutrition as in those with grade 2. This is a very significant observation, as it shows that uncomplicated cases of grade 3 malnutrition can be successfully managed by this home-based approach, thus obviating the difficulties and greater expenses involved in the treatment of such cases at nutritional centres and hospitals.

It is generally agreed that nutrition supplement programmes must be based on foods that are cheap, locally available, and culturally acceptable. However, advice given to mothers to cook special food items for pre-school children is generally not followed because of the additional expense incurred in buying the materials and the extra work involved in cooking for the least demanding member of the family. The psychological factor of giving porridge or panjiri to one child and denying it to others also inhibits mothers. The approach proposed obviates all of these difficulties.

Our results show that, when backed by health personnel who have gained the confidence of the public, this approach was accepted by all mothers even though many expressed hesitation and anxiety in the beginning. Their common concern was whether the child would be able to digest the family diet. To this the health worker's stock answer was: "Yes, every child can digest family food, and we have medicines to cure digestive upsets that may occur for some other reason."

Another noteworthy fact is that eight subjects who were not included in this study because their nutritional status was grade 1 in the beginning declined to grade 2 status over a period of 18 months. This finding is in sharp contrast to the improvements noted in the demonstration group and suggests the possibility of preventing the onset of malnutrition in vulnerable pre-school children from poor families by nutrition demonstrations.

We are convinced that in every developing country large segments of the population whose children are malnourished are simply unaware of the fact that their children can digest family food and thrive on it. There are few families so indigent that they are unable to afford even half a chappati and half a cup of pulses (legume gruel) per day [10] .

The approach employed by us was very economical. The total salary of two health workers was 1,200 rupees (US$100) per month, which, when divided by 76 children, amounts to US$1.30 per month per malnourished child. Even if the total cost of employing the two workers were attributed to this programme (ignoring their role in surveillance and primary care), it would still turn out to be less costly than any other nutrition supplement programme being run in the country at the present moment. Cook [10] estimated that the cost of treatment of a malnourished or marasmic child in hospital ranged from US$95 to US$950 per child and in a nutrition rehabilitation centre from US$25 to US$70 per child.

We suggest that illiterate parents should not be confused by talks on the caloric content of foods or on their essential amino-acid content. A simple demonstration that a child will eat family food if given the chance and will grow strong on it speaks far more eloquently than laboriously prepared academic lectures. The solution of the problem of prevention and treatment of malnutrition lies in offering to the child the food that is already in his own home.

REFERENCES

1. Integrated Child Development Services Scheme (Revised) (Ministry of Social Welfare, Government of India, New Delhi, 1982).

2. Report of the National Seminar on Special Nutrition Programme (Department of Social Welfare, Government of India, New Delhi, 1978).

3. S. G. Srikantia, Proceedings of the Nutritional Society of India (National Institute of Nutrition, Hyderabal, India, 1976).

4. M. C. Swaminathan, "Evaluation of Supplementary Feeding Programmes," Proc. Nutr. Soc. India, 15: 126 ( 1973).

5. M. King, Nutrition in Developing Countries (Oxford University Press, London, 1973).

6. T. H. E. Staff, "Treatment of Severe Kwashiorkor and Marasmus in Hospital," E. Afr. Med J., 45: 399 (1968).

7. D. E. Sahn and N. S. Scrimshaw, "Nutrition Interventions and the Process of Economic Development," Food Nutr. Bull, 5: 1-2 (1983).

8. D. Morley, Pediatric Priorities in the Developing World (Butterworth, London, 1974)

9. H C. Stuart and S. S. Stevenson, "Physical Growth and Development," in W. E. Nelson, ed., Textbook of Pediatrics, 7th ed. (Saunders, Philadelphia, Pa., 1959), pp. 12-61.

10. R. J. Cook, "Is Hospital the Place for Treatment of Malnourished Children?" J. Trop. Pediatr. Environ. Child Health, 17: 1-15 (1971).

11. F. J. Levinson, "The Morinda Experience-An Economic Analysis of the Determination of Malnutrition among Young Children in Rural India," Cornell/MIT International Nutrition Policy Series (Cambridge, Mass., 1974).

Breast-feeding and weaning practices for infants and young children in Rangoon, Burma

Tin Tin Oo and Khin Maung Naing
Ministry of Health, Nutrition Research Division, Department of Medical Research, Rangoon, Burma

INTRODUCTION

In many developing countries, feeding patterns and sanitary practices during the weaning period from six months to two or three years are critical in determining whether a child will grow poorly or well. In Burma, several studies have reported that the growth curves of infants compared to the fiftieth centile of the Harvard Standard [1] tend to flatten between six months to two years of age and then resume a parallel course at a lower level [2, 3]. Infections, such as diarrhoea and acute respiratory diseases, and nutritional inadequacy may be important determinants of this growth pattern. Previous studies have shown that in some communities the nutrient intake during the weaning period is inadequate for the nutritional needs of growing children. [3, 4, 5] .

In the present study, we have investigated the nutritional contribution of several traditional weaning foods to the diet of Burmese infants and children ranging from new-born to three years old. We have compared the feeding patterns and calorie intake of the children of rural housewives, urban housewives, and urban itinerant wage-earning mothers of low socio-economic status.

MATERIALS AND METHODS

A total of 1,034 pairs of infants and mothers were studied, from two urban communities in Rangoon and one rural community in a village near the capital. The proportion of children under three years of age studied at each site comprised approximately 8 per cent of the total resident population of the area. The two urban communities studied were itinerant wage-earning mothers and housewives. Both these groups were from the lower socio-economic strata and lived in poor environmental conditions. The rural mothers were also housewives and were not regular wage-earners. Like most rural women, they may participate in some of the farming and agriculture activities at times, but do so less during late pregnancy and the early infancy of their children. All 1,034 mothers were interviewed for breastfeeding and weaning practices. Anthropometric measurements were also made of all the infants and children.

Nutrient intake from the weaning foods given was determined for a three-day period on a sub-sample of the 304 infants and young children by using the FAO food composition table [6]. The breastmilk intake of infants less than one year old was derived from a previous study on the lactation performance of Burmese mothers [7]. For oneto three-year-old children, breast-milk intake was determined only in the rural communities by the methods previously described [81. The nutrient composition of snacks and of those foods not identified in the FAO food composition tables was determined in our laboratory using the methods of the Association of Official Agriculture Chemists (AOAC) [91.

TABLE 1. Number of children studied by age group

RESULTS

Table 1 shows the number of children studied by age group. Figure 1 shows the types of feeding practices by occupation of mother and age of children.

It can be seen that 95 per cent of all mothers continued to breast-feed their infants up to 12 months of age, and at 24 to 36 months 30 per cent of the children were still receiving some breast milk. Surprisingly, a small proportion of children were receiving only breast milk at 12 to 18 months (5 to 10 per cent) and at 18 to 24 months (4 per cent).

Supplementary food, in token amounts only, may be introduced during the first three months of an infant's life. By 6 to 12 months, 70 to 80 per cent of children were receiving solids, and by 18 to 24 months about 95 per cent were receiving solid food essentially of the adult type.

There was no significant difference in feeding patterns between rural mothers and urban housewives, although there was a tendency for more urban housewives to introduce solids early, that is, before their children were six months old. Urban itinerant working mothers differed from the others; they breast-fed infants less in the first three months of life and gave them more supplementary foods, a pattern that reflected their irregular working conditions.

FIG. 1. Type of feeding practiced by mothers of different occupational groups at various ages of their children

TABLE 2. Nutrient composition of cooked Burmese commercial weaning foods compared to cooked rice (amount per 100 g)

a. 20 gm of weaning food + 80 ml of water.

Table 2 shows the nutrient composition of cooked Burmese commercial weaning foods compared to cooked rice. The commercial foods were obviously inferior in nutrient composition as judged by PAG guidelines [10] and far more costly. The cost per 100 kcal of commercial weaning foods in 1982 (during the survey period) was 0.5 kyats, compared to 0.1 kyats for the traditional combination of rice and oil, which is also less bulky (9 kyats = US$1). One hundred grams of cooked rice and oil yields 200 calories for 9 kyats. Figure 2 shows the calories contributed by breast milk as well as by several weaning foods used in the diets of urban and rural Burmese infants and children of various ages.

As figure 2 indicates, breast milk continued to make a significant contribution to the calorie and nutrient intake of the child well beyond one year and up to two years of age. Our results also show that even though solid foods may have been introduced during the first three months (fig.1) they contributed very few calories. At three to six months and six to nine months, when weaning foods should be compensating for the inadequacy of breast milk, the traditional weaning foods, such as rice alone or rice with oil, were found to contribute only 100 to 200 calories a day (17 to 30 per cent of total calories); rice together with other food items from the family pot and snacks contributed 200 to 350 calories, about 50 per cent of the total calories. Burmese commercial weaning foods generally contributed fewer calories than the traditional weaning foods.

By six months of age breast-milk output and its caloric contribution had levelled off, and the total calories received by the child depended mainly on the kind of weaning foods given. It should be noted that the total calories received from some of the traditional weaning foods, such as rice alone or rice with oil, were still inadequate for the nutritional needs of the child as judged by FAD/WHO requirements of calories for age or calories for weight [11] . Only when rice with other food items from the family pot and snacks were given could it be said that calorie intakes approached the nutritional requirement.

Snacks were observed to fulfil an important role, especially for the older child. Snacks accounted for a significant proportion of the nutrient intake of urban children and assumed an increasing share as the child grew older, accounting for 20 to 30 per cent of the calorie intake of the children over one year old (table 3).

In Burma, main meals are usually eaten twice a day by adults, infants, and children, and rice is the most important item. Snacks are eaten before and after the main meals at irregular times. Most snacks are rice-based, but are prepared very differently from the rice, which is cooked and eaten for the main meals. Rice for snacks may be mixed with many other ingredients such as jaggery, peas, and fruit (such as bananas), and may be boiled, baked, or fried.

In this study, children were found to eat 80 different types of snacks, which have been analysed and classified on the basis of caloric density. Of these snacks, 40 were of high caloric density (i.e. denser than 2.5 kcal/gm), 35 of medium density (between 1 and 2.5 kcal/gm), and 16 of low density (less than 1 kcal/gm). By comparison, rice alone has a density of 1.4 kcal/gm, a combination of rice and oil 2 kcal/gm, and rice combined with other food items 3.6 kcal/ gm.

FIG. 2. Caloric contribution by breast milk and different weaning foods of infants and young children in Rangoon area

TABLE 3. Percentage contribution toward intakes of calories and proteins provided by main meals and snacks given to urban children

Most of the prepared snacks given to the children (62 to 64 per cent) were bought from itinerant food vendors who prepared and sold them on a daily basis; 19 to 22 per cent were from cottage industries; 6 per cent were manufactured foods, such as biscuits and cakes; 3 to 5 per cent were home-made; and 6 to 10 per cent were fruits bought from food vendors.

Mean weight, height, and mid-arm circumference of the infants and young children of the three groups of mothers at different ages are given in table 4. There appeared to be a tendency for rural infants and children to be physically less developed in the first six months, but this tendency was not significant. The mean weights and heights per age of infants and children were less than the Harvard fiftieth centile, a finding consistent with our previous observations and those of others

DISCUSSION

The practice of breast-feeding appears to be declining in many developing countries. In Thailand [12] between 1964 and 1979, the average duration declined by almost 5 months from 12.9 to 8.4 months in cities and from 22.4 to 17.5 months in rural areas. The present study as well as a previous study [4] shows that, in Burma, breast-feeding is still generally practiced in both rural communities and low socio-economic urban communities However, another study in Rangoon has shown that among all mothers the average breastfeeding rate is around 65 per cent [5].

The significance and importance of breast milk in Burma as a source of calories and nutrients even up to two years of age has been previously reported by us [4] and is further confirmed by this study.

Patterns of supplementary feeding vary widely in different cultures. Supplementary foods are given to infants as early as one to two months or as late as 18 months [13-20] . A WHO study conducted in nine countries reported that more than half of the rural Chilean women in the study sample were regularly supplementing their infants' diets at two to three months compared with only 2 per cent of rural Indian women [20]. The type and amounts of food given also varied depending especially upon the products locally available. In Zaire supplementary foods offered to infants in the first six months are cereals and legumes, while in India only milk products are given [20].

In Burma 10 to 20 per cent of urban and rural mothers start giving supplementary food to infants in the first three months of life, but only in token amounts. In the present study, we have compared the nutrient value of the different kinds of traditional weaning foods. Rice alone or rice with oil given twice a day appears to be inadequate for nutritional needs. The nutritive value of the traditional weaning foods improves markedly when food items are added from the family pot and also when snacks are given. Commercial weaning foods appear to be gaining ground as a supplementary food item for urban mothers, but only for young infants; they are replaced by traditional weaning foods when the child grows older. The commercial weaning foods are generally nutritionally inferior and their cost is much higher but they are used for convenience and also because they are mistakenly believed to be nutritionally superior.

TABLE 4. Anthropometric measurements of infants and children in comparison to Harvard standard [1]

a The Wolanski arm circumference standards are cited in D. B. Jelliffe, The Assessment of the Nutritional Status of the Community (WHO, Geneva, 1966).

The importance of snacks has been underlined because of their considerable contribution to nutrition during the weaning period, and also because they have a high nutritional density and are widely used in urban and semi-urban populations. In typical Burmese villages, snacks are less readily available from vendors.

ACKNOWLEDGEMENTS

We are indebted to Dr. Anug Than Batu, Director-General of the Department of Medical Research, Ministry of Health, Rangoon, Burma, for his critical and constructive reading of the manuscript draft of this article.

REFERENCES

1. H. C. Stuart and S. S. Stevenson, "Physical Growth and Development," in W. E. Nelson, ed., Textbook of Pediatrics, 7th ed. (Saunders, Philadelphia, Pa., 1959), pp. 12-61.

2. "Growth Studies of Urban Burmese Infants and Children in Insein and Thuwana Townships," Department of Medical Research Report (Ministry of Health, Nutrition Research Division, Rangoon, Burma, 1972).

3. Khin Mg Naing and Tin Tin Oo, "Weaning Foods and Practices and their Nutritional Adequacy in a Rural Community in Burma," Proceedings of the Research Seminar on Breastfeeding and Weaning Practices in Burma (Ministry of Health, Department of Medical Research, Rangoon, Burma, 1979).

4. Tin Tin Oo and Khin Mg Naing, "The Pattern of Breast-feeding and its Nutritional Adequacy in Rural Communities," Proceedings of the Research Seminar on Breast-feeding and Weaning Practices in Burma (Ministry of Health, Department of Medical Research, Rangoon, Burma, 1979).

5. Hla Myint, "The Pattern of Breast-feeding and its Nutritional Adequacy in Rangoon," Proceedings of the Research Seminar on Breast-feeding and Weaning Practices in Burma (Ministry of Health, Department of Medical Research, Rangoon, Burma, 1979).

6. Food and Agriculture Organization (FAO), Food Composition Table for Use in Asia and the Far East (FAO, Rome, 1972).

7. Khin Mg Naing, Tin Tin Oo, and Kywe Thein, "Lactation Performance of Burmese Mothers," Am. J. Clin. Nutr., 33: 2665-2668 (1972).

8. Tin Tin Oo and Khin Mg Naing, "A Comparison of Milk Output of Burmese Mothers by Three Different Methods," Food Nutr. Bull., 4(4): 66-68 (1982).

9. Official Methods of the Association of Official Agriculture Chemists (AOAC, Washington, D.C., 1965).

10. Protein Advisory Group (PAG) of the United Nations System, "PAG Guideline No. 10, Marketing of Protein-Rich Foods in Developing Countries," in PAG Compendium, 14/10: G. (John Wiley & Sons, New York, 1975),

11. FAD/WHO Handbook on Human Nutritional Requirements (WHO, Geneva, 1974).

12. J. Knodel, "Breast-feeding in Thailand: Trends and Differentials 1969-1979,"Stud. Fam. Plan., 12: 335-337 (1980).

13. Anon, "Breast-feeding and Weaning among the Poor," Lact. Rev., 3(1): 1-6 (1978).

14. A. C. I. K. Autrobus, "Child Growth and Related Factors in a Rural Community in St. Vincent," J. Trop. Pediatr. Environ. Child Health, 17(4): 188-210 (1971).

15. W. P. Butz, "Determinants of Breast-feeding and Weaning Patterns in Malaysia" (unpublished draft).

16. N. E, Hitchcock, "Growth of Health Breast-fed Infants in the First Six Months," Lancet 2 (8237): 64-65 (1981).

17. T. J. Marchionet, "A History of Breast-feeding Practices in the English-speaking Caribbean in the Twentieth Century," Food Nutr. Bull., 2(2): 9-18 (1980).

18. S. R. Mudambi, "Breast Feeding Practices of Mothers of Midwestern Nigeria," J. Trop. Pediatr., 27(2): 96-100 (1981).

19. H. F. Welborn, "Bottle Feeding: A Problem of Civilization," J. Trop. Pediatr., 3(4): 157-166 (1958).

20. World Health Organization (WHO), Patterns of Breast-feeding: Report on the WHO Collaborative Study on Breast feeding (WHO, Geneva, 1980).

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