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Nutrition and health

The present trend in infant-feeding practices in Saudi Arabia
Breast-feeding practice in Saudi Arabia

The present trend in infant-feeding practices in Saudi Arabia

Abdulaziz I. Al-Othaimeen, Benilda P. Villanueva, and Edward B. Devol
King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

EDITORIAL NOTE

This paper and the one that follows represent an exception to the usual policy of the Food and Nutrition Bulletin not to publish reports of national surveys or other articles with findings applying only to a single country. Saudi Arabia, however, is of interest as a country with a unique culture that has experienced very rapid economic change.

Both articles indicate that traditional breast-feeding patterns have persisted despite the modernization that the country has undergone. Because there has been some decrease in early breast-feeding, policies and educational efforts to promote the practice and prevent further change are recommended. These two reports provide clear evidence that economic development need not necessarily have a significant effect on breast-feeding.

INTRODUCTION

This study is one of many on breast-feeding and weaning methods and practices but is of special importance because it was done in a country where data on these issues are scant.

Saudi Arabia is a large country with almost 12 million inhabitants, 17 per cent of whom are 0-4 years old and 28 per cent 5-14 years old [11]. It is a harsh country, whose economy traditionally relied mostly on date culture and animal husbandry but which experienced a spurt in economic growth with the discovery of oil. For a while, the economy was totally dependent on oil, but because of recent changes in world economic trends, the country has shifted its dependence to agriculture and manufacturing.

As the economy grew, social changes occurred. The country now boasts educational institutions and health-care facilities that serve the needs of the population, with special emphasis directed to maternal and child health care. In the matter of infant feeding, religious teachings advise continuing breast feeding up to two years; mothers who do not lactate for some reason or other send their babies to wet nurses. During the 1 930s, however, as a result of industrialization animal milk began to be produced in large-scale dairy plants to be used as a substitute for breast milk [21].

Saudi Arabian mothers are generally convinced of the many benefits of breast-feeding. This paper attempts to study their practices and relate them to weaning: when it is begun, how, why, what weaning foods are given to infants, and at what age. Other studies corroborate our own. Research on the nutritional status of Saudi Arabian infants and pre-school children found that around 40 per cent of infants are breastfed completely and weaning starts after age 6 months 1161. Another report indicated that 23.7 per cent of pre-school children in central Saudi Arabia suffered from acute undernutrition of all grades, with maximum frequency in children 12-23 months old 12]. The reasons offered were inadequate supplementation of breast-feeding and infection. In addition, bottle-feeding has apparently increased in the Saudi community during the last few years because it has become a status symbol signifying "modernization and sophistication" 1191.

This article constitutes part of a comprehensive report about feeding and weaning practices in Saudi Arabia and their relationship to children's nutritional status [15].

METHODS

Sample

The information presented here is based on data collected by a survey questionnaire. The survey used a non-probability sample of 767 children 0-9 years old in eleven health centres situated all over the country. A team composed of a nurse, a social worker, and a health technician was trained in collecting data. Information about the children was gathered from the mothers, some of whom were asked retrospectively about their children's breast-feeding and weaning habits. Data on the mothers' education and socio-economic status were also recorded. Specific weaning foods were identified, as well as the age at which they were introduced. The foods were then grouped with respect to their major nutrients, such as meats, fruits, and so on.

Statistical Analysis

Summary measures are reported as averages, median, standard deviations, and standard errors. Relationships among variables were investigated by computing correlation coefficients from contingency tables. Statistical significance of these coefficients was determined using the chi-square test.

RESULTS

Breast-feeding and Weaning Practices

Table 1 presents the number and percentages of the children in the study by sex and age of weaning. Among them, 10.04 per cent (n=77) did not breast-feed and 89.96 per cent did. There was a prevalence of first-born children, as shown in figure 1.

TABLE 1. Children included in the study

TABLE 2. Method of infant feeding for 767 Saudi Arabian children by age of weaning (percentages)

Figures in parentheses are numbers of children.

FIG. 1. Birth ranks of children in the study

The ways the infants were fed are shown in table 2. Only 21.5 per cent were completely breast-fed; 20.6 per cent were fed by artificial methods (bottle or glass) at some period and over 50 per cent by a combination of breast and artificial methods. Infants weaned before 6 months of age accounted for the highest percentage of those fed by combined methods (29.07 per cent).

Figure 2 shows the children's ages at the start of weaning. Of the total sample, 33.5 per cent started weaning before 6 months of age, nearly 51 per cent between 6 and 18 months, and almost 5 per cent after 18 months. Most of the children (87.1 per cent) were weaned gradually; only 12.9 per cent were weaned abruptly. Among the former, almost half (47.68 per cent) completed weaning within the second year of life (table 3).

Age at the start weaning

TABLE 3. Age of completion of gradual weaning

Mothers between 21 and 30 years of age weaned their children earlier than their older (31-40 years) or younger (20 years or under) counterparts (table 4). Mothers who had attended school weaned earlier than those who had no education. The correlation of mother's age and education to early weaning was statistically significant. Those with higher socio-economic status, as shown by ownership of a radio, television set, or phonograph, tended to wean earlier (table 5). This variable was also statistically significant.

The reasons for weaning can be categorized as related to the child or related to the mother. Among the former, children were weaned principally because they were old enough (77.6 per cent); among the latter, new pregnancy was the main reason (67.7 per cent) (table 6). Using a bitter substance was a more favoured weaning method 160.82 per cent) than separating the child from the mother (table 7).

Weaning Foods

Table 8 presents the number of children in each age group who were taking other foods and the ages at which they started to take them. Fruits were given as early as 4 months to children in the "age-of-weaning-not-given" group, followed by fruit juices at 4.6 months for the ''not-breast-fed" group. Starches such as bread (khobz), cornstarch pudding (mahalabiya), and biscuits were introduced at an average of 4.9 months to those who were weaned at 13 to 18 months, and 5.1 months to those weaned at less than 6 months. For children who did not breast-feed and those who were weaned below age 6 months, cereals (consisting of rice and Cerelac) and vegetables were introduced at ages 5.0 and 5.5 months and 6.0 and 6.3 months respectively. Eggs began to be eaten at 6.8 months by infants who were not breast-fed. Meat and fish were given later (10 months) to those weaned before age 6 months.

TABLE 4. Age of the child at start of weaning by mother's age (percentages)

Figures in parentheses are numbers of children.

TABLE 5. Age of the child at start of weaning by two socio-economic indicators (relative percentages)

Figures in parentheses are numbers of children.

DISCUSSION

The results of the study showed a tendency for the young, rich, and less-educated mothers to prolong breast-feeding up to two years and to introduce other foods early (less than six months). This could be due to lack of nutrition education and the influence of commercial campaigns for the use of foods other than breast milk. The same observations about the relationship between age, education, and socio-economic factors and early weaning and prolonged breast-feeding have been made by others (12, 171. Young rural mothers in Haiti were also found to bottle-feed more than breast-feed [7]. Those who attended school and who had a higher socio-economic status (radio ownership, school attendance, employment) generally breast-fed less, weaned earlier, and bottle-fed more. This trend in breast-feeding is true of most developing countries [5, 6].

Extending breast-feeding up to two years for most age groups in this study is not unusual in traditional cultures. In studies of weanlings of rural Bangladesh, one report stated that 91 per cent of 689 infants are still breast-fed at age 24 months [9]. Another found breast-feeding to continue well into the third year of life for most children [4]. in Saudi Arabia, breast feeding for up to two years is the generally accepted practice. Some cultures find prolonged lactation convenient. In rural Haiti, 59.8 per cent of women employed in farming weaned their children after 18 months of age [7]. In both rural and urban communities in Burma 113, 14], the prevailing reasons for weaning were socio-economic. Some observers [3] see the shift from breast to bottle as a symbol of urban sophistication that rural persons adopt.

TABLE 6. Reasons for weaning

TABLE 7. Method of weaning

Our findings show that breast-feeding is still prevalent, although only 21.5 per cent of the infants were breastfed completely and an additional 57.89 per cent were fed by breast, bottle, and glass. The reverse trend was seen in a 1981 study of pre-school children, 58.8 per cent of whom were fed breast milk alone and 35.7 per cent of whom were fed by a combination of methods [1].

We found that the pattern of introducing weaning foods to children appears to follow growth patterns that are frequently described. It is generally observed that the average growth of babies in developing countries is satisfactory up to the age of 3 months and then begin to falter [8, 18]. Jelliffe observed that

TABLE 8. Number of children taking weaning foods and age started

Figures in parentheses are percentages.

Figures in parentheses are percentages. babies in poorly nourished communities thrive solely on breast milk for up to 3-4 months [10], when they are transferred from breast milk to formulas or supplementary foods. For Saudi Arabian children, the change was gradual and involved the introduction of milk formulas and/or solid foods that are customarily eaten in the locality.

Breast milk is insufficient by itself to sustain the increasing needs and replenish the declining stores of nutrients for children 6 months to 2 years old or more. It thus becomes the infants' decreasing but valuable source of complete protein, fat, calcium, and vitamins [10]. The sample population were given fruits and fruit juices at 4 months and vegetables at 6 months. These could supply needed vitamin C and A. Cereals that were started at 5 months could provide additional calories. Vegetables and cereals also may be sources of plant proteins. Eggs were introduced at 6 to 8 months, rather late if they are to supply the iron that has already been depleted by these ages [20]. Meat and fish, sources of good quality protein, were given at age 10 months.

CONCLUSIONS

Many factors have to be considered in making generalizations about the breast-feeding and weaning practices in Saudi Arabia. A few of them disclosed by our study could affect the nutritional condition of the children.

First, this is a traditional culture bound by inherent beliefs and customs that may limit the use of the best infant-feeding practices. For example, the dependence on breast milk for a prolonged period of time and the failure to provide sufficient supplementary foods may imperil the health of the infants. The belief that a pregnant woman's milk may be harmful to the nursing baby could deprive the baby of the mother's milk unnecessarily. Separating the child from the mother as a method of weaning may have traumatic consequences for both mother and child.

Second, there is increasing dependence on the bottle and other artificial method of feeding. Resource-poor, less-developed countries must be cautioned on this approach because of the possibility of weanling diarrhoea and the decreased secretion of breast milk due to minimal sucking stimulation [21]. This is not to mention the considerable drain on the family's resources and community-wide efforts to produce infant food products on a large scale.

Our findings call attention to the need for more research on the adequacy of breast milk being fed to Saudi Arabian infants. Numerous opinions are being expressed about the introduction of solid foods and the use of other forms of milk, but mothers do not know enough about either one. Many questions are asked: when to start, what to give, how much to give, the methods used in preparation, and so on. What are needed are (a) extensive education programmes for the people, with particular emphasis on nutrition, and (b) additional investigations by nutritionists about the significance of breast-feeding as well as timely and appropriate complementary feeding and the implications of both for the health of infants.

REFERENCES

1. M.A. Abdullah, Z.A. Sebai, and A.R. Swailem, "Health and Nutritional Status of Preschool Children," Saudi Med. d. Monograph, 1: 11-18 (1982).

2. M.A. Abdullah, A. Swailem, and S.A. Taha, "Nutritional Status of Preschool Children in Central Saudi Arabia," Ecol. Food Nutr., 12: 103-107 (1982).

3. M.P. Bader, ''Breast-feeding: The Role of Multinational Corporations in Latin America," Int. J. Health Services, 6: 604626 (1976).

4. K.H. Brown, R.E. Black, S. Becker, N. Shamsun, and J. Sawyer, ''Consumption of Foods and Nutrients by Weanlings in Rural Bangladesh," Am. J. Clin. Nutr., 36: 878-889 (19B2).

5. M Cameron and Y. Hofvander, Manual on Feeding Infants and Young Children (Oxford University Press, Oxford, UK, 1983).

6. Division of Family Health, World Health Organization, "The Dynamics of Breast-feeding,'' WHO Chron., 37 (1): 6-7 (1983).

7. P.L. Graitcer, J. Allman, M. Amedee-Gedeon, and E.M. Gentry, ''Current Breast-feeding and Weaning Practices in Haiti," J. Trop. Pediatr., 30 (1): 10-16 (1984).

8. J.P. Habicht, R. Martorell, C. Yarbrough, R.M. Malina, and R.E. Klein, ''Height and Weight Standards for Preschool Children: How Relevant Are Ethnic Differences in Growth Potential?" Lancet, 1: 611 -615 (1974).

9. S.L. Huffman, A.K.M.A. Chowdhury, J. Chakraborty, and N.K. Simpson, "Breast-feeding Patterns in Rural Bangladesh,''Am. J. C/in. Nutr., 33: 144-154 (1980).

10. D.B. Jelliffe and E.F.P. Jelliffe, "The Volume and Composition of Human Milk in Poorly Nourished Communities," Am. J. Clin. Nutr., 31: 492-514 (1978).

11. Ministry of Planning, Fourth Development Plan: 1985-1990 (Ministry of Planning, Kingdom of Saudi Arabia, 1985).

12. N. Newton, "Psychologic Differences between Breast and Bottle-feeding,'' Am. J. Clin. Nutr. 24: 993-1004 (1971).

13. T.T. Oo and K.M. Naing, "Breast-feeding and Weaning Practices for Infants and Young Children in Rangoon, Bur ma," Food Nutr. Bull., 7 (4): 47-53 (1985).

14. T.T. Oo and K.M. Naing, "The Pattern of Breast-feeding and Its Nutritional Adequacy in Rural Communities,''

Proceedings of the Research Seminar in Breast-feeding and Weaning Practices in Burma (Ministry of Health, Department of Medical Research, Rangoon, Burma, 1979).

15. All. Al-Othaimeen, "Weaning Practices in the Kingdom of Saudi Arabia" (Ministry of Health, Kingdom of Saudi Arabia, 1986).

16. All. Al-Othaimeen, W.N. Sawaya, R.l. Tannous, and B.P. Villanueva, ''A Nutrition Survey of Infants and Pre-school Children in Saudi Arabia," Saudi Med. J. (1986, in press).

17. D. Raphael, Breast-feeding and Food Policy in a Hungry World (Academic Press, New York, 1979).

18. M.G.M. Rowland, T.J. Cole, and R.G. Whitehead, "Wean ing and Diarrhea in the Gambia," Br. J. Nutr., 37: 441450 (1977).

19. Z.A. Sebai, "Anthropometric Measurements among Preschool Children in Wadi Turaba, Saudi Arabia," J. Trop. Pediatr., 27: 150-154 (1981 ).

20. S.E. Snyderman, "Nutrition in Infancy and Adolescence," in R.S. Goodhart and M.E. Shils, ads., Modern Nutrition in Health and Disease (Lea & Febiger, Philadelphia, Pa., USA, 1980).

21. B. Vahlquist, "Contemporary Patterns of Breast-feeding: Introduction," Report on the WHO Collaborative Study on Breast-feeding (World Health Organization, Geneva, 1981).

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