Indian J Pediat 49 : 285-288, 1981

EDITORIAL COMMENTARY

Infant feeding in India

K.N. Agarwal, M.D., and De,/K. Agarwal, M.D.

From times immemorial breast feeding has been the only method of feeding infants in our country (Charaku Samhita, pre Buddha era). Even in royal families where women never wanted to feed their babies, they deployed wet nurses (healthy lactating women) to feed them rather than depending on cow or buffalo milk. Although breast milk was thought to be ideal but colostrum was never fed to the newborn child. The oldest Indian book giving information on the care and nutri- tion of newborn (Charaka Samhita) l shows clearly the value of human milk. Susruta:, the ancient Indian physician recommend- ed that the colostrum should be thrown away for first 4 days after birth, honey and butter with gold ash should be fed to the newborn to facilitate the discharge of meconium and breast feeding should be started only on the fifth day. In addi- tion, Kashyap Samhita recommends to offer fruits by six months and semi solid cereal preparation at 10 months. However, Susruta advised cereals after 6 month of age (Kashyap Samhita, Chap. 12).

This is the ancient culture on infant feeding practices which has been adopted with variations in different parts of the country due to socio-cultural and religious

From the Departments of Pediatrics and Preventive & Social Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005, India.

Reprint requests : Dr. K.N. Agarwal, Pro- fessor of Pediatrics.

beliefs, literacy status, family size and availability of health services. If we try to review the current literature on infant feeding we can bring certain facts to lime- light as they exist today.

See related articles, pp. 277, 281

First feed at birth

Community based data from eastern Uttar Pradesh show that only 10% of urban and 1% of rural mothers started feeding their babies on breast within first 24 hours. More than 90 per cent urban and almost 99~/o mothers started breast feeding their babies within 48-72 hours, z'4 Similarly data from different parts of the country amply demonstrate the delay of 48-72 hours in starting the breast feeding.5-11 The first feed is generally given with.in 6-8 hours. It is either honey, sugary water, honey with castor, dates dipped in honey, honey in water, jaggary in water, jaggary in ghee, glucose water, rarely boiled water with sugar followed by diluted cow, buffalo or goat milk kept in diya (earthen saucer) or katori (ordinary bowl), sutahi (handless spoon) the utensils varying from place to place, z-~4 The exact role of these prelacteal feeds is difficult to apprehend; may be the ancient Indian physicians knew about the fall of blood glucose level in the newborn baby after 6-8 hours of birth.

Colostrum

Colostrum, yellowish thin milk secreted

286 THE INDIAN JOURNAL OF PEDIATRICS Vol. 49, No. 393

immediately after delivery having 10% protein with anti-infective factors, is tradi- tionally not given to majority of rural newborns (90~ at Varanasi, 86% at Gwalior, more than 80~ at Hyderabad) and substantial percentage of urban new- born as well (more than 60% in urban slum of Varanasi). z'4'~'~4 It is one of the responsibilities of the pediatricians and health administrators to suitably educate health workers including traditional birth attendants and grand old ladies in the families regarding the value of colostrum.

Breast feeds

Human breast milk is beneficial nutritionally, immunologically and psy- chologically besides being of enormous economic value in developing, countries. On this ideal natural food the infant main- tains an optimum ratio between the deve- lopment of body mass and body height through a self regulatory mechanism

Two factors need emphasis re~arding anti-infective properties of breast milk. Firstly, these factors are not influenced by nutritional status of the mother. These findings are important specially for our country as majority of mothers in India are undernourished. Secondly even at the end of one year of lactation the hu- man milk contains significant amounts of immunoglobulins, lactoferrin and lysozy- me which give protection to the infant specially in an environment to which he is constantly exposed and where chances of infection are very high.

In a study from Varanasi 53.9% of urban mothers stopped breast feeding their babies before 6 months as compared to 10.2~/~, in urban slum and 12.2% in l ural area. 3 Only 14.6~ of urban mothers were breast feeding their baby beyond 1

year of age as compared to 35.6~ in urban slum and 61.0 per in rural area. 3

The trend in urban communities where maternal education and nuclear families are more is either towards discontinuing or supplementing the breast feed s between 6-!2 months of age. 14-17 The diluted cow or buffalo milk is used as top feeds although in urban and urban slums tinned milk is equally popular 3-9':5-17

The data demonstrates that although majority of Indian mothers continue to breast feed their babies for sufficiently long periods, still there is a trent towards formula feeding and replacing breast with other milk in urban and urban slum areas. Weaning as a rule is never done in the proper way. It may be just a ceremony (ennaprasan or chattawan) somewhere in midhalf of infancy, when some watery preparation of dal or sago in very small quantities which hardly contribute in term of calories but is accompanied with a heavy risk of infection. 3'4 There is strong belief that child needs no weaning food so long as mother has milk in the breasts and hence no cereals are given ff, r fear of diarrhea, protuberant belly or liver damage in the baby. These women have to be convinced that cause of weanl- ing diarrhea is not the cereal food but impure water from the insanitary wells, unhygienic surroundings and poor per- sonal hygiene and food sanitation for preparing infant food.

Comments

The review of these studies suggests that teachings of our ancient physicians and surgeons still remain in the mind and heart of our people. It appears that cot- ostrum was not fed in any part of the

K.N. AGARWAL • D.K. AGARWAL : INFANT FEEDING IN INDIA 287

country. Study o f ancient Indian medical literature does not give sufficient justifica- tion in this regard. Hewever, i t appears that these physicians were possibly concerned with avoiding of hypogly- cemia in neonates and thus suggested use of honey, jaggery as feeds for first few days. The recommended use of gold ash, herbal preparations (Janam Gutti), butter fat, castor oil, dates etc. is difficult to discuss in the perspective of present day knowledge. It is likely" that these recom- mendations ~ere given wilh an idea to r~move meconium faster. It appears that

in urban areas with increasing inputs in maternal education, availability of proper feeding advice and more nuclear families the baby is finding opt~ortunity to reach the breast by first or second day. Further, introduction of semisolids and solids is earlier. ]n contrast, in rural and urban slLm areas with very few educated mothers, larger family size, and feeding advice mainly handed over by the old ladies in the family ate-old traditional feeding prac- tices are still continuing. The prolon- ged breast feeding without any weaning food (called breast starvation by Jellife), poor environmental conditions and socio- economic deprivation are the main factors responsible for higher degree of under- nutrition and morbidity in early child- hood.

In order to significantly improve feed- ing practices in infancy, it is necessary to convincingly modify the knowledge and attitude of the grand old ladies of the area. The school level education for girls needs inclusion of baseline knowledge on breast milk, colostrum (as a food, anti- infective properties, etc.) and proper weaning. At the same time our community health workers, village level workers,

anganwadi workers of Integrated Child Development Services and all other middle level workers e.g. multipurpose workers, mid-wives must be trained and convinced beyond doubt about the advantages of starting breast feeding right from the day of birth, why nature has provided colos- trum for the baby and early weaning with semisolids and solids in sufficient quantity. They must be taught that traditional feeding utensils like sutahi (pap boat), katori or cup with spoon are better suited when used with hygienic care rather than the use of the bottle. The latter is not only uneconomical but difficult to clean. Our achievements will be further enhanced by laying constructive stress on nutrition o f pregnant and lactating mothers, spacing, clean and hygienic methods of feeding and weaning, in the undergraduate medical curriculum.

References

1. Piper A : Geschichte der Kinderheilkunde, In, handbuch der Kinderheilkunde, Ed. Opitz H, Schmid FI. Berlin. Heidelberg N.Y. Band Spriner Verlag, I. 1971. p. 15

2. Singhal GD, Guru LV : Anatomical and Obsteriical Considerations in Ancient Indian Surgery (Based on Susrata Samhita). B.H.U. Press, Varanasi 1973, p 218

3. Agarwal DK, Agarwal KN, Tewari IC, Singh R, Yadav KNS : Breast feeding practices in urban slum and rural area of Varanasi. J Env Child Hlth 1981. (In press)

4. Agarwal DK, Katiyar GP, Agarwal KN : Feeding practices in district Varanasi. Indian Pediatr 1981. (In press).

5. Rao KS, Swaminathan MC, Swarup S, Patwardhan VN: Protein malnutrition in South India. Bull WHO 20 : 603, 1959

6. Thaman OP, Manchanda SS : Child rearing practices in Punjab. Indian J Pediat 35 : 334, 1968

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7.

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Banik ND : Breast feeding and weaning practices-of preschool children in urban community in Delhi. Indian Pediatr 12 : 569, 1975

8. Bhandari NR, Patil OP : Dietary and feed- ing habits in various socio-economic groups. Indian Pediatr 10 : 233, 1973

9. Sharma DB, Lahori UC : Some aspects of infant rearing practices and beliefs in the urban and rural areas of Jammu (Kashmir). Indian Pediatr 14 : 511 1977

10. Ojha K, M: A Study of Socio- economic and Cultural Aspects of Infant Practices in Rural Owalior. MD Thesis, Jiwaji Univer- sity, Gwalior, 1979.

l l. Kesaree N, Shivamurly KS, Prakash BS, Ramachandra Haridas CK: Feeding pattern of infants in Deva~gere. Indian Jr:Pediat 49 : 281, 1981

12. Rao M Rao NP, Mathur YC: A survey of infant feeding and weaning practices in the village, Fathepur Hyderabad. Indian Pediatr 9 : 480, 1972

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13. Narayanan I, Purl RK, Dhanablan M, Rao D C V P, Fernandez A, Balkrishnan S: Some infant feeding and rearing practicgs in a rural community in Pondicherry. Indian Pediatr 11:667, 1974

14. Metha M J, Pawar RG, Belkernr U N: Inf- ant feedings in Surat city (South Gujarat). Indian Ped/atr 9:290,1972

15. Ghosh S, Gidwani S, Mittal SK, Verma RK: Socio-cultural factors affecting breast feeding and infant feeding practices in an urban community. Indian Pediatr 13 : 827, 1976

16 Seth V, Ghai O P: Feeding habits of infants and the preschool children in urban, semi- urban and rural community. Indian J. Pediatr 8:45.~, 1971

17. Indra Bai K, Sastry VN, Reddy CC: Feed- ing patterns of infants-a comparative study of rural and urban areas. Indian J Pediatr 49 : 277, 1981

Atypical pneumonia in Spain

Early in May 1981, Spanish health

authorities noted an abrupt increase in numbers of hospitalisations for atypical pneumonia in communities on the outskirts of Madrid (1029 patients).76% of the cases were in the age range of 5-44 years. Of 219 who were xrayed 188 had abnormal findings in the chest. Of these 91% had fever, 63% dry cough, 61~ headaches, 42% dyspnea, 33% chest pain 29% vomiting, 22% rash, 21% productive cough, 14% diarrhea and 11% obtunda- tion. The patients were treated with erythromycin, and in some instances

tetracycline.

Results of initial viral and bacterial cultures, serologics tests, and electron microscopic studies suggest that Myco- plasma pneumoniae played a role in the outbreak. Rapid action in conducting epidemiologic and microbiologic investi- gatiogs by Spanish health authorities helped to dispel rumours regarding contaminated fruits and vegetables, in- fected birds and dogs, or biologic warfare agents as factors in the outbreak.

Abstracted by L C. Verma From Morb & Mort Vrkly Rep 30 : 237, 1981