[odtan f Podiatt. 45 : 318, Iq7g

M A T E R N A L P R A C T I C E S OF BABY F E E D I N G AND H Y G I E N E IN T H E ' ~ CITY OF L U D H I A N A , P U N J A B , I N D I A

('~ A | |1 P,[r I b E HUBBARD*

London

Many misconceptions of baby care

practices in the developing world circulate in Western countries, a l though the richer nations have some responsibility in directing

current trends. This is especially well i l lustrated by the large number of rural

Africans that have opted for powdered milk

feeds instead of the previously adequate breast feeding.

In Ind ia this practice has been severely

restricted by short supplies of milk powder

preparat ions. The current trend towards bot t le feeding is largely a mystery with the exception of a few studies (Gopalan and

Rao 1969, Walia ct al. 1974, Ghose t t al.

1976), and even less is known about the

knowledge of :he mothers to carry out adequate feeding apparatus asepsis.

With 80% of India ' s populat ion living

in rural areas, our survey in tile fairly prospelous industrial city of Ludhiana is

atypical . Moreover, tile Pun j ,b is the most productive farming land in the world

and this ma-/ influence the nu:ritional state

of the indigenous children. The community studied was mixed, ranging from the

impoverished Rajasthani immigrants to local Sikhs, many of whom were educated

to college level. Our sample was taken from a popula-

tion aged between ~2-24 months. With the

dea th rate in the second year of life 27

*Address: 1119, Albert Street , C a m d e n T o w n , London

N W 1, England .

Received September 1, 19"/7.

times greater than the rate in the U . ~

and diarrhoea the leading cause, we T ~

this age group would reflect baby hea l l l l care most accurately. Workers in m a h d i

parts of the Third World believe tha[ I mortality in the 1-4 year olds is the mol i l

significant index of health and hygiene in Lll

community .

Methods

Sixty-fix mothers with children ag~m between 12-24 months were i n t e r v i e w ~

with a precise questionnaire which c o v e r ~

the following topics:

a) Family constitution and s o c i o - e t o n o m ~

status.

b) age and weight of the child studied.

c) onset and duration of breast feeding.

d) in,roduction of additional animal mill~

with nature, quamity and preparatiofi

of feeding.

e) the cleaning ~nd boiling techniques of the feeding apparatus.

f) the retrospective assessment of the

incidence of diarrhota and vomiting in the child.

R e s u l t s

The average age of the mothers ranged

from 18-45 years. 1'2.% were under 21

years, 66% were beween 21-30 years, 92%

were over 30 years. 39% mothers had only one living child.

Inversely, larger families were less common.

I |uBBARD~MATILRNAL I'RAC'I'IGE5 OF BABY FEEDINO AND IIY(/,IENE 319

The incomes per month iu Fel , r ,ary 1977 were as follows: (Rs. 15----s 1).

16 6 ~ earned Rs. 200/- r les~; 47.0%

earned between Rs. 200/- a,,d Rs 400/-; 18.2')o earned betwe.,'n Rs. 400/- and Rs. 600/-; 18.2% ea r , ed between Rs. 600/- and Rs. 1500/-.

41% children were ~ell nourished according to the Harvard scale; 29%

children ~ere first degree malnourished according to the Harvard scale; 9% children were second degree malnourished; 21% children were third degree malnourished.

91~, were breast fed from birth; 9% were never breast fed because of lactat ion failure or infant prematuri ty; 33% stopped breast feeding before 6 months; 5 9 % s t o p p e d breast feeding before ! year. The reasons for discontinuing breast feeding included

lactation failure in 36~/o, pregnancy in 3 0 ~

contrived weaning in 11%, breast rejection

in 11%, breast infection in 3%, and mater-

nal tuberculosis in 3%.

5% mothers never gave their babies

animal milk; 30% mothers gave milk top feeds from birth; 2~% mothers gave milk top feeds after birth but before the first month, 8% mothers gave milk top feeds after 1 month but before 3 months; 14% mothers gave milk top feeds after 3 months but before 6 months.

Reasons for ini t iat ing top feeds includ- ed lactation insufficiency in 46%, " to

benefit the chi ld" in 30%. further pregnancy in 14% and illness in 10%.

Source of the addit ional milk was fresh buffalo milk in 84% (since it was easily avai!able),fresh cow's milk in 8% (preferred

by either the mother or baby), or powdered

milk in 8% (preferred by ei ther the medical staff or the mother).

Th em i lk w,,~ boiled in 100% .,:,f cases and the water diluting the feeds was boiled.. ̀

in 46% ca~es; mostly because the water was added before the milk was boiled.

The breakdown of quantities given by the mothers giving animal milk exclusively in the second 5,ear was: 32% gave less than 250 grams of whole milk daily, 30% gave ieis than 500 grams, and 38% gave less than 1000 grams.

Quantities given by the mothers top feeding in the second year:

46% gave less than 100 grams milk daily, 31% gave between 100-300 grams, and 23% gave between 300-500 grams.

65% used bottles initially for supplemen- tary feeds, whereas 35% used cups and spoons. By the second year, 52% were still using bottles, and 48% were using cups and

spoons.

Methods of bottle cleaning varied but were roughly divided thus :

5~ of mothers washed the bottle with

water alone; 30~/o washed with an abrasive such as sand, ash or brush and water; 18% washed with ap. abrasive, soap and water, and 17~ washed with soap and water.

Cups and spoons were washed thus: 4% of women washed them with water alone, 72~ with an abrasive such as sand, ash, brush and water, 10~ with soap, abrasive and water, and 14~/o with soap and water.

No mother boiled the cup or spoon.

49% never boiled the feeding bottle; 33% boiled the bottle once a day, and 18~/o boiled it before each feed. (In every case

but one, the mothers rinsed the boiled bottle in cold unsterile water.

~0 INDIAN JOURNAL OF PEDIATRICS Vot.. 45, NoT~;~m

The claimed frequency of vomiting and diarrhoea was as follows:

2:3% interviewees claimed that there had been no incident of vomiting or diarrhoea; 26% interviewees admitted 1-2

incidents of vomiting or diarrhoea and vomiting; 21% less than monthly bouts, 12%more than monthly bouts; and 18% interviewees admitted to weekly or more incidents of diarrhoea and vomiting.

D i s c u s s i o n

"59% children stl,died were under- nourished, 30% at least second degree malnourished. This is in spite of

each family having 3 monthly visits from a health visitor who had been careful to point out the need for

frequent, easily digested meals. Predic- tably, there was a positive correlation at the 5% level bets~een nutritional status and family income. Gordan t t al. (1963) have ~hown that age/weight charts are analogous for beth countries of the Thi rd

World and richer nations during the first six months of life. It is in the following 18 months that the children from the poorer nations fall behind, gaining little weight as they struggle from recurrent

infections and an inadequate calorie intake; a double effect of the termination of breast m i l k - a source free from pathogens, with

immunological protection, if only within the gut, and rich and well-balanced calories.

This point is emphasised by the finding that children exclusively fed on breast milk

during the peak incidence of vomiting and diarrhoea show the best weight gains of

babies in their first year. Deaths in rural India in the 'under

fives' are at tr ibuted to malnutrit ion in 50% of cases. Frequently, secondary disease is

present because inadequate nt,trition hmm

been shown to predispose to a gamutml infections, includilig measles uf a sev~,h~ nature, chest infection and gastroenter~i disease. After the age of 3 years the ehlll~ is increasingly more likely to survive a s ' ~

acquires the wit, vigour and patience t l compete for high bulk, communal food.

Retardat ion of physical capacities d u ~ to malnutrit ion is possible in the early yeatR

of development. Despite the attention and

encouragemer~t of the hea!th ~:isl.'or: th~ problem of infant underfeeding is apparent~

ly intractab!e. So obdt,rate is the problem that at Ludhiana and the surrounding rural areas daily food kitchens are being set u ~ to provide underweight, under t h ree -yea~ olds with about 250 grams of milk: av,~ porridge enriched with sugar and soya flour, The children 'qualify' after a biceps strip test'. This is a device made from a plastic pliable strip calibra~.ed with band-, of colour that indicate the nutritional statusof the left arm biceps area circumference. Malnutri- tion is confirmed by weighing. This strip method is able to detect 9~g of the children

under 5 years with second and third degree under nutrition aud about 60% oi children with first degree undernutrition.

Over 90% mothers initially breast feed,

a figure which compares well with a :imilar investigation from South Delhi (Ghosh el al.

1976) and in Chandigarh (Walia tt al. 1974). As in Chandigarh, we noticed the trend of educated richer mothers to introduce top feeds earlier. Highly educated mothers in Chandigarh were four times more likely to have weaned their babies by 9 months

compared with the illiterates in the sample. The most common reason put forward for discontinuing breast feeding was ' lactation

failure'. David Morley (1973) suggests

~lltlllt~RD--MATltRN,~t. PRACTICES OF BAI~Y rEEDL'~O

,that materna l depression, be it reactive or ~dogenous , is likely to precede milk failure. blonckleburg st al. (1973) wrote: ~ is a ~markable capacity for Ind ian women to continue an adequate supply o f breast milk despite a very poor food supply'. So called 'lactation insufficiency' appears to be related to economic, cultural, psychological and social factors associated with a change to

urban life. Surprisingly, for a large Industrial town, the reason for stopping breast feeding was rarely work commit-

ments. In rural Punjab, Scrimshaw and Behar

(1901) found only 1 in 20 artificially fed in- fants survived more than 2 years. We feel lhat this milk deprived 'dea th sentence' is Imlikely in a more closely medical!)" attended city, although the morbidity, in

artificially fed infants is likely to be

increased. The field workers in Ludhiana and the surrounding areas often noticed milestone re tardat ion in the marasmic children. The Delhi report concluded: 'an alarmingly high number (22.8%) of mothers

had stopped breast feeding by 6 months ' (Ghosh et al. 1976). In Ludhiana we found

this figure to be a third higher aud most

constitute an even greater cause for concern. Surprisingly, by one month 53% of the

Ludhiana study were giving animal feed supplements compared to the 1976 Delhi study where only 16 8% had init iated addi- tional feeds. In Bombay, where only 9.7% babies received animal top feeds from birth, milk consumption was the highest in India.

A study from 195',-1960 in the rural areas around the Punjab found only 29% of in-

fants having addional milk by the age of three months. Less than half the Punjabi mothers from the rural study were adding

animal milk at 6 month compared to our

X~D nVOm~E 32l

s tud ' i ;':~ere o , : :r 75o/o mothers were breast and bottle feeding.

Th,. promotion of the milk marketing schemes may be having the antithetical effect of making the milk safe, and more freely available to all. It is expensive and for the moderately poor, representative family from my study, represented 10-15% of their daily income. It attracts the milk

from the rurM areas where it wa.~ previously given to the family and now goes to the

cities in exchange for good cash. "lhere are good reasons for encouraging

the use of the cup and spoon (Morley 1973) rother than a bottle and teat, although the mother obviously finds practical advantages; it is a comforter, cannot spill, and is pro- tected from particulate contamination like

scot and insects.

In well nourished children diarrhoea

and vomiting is an acute episode bat under- nourished ehidren have chronic disease

Recognition of the illness becomes more difficult, and mothers may be unaware of their offspring, is sicly state. The absorptive

capacity of an inflamed gut coupled with a catabolic state leads to slow replacement

of the gut mucosa, a deficient replacement of gut enzymes, especially lactase, that in itself caases diarrhoea and malabsorption. In this first 18 months tF.is diarrhoea- marasmus syndrome sets in carrying the possible risk of impaired or delayed develop- mental a t ta inment at a time of ac t ive growth and development (Karkal 1975) and depression of lymphocyte-mediated

immunity with a shrunken thymus. With the standard of utensil c lean ing

so low, the contaminated water supply and inadequate understanding of hygiene, it can come as no surprise that the weaning

period coincides with a very high

322 INDIAN JOUNAL OF PLDIAIRICS VOL. 45,

inc idence of d iar rhoea and vomit ing.

Symr, nds ( 1 9 5 8 ) s h o w e d ti~at i , T r in idad

the incidence of d iar rhoea reached a peak earl ier than in Gua t ema la where extended

breast feeding was comma1,. We are dissatified with t h e replies to

the quest ion of the previous incidents of d ia r rhoea and vomit ing. T h e mothers are

likely to be poor historians and probably

do not reeo~ise their baby 's sickly state.

F requen t ly these bouts of d i a r r h o e a and

vomi t ing are ascribed to tee th ing ' . The Punjab is a fruitful area and inade-

qua te food supplies cannot explain the low

nut r i t iona l status o f ha l f our sample. I t

reflects a compl ica ted picture tff poverty, per_q~*~nt disease and nutr i t ional ignorance . O n e of the most profitable moves would be to provide clean piped water. This com- b ined with empha t i c teaching of nutr i t ion and hygiene could improve the long.,tanding

problem. I would like to thank all the helper~ at the Chril-

tian Medical College, Ludhiana, ar.d my sponserl, Kirby Pharmaceuticals of Middenhali, buffolk.

Re~erencea

Ghosh, S, Gidwanl, $.. Mittal, S.K., V e r ~ (3978). Socio-cultural factor, affecting breast pra~.ti~.es in an urban community. Indian P#cF~OTi~ il27.

Gordan, J.E. Chitnara, l.B.,Wvan, J.B. ( ~ Weanling diarrhoea. Arnar. .7. Med, Sr 245,

Karkal, M. (1975). $ocio-cuhural lad e ~ aspects of infant feeding Indian Ptdiatr. 12, 1~3.

Moncleburg, F B. (1973). Infant feeding.~ll m weaniT~g practice; the problem as it exists in dcve|ol~,Ulll countries. Austr. Pediatr..7. 9, 48.

Morley, David. (1973). Paediatric P r i o r i t i e s ~ Developing World. P.G. Paed, servicea 8 m ~

ScrlrnJhaw, N.S., Behar, M. ( 1~1}. P r m e ~ nutrition in young children. $cienct, !$3, 2099.

Symonds, BE. (1958). Clinical studies in Trinidadian chddren. 1 Fatal malnutrition. 3. Paed~a:r. 4, 75.

Walia B N.S, Gambhir, S.K., Bhatia, U. (19"/~ Breast feeding and weaning patterns in an population. Indian P~diatr. 51, 133.