Influence of Infant-feeding Practices on Nutritional Status of Under-five Children
43 Original Article
Influence of Infant-feeding Practices on Nutritional Status
of Under-five Children 1 2 Dinesh Kumar, N.K. Goel, Poonam C. Mittal and Purnima Misra 1 Department of Community Medicine, GMCH, Sector 32A, Chandigarh, India. 2 Biochemistry Department, & Centre of Food Technology, University of Allahabad, Allahabad, India.Centre of Food Technology, University of Allahabad, Allahabad, India.
ABSTRACT. Objectives: To study the nutritional status of under-five children and to assess whether infant feeding practices
are associated with the undernutrition in anganwari (AW) areas of urban Allahabad. Methods : Under-five-years children and their mothers in selected four anganwari areas of urban Allahbad (UP) participated in the study. Nutritional assessment by WHO criterion (SD- classification) using summary indices of nutritional status: weight-for-age, height-for-age and weight-for-height was done. Normal test of proportions, Chi-square test for testing association of nutritional status with different characteristics and risk analysis using odds ratios with 95% confidence intervals was also done. Results : Among all under five children surveyed, 36.4% underweight (<2SD weight- for -age), 51.6% stunted (<2SD height- for- age), and 10.6% wasted (<2SD weight- for- height). Proportions of underweight (45.5%) and stunting (81.8%) were found maximum among children aged 13- 24 months. Wasting was most prevalent (18.2%) among children aged 37-48 months. Initiation of breast-feeding after six hours of birth, deprivation from colostrum and improper complementary feeding were found significant (P<0.05) risk factors for underweight. Wasting was not significantly associated (P>0.10) with any infant feeding practice studied. ICDS benefits received by children failed to improve the nutritional status of children. Conclusion : Delayed initiation of breast-feeding, deprivation from colostrum, and improper weaning are significant risk factors for undernutrition among under-fives. There is need for promotion and protection of optimal infant feeding practices for improving nutritional status of children.
[Indian J Pediatr 2006; 73 (5) : 417-421]
Key words : Colostrum feeding; Complementary feeding (CF); Exclusive breastfeeding; Odds ratio (OR); Two-stage Random
sampling technique. 5,6,7 Proper nutrition of children leading to adequate growth and other aspects of childcare has also been felt. It is and good health is the essential foundation of human important o explore the role of infant feeding practices in development. Despite global efforts for improving the etiology of malnutrition in Uttar Pradesh, as growth maternal and child health and specific efforts like retardation is very high among under five children in this Integrated Child Development Services (ICDS), state. The present study was conducted to study malnutrition among children remains a significant nutritional status of under five children and to assess problem in India. The proportions of underweight, whether infant feeding practices are associated with stunting and wasting among under-three children have undernutrition in anganwari (AW) areas of urban been reported to be 47%, 45% and 16% respectively at the Allahabad. 1 national level.
Infant-feeding practices constitute a major component
MATERIALS AND METHODS
of child caring practices apart from socio-cultural, economic and demographic factors. Somehow, these practices constitute one of the most neglected
The present cross- sectional study was conducted during determinants of young child malnutrition in spite of their 2003-04 in four selected AW areas of urban Allahabad. A important role in growth pattern of children. Recent stratified two-stage random sampling technique was used studies have recognized the link between malnutrition 2,3,4 to select under five children as study subjects. The and child feeding practices. Need for educating optimum sample size of 217 study subjects was calculated mothers for promotion of proper infant-feeding practices on the basis of 25% prevalence of undernourished children found in a pilot survey, 5% limit of error, and 90 % confidence coefficient.
Mothers of selected children who were willing to
Correspondence and Reprint requests : Dr. Dinesh Kumar,
participate in the study were interviewed for collecting
Department of Community Medicine, Govt. Medical College and
the desired information. Information on selected socio-
Hospital, Sector 32-A, Chandigarh, India
44 Dinesh Kumar et al
demographic characteristics: age of children, caste, religion, socio-economic status (SES), educational status of mother; infant feeding practices: initiation of breastfeeding, feeding of colostrum, exclusive breast- feeding (Exclusive BF) up to 6 months, complementary feeding and also receipts of ICDS benefits by children was collected. Anthropometric parameters (weight and height) were also obtained on children included in the study ensuring reliability as far as possible. New participants selected at random replaced non-respondents arising due to any reason.
The weight and height measurements were converted into three summary indices of nutritional status: weight- for-age, height-for-age and weight-for-height. According to WHO criterion based on standard deviation (SD) units (termed as Z-scores), children who were more than two standard deviations below the reference median on the basis of weight-for-age, height- for-age and weight-for- height indices were considered respectively to be underweight, stunted and wasted.
Exclusive breastfeeding rate i.e. proportion of infants exclusively breastfed for first six months and complementary feeding rate i.e. the proportion of infants aged 6-9 months who receive both breast milk and solid or semi-solid food as suggested by WHO 8 were used in the present study. Modified Prasad’s classification adjusted with current income levels was used to determine socio-economic status (SES). 9 Normal test of proportions (Z-test) to test the significance of difference between proportions and
Chi-square test for testing the association between different attributes were used. Risk factor analysis was done using odds ratios (OR) along with their respective 95% confidence intervals (CI) for finding risk factors of undernutrition.
RESULTS
The present study included 217 (138 males and 79 females) under five children with overall mean age of 18.4±17.8 months. Study subjects represented all caste categories mostly from low SES category. Mothers of 115 (53.0%) children were either illiterate or just literate. Only 110 (50.7%) children were ICDS beneficiaries. Table 1 shows nutritional status of studied children based on WHO criterion according to selected background characteristics. Out of all studied children , there were 36.4% underweight; 51.6% stunted and 10.6% wasted. Undernutrition showed variations with age of children. Maximum prevalence of underweight (45.5%) as well as of stunting (81.8%) was found in the age group 13-24 months. Underweight and stunting during infancy were observed to be 34.7% and 47.5% respectively. There was decline in the prevalence of stunting after age 24 months. Wasting was found to be most prevalent (18.2%) in the
T ABLE
1. Nutritional Status of Children in Relation to Socio-demographic Characteristics (SD – Classification) Characteristic N Underweight Stunting Wasting Age in Months
Mean age ± SD 18.4 ± 17.8 17.9±17.1 16.5±14.2 18.9±19.5 Sex Male 138 51 (37.0) 62 (44.9) 15 (10.9)
Female 79 28 (35.4) 50 (63.3) 8 (10.1) Caste
SC/ST 65 24 (36.9) 36 (55.4) 4 (6.2) OBC 77 29 (37.7) 37 (48.1) 11 (14.3) General 75 26 (34.7) 39 (52.0) 8 (10.7) Educational Status of Mothers
Illiterate/Just Literate 115 39 (33.9) 60 (52.2) 12 (10.4) Class V to VIII 39 19 (48.7) 24 (61.5) 5 (12.8) Class IX to XII 33 15 (45.5) 16 (48.5) 5 (15.2) Graduate & Others 30 6 (20.0) 12 (40.0) 1 (3.3)
SES Lower 126 47 (37.3) 64 (50.8) 14 (11.1) Middle
91 52 (57.1) 48 (52.7) 9 (9.9)
ICDS Beneficiary Yes 110 41 (37.3) 52 (47.3) 10 (9.1) No 107 38 (35.5) 60 (56.1) 13 (12.2) Overall 217 79 (36.4) 112 (51.6) 23 (10.6)
0-12 118 41 (34.7) 56 (47.5) 13 (11.0) 13-24 44 20 (45.5) 36 (81.8) 4 (9.1) 25-36 24 9 (37.5) 12 (50.0) 1 (4.2) 37-48 11 2 (18.2) 3 (27.3) 2 (18.2) 49-60 20 7 (35.0) 5 (25.0) 3 (15.0)
2. Infant Feeding Practices and Nutritional Status of Children
0.64 (1.01-2.03) (1.03-3.34) (0.24-1.71) Colostrum Feeding
1.50 (1.04-3.31) (0.91-2.96) (0.55-425) Overall 217 (100.0) 79 (36.4) (112 (51.6) (23 (10.6)
1.00 No 133 (61.3) 55 (41.3) 1.76* 75 (56.4) 1.64 16 (12.0)
Yes 84 (38.7) 24 (28.6) 1.00 37 (44.0) 1.00 7 (8.3)
2.19 (0.81-3.60) (0.58-2.25) (0.58-6.61) Proper CF
1.00 No 166 (76.5) 65 (39.2) 1.70 87 (52.4) 1.15 20 (12.0)
Yes 51 (23.5) 14 (27.4) 1.00 25 (49.0) 1.00 3 (5.6)
1.08 (1.11-3.77) (1.24-3.98) (0.49-2.34) Exclusive BF
1.00 No 119 (54.8) 52 (43.7) 2.04** 72 (59.0) 2.22*** 13 (10.6)
Yes 98 (45.2) 27 (27.5) 1.00 40 (42.1) 1.00 10 (10.5)
1.00 After six hours 96 (44.2) 42 (43.7) 1.77* 62 (64.6) 1.85* 8 (8.3)
45 Infant-Feeding Practices and Nutritional Status
Within six hours 121 (55.8) 37 (30.6) 1.00 60 (49.6) 1.00 15 (12.4)
No (%) No (%) OR No (%) OR No (%) OR (CI) (CI) (CI) Initiation of BF
Infant Feeding Practices Nutritional Status Total Underweight Stunting Wasting
In the present study less proportions of underweight (36.4% against 42.4%) and stunting (51.6% against 66.1%) were found as compared to those reported in an earlier survey in Allahabad. 10 Proportions of underweight and stunting reached peak levels of 45.5% and 81.8% respectively during 13-24 months of age and then it decreased gradually with increasing age. Other studies have also reported maximum prevalence of malnutrition in children within this age group. 4,10,11,12 Significant proportions of underweight and stunted children were observed during infancy, which may be attributed to sub optimal breast-feeding practices. Children of middle SES were more likely to be underweight than those of lower SES. Boys were found more likely than girls to be underweight but stunting was more common among girls as compared to boys. In the NFHS survey 8 girls were found more likely than boys to be underweight and stunted. Boys are earlier reported to have higher weights and lengths than those of girls of the same age 13 Proportion of wasting in the present study was 10.6% with no gender differential against 11.7% found in an earlier study conducted in urban Allahabad. 10 Present study reports higher prevalence of malnourished children in case of illiterate mothers as compared to that in case of literate mothers. This finding is in agreement with IASDS study. 10 This may be due to expected better childcare
DISCUSSION
colostrum (42.1%) was significantly less (P<0.01) than that among those who were not fed colostrum (59.0%). None of the infant feeding practice studied was significantly associated with wasting (P>0.10).
T ABLE
Infant feeding practices were analyzed for their risk on undernutrition using odds ratios along with their respective 95% confidence intervals (Table 2). Initiation of breastfeeding after six hours of birth, deprivation from colostrum and improper complementary feeding were found significant risk factors of underweight at various levels of significance shown in the table. Proportions of underweight among children whose mothers reported initiation of breastfeeding within six hours of birth (30.6%), children who were fed colostrum (27.5%), and got proper complementary feeding (28.6%) were found to be significantly less (P<0.05) as compared to proportions of underweight among their respective counterparts. Late initiation of breast-feeding beyond six hours and deprivation from colostrum came out to be significant risk factors of stunting. The proportions of stunting among children whose mothers initiated breastfeeding within six hours (49.6%) was significantly less (P<0.02) than that (64.6%) for those whose mothers initiated breastfeeding after six hours. Stunting among children who were fed
age group 37-48 months. In case of higher levels of education of mothers, the prevalence of undernourished children was low. There were more male underweight children (37.0%) as compared to those of female children (35.4%) but the prevalence of stunting was more among females (63.3%) than that for males (44.9%). Undernutrition in terms of underweight and stunting was found to be significantly associated (P<0.05) with each of the variables: gender of the child, maternal education, SES, and antenatal registration, but their association with caste and receipts of ICDS benefits by children was not found to be significant (P>0.10). The association between wasting and any of these characteristics was also not found significant (P>0.10).
- P<0.05, ** P<0.05, ** P<0.01)
- Delayed initiation of breast-feeding, deprivation from colostrum, and improper complementary feeding are significant risk factors for undernutrition among under five children.
- Optimal infant- feeding practices should be promoted and protected to improve nutritional status of under five children.
46 Dinesh Kumar et al
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REFERENCES
Key Messages
Acknowledgement Authors are highly grateful to the referee for his/her valuable comments for improving the paper.
Adolescent girls, pregnant and lactating mothers and also elderly women should be educated for promotion and protection of optimal infant-feeding practices for improving nutritional status of children. Also, conflicting messages regarding infant- feeding should be avoided.
The study concludes that there is a significant relationship between improvement in nutritional status of under five children and adoption of proper infant-feeding practices by their mothers. Delayed initiation of breast feeding, deprivation from colostrum and improper complementary feeding come out to be significant risk factors for undernutrition among under five children.
CONCLUSION
This study suffers some bias in terms of more representation of infants selected according to inclusion criterion, which was due to their easy availability with mothers at home at the time of survey and more willingness to participate shown by their mothers.
ICDS benefits received by the children failed to improve significantly their nutritional status in the present study whereas in several earlier studies 16,17,18 a positive impact of ICDS scheme on nutritional status of children has been attributed. In ICDS area comparatively more satisfactory infant feeding practices are also reported than that in Non-ICDS area. 19,20
Initiation of breastfeeding within six hours and proper complementary feeding in the present study are found to be only 30.6% and 38.7% respectively. Exclusive breastfeeding practice was not so common in the study area. According to a latest report, 14 16.7% mothers initiated breastfeeding within one hour, 48.3% mothers practiced complementary feeding during 6-9 months and exclusive breastfeeding rate (0-6 months) has been found to be 60.5% in the studied area. Present study reports 54.8% mothers discarding colostrum. Delayed initiation of breastfeeding, deprivation from colostrum, and improper complementary feeding came out to be significant risk factors of underweight. Risk of stunting was more in case of late initiation of breast-feeding and deprivation from colostrum. Exclusive breast-feeding was not found a significant correlate of nutritional status in the present study while this practice along with timing of initiation of breastfeeding and age at introduction of complementary feeding were found to be significantly associated with nutritional status of children in an earlier study. 10 This finding supports the conclusion drawn earlier based on data from NFHS-1, that breastfeeding with supplements is more beneficial than exclusive breastfeeding even for children at very young ages (less than four months). 15 Infant-feeding practices could not influence nutritional status as assessed by weight-for-height index. Impact of infant-feeding practices on underweight and stunting but not on wasting can be explained by the fact that wasting describes a recent and severe process that led to significant weight loss as a consequence of acute starvation and/or severe disease whereas stunting implies long-term malnutrition and poor health, and underweight implies linear–growth retardation. Infant- feeding practices have some long-term beneficial effects in improving the nutritional status of children. In case of low incidence of wasting in a community, underweight and stunting both reflect the long-term health and nutritional experience of the population.
Nutritional assessment of preschool children of rural community 1970. Indian Journal of Medical Research 58: 1621- 1628.
47 Infant-Feeding Practices and Nutritional Status 12. Yashoda Devi P, Geervani P. Determinants of nutritional status psychosocial development parameters of children, 1991. of rural preschool children in Andhra Pradesh, India. Food
17. Long-Term Effects of ICDS on Beneficiaries, MD (Ped.) Thesis, Nutr Bull 1994; 15: 335-342. 1999, University of Allahabad.
13. Saxena N, Nayar D, Kapil, U. Prevalence of underweight,
18. Kushwaha KP, Mathur GP. Delivery of better maternal and stunting and wasting. Indian Pediatric 1997; 34 : 627-631. child health services through monitoring of grade III and
14. Status of Infant and Young Child Feeding Feeding , Delhi, grade IV malnourished children in ICDS scheme. Indian
Breastfeeding Promotion Network of India (BPNI), 2003. Pediatrics 1983, 20:37-40.15. Anandaiah, Ravilla and Minja Kim Choe. Are the WHO
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48 Current Literature
Use of New TB Test in Children Should be Limited
A new diagnostic test called the “Quanti FERON - TB Gold test” for detection of tuberculosis infection
has been introduced. Quanti FERON - TB Gold represents a significant advances and has some potential
advantages compared to the tuberculin skin test (TST). OFT-G may be used in all circumstances in
which TST is currently used, including contact investigations and sequential-testing surveillance
programs for infection control.The QFT-G test detects the release of interferon gamma. [IFN-g] in fresh heperinized whole blood
when it is incubated with the synthetic peptides representing two proteins present in Myobacterium
tuberculosis: early secretory antigenic target 6 (ESAT-6) and culture filtrate protein 10 (CFP-10).
The QFT-test kids include a positive (phytohemagglutinin) and negative (saline) control. The amount
of antigen-specific IFN-g release is determined by subtracting the amount in the negative control from
the amount in the ESAT-6, CFP-10 or positive control. Special software computes the corrected amounts
and gives guidelines for the interpretations of the results.The QFT-G test offers some distinct advantages over the TST. First, it requires only one patient
encounter to draw the blood, not two encounters as is required for the placing and reading of a TST.
Second, the proteins used in the QFT-G are absent from all bacille Calmette-Guerin (BCG0 strains and
from commonly encountered non-tuberculous mycobacteria, except M. kansasii, M. szulgai and M.
marinum. This should make the test more specific for M. tuberculosis infection than the Quanti FERON
and TST, both of which use PPD as an antigen. This could make QFT-G particularly attractive for use
in children who previously received one or more BCG vaccinations, as the QFT-G test will not be
affected by the previous BCG while the TST may be.Third, QFT-G does not trigger an anamnestic response (i.e. booster reaction with repeated testing) as can the TST because the QFT-G does not expose persons to antigens.
To conclude, there is little doubt that new immunologic tests will improve diagnosis of tuberculosis
infection and disease in the pediatric population once their performance in children is better
understood.Abstract from Jeffrey R. Stark, AAP News, 2006; 27 : 14-15.