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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation 2 Feeding Practices and Their Determinants FEEDING PRACTICES, FOOD, AND DIARRHEA RISK Infant feeding practices have long been recognized as important determinants of specific infections. Gordon et al. (1963) noted the temporal relationship between the onset of weaning and increased rates of diarrhea and coined the term ''weanling diarrhea'' to describe this association. Since these early epidemiologic investigations, the relationships between infant feeding practices and infectious diseases have been examined in numerous additional studies. These studies have been reviewed (Jason et al., 1984). In the sections that follow, the variety of feeding practices found in different societies is briefly reviewed. These practices carry relatively greater or lesser risk of diarrheal disease for the infant and young children. SOCIOCULTURAL DETERMINANTS OF BREASTFEEDING Until the Twentieth Century nearly all infants were breastfed. With the widespread availability of the baby bottle and various forms of processed animal milks the initiation and duration of breastfeeding has become a significant issue. The decision to breastfeed, as well as the duration of breastfeeding, is influenced by social and individual, personal factors; among these are women's work patterns; available health care services and personnel, marketing practices of infant formula manufacturers and urbanization.
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation Women's Work Women's employment outside the home does not appear to be a primary determinant of early discontinuation of breastfeeding, but rather the conditions under which women work may be influential (Laukaran et al., 1981). Important aspects of the potential impact of employment on infant feeding decisions include the following: (1) the duration of formal or informal maternity leave, which affects whether the mother has sufficient time with her Want during the initial postpartum period to successfully establish lactation before enduring prolonged intervals of separation from her infant during the work day, (2) the proximity of the work site, which affects the length of intervals of separation between mother and infant; and (3) the frequency and duration of break times during working hours, which determine the number of occasions during the day that a mother is able to breastfeed her child. While work hi the formal sector has been associated with serious constraints to breastfeeding, the seventy of restrictions in the modern work force can be ameliorated by progressive government and corporate policies and specific pieces of labor legislation (Popkin et al., 1979). In many communities traditional work patterns also place heavy time and energy demands on women. These demands affect breastfeeding. The degree of flexibility in adjusting to these demands is often less during periods when the demand for example, for agricultural labor, is at its peak, so that the impact of women's work on breastfeeding may vary seasonally. Moreover, changing employment activities of men, including migration out of rural areas, affects infant feeding decisions and produces greater variability within communities, based on the economic adjustments of individual households. Health Services and Personnel A number of aspects of modern systems of maternity and newborn care are associated with decreased rates of breastfeeding initiation and poor rates of continuation among those who do initiate it (Winikoff et al., 1986b). The features of modern health care found to be associated with lower rates of breastfeeding include the following: (1) delays or interruptions of nursing; (2) routine use of supplemental formula in the hospital and its distribution to the mother at discharge; (3) fixed feeding schedules; (4) lack of knowledge about breastfeeding technique and management among medical and nursing practitioners or a lack of initiative to modify standing procedures to better assist the new mother (AAP, 1982, Lawrence, 1982).
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation Marketing Practices of Infant Formula Manufacturers Advertising and product promotion may target the consumer directly, or indirectly through the health practitioner, clinic or hospital (Laukaran et al., 1981). Promotional strategies to consumers often portray formula as superior to breast milk while marketing to practitioners may attempt to deemphasize differences between breast milk and formula, touting improved formulations of the substitute products. The following are some of the ways in which breast milk substitutes reach consumers: (1) provided free to consumers as samples during prenatal medical visits or at hospital discharge; (2) provided at a discount to consumers via hospital dispensaries; (3) lack of restrictions at retail outlets; and (4) provided by medical prescription only at pharmacies. Urbanization With the move from rural areas, the factors described above may exert greater influence on women's infant feeding decisions. In cities, hospital births are likely to replace midwife-assisted home births and bring into play the numerous factors associated with modern health care systems. The mother also may find herself without adequate social support for breastfeeding. Finally, advertising for infant formula, both direct and indirect, is more pervasive in urban than rural environments. Unfortunately, although economic factors play a significant part in decisions about breast versus artificial feeding, the links among urbanization, socioeconomic factors, biological conditions, and cultural decisions, and the ability of mothers to initiate and sustain appropriate milk volumes are poorly understood. INITIATING BREASTFEEDING: COLOSTRUM AND PRELACTEAL FEEDS In all continents of the world there are some cultures in which colostrum is discarded; it is also common to find the practice of giving newborns a liquid (prelacteal feed) prior to initiating breastfeeding, whether or not colostrum is given. At present little is known about the biological or social impact of these practices. While there are reasons to hypothesize that the effects may be negative, the evidence to confirm this is not available. In some areas colostrum is regarded as a harmful substance that is capable of causing diarrhea, pneumonia or other illness (Harfouche, 1981; Jelliffe,
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation 1962). In other societies colostrum may be viewed as simply inadequate and is withheld until the point at which the mother judges her milk is mature (Mata, 1979). Within communities, rejection of colostrum is not uniform; some women discard it while others do not (Mata, 1978; Cruz et al., 1970). Intracommunity differences in behavior may be related to the degree of adherence to traditional beliefs, and in some situations the variability may be an indication that the practice of discarding colostrum is open to change. In many societies herbal preparations or oils are given to newborns as a laxative for the purpose of clearing out the meconium, while in others "lubrication" of the intestinal tract is the motivation for the practice. In some cultures an early supplement (water or water sweetened with sugar or honey) is given only for the first few days of life (Bansal et al., 1973); in others, the practice of giving water continues even after lactation is established. In some cultures the use of water as a prelacteal feed is a new introduction, rather than a traditional practice. Hospitals often give glucose water to newborns, whether or not they are being breastfed. Usually the water precedes the first nursing which may be delayed for many hours. Health personnel may encourage mothers to continue giving water by bottle after they return home, and whether or not mothers receive instructions to continue this practice, the example set in hospital is often followed. Evidence suggests that this practice increases the prevalence of bottle feeding and decreases the duration of breastfeeding (Winikoff et al., 1986a). INTRODUCTION OF FOODS IN ADDITION TO BREAST MILK The weaning process spans the period from the first introduction of nonbreast milk foods or liquids until the time that breastfeeding is discontinued. Unmodified animal milks and infant formulas are common as early weaning foods, and the first nonmilk foods are typically thin gruels (paps and porridges), prepared from the staple cereal, tuber or root crops of a region. Other common first foods are fruit juices, soups or herbal teas. These may not be regarded locally as food and are given for a variety of reasons: Teas prevent illness or give strength; teas "stay the child's hunger," making it possible to increase the time between breastfeedings because breast milk is inadequate to prevent thirst. Studies have shown, however, that supplementary water is physiologically unnecessary if the child is exclusively breastfed (Brown et al., 1986). There is a wide range, both between and within cultures, in the age at which additional foods, especially protein-rich and energy-dense foods, are given. In the second six months of life, infants in many societies are exposed to an increasingly wider range of food. Often the staple carbohydrate
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation prepared in the manner consumed by adults is offered first. Since the water content of the family preparation is less than that of gruels, the energy concentration of the foods is generally increased. FEEDING METHODS A variety of methods are used to give foods to infants and young children that affect the exposure to diarrheal pathogens and the quantity of food the child consumes. In some cultures the mother's hand serves as the utensil from which gruels, water or other liquids are poured into the child's mouth. In other communities, mothers use their fingers to place porridges or soft pastes in the infant's mouth. Feeding bottles have become increasingly common as infant feeding utensils in many parts of the world. Cups and spoons are also used to give foods, but since infants cannot manage these alone, busy mothers often turn to the bottle, which can be propped or easily held by an older sibling. SEVERANCE: THE CESSATION OF BREASTFEEDING Depending on the pace of severance and the amount of breast milk being consumed at the time it occurs, the cessation of breastfeeding can put children at increased nutritional risk. In a few cultures, special foods may be offered to the child who is being denied breast milk (Osuhor, 1980). In many societies the cultural ideal stresses gradual reduction of breastfeeding as opposed to abrupt cessation. (Darwish et al., 1982; Sanjur et al., 1970). Abrupt weaning also occurs particularly in cultures in which pregnancy is thought to spoil a woman's milk. With the onset of a new pregnancy, a woman often resorts to very rapid removal of the child from breastfeeding. Physical separation of mother and child is also used to facilitate abrupt weaning; this practice can be stressful psychologically for the young child. SPECIFIC DETERMINANTS FOR INTERVENTION PLANNING Although there are typically several interacting factors that influence feeding practices, it is often possible to discern a hierarchy of influence, given sufficient empirical data. This suggests the utility of the following algorithm in identifying the primary determinants in a given situation:
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation Are foods that are appropriate for the young child available in the community? Are they available in the household? Does the child receive the appropriate food? Does the child eat the foods if they are offered? Food Availability to the Community In the industrialized countries of the world most communities have access to many food products. This is not the case in many areas of the developing world. It is not unusual to find that many foods, even locally produced item, are not available to the population because of the marketing decisions of food producers and distributors. Food Availability at the Household Level As has been repeatedly documented, the economic conditions of households are a primary determinant of household food availability. The role of economic conditions can be partitioned into two basic sectors: (1) direct food production by the household and (2) household economic resources (especially cash income) that can be allocated to food purchases. Among land-owning farmers in rural areas, the size and nature of holdings, ecological conditions, and the types of crops and animals raised, greatly influence food availability and the amount of additional food that must be purchased. National and international agricultural and food price policies also have powerful effects on the purchasing power of both rural and urban families. In urban communities, household food production is usually quite limited. The significance of cash income for food availability is readily apparent among rural families who purchase substantial portions of their food. There is a direct, inverse, approximately linear relationship between proportion of income spent on food and total income, with the poorest families expending the largest percentage of income on food (although families with more economic means generally spend more money on food in absolute terms). Household demographic characteristics influence the amount of food available to the household as a unit. The number of wage earners is a significant factor in household income, and household labor availability often affects food production directly. Economic factors are rarely the sole determinants of food availability to the household. The allocation of household economic resources may be directed to economic and social investment (including education), social
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation prestige symbols (including new technologies) or even alcohol and other recreational expenses. Food Availability to the Child Significant factors affect the child's diet: (1) the caretaker's beliefs about foods that are appropriate for the child and perceptions of the child's needs; (2) the caretaker's allocation of time to food procurement and preparation activities; (3) the availability of fuel, water, equipment and other resources for preparation of food for the child; and (4) family food consumption patterns and expectations, including distribution of the household food supply within the family. Cultural Beliefs While not all cultures have clearly developed conceptions about the relationship of food to growth or health, virtually all cultures classify some foods as good for young children and others as inappropriate or bad. While many beliefs about what foods to feed children are shared by members of the same community or cultural group, there is also a great deal of intracommunity diversity, especially under conditions of rapid social change, in which exposure to new ideas and generational and educational differences amplify diversity in beliefs. Ideas about what children require is equally important. These concepts influence the presence of a superfood found commonly among communities that are highly dependent on a single cereal as the major food resource (Jelliffe, 1968). Rice, for example, is a superfood throughout much of Asia, and its provision to children can be seen as sufficient to meet their needs. Parental perceptions about child development, including perceptions about adequacy of size, rate of growth, and physical appearance, also are influenced by community norms. Therefore, it is probable that in communities where growth retardation is endemic, people's conceptions about children's needs reflect the influence of generations of malnutrition (Pelto, 1987). One mechanism through which growth monitoring may have an influence on feeding practices is its educational impact on parents. Growth monitoring may influence cultural expectations about growth by providing an alternative growth model. From a cross-cultural perspective it is impossible to make blanket generalizations about the correctness or dangers of traditional cultural beliefs and practices about the foods that are fed to infants and young
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation children. One usually finds positive (health-promoting), negative, and neutral beliefs in all social groups, as well as variation within a group with respect to such beliefs. It is essential that beliefs and practices be evaluated on a specific, case-by-case basis, rather than making a priori assumptions about the positive or negative consequences of widely held traditional beliefs. Allocation of Caretaker Time for Food Preparation In recent years there has been increasing attention to the multiple roles—economic, domestic, and child care—that women play. There is often conflict between these roles, particularly conflict of time, one of the scarcest resources in many communities. To the went that infants and young children require special or extra food preparation activities, women may find it difficult to allocate such extra time, particularly when cultural beliefs do not reinforce the value of doing so. Moreover, women often adopt new feeding practices because they are perceived as time saving. For example, the appeal of bottle feeding is often that it is easier than breastfeeding or that it extends the time between feedings, implying the availability of time free for other activities. Availability of Fuel Water, and Other Food Preparation Resources In many, if not most, communities in the developing world, fuel is expensive, in short supply, or, in the case of firewood and other natural fuels, acquired with considerable physical effort and time. A parallel situation exists with water. Conserving fuel and water leads to food preparation practices that are not always consonant with optimal young child feeding. For example, prepared foods are left in ambient temperatures for many hours permitting the growth of pathogens. Food preparation tools for sieving or pureeing solid foods are frequently unavailable. As a result, young children often are given only the liquid portion of foods prepared for the family, a portion that has low nutrient density. Family Food Consumption Patterns Patterns of intra-household food distribution often favor adults over children and males over females. This can be rationalized explicitly in the cultural belief system or occur implicitly as a consequence of serving and
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation eating sequences. In conditions of undernutrition, the consequences of inappropriate food distribution patterns are evident in anthropometric and nutrient intake data. Hence, food scarcity and cultural patterns of food distribution can interact to reduce food availability to young children. Child Feeding Methods and Practices The final component of the algorithm proposed above is whether the child actually consumes the food that is available to him or her. There are several folk sayings to the effect that "when the child is hungry, he'll eat," or "a child will eat to meet her needs." However, there is growing reason to doubt the wisdom of conventional beliefs. Anorexia often accompanies illness and malnutrition itself depresses appetite. Adult cultural patterns restrict eating to two or three times a day in many societies. If young children are expected to conform to these mealtimes, the quantity of total food consumed may be reduced. When children are expected to feed themselves at a very young age, their consumption often is less than when they are fed directly. When caretakers are themselves children, the young child's intake also is often reduced. In addition, parental feeding practices may vary with other circumstances, e.g., during periods of heavy work activity. In comparison with other social factors that affect the food intake of children, immediate feeding behaviors have received less attention. It can be said, however, that such behaviors probably form an important part of what is sometimes referred to as "maternal competence" or "quality of child caretaking." It is likely that under further scrutiny, the significance of feeding behaviors on food intake of infants and young children will become apparent SUMMARY Studies of associations between nutritional status and diarrhea in infancy and childhood require consideration of the cultural, social and economic factors that influence feeding practices. The extent and determinants of breastfeeding, the availability of appropriate weaning foods, and the use by specific communities of foods for infants and children merit careful evaluation. The characteristics that require evaluation span from macro-level economic conditions that influence food availability to micro-level characteristics that include the behaviors of caretakers. Site-specific features of primary importance may be quite restricted in number but are essential to
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation the planning, development and implementation of interventions. Without such localized knowledge one would be in a situation parallel to that of prescribing a medical treatment with no knowledge of the condition's etiology. REFERENCES AAP (American Academy of Pediatrics). 1982. The promotion of breastfeeding; Policy statement based on task force report. Pediatr. 69:659–661. Bansal R.D., B.N. Ghosh, U.D. Bhardwaj, S.C. Joshi. 1973. Infant feeding and weaning practices in Simla-Hills Himachal Pradesh. Ind. J. Med. Res. 61:1869–1875. Brown, K.H., H. Creed de Kanashiro, R. Aguila, G. Lopez de Romans, and R.E. Black 1986. Milk consumption and hydration status of exclusively breastfed infants irk a warm climate. J. Pediatr. 108:677–680. Cruz, P.S., C. Calingo, A. Capino, F. Castrence, M. Cosca, and T. Cruz 1970. Maternal and infant nutritional practices in the rural areas. J. Philipp. Med. Assn. 46.668–680. Darwish, O.A., E.K. Amine, A.F. El-Sherbiny, H.E. Aly, and M.H. Salama. 1982 Weaning practices in urban and rural Egypt. Food and Nutr. Bull. 4:1–6. Gordon, J.E., I.D. Chitkara, and J.B. Wyon. 1963. Preventive medicine and epidemiology—weanling diarrhea. Am. J. Med. Sci. 245:345–377. Harfouche, J.K. 1981. The present state of infant and child feeding in the Eastern Mediterranean region. J. Trop. Pediatr. 27:299–303. Jason, J.M., P. Nieburg, and J.S. Marks. 1984. Mortality and infectious disease associated with infant-feeding practices in developing countries. Pediatr. 74.702–727. Jelliffe, D.B. 1962. Culture, social change and infant feeding: Current trends in tropical regions. Am. J. Clin. Nutr. 10:19–45. Jelliffe, D.B. 1968. Infant Nutrition in the Subtropics and Tropics, 2nd. Ed. World Health Organization Monograph, No. 27. World Health Organization, Geneva. 335 pp. Laukaran, V.H., E.K. Kellner, B. Winikoff, G. Solimano, M. Latham, P. Van Esterik, and J. Post. 1981. Research on Determinants of Infant Feeding Practices. A Conceptual Framework. Working Paper No. 15. The Population Council, New York. Lawrence, R.A. 1982. Practices and attitudes towards breastfeeding among medical professionals. Pediatr. 70:912–920. Mata, L.J. 1978. The Children of Santa Maria Cauque. MIT Press, Cambridge, Mass. Osuhor, P. 1980. Weaning practices amongst the Hausas. J. Hum. Nutr. 34.273–280. Pelto, G.H. 1987. Cultural issues in maternal and child health nutrition. Soc. Sci. and Med. 25:553–559. Popkin, B.M., R.E. Bilsborrow, M.E. Yamamoto, and J. Akin. 1979. Breastfeeding practices in low-income countries: Patterns and determinants. Carolina Population Center Papers, No. 11. Carolina Population Center, Chapel Hill, N.C. Sanjur, D.S., J. Cravioto, L. Rosales, and A. Van Veen. 1970. Infant feeding and weaning practices in a preindustrial setting: A sociocultural approach. Acta Paediatr. Scand. 200:3–45.
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Nutrition Issues in Developing Countries: Part I: Diarrheal Diseases - Part II: Diet and Activity During Pregnancy and Lactation Winikoff, B., V.H. Laukaran, D. Myers, and R. Stone. 1986a. Dynamics of infant feeding: Mothers, professionals, and the institutional context in a large urban hospital. Pediatr. 7:357–365. Winikoff, B., M.C. Latham, G. Solimano, et al. 1986b. The Infant Feeding Study: Semarang Site Report. The Population Council, New York.
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