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Indian Journal of Community Medicine

Nutritional Status and Feeding Practices of Children Attending MCH Centre

Author(s): Rasania SK, Sachdev TR

Vol. 26, No. 3 (2001-07 - 2001-09)

Abstract:

Research question: What is the effect of feeding practices on the nutritional status of children?

Objective:To assess the nutritional status and breast-feeding practices among children and to correlate the findings with some potential determinants.

Study design: Cross-sectional.

Setting: A maternal and child health centre, Mehrauli, Delhi.

Participants: Mothers and underfive children attending immunization clinic. Study variables. Anthropometric measurement of children, breast-feeding practices and other feeding practices.

Statistical analysis: Proportions, chi-square test.

Results: A total of 354 children were included in the study, of which 187(52.8%) were male and 167(47.2%) were female children. 114(32.2%) children belonged to illiterate mothers while only 31(8.8%) children belonged to educated mothers beyond school level. Anthropometric examination of children revealed mean weight of 6.87 2.47 Kg. and mean height of 64.73 10.13 cms. 71.5% children were underweight as per weight for age while 70.1% and 62.7% of children had deficit in height for age (stunting) and weight for height (wasting) respectively. The mother's report on breast-feeding revealed that 92.37% children were breast fed. Children who were not breast fed were found to be significantly more underweight and stunted. Out of total 354 children, weaning was started at the time of observation, only in 147 children. Prevalence of malnutrition was higher in bottle fed children (83%) than children on Katori/Cup feeding (55.1%).

Keywords: Anthropometric measurement, Breast feeding practices, Weaning practices, Container for top feeding

Introduction:

Nutrition and infection are the two most important factors that affect growth of the children. Among children, malnutrition especially strikes those, who lack nutritionally adequate diet, not protected from frequent illnesses and do not receive adequate care1. Monitoring of children under five years of age, using anthropometric parameters was found to be most effective method of determining health status and can be used to screen these children in order to determine their nutritional status2. Poor nutritional status can be measured using three types of anthropometric indicators; each of these indicators gives different information about the growth and body composition of children3-5.

WHO and other international agencies have recommended exclusive breast feeding in the initial four months and to continue breast feeding supplemented by other appropriate foods upto second year of life6,7. Malnutrition, a public health problem among infants and young children, is associated with a web of factors including insufficient food intake, incorrect feeding practices, frequent infections and literacy status of parents etc8. Vaccine preventable diseases and faulty feeding practices are associated with profound growth retardation9,10. Keeping these aspects of nutrition in view, this study was undertaken.

Material and Methods:

A clinic based observational study was conducted in the month of October 1999, in a Maternal and Child Health Center, Mehrauli, Delhi and two subcentres under its supervision. Children not accompanied by their mothers or with some serious or chronic illness were not included in the study. All underfive children attending these centres, on immunization days were assessed anthropometrically. Children were weighed on the portable infant weighing scale, with minimum clothing and to the nearest of 100 gms. Recumbent length was obtained for younger children. Standing height was measured for older children, to the nearest of 0.5 cm. Anthropometric data was classified as per Gomez classification for weight for age, Kanawati and McLaren classification for height for age and Waterlow classification for weight for height3,4. Age and immunization status of child was determined from the immunization card. The additional data obtained included mother's literacy status and her occupation. Information was also collected on feeding practices of the child, breast feeding status, initiation and duration of breast feeding etc. The collected data was analyzed using SPSS software. Categorical data was evaluated by chi square test comparing normal and malnourished children.

Results:

Table I: Nutritional status of children.

Variables Sex Child breast fed Total
Male Female Yes No
Weight for age (Under weight)
Normal 68(36.4) 33(19.8)** 96(29.4) 5(18.5)* 101(28.5)
Mild 76(40.6) 80(47.9) 146(44.6) 10(37.0) 156(44.1)
Moderate 27(14.4) 39(23.4) 60(18.3) 6(22.2) 66(18.6)
Severe 16(08.6) 15(09.0) 25(07.6) 6(22.2) 31(08.8)
Height for age (Stunting)
Normal 65(34.8) 41(24.6)* 101(30.9) 5(18.5)* 106(29.9)
Mild 90(48.1) 81(48.5) 160(48.9) 11(40.7) 171(48.3)
Moderate 23(12.3) 32(19.2) 49(15.0) 6(22.2) 55(15.5)
Severe 9(04.8) 13(07.8) 17(05.2) 5(18.5) 22(06.2)
Weight for height (Wasting)
Normal 79(42.2) 53(31.7) 123(37.6) 9(33.3) 132(37.3)
Mild 78(41.7) 77(46.1) 145(44.3) 10(37.0) 155(43.8)
Moderate 23(12.3) 29(17.4) 47(14.4) 5(18.5) 52(14.7)
Severe 7(03.7) 8(04.8) 12(03.7) 3(11.1) 15(04.2)

Figures in parentheses indicate percentages; *significant; **highly significant. A total of 354 children were included in the study, of which 187(52.8%) were male and 167(47.2%) were female children. Anthropometric examination of these children revealed mean weight of 6.87 2.47 Kg. (7.02 2.53 for male and 6.69 2.39 for female children) and mean height of 64.73 10.13 cms. (65.57 10.26 for male and 63.77 9.85 for female children). 71.5% children were underweight as per weight for age while 70.1% and 62.7% of children had deficit in height for age (stunting) and weight for height (wasting) respectively. Female children were significantly more underweight (p<0.001) and stunted (p<0.05). Severe degree of stunting and wasting was observed more in the female children. 327(92.37%) children were breast fed. Non-breast fed children were found to be significantly more underweight and stunted (p<0.05).

Table II: Nutritional status of children according to breast feeding practices.

Variables Normal (n=96) Mild (n=146) Moderate (n=60) Severe (n=25) Total (n=327)
When breast-feeding started**
Within 2 hrs 37(51.4) 22(30.5) 12(16.7) 1(1.4) 72
2-6 hrs 31(46.3) 27(40.3) 7(10.4) 2(3.0) 67
6-12 hrs 9(20.0) 24(53.3) 10(22.2) 2(4.4) 45
12-24 hrs 9(19.1) 24(51.1) 9(19.1) 5(10.6) 47
24-48 hrs 5(12.5) 23(57.5) 8(20.0) 4(10.0) 40
>48 hrs 5(8.9) 26(46.4) 14(25.0) 11(19.6) 56
How often breast-fed
1-4 times 16(20.8) 31(40.2) 21(27.3) 9(11.7) 77
5-8 times 46(30.9) 71(47.6) 23(15.4) 9(6.0) 149
9-12 times 27(35.1) 33(42.8) 12(15.6) 5(6.5) 77
>12 times 7(29.2) 11(45.8) 4(16.7) 2(8.3) 24
How long breast-fed*
1-6 months 81(33.6) 103(42.7) 41(17.0) 16(6.6) 241
7-12 months 15(21.4) 35(50.0) 13(18.6) 7(10.0) 70
13-18 months 0(0) 5(55.6) 3(33.3) 1(11.1) 9
19-24 months 0(0) 3(42.9) 3(42.9) 1(14.2) 7
Breast-feeding according to
Fixed time 30(28.0) 42(39.3) 24(22.4) 11(10.3) 107
On demand 66(30.0) 104(47.3) 36(16.4) 14(6.3) 220
Any problem in breast feeding*
Yes 4(11.8) 13(38.2) 9(26.5) 8(23.5) 34
No 97(30.3) 143(44.7) 57(17.8) 23(7.2) 320

Figures in parentheses indicate percentages; *significant; **highly significant. Only in 72(20.3%) children breast-feeding was initiated within two hours of birth while in 56(15.82%) children it was delayed beyond two days of delivery. These were the children in whom severe degree of malnutrition was observed (p<0.001). The duration of breast feeding was found to be significantly associated with malnutrition (p<0.05), however, the frequency of breast feeding was found to be insignificant.

Table III: Nutritional status of children according to the initiation of weaning.

Weaning started* Normal
(n=41)
No. (%)
Mild
(n=66)
No. (%)
Moderate
(n=27)
No. (%)
Severe
(n=13)
No. (%)
Total
(n=147)
<4 months 13 (36.1) 16 (44.4) 6 (16.7) 1 (2.7) 36
4-6 months 21 (33.3) 30 (47.6) 11 (17.5) 1 (1.6) 63
6-8 months 6   8 (32.0) 6 (24.0) 5 (20.0) 25
8-10 months 1 (6.7) 7 (46.7) 3 (20.0) 4 (26.7) 15
10-12 months 0 (0) 5 (83.3) 1 (16.7) 0 (0) 6
>12 months 0 (0) 0 (0) 0 (0) 2 (100.0) 2

Figures in parentheses indicate percentages; *significant.

Severity of malnutrition was more in children where mother had some problem in breast-feeding. Weaning was started, at the time of observation, only in 147 children. It was started at optimum age of 4-6 months in 42.9% children, started early (<4 months) in 24.5% children while in rest it was delayed beyond six months. Severe malnutrition was significantly higher (p<0.05) in children where weaning was delayed.

Table IV: Nutritional status according to top feeding practices.

Variables Normal
No. (%)
Mild
No. (%)
Moderate
No. (%)
Severe
No. (%)
Total
Container used for top feeding*
Katori/cup 40 (44.9) 31 (34.8) 13 (14.6) 5 (5.6) 89
Bottle 29 (17.0) 80 (46.8) 41 (24.0) 21 (12.3) 171
Method used for cleaning feeding container*
Water only 10 (17.5) 24 (42.1) 13 (22.8) 10 (17.5) 57
Soap 21 (23.9) 44 (50.0) 19 (21.6) 4 (4.5) 88
Boiling 32 (42.66) 27 (36.0) 10 (13.3) 6 (08.0) 75
Ash 6 (15.0) 16 (40.0) 12 (30.0) 6 (15.0) 40

Figures in parentheses indicate percentages; *highly significant.

In addition to breast milk, 260 mothers were supplementing with top milk and among them 65.8% were using bottle for feeding top milk. 62.7% mothers cleaned the containers used for top feeding, either by soap or by boiling. Even some mothers used ash (15.4%) or water only (21.9%). Overall malnutrition prevalence was higher (p<0.001) in bottle fed children (83%).

Discussion:

The study, carried out in a Maternal and Child Health center, situated in the capital, consisted of children from health conscious mothers, coming to the center for immunization. A small sample size and selection bias due to clinic based nature of study, are some of the limitations of our study.

One of the major advantage of defining problem of malnutrition in children in terms of "stunting", "underweight" and "wasting" is that it distinguishes between types of malnutrition i.e. whether it is chronic or acute11. Height for age i.e. stunting, is the sign of chronic malnutrition. Weight for age (under-weight), is quite often used as an indicator of malnutrition in the surveys, for nutritional assessment. Weight for height i.e. wasting, is an age independent index and reflects the nutritional deprivation of shorter duration12. The present study revealed that chronic malnutrition was more prevalent than acute malnutrition and findings are similar to those of others10,11. Prevalence of malnutrition was also comparable to other studies10,11. However, prevalence of severe malnutrition was lower than that observed by Ray13. Female children were more malnourished than male children and severe degree of stunting and wasting was observed more in female children, findings similar to that of Hossain10 and Ray13; however, Sastry11 observed no sex difference.

Breast milk is the best available food for infants and those who have been deprived of this, are expected to show a greater prevalence of malnutrition. The present study also reinforced this fact with the observation of significant association of breast-feeding and higher prevalence of underweight and stunting among non breast fed children. Frozani14, while observing the effect of breast feeding education, also found nutritional status of breast fed children to be significantly better than non-breast fed children. Delays in the initiation of breast-feeding are known to be detrimental to the health of infants and children and lead to malnutrition. This explains higher prevalence of malnutrition in children where breast-feeding was initiated late. But the duration of breast-feeding showed indirect relation to the nutritional status, longer the duration of breast feeding higher the prevalence and the severity of malnutrition. A number of studies reported that prolonged breast feeding is associated with increase in weight for age after 6-12 months of age15,16. Other studies, however, found increase in mild to severe malnutrition in children who were breast-fed during second year17-19. One may expect breast-fed children receiving complementary foods to be protected against growth retardation from illness and poor weaning diet. Yet this has not been observed consistently. Prolonged breast feeding may reduce the consumption of complementary foods without an equivalent increase in human milk intake, thereby, diminishing total energy intake17. Assenso20, while assessing the effect of prolonged breast feeding on the nutritional status, observed considerably lower nutritional status of children who continue to receive the breast milk upto 2nd and 3rd year of life in comparison with fully weaned children in the same year. Higher prevalence of malnutrition, in the present study, with prolonged breast-fed children is because weaning is delayed or supplementary feeding is not given to these children at appropriate time. The association of severe degree of malnutrition with prolonged breast-feeding is also in agreement with the findings of Hossain10 and Jahan9.

Delayed weaning is also detrimental to health. This explains the significantly higher prevalence of malnutrition in children, who were weaned late, i.e. beyond 6 months of age. This also explains higher prevalence of malnutrition in children where breast-feeding was continued for longer period, because as the age advances, breast milk remains inadequate for the children. A significantly higher prevalence of malnutrition among bottle fed children can be because they are more prone to get infection due to poor hygienic conditions of both bottle and nipple. Moreover, even ash or plain water were also observed to be common methods of cleaning these containers. It shows that mothers are not adequately aware of the importance of cleanliness of containers used for feeding.

Conclusion:

The study was carried out to know the feeding practices and their effect on nutritional status of children. Study clearly highlights the need of nutrition education to the mothers for promotion of breast-feeding, appropriate weaning education and education for hygiene maintenance in feeding of child, so that childhood malnutrition can be reduced.

References:

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  4. Kanawati AA, McLaren DS. Assessment of marginal malnutrition. Nature 1970; 228: 573-5.
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  17. Brakohiapa LA, Yartey J, Billy A. Does prolonged breast feeding adversely affect a child's nutritional status? Lancet 1988; ii: 516-8.
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Rasania SK, Sachdev TR
Deptt. of Community Medicine,
Lady Hardinge Medical College, New Delhi

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