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Indian Journal of Community Medicine

A Study of Infant Feeding Practices and the Underlying Factors in a Rural Area of Delhi

Author(s): D.K. Taneja, (Mrs.) Renuka Saha, Pratibha Dabas, V.P. Gautam, Y. Tripathy, M. Mehra

Vol. 28, No. 3 (2003-07 - 2003-09)

Deptt. of Community Medicine, Maulana Azad Medical College, New Delhi -110 002


Research questions: 1. What are the infant feeding practices in a rural area? 2. What are the reasons underlying the harmful infant feeding practices?

Objectives: l. To study feeding practices among infants. 2. To find out the factors underlying various harmful practices. 3. To find out the sources of information/advice for the prevailing practices. 4. To determine whether the practice of giving diluted animal milk to infants is associated with type of family, caste or educational status of mother.

Design: Cross-sectional.

Setting: Rural field practice centre of a Medical college in Delhi.

Participants: Mothers of infants 6-9 months of age, attending immunization clinic.

Statistical analysis: Percentages, chi square test.

Results: Water was commonly given to breast fed babies and top feeds introduced early. Consequently exclusive breast-feeding was uncommon. Semisolids were started late and diluted animal milk was commonly given to infants; as mothers often thought that child can not digest semisolids or undiluted milk. Milk was also diluted for economic reasons. Insufficient breast milk, illness of mother or child were cited as main reasons for early introduction of top milk.

Key Words: Breast feeding practices, Supplementary feeding practices, Feeding of infants


Exclusive breast-feeding is recommended worldwide as the optimum feeding for first 6 months of life and semisolid foods are recommended to be introduced after 6 months of age while continuing breast feeding to meet the increased physiological requirements of the growing infant1,2. Studies from different parts of the country have brought out the practices of early introduction of top feeds in the form of diluted animal milk or giving water to breast fed babies and late introduction of semisolids to be widely prevalent3-5

These practices adversely affect the health and nutritional status of infants and young children resulting in varying degree of malnutrition that affects almost half of the nation's children.

Material and Methods:

The study was carried out in the rural field practice area of a Medical College in Delhi. Since as per recommendations, infants over six months of age are expected to be getting semisolid foods, 6-9 months age group was decided as the target group for study so as to get the current feeding patterns and previous feeding history to cover exclusive breast feeding and supplementary feeding practices.

All the 106 mothers of infants aged 6-9 months, attending immunization clinic at the health centre were enrolled. They were interviewed using a semistructured questionnaire. It included questions relating to identification and socio-demographic data, current feeding practices, age at which various food items were introduced and who had advised for these; degree of dilution of animal milk given to infants, reasons for early introduction of top feeds and late introduction of semisolids. Subsequently focus group discussions were held with the mothers to elicit reasons for giving diluted animal milk to infants.

The following WHO 6 definitions were used for infants <4 months of age;

Exclusively breast-fed: If given only breast milk (no other liquid or solid).

Predominantly breast-fed: If given breast milk plus water and/or oral rehydration salt solution.

Partially breast-fed: If given top milk or gruel in addition to breast milk.


A total of 106 mothers of infants 6-9 months of age were interviewed. Majority were Hindus (96.2%), followed by Muslims (1.9%) and Sikhs (1.9%). Caste-wise 32.1% were scheduled castes, 29.2% Jats, 15.1% Brahmins, 3.8% Baniyas, 2.8% Kshatriyas and the rest belonged to other castes. Joint family system was predominant (58.5%) and most mothers (59.4%) had primary and higher level of education. Among the infants studied, 58.5% were males and 41.5% females.

Breast feeding practices:

Most of the infants (90.6%) were breast fed up to 6 months of age. The percentage declined to 88.68% by 9 months of age. In the 12 cases in which breast feeding was stopped, the reasons for stopping were - inadequate or no breast milk (7), cracked nipples (1)- 0 breast abscess (1), abortion (1), child ill (1) and child stopped accepting breast milk (1).

Feeding practices in Infants:

Exclusively breast fed: Exclusive breast feeding was uncommon (26.4%) as water was started in most infants in the first month itself.

Predominantly breast fed: One third (33.0%) of infants were predominantly breast fed as they were getting water and/or oral rehydration salt solution in addition to breast milk.

Partially breast fed: In 40.6% infants top milk or semisolids were started before 4 months of age in addition to continuing breast feeding. Most commonly (36.8%) they received diluted animal milk (Table I). The reasons for starting top milk in these infants were - insufficient breast milk (66.7%), mother ill (15.4%), child ill (5.1%), normal to start at this age (2.6%) and others (10.3%).

Table I: Age of starting foods other than breast milk (n=106).

Cumulative Percentages

Age in months Animal milk Milk powder Liquids Semisolids Fruits
0 12.3 1.9 0.0 0.0 0.0
1 24.5 3.8 0.0 0.0 0.0
2 30.2 3.8 0.0 0.0 0.0
3 36.8 6.6 2.8 2.8 0.0
4 49.1 7.5 14.2 12.2 4.7
5 67.9 8.5 34.0 25.4 13.2
6 73.6 10.4 55.7 50.0 30.2
7 78.3 11.3 69.8 63.2 43.4
8 80.2 12.3 77.4 73.6 50.0
9 80.2 12.3 79.2 76.4 51.8
Not started 19.8 87.7 20.8 23.6 48.2

Supplementary feeding:

As seen in Table I, the practice of giving top milk (animal milk 73.6%, milk powder 10.4%) or liquids like dal water, fruit juice or soup (55.7%) was more common than giving semisolids which were being given only to 50.0% infants at 6 months of age. Semisolids were not being given to 23.6% infants even at 9 months of age.

Breast milk plus semisolids were being given to 65.1 % infants 6-9 months of age. Home made semisolids were more popular (72.6%) than commercial ones (24.5%).

Reasons for late introduction of semisolids

Ignorance was the predominant factor as among 53(50.0%) mothers who had not started semisolids to their infants by 6 months of age, 33.9% stated child was too weak to digest and 26.4% stated breast milk to be sufficient as reasons for not starting semisolids. These reasons were followed by child did not accept (24.5%), family members did not allow (9.4%) and others (5.7%).

Practice of diluting animal milk:

Table II: Relationship of degree of dilution of animal milk with type of family, caste and education of mother.

Half 40 ≤ One third 41 No. dilution 4 Test Value
No. (%) No. (%) No. (%)
Type of Family
Nuclear 19 (51.4) 16 (43.2) 2 (5.4) X2 = 0.83; df =1 p>0.05
Joint 21 (43.7) 25 (52.1) 2 (4.2)
Brahmin 5 (50.0) 4 (40.0) 1 (10.0) X2 = 0.477; df = 2; p>0.05,
Jat 12 (46.2) 13 (50.0) 1 (3.8) Jat & SC Vs. Brahmin & others
Scheduled caste 12 (42.9) 14 (50.0) 2 (7.1)
Others 11 (52.4) 10 (47.6) 0 (0.0)
Education of mother
<Primary 13 (59.1) 9 (40.9) 0 (0.0)  
Primary 7 (53.8) 4 (30.8) 2 (15.4) X2 = 8.155; df =1; p<0.05
Middle 13 (59.1) 8 (36.4) 1 (4.5)
Matric 4 (26.7) 10 (66.7) 1 (6.7)
Sr. Secondary 2 (25.0) 6 (75.0) 0 (0.0)
Graduate & above 1 (20.0) 4 (80.0) 0 (0.0)

The practice of diluting animal milk was nearly universal (95.3%). The proportion of water was half in 47.1%, 1/3rd in 16.5%, 114th in 20.0% and 115th in 11.8% cases. Dilution was irrespective of age of the child as equal amounts of milk and water were added in case of 46.2% infants below 4 months of age compared to 47.1 % in infants 6-9 months of age. The extent of dilution was not significantly (p>0.05) related with caste or type of family (Table II). However, mothers educated up to matric or higher were adding less water than those educated up to middle or lower level (p<0.05).

Through focus group discussion with mothers it was revealed that diluted milk was given to infants commonly for economic reasons, so that all the family members could have it. Even those who owned buffaloes, gave diluted milk to infants so as to save milk for selling it. Other common reason was based on widely held belief that infant can not digest undiluted milk.

Influencers for feeding practices:

Table III: Source of information/advice for starting various food stuffs.

Liquids Fruits Semisolids
Govt. Doctor 4.7 0.9 6.6 3.8 7.5 1.9
Private Doctor 2.8 0.0 3.8 3.8 3.8 4.7
Health worker 0.9 0.0 2.8 1.9 3.8 0.9
Anganwadi worker 0.0 0.0 0.0 0.9 0.0 0.9
Mother in law 21.7 1.9 20.8 11.3 16.0 1.9
Other relative 3.8 0.9 6.6 6.6 4.7 4.7
Friends and Neighbours 5.7 1.9 5.7 4.7 3.8 2.8
Television 1.9 0.9 1.9 0.0 1.9 0.9
Radio 0.0 0.0 0.9 0.0 0.9 0.9
News papers and magazine 0.0 0.0 0.0 0.0 0.0 0.0
Self 36.8 5.7 29.2 18.9 29.2 3.8
Multiple response 1.8 0.0 0.9 0.0 0.9 0.0
Not applicable 19.8 87.7 20.8 48.1 27.4 76.4

Table III shows that in most cases various food items were started by mother herself or on the advice of her mother in law. Role of media or health care personnel was negligible.


Continued breast feeding at six as well as nine months of age was common (88.68%) and is consistent with other recent studies5. However, there seems to be a decline in this practice as compared to earlier studies3. Reasons cited for discontinuing breast feeding before 4 months of age are also similar to other studies4, most important being insufficient breast milk, breast problems e.g. infection and illness of mother or baby.

Early introduction of top feeds was common because mothers thought either breast milk to be insufficient or it was in the event of their illness or that of the child. These problems along with usual practice of giving water to breast fed infants resulted in very low percentage of infants (26.4%) being on exclusive breast feeding before 4 months of age. Though these figures are similar to the results of NFHS-2 for Delhi, but are much lower than All India figures (55.2%) 5. By training medical and paramedical personnel in lactation management and counselling these problems can be overcome in most cases and exclusive breast feeding ensured.

Although the desirable practice of giving breast milk along with semisolids to infants 6-9 months of age was almost twice as common as that of Delhi and India as a whole s , however, still a large percentage of infants (34.9%) were deprived of it either due to stopping of breast milk or withholding of semisolids.

Although dilution of animal milk is not recommended for infants beyond 2 months of age7,8, it was almost universal practice irrespective of age, in the current as well as previous studies3,9. The harmful practice prevailed either due to the belief that child cannot digest whole milk or because of economic reasons, although milk is an excellent food of high nutritional value, it alone is insufficient for most infants beyond six months of age as it cannot provide all the vitamins and minerals and has low calorie density. For improving nutritional and health status of the infants, mothers and families should be informed about the need for introduction of semisolids, vegetables and fruits, on completion of 6 months, depending on the growth of the child. In case they cannot afford animal milk, breast milk along with semisolids will suffice to make it a balanced diet. Affordable amounts of animal milk may be added if so desired.

Limitations: Since the study has been carried out by interviewing mothers of infants attending immunization clinic of a rural health centre, it is subject to selection bias. However, this was minimal and, therefore, findings can be extrapolated to the rural population in the area as almost all mothers attend this clinic to get their children immunized. It is supported by the fact that 93.0% infants in the area were fully immunized, 4.0% partially immunized and only 3.0% were not immunized and all immunizations except BCG in case of institutional deliveries are given in this clinic. Mothers are also available to bring their children to this immunization clinic as 90.5% are non working, 5.7% are part time workers and only 3.8% are full time workers.

Conclusions and Recommendations:

Although breast feeding is a universal practice, but early introduction of top feeds, giving water to breast fed babies and late introduction of semisolids are common problems in infant feeding which significantly contribute to malnutrition, so common among infants and young children. Extensive IEC efforts through mass media and education of mothers during antenatal visits and immunization sessions is needed on the facts that infants do not need water or top feeds before 6 months of age, that these can be harmful and breast milk alone is sufficient for normal growth of infants in this age group. Mothers also need to be informed that infants at 6 months of age can digest semisolids foods, giving diluted animal milk or other liquids such as dal water instead of semisolids will deprive the infant of the required nutrients, leading to malnutrition. Exclusive breast feeding up to six months as recommended by WHO in its global strategy and advocated by BPNI in India should become universal practice. The global strategy on infant and child feeding adopted by World Health Assembly in 2002 is most appropriate in our situation to ensure adequate growth and development of young children10,11.


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  2. National guidelines for infant feeding. Food and Nutrition Board, Department of Women and Child Development, Government of India, 1995.
  3. Datta Banik ND. Breast feeding and weaning practices of Indian preschool children. IJCM 1987; XII (3):109-16.
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  9. Agarwal A, Arora S, Patwari AK. Breast feeding among urban women of low socio-economic status: factors influencing introduction of supplemental feeds before four months of age. Indian Pediatrics 1998; 35: 209-73.
  10. Bhandari N, Bahl R, Mazumdar S, Martines J, Black RE, Bhan MK et al. Effect of community based promotion of exclusive breast feeding on diarrhoea! illness and growth. Cluster randomized controlled trial. Lancet 2003, 361, 1418-23.
  11. BPNI technical Info Series-2. Breast feeding 2003.
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