Infant feeding - An evaluation of text and taught
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《美国医学杂志》
1 Departments of Community Medicine, Maulana Azad Medical College and Associated Hospitals, New Delhi, India
2 Departments of Pediatrics, Maulana Azad Medical College and Associated Hospitals, New Delhi, India
Abstract
OBJECTIVE: Study was conducted to 1) assess knowledge of doctors, medical interns and nurses/ANMs regarding exclusive breast-feeding, management of common problems related to breast feeding and appropriate complementary foods 2) review the above aspects in books commonly read by medical and nursing students. METHODS: Cross-sectional study conducted in the department of Community Medicine, Maulana Azad Medical College, New Delhi during a seven-month period on 93 interns, 58 medical officers and 44 nurses/ Auxillary Nurse Midwives (ANMs) with the help of a pre-tested structured multiple choice questionnaire and review of some commonly read books of Pediatrics, Community Medicine and Nursing. RESULTS: The concept of 'exclusive breast-feeding' was clear to most health personnel but the fact that water should also not be given was not clear in the books reviewed. The books also lacked emphasis on management of common lactation problems and this was also seen in the knowledge of the health personnel. CONCLUSION: As inappropriate feeding practices are widely prevalent, knowledge of large proportion of health personnel is incorrect and commonly read books are inadequate on this issue, there is need for greater emphasis on this in books and training sessions.
Keywords: Infant feeding; Knowledge of health personnel; Review of books
Breast-feeding is the ideal food for an infant. On 18 May 2001, World Health Organization endorsed exclusive breast-feeding till an infant is 6 months of age.[1] Since several years before that, especially since the adoption of the Baby Friendly Hospital Initiative in 1991, exclusive breast-feeding has been recommended for 4 months. Women are encouraged to initiate and maintain lactation exclusively for at least 4 months. Staff of Baby Friendly Hospitals advice and help women breast feed and allay any anxiety regarding breast-feeding. However, since most deliveries are conducted at domiciliary level, NFHS-2 data shows that only 55% children are exclusively breast-fed till the age of 4 months and introduction of complementary foods is delayed for most children.[2] Similarly, studies in urban slums indicate that only 20% of children are exclusively breast-fed till 5-6 months of age.[3] 'Insufficient milk' is the commonest reason cited by mothers for early introduction of top feeds rather than exclusive breast-feeding and 'child unable to digest' for late introduction of semi solids.[4],[5]
The importance of medical and paramedical personnel in providing correct information to mothers about proper feeding of infants and guiding them in case of problems cannot be overemphasized. But, studies indicate that hospital and rural health personnel are inadequately prepared for this important task.[6],[7] The present study was designed therefore to: 1) assess knowledge of doctors, medical interns and nurses/ANMs regarding exclusive breast-feeding, management of common problems related to breast-feeding and appropriate complementary foods 2) review the above aspects in the books commonly used by medical and nursing students.
Materials and methods
The present study was conducted during the period June 2002- December 2002 in the Department of Community Medicine, Maulana Azad Medical College, New Delhi. Study subjects were 93 interns posted in the department by rotation and 58 medical officers and 44 Nurses/ANMs who attended HIV/AIDS and TB trainings held in the department during the study period. All subjects filled a pre-tested structured, multiple-choice questionnaire that contained questions on ideal duration of exclusive breast-feeding and action to be taken if a mother complains of insufficient breast milk.
For review of the books, five books commonly used by medical and nursing students were selected. Four of these were by Indian authors, one each in the subject of Pediatrics, Community Medicine, Nutrition and Nursing. One of the books was by foreign authors and is an internationally recognized textbook of Pediatrics.
Results
Knowledge of Health Care Personnel
All interns and majority of medical officers and nurses responded correctly what exclusive breast-feeding means. However, 19% medical officers and 25% nurses believed that a child below 4 months can be given breast milk + water or breast milk + water + fruit juice or breast milk + diluted animal milk table1.
96.7% Interns knew that if a mother of a newborn child is worried that her breast milk is insufficient, she should be advised to continue breast feeding, milk will augment. However, 8.7% medical officers and 11.4% nurses were not aware of this.
If a two-month-old baby cries often, mother commonly assumes that her milk is insufficient to satisfy her baby's hunger. Half of the nurses and one third medical officers believed that in such a situation, the child should be given either animal milk or reconstituted powder milk. Knowledge of 82.8% interns was correct in this regard as they indicated that they would serially weigh the child to see if it is growing adequately and counsel the mother to allay her anxiety.
The study subjects were given a list of foods and asked to select appropriate complementary foods for an infant. As indicated in table2, more than 85% selected dal (pulse) water as an appropriate complementary food. Liquids like fruit juice and vegetable or chicken soup were favored by 77%. It is revealing to know that 11% study subjects rejected semi solids as appropriate complementary foods. Majority (two third) of nurses recommended diluted animal milk as complementary food. Approximately a third of the medical officers and interns also favored it.
Review of Books
In all the books it is mentioned that breast-feeding should be started as early as possible and continued till at least 1 year. Exclusive breast-feeding is defined as 'no other food to be given except breast milk' by all books. Three books, (nursing, community medicine and one of pediatrics) do not mention that even water should not be given while exclusively breast-feeding a child. Advantages of breast milk are clearly enlisted in all books. The age for 'weaning' is defined as 4-5 months in nursing and community medicine and 4 months in one of the pediatrics books. The other pediatric book and book on nutrition mention that in developing countries it is advisable to wean at 6 months.
Only the books on nutrition and pediatrics mention action to be taken and advide to be given if a mother worries that her breast milk is insufficient, which is a common problem during breast-feeding of infants.[4],[5] It is described that when a baby is few days old, milk may be less but increases if mother continues breast-feeding. Secondly, if mother of a two months old child feels that breast milk is insufficient because the infant cries often, she should keep a watch over the child's weight and see whether it is growing properly and be counseled to allay her anxiety. This will assure her about the sufficiency of breast milk. The latter problem is discussed in only one pediatrics book and in the book on nutrition.
Complementary foods have been described in all the books. Foods appropriate age-wise are described in all the books except community medicine and one of pediatrics. While pediatrics book refers to the foods as 'weaning foods', nursing and community medicine books call them 'supplementary foods.' None refers to them as 'complementary foods' or 'introduction to semi-solids' as per the current recommendations.
Nutrition, nursing and one book on pediatrics list semi-solid foods as ideal 'weaning foods' and suggest starting 'weaning' with soft cereals. Besides semi solids, community medicine and one of the pediatrics books mention liquids like cow's milk, vegetable soup and fruit juice as 'weaning foods'. The other pediatric book also mentions formula milk.
Discussion
Although all books reviewed describe what exclusive breast-feeding means there is need to emphasize that it means only breast milk and not even water. All interns were clear about the meaning of exclusive breast-feeding but there was a gap in the knowledge of medical officers and nurses/ANMs. They should be reoriented on this important aspect. The duration recommended for exclusive breast-feeding is from 4 to 6 months. There is need for updating this information in view of the WHO guidelines of 6 months, given in May 2001.
Most mothers have adequate milk for proper growth of an infant upto 6 months of age. However, it is commonly observed that mothers often introduce top milk to infants much before 6 months as they think their milk to be insufficient either because of their perception of inadequate growth of infant or assumed cause of child crying too often. Such a common problem and its management are described only in pediatrics and nutrition books. Poor knowledge on this aspect was seen among interns, medical officers and nurses as a significant proportion of them opted for introduction of top feeds as a solution to this problem. This kind of advice leading to unwarranted top feeding can seriously compromise the growth of an infant. The importance of correcting this deficiency in text and training of medical and para medical personnel can be realized from the extent of the problem in the community.[4],[5] In a study conducted in urban slums of Delhi, 68% children started receiving top milk when they were less than 6 months of age. Most of them were being given diluted top milk.[3]
Although liquids like fruit juice and vegetable and chicken soup do not provide much needed energy and proteins, majority of the medical and paramedical personnel favored these. An emphasis on these leads to lesser intake of the more nutritive semi-solid foods and unnecessary economic loss to a family in buying expensive fruits. 'Dal water' does not feature in the list of appropriate weaning foods in any of the books. Among all groups-interns, medical officers and nurses/ANMs, more than 85% favored it. Books need to clearly spell out that such liquids cannot substitute semisolids as complementary foods and if the infant is still breast fed, top milk alone is not the food of choice, but semi-solids based on milk are nutritious.
Thus there is an urgent need for the text books to incorporate uniform guidelines on duration of exclusive breast-feeding, adequate description on management of common infant feeding problems and stress on semi- solids as appropriate complementary foods. In order to further clarify the issue, these should also describe commonly used complementary foods that are inappropriate and thus not commensurate with energy needs of the growing infant. There is also need for reorientation of doctors and nurses in this important aspect if the nutritional status of infants and young children is to be improved.
References
1. The Optimal Duration of Breast Feeding. Breastfeeding Briefs, Geneva Infant Feeding Association. 1211, Geneva 19, 2001; 31 & 32: 1.
2. National Family Health Survey (NFHS-2). International Institute for Population Sciences (IIPS) and ORC Macro, Mumbai IIPS Press, India 2000; P18.
3. Aneja B, Singh P, Tandon M, Pathak P, Singh C, Kapil U. Etiological Factors of Malnutrition Among Infants in Two Urban Slums of Delhi. Indian Pediatr 2001; 38: 160-164.
4. Taneja DK, Saha Renuka, Dabas P, Gautam VP, Tripathy Y, Mehra M. A study of infant feeding practices and the underlying factors in a rural area of Delhi. Ind J Comm Med 2003; 28: 107-111.
5. Mallikarjuna HB, Banapurmath CR, Banapurmath S, Kesaree N. Breastfeeding problems in first six months of life in rural Karnataka. Indian Pediatr 2002; 39: 861-864.
6. Singhal PK, Taneja DK, Patwari AK, Mullick DN. Advantages of Breast Feeding- Knowledge Among Paramedical Health Personnel and Mothers. Indian Pediatr 1989; 26: 492-495.
7. Maheshwari RK, Gupta BD, Arora AK, Karunakaran M, Bhandari SR. Knowledge and Attitude of Rural Health Personnel about Breast Feeding. Indian Pediatr 1985; 22: 371-374.(Taneja DK, Misra Amrita, )
2 Departments of Pediatrics, Maulana Azad Medical College and Associated Hospitals, New Delhi, India
Abstract
OBJECTIVE: Study was conducted to 1) assess knowledge of doctors, medical interns and nurses/ANMs regarding exclusive breast-feeding, management of common problems related to breast feeding and appropriate complementary foods 2) review the above aspects in books commonly read by medical and nursing students. METHODS: Cross-sectional study conducted in the department of Community Medicine, Maulana Azad Medical College, New Delhi during a seven-month period on 93 interns, 58 medical officers and 44 nurses/ Auxillary Nurse Midwives (ANMs) with the help of a pre-tested structured multiple choice questionnaire and review of some commonly read books of Pediatrics, Community Medicine and Nursing. RESULTS: The concept of 'exclusive breast-feeding' was clear to most health personnel but the fact that water should also not be given was not clear in the books reviewed. The books also lacked emphasis on management of common lactation problems and this was also seen in the knowledge of the health personnel. CONCLUSION: As inappropriate feeding practices are widely prevalent, knowledge of large proportion of health personnel is incorrect and commonly read books are inadequate on this issue, there is need for greater emphasis on this in books and training sessions.
Keywords: Infant feeding; Knowledge of health personnel; Review of books
Breast-feeding is the ideal food for an infant. On 18 May 2001, World Health Organization endorsed exclusive breast-feeding till an infant is 6 months of age.[1] Since several years before that, especially since the adoption of the Baby Friendly Hospital Initiative in 1991, exclusive breast-feeding has been recommended for 4 months. Women are encouraged to initiate and maintain lactation exclusively for at least 4 months. Staff of Baby Friendly Hospitals advice and help women breast feed and allay any anxiety regarding breast-feeding. However, since most deliveries are conducted at domiciliary level, NFHS-2 data shows that only 55% children are exclusively breast-fed till the age of 4 months and introduction of complementary foods is delayed for most children.[2] Similarly, studies in urban slums indicate that only 20% of children are exclusively breast-fed till 5-6 months of age.[3] 'Insufficient milk' is the commonest reason cited by mothers for early introduction of top feeds rather than exclusive breast-feeding and 'child unable to digest' for late introduction of semi solids.[4],[5]
The importance of medical and paramedical personnel in providing correct information to mothers about proper feeding of infants and guiding them in case of problems cannot be overemphasized. But, studies indicate that hospital and rural health personnel are inadequately prepared for this important task.[6],[7] The present study was designed therefore to: 1) assess knowledge of doctors, medical interns and nurses/ANMs regarding exclusive breast-feeding, management of common problems related to breast-feeding and appropriate complementary foods 2) review the above aspects in the books commonly used by medical and nursing students.
Materials and methods
The present study was conducted during the period June 2002- December 2002 in the Department of Community Medicine, Maulana Azad Medical College, New Delhi. Study subjects were 93 interns posted in the department by rotation and 58 medical officers and 44 Nurses/ANMs who attended HIV/AIDS and TB trainings held in the department during the study period. All subjects filled a pre-tested structured, multiple-choice questionnaire that contained questions on ideal duration of exclusive breast-feeding and action to be taken if a mother complains of insufficient breast milk.
For review of the books, five books commonly used by medical and nursing students were selected. Four of these were by Indian authors, one each in the subject of Pediatrics, Community Medicine, Nutrition and Nursing. One of the books was by foreign authors and is an internationally recognized textbook of Pediatrics.
Results
Knowledge of Health Care Personnel
All interns and majority of medical officers and nurses responded correctly what exclusive breast-feeding means. However, 19% medical officers and 25% nurses believed that a child below 4 months can be given breast milk + water or breast milk + water + fruit juice or breast milk + diluted animal milk table1.
96.7% Interns knew that if a mother of a newborn child is worried that her breast milk is insufficient, she should be advised to continue breast feeding, milk will augment. However, 8.7% medical officers and 11.4% nurses were not aware of this.
If a two-month-old baby cries often, mother commonly assumes that her milk is insufficient to satisfy her baby's hunger. Half of the nurses and one third medical officers believed that in such a situation, the child should be given either animal milk or reconstituted powder milk. Knowledge of 82.8% interns was correct in this regard as they indicated that they would serially weigh the child to see if it is growing adequately and counsel the mother to allay her anxiety.
The study subjects were given a list of foods and asked to select appropriate complementary foods for an infant. As indicated in table2, more than 85% selected dal (pulse) water as an appropriate complementary food. Liquids like fruit juice and vegetable or chicken soup were favored by 77%. It is revealing to know that 11% study subjects rejected semi solids as appropriate complementary foods. Majority (two third) of nurses recommended diluted animal milk as complementary food. Approximately a third of the medical officers and interns also favored it.
Review of Books
In all the books it is mentioned that breast-feeding should be started as early as possible and continued till at least 1 year. Exclusive breast-feeding is defined as 'no other food to be given except breast milk' by all books. Three books, (nursing, community medicine and one of pediatrics) do not mention that even water should not be given while exclusively breast-feeding a child. Advantages of breast milk are clearly enlisted in all books. The age for 'weaning' is defined as 4-5 months in nursing and community medicine and 4 months in one of the pediatrics books. The other pediatric book and book on nutrition mention that in developing countries it is advisable to wean at 6 months.
Only the books on nutrition and pediatrics mention action to be taken and advide to be given if a mother worries that her breast milk is insufficient, which is a common problem during breast-feeding of infants.[4],[5] It is described that when a baby is few days old, milk may be less but increases if mother continues breast-feeding. Secondly, if mother of a two months old child feels that breast milk is insufficient because the infant cries often, she should keep a watch over the child's weight and see whether it is growing properly and be counseled to allay her anxiety. This will assure her about the sufficiency of breast milk. The latter problem is discussed in only one pediatrics book and in the book on nutrition.
Complementary foods have been described in all the books. Foods appropriate age-wise are described in all the books except community medicine and one of pediatrics. While pediatrics book refers to the foods as 'weaning foods', nursing and community medicine books call them 'supplementary foods.' None refers to them as 'complementary foods' or 'introduction to semi-solids' as per the current recommendations.
Nutrition, nursing and one book on pediatrics list semi-solid foods as ideal 'weaning foods' and suggest starting 'weaning' with soft cereals. Besides semi solids, community medicine and one of the pediatrics books mention liquids like cow's milk, vegetable soup and fruit juice as 'weaning foods'. The other pediatric book also mentions formula milk.
Discussion
Although all books reviewed describe what exclusive breast-feeding means there is need to emphasize that it means only breast milk and not even water. All interns were clear about the meaning of exclusive breast-feeding but there was a gap in the knowledge of medical officers and nurses/ANMs. They should be reoriented on this important aspect. The duration recommended for exclusive breast-feeding is from 4 to 6 months. There is need for updating this information in view of the WHO guidelines of 6 months, given in May 2001.
Most mothers have adequate milk for proper growth of an infant upto 6 months of age. However, it is commonly observed that mothers often introduce top milk to infants much before 6 months as they think their milk to be insufficient either because of their perception of inadequate growth of infant or assumed cause of child crying too often. Such a common problem and its management are described only in pediatrics and nutrition books. Poor knowledge on this aspect was seen among interns, medical officers and nurses as a significant proportion of them opted for introduction of top feeds as a solution to this problem. This kind of advice leading to unwarranted top feeding can seriously compromise the growth of an infant. The importance of correcting this deficiency in text and training of medical and para medical personnel can be realized from the extent of the problem in the community.[4],[5] In a study conducted in urban slums of Delhi, 68% children started receiving top milk when they were less than 6 months of age. Most of them were being given diluted top milk.[3]
Although liquids like fruit juice and vegetable and chicken soup do not provide much needed energy and proteins, majority of the medical and paramedical personnel favored these. An emphasis on these leads to lesser intake of the more nutritive semi-solid foods and unnecessary economic loss to a family in buying expensive fruits. 'Dal water' does not feature in the list of appropriate weaning foods in any of the books. Among all groups-interns, medical officers and nurses/ANMs, more than 85% favored it. Books need to clearly spell out that such liquids cannot substitute semisolids as complementary foods and if the infant is still breast fed, top milk alone is not the food of choice, but semi-solids based on milk are nutritious.
Thus there is an urgent need for the text books to incorporate uniform guidelines on duration of exclusive breast-feeding, adequate description on management of common infant feeding problems and stress on semi- solids as appropriate complementary foods. In order to further clarify the issue, these should also describe commonly used complementary foods that are inappropriate and thus not commensurate with energy needs of the growing infant. There is also need for reorientation of doctors and nurses in this important aspect if the nutritional status of infants and young children is to be improved.
References
1. The Optimal Duration of Breast Feeding. Breastfeeding Briefs, Geneva Infant Feeding Association. 1211, Geneva 19, 2001; 31 & 32: 1.
2. National Family Health Survey (NFHS-2). International Institute for Population Sciences (IIPS) and ORC Macro, Mumbai IIPS Press, India 2000; P18.
3. Aneja B, Singh P, Tandon M, Pathak P, Singh C, Kapil U. Etiological Factors of Malnutrition Among Infants in Two Urban Slums of Delhi. Indian Pediatr 2001; 38: 160-164.
4. Taneja DK, Saha Renuka, Dabas P, Gautam VP, Tripathy Y, Mehra M. A study of infant feeding practices and the underlying factors in a rural area of Delhi. Ind J Comm Med 2003; 28: 107-111.
5. Mallikarjuna HB, Banapurmath CR, Banapurmath S, Kesaree N. Breastfeeding problems in first six months of life in rural Karnataka. Indian Pediatr 2002; 39: 861-864.
6. Singhal PK, Taneja DK, Patwari AK, Mullick DN. Advantages of Breast Feeding- Knowledge Among Paramedical Health Personnel and Mothers. Indian Pediatr 1989; 26: 492-495.
7. Maheshwari RK, Gupta BD, Arora AK, Karunakaran M, Bhandari SR. Knowledge and Attitude of Rural Health Personnel about Breast Feeding. Indian Pediatr 1985; 22: 371-374.(Taneja DK, Misra Amrita, )