Breastfeeding is the oldest method of feeding a child and has existed since the beginning of time. Most of the mothers received advice on the methods of feeding their infants and it comes from a variety of different sources like relatives or their mothers, health professionals, friends, books, magazines and baby food manufacturers. Similar findings were reported by Worsfold (1996).
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It is found to confer several advantages to both the breastfed child and his mother. This is in line with the study by Gartner et al. (2005). 98.0% of mothers knew about the importance of breast-feeding. The most prominent benefit identified by 92.6% of mothers were protection of the baby from diseases as stated by Duggan et al. (1990) and Berg et al. (1984). 23.4% who found it to be economical and this matches the study by Duggan et al. (1990) and NRDC (2005). 8.5% of mothers concluded that breastfeeding protects the baby from childhood obesity as suggested by Cook et al. (2003) compared to the study by Clifford (2003) who did not find any association between them. Also, 8.5% of mothers agreed that breastfeeding prevents the mother from gaining weight. This is explained by the fact that during lactation, many calories are spent to produce milk as mentioned by NRDC (2005) and Brudenell et al. (1995). It can be seen that mothers in Mauritius had a good knowledge on the beneficial aspects of breastfeeding. Therefore mothers will try their best to breastfeed their child. This will not only provide adequate nutrition to their child but also some beneficial health effects to the breastfeeding mothers.
Out of those 98 mothers who said that breastfeeding is important, 90 breastfed their child. However, all those who said that breastfeeding is not important breastfed their child. Those eight mothers who could not breastfeed their baby despite being aware of its benefits reported that they were either drug addicts, HIV positive or their baby was adopted. A study by Ashworth (2005) reported that the HIV virus can be passed from an HIV-infected mother to her baby, known as mother-to-child transmission (MTCT). This study also suggested that one in every 20 babies will become infected if breast-fed for six months while three in every 20 will become infected if breast-feeding continues for two years.
Breast milk substitutes and their hazards
Breast milk substitutes are alternatives to breast milk. They include powdered or liquid milks or formula, wet-nurses and exclude therapeutic formulas used under medical supervision (USAID, 2006). 82.0% of mothers knew about the hazards associated with breast milk substitutes. 61.0% of mothers reported diarrhea as the utmost hazard which does not tally with the study by Fein§ et al. (1997). The second hazard mentioned by 48.8% mothers was severe abdominal pain. 41.5% of mothers stated that vomiting was associated with the use of breast milk substitutes as researched by Dugdale and Eaton-Evans (1987). Allergy and childhood obesity were reported by only 31.7% of 7.3% of mothers respectively. These show that the mothers were very much aware of the hazards associated with breast milk substitutes. Mother would probably try to limit the use of breast milk substitutes as much as possible by taking into account the hazards associated with them. In this way, breastfeeding will be promoted leading to an improved health status of the children of Mauritius. However, for mothers who cannot or choose not to breastfeed for genuine and valid reasons, the use of breast milk substitutes may still be considered as a safe choice.
Colostrum is the yellowish, sticky breast milk produced at the end of pregnancy (WHO, 2010). 78.0% of mothers knew about colostrum. 72.5% of mothers correctly rightly defined it as the ‘precursor to breast milk’ while 78.0% 0f mothers correctly described its appearance as a ‘sticky pale yellow liquid. This shows that Mauritian mothers knew that colostrum is the first milk produced just after delivery and was able to describe it properly.
4.2 BREASTFEEDING PRACTICES
Initiation of breastfeeding
47.3% of mothers breastfed their child in less than one hour after birth as recommended by the WHO (2010) and USAID (2006) while some breastfed their child after several days. A 22% reduction in neonatal mortality was seen in rural Ghana if breastfeeding is started within the first hour after birth (Edmond et al., 2006). It was also found that early initiation of breastfeeding builds on the baby’s innate reflexes and babies who start breastfeeding at this time continue to breastfeed exclusively thus adopting optimal feeding. The mother’s body produces the hormone while enhancing the flow of milk. The mother’s commensal (normal) bacteria start colonizing the baby’s skin and gut thereby protecting the baby against the harmful bacteria in the environment. During this time, the baby is calmer, is in an alert state with stable breathing and heart rate. Early initiation of breastfeeding has also been shown to help reduce post-partum bleeding, a major cause of maternal mortality in developing countries (IBFAN-Asia, 2007). In light of these studies, mothers should be advised and encouraged to breastfeed their baby just after birth or in less than one hour after birth.
66 mothers claimed that breastfeeding must be initiated in less than one hour after birth but unfortunately only 39 of them practised it. The main barriers associated with late initiation of breastfeeding in cesarean section deliveries were the adverse effects of anesthesia on mother-infant pairs, maternal discomfort and delayed onset of lactation as stated by Emel. (2010).
36.8% of mothers rightly carried out exclusive breastfeeding for six months. Exclusive breastfeeding was found to contribute to protection against common infections during infancy and to lessen the frequency and severity of infectious episodes while partial breastfeeding did not seem to provide this protective effect and this was confirmed in a research by Galanakis et al. (2010). Unfortunately very few Mauritian mothers did exclusive breastfeeding for six months. This implies that mothers introduced breast milk substitutes like for example infant formula or food items earlier in the baby’s diet. Stopping breast-feeding before four months and introducing solid foods were associated with overweight and obesity at three years old as reported in a study by Hawkins et al. (2009). Formula-fed babies show quicker growth rates than breast-fed babies and seem to be at a greater risk of obesity as they progress into childhood. This could be explained by arguing that a breast-fed infant has more control over the rate of feeding and the timing of the end of feeding while bottle-fed infant might feel pressured to take in more feed due to being led by a parent to finish the bottle as stated by Ebbeling et al. (2002).
Among 51 mothers who knew that exclusive breastfeeding must be carried out for six months, only 28 of them did so. The major reason reported by mothers was insufficient milk production which was in line with the study by Petit (2008). A small group of mothers thought that breast milk did not satisfy their baby as it is easily digested as stated by Maeda et al. (2001) and that infant formula would prevent their baby from getting hungry more often. Some mothers stopped breastfeeding before six months due to fatigue, backache, nipples infection, child refuses to suckle or simply due to the easy availability of breast milk substitutes on the market. Others wanted their baby to get used to infant milk so that they can leave their baby with some family members when they had to go out or had to resume work.
22.3% of mothers carried out breastfeeding for up to two years which shows that only a minority of mothers practiced breastfeeding for two years. However, the data showed that 17.0% of mothers carried out breastfeeding for eighteen months, 12.8% for twelve months followed by 11.7% for three months only. This was explained in terms of several reasons like inadequate amount of milk produced and baby was not receiving enough milk. Some mothers stopped breastfeeding as they wanted to get pregnant again and for aesthetic reasons. Those who work reported that they did not get breastfeeding time. Others mentioned that their infants have lost interest in nursing and their husbands had negative opinions on breastfeeding. Among the respondents, few mothers stopped breastfeeding as they had sore nipples. Others were under medication and were advised by doctors to stop breastfeeding. Certain mothers found it difficult to breastfeed their baby when they had to go out and found it more convenient to use infant formula in public places. A study claimed that the leading reason why mothers stopped breastfeeding was insufficient amount of milk produced (Hussain, 2003). Most Mauritian mothers did not breastfeed their child for two years for several reasons and this would probably had adverse health effect on the child with a reduced beneficial effect of breastfeeding to the mother herself.
Weaning is the process of expanding the diet of the infant to include foods and drinks other than mother’s or formula milk, to enable them to meet the extra nutritional needs for rapid growth and development (DOH, 1994).The weaning period is a crucial stage in the growth and development of the infant and child. The timing of weaning, the choice of foods, their methods of preparation, and how weanlings are fed, all affect the outcome46.5% of mothers introduced supplemental feed at six months of age. 93.0% of them introduced infant formula while others introduced mostly solid foods. It can also be seen that 29.4% of mothers started weaning before six months compared with 18.1% of mothers who began it after six months. The introduction of solid foods before 3 to 4 months were found to be associated with increased fatness and wheeze later in childhood, with an increased risk of allergy, and with higher rates of coeliac disease and type 1 diabetes in infants while the European Food Safety Authority’s panel on dietetic products, nutrition, and allergies concluded that for infants across the EU, complementary foods may be introduced safely between four to six months, and six months of exclusive breast feeding may not always provide sufficient nutrition for optimal growth and development as shown by Booth et al. (2011).
Out of those 58 mothers who knew that supplemental food must be introduced at six months, 42 rightly introduced it in the baby’s diet at this age. At around 6-9 months changes occur in babies’ mouths that help them cope with the change from drinking to eating. Babies younger than this may be more at risk of choking on solid foods. For parents, leaving solid foods until around six months means less time spent preparing smooth purées as babies can then cope with finger foods and lumpy foods more quickly and also fewer smelly nappies. Mothers who encourage their babies to help themselves to solid foods (an approach called baby-led weaning), rather than spoon-feeding them, say that this makes introducing solids an easier, more enjoyable and sociable experience. If breastfeeding is being continued to six months or more implies that your baby receives more antibodies and other protective factors. Giving only breast milk also means your baby is less exposed to harmful bacteria. Babies are more likely than adults to develop diarrhea and vomiting from such exposure as they have less acid in their stomachs. Early weaning is not convenient as babies do not actually produce all the enzymes needed to digest food thoroughly until they are about a year old. Under four months, any foods other than milk could put strain on the baby’s kidneys and the larger molecules in food are more likely to trigger an allergy. Although a baby given solids early may appear fine at the time, there are increased risks of eczema, wheezing and chest infections in childhood as suggested by NCT (2008). Others factors affecting weaning may include young maternal age, low maternal education, low socioeconomic status, absence or short duration of breastfeeding, maternal smoking, and lack of information or advice from health care in compliance with the study by Lakshman et al. (2009).
Preparation of baby’s food at home and Use of ready-made pots
99.0% of mothers were preparing their baby’s food at home with 53.0% of mothers not using ready-made pots at all. This implied that among the 99.0% of mothers who were preparing their baby’s food at home, 40.0% of them were using ready-made pots in parallel as mothers found the cost of ready-made pots high. But due to its availability and convenience for babies, mothers tried to buy them for some meals. Therefore mothers would prepare one meal and use pots for others. Moreover, 29.4% mothers were using ready-made pots everyday while 30.4% claimed to use them rarely. The reasons for using ready-made pots rarely were due to their unaffordable price to some parents, unacceptable taste by babies, had to resume work, low freshness and less nutritious compared to ready-made pots. Mothers who prepared their baby’s food at home were mostly unemployed.
Practice of exclusive breastfeeding and weight classification of children and BMI classification of children
35 children were exclusively breastfed for six months. From the findings, it can be seen that most of them (19) had a healthy weight represented by a percentile range which lies between 5th percentiles to less than the 85th percentile as mentioned by the CDC (2011). Also, most children had a weight of more than twice their birth weight at six months. This implied that the child’s weight doubled between four to six months which tallied with the study by Mahan and Escott-Stump (2008). This indicted that exclusive breastfeeding for duration of six months did prevent excessive weight gain in children thereby protecting the children against childhood obesity.
Practice on complete duration of breastfeeding with BMI classification of children
Among the 21 children who were breastfed for two years, most of them had a healthy weight represented by a percentile range which lies between 5th percentiles to less than the 85th percentile. This showed that breastfeeding for two years prevents childhood obesity. However, some of the children were underweight as classified with a percentile range of less than 5th percentile. This could be explained by the fact that mothers wrongly timed the introduction of food in the baby’s diet or the amount and type of food given to the baby was not correct.
Practice on age at which weaning started with BMI classification of children
31 children out of those 46 children who were weaned at six months had a healthy weight classified by a percentile range between 5th percentiles to less than the 85th percentile. This demonstrates that weaning at the right time prevent excessive gain of weight by children thereby preventing them from becoming obese. It was also seen that despite some mothers rightly introduced supplemental food in the baby’s diet, the baby was overweight as she was not breastfed.
4.3 AGE OF INTRODUCTION OF SPECIFIC FOOD ITEMS
‘The WHO (2011) recommends that infants start receiving complementary foods at 6 months of age in addition to breast milk, initially 2-3 times a day between 6-8 months, increasing to 3-4 times daily between 9-11 months and 12-24 months with additional nutritious snacks offered 1-2 times per day, as desired’. The main items that were introduced early were cow milk, mashed fruits, fresh vegetables and mashed vegetables.
61.1% of mothers introduced cow’s milk before 8 to 9 months as reported by CHW (2008). This was a bad practice as early introduction of cow’s milk is associated with an increased risk of developing Type-1 diabetes afterwards and a protein in cow’s milk was responsible in causing an unusual immune response as stated by Goldfarb (2008). Also, early introduction of cow’s milk and infant formula increases the frequency of atopic dermatitis, cow milk allergy, and wheezing in early childhood which is in line with a study by Burks et al. (2008) and IDACE (2005). Fortunately the majority of mothers (49.0%) rightly introduced infant formula in their baby’s diet at 6 months.
Mothers introduced eggs irrespective of whether it is egg yolk, white egg or whole egg at around 9- 12 months as stated by ADC (2005) to prevent allergies. However, a study by Koplin et al. (2010) showed that introduction of cooked egg at 4-6 months of age does not increase the risk of egg allergy but can rather protect against its development.
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Bread was introduced earlier than recommended by 37.0% of mothers which is a bad practice. Bread is a starchy food and consists of sugars. Therefore, early introduction bread in a child’s diet may lead to unusual weight gain in children. With time, the child may become overweight and obese. Research showed that overweight and obesity in children in most cases turned out to be obese adults which elevates the risk of diseases like heart disease, high blood pressure, diabetes and breathing problems as stated by AACAP (2010).
Meat was introduced early by 40.8% of mothers. Meat is rich in saturated fats which is stored in the child’s body. The digestive system of the child is affected and with time, the walls of the arteries may thicken leading to atherosclerosis together with many other chronic diseases.
20.0% of others introduced salty snacks earlier than recommended in their baby’s diet. Excessive salt consumption leads to storage of water in the body and affects the normal functioning of the digestive system. Afterwards, this person is more likely to suffer from high blood pressure and others health related problems.
The main reason claimed by mothers for the introduction of milk and milk products were mainly as a source of calcium for the child. Other reasons include strength of bones and teeth, proper growth and development of the child. Eggs were given to children as a source of vitamin D, protein and to test for allergies. Cereal and cereal products were given as a source of carbohydrate to provide the child with adequate amount of energy to carry out his daily activities and for basal metabolism. Meat and meat products were given mostly as a source of protein and to vary the type of food the child consumes. Sweet and salty biscuits were given to children as snacks usually at tea time with a glass of milk to prevent the child from being over hungry at dinner time thereby preventing overconsumption of nutrients during the meal. The purpose of inserting fruits and vegetables in the diet is to provide the child with all the essential vitamins and to prevent constipation and other health problems related to malnutrition. Ice cream was rarely given as a dessert while custard was given to the child when he could not eat normal meals or during illnesses.
With respect to my study, no problem was encountered with children. However, some children may be allergic to eggs, some specific brands of infant formula or fish while some children may suffer from cold while eating ice cream.
4.4 DETERMINATION OF THE ACTUAL BMI OF THE CHILDREN
The Body Mass Index (BMI) is a number calculated from a child’s weight and height and is used to assess obesity (CDC, 2011). The BMI of the children ranges from 12.82 to 21.33. These values were plugged on the body mass index-for-age percentiles to determine the percentile curve to which the children’s BMI tally with. Using this percentile and the data in Table 2, it can be easily seen whether the child is underweight, has a healthy weight, is overweight or is obese. The majority of children had a healthy weight compared to a small majority of children being underweight, overweight and obese. Therefore, it can be concluded that most Mauritian children had an ideal weight.
4.5 WEIGHT EVOLUTION OF CHILDREN
Most children had a weight of more than twice their birth weight at six months and thrice their birth weight at twelve months. This implied that the child’s weight doubled between four to six months and tripled at one year which tallied with the study by Mahan and Escott-Stump (2008). This showed that exclusive breastfeeding for six months, introduction of supplemental food at six months with continued breastfeeding till two years enable the proper growth and development of the child by preventing excess weight gain by the baby. In some cases, the children’s weight did not double at six months as they were ill and lost some weight during that period. Some children whose weights were more than thrice their birth weight were not properly breastfed. That is why their weights were higher than thrice their birth weight even though supplemental food was introduced at the right time.
Breastfeeding is and will always remain the best way of feeding a child. Children who were exclusively breastfed for 6 months and were given supplemental food at this age with continued breastfeeding till 2 years were found to grow properly with a healthy weight. It was also found that those children who were not breast fed as recommended probably gained more weight despite the fact that supplemental food was introduced at the right time. Therefore, exclusive breastfeeding for 6 months with the right age of introduction of complementary food in the baby’s diet together with prolonged breastfeeding till 2 years old is essential for the proper growth and development of a child. Mothers should be given knowledge on breastfeeding so that they can practice it in a more effective manner.
Breastfeeding must be initiated within the first hour after birth.
Exclusive breastfeeding should be carried out for the first six months with continued breastfeeding for two years or more, together with safe, nutritionally adequate, age appropriate, responsive complementary feeding starting in the sixth month.
Mothers should be informed about the advantages of breastfeeding to both their baby and themselves
Medical staffs should make mothers aware of the hazards associated with breast milk substitutes and its consequences, which may arise afterwards throughout the baby’s life.
The weight of children must be controlled regularly to ensure that the child is growing properly i.e. to see if his weight doubles at 4-6 months and triple at around 12 months.
HIV mothers must not breastfeed their child to prevent the Mother To Child Transmission (MTCT) of the virus.
Advice must be given to mothers regarding the preparation of baby’s food at home and ready-made pots available for babies so that babies can be given more hygienic and nutritious food.
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