indimt J. Pedial., 26: 467, t959.

F E E D I N G OF C H I L D R E N IN U R B A N WEST BENGAL*

P. S. MUKHE~JEE

Calcutta

hJdia is a vast country and the peoples living in different parts of this country have their own customs and cultural patterns. This is very well depicted in the feeding habits of infants and children, which not only differ in different areas, but also differ amongst the people who live in the same part of the country having different religions and speaking different languages, regardless of whether they are in urban or rural areas. There is no uniformity of the feeding habits as in Western countries. A summary of the feeding patterns in different parts of India has been described3 These also differ according to the socio-economic conditions, sophistication and education of the mothers. An attempt has been made here to find out m detail the feeding habits of infants and toddlers in an unsophisticated group of the urban population.

MATERIAL AND METHOD

Gomplete t~ediug histories of 538 single-born full-term infants and toddlers of the age-group one month to 5 years were collected. The mothers attended the MCH Clinic of the urban health centre of the All-India Insti- tute of Hygiene and Public Health at Chetla in the city of Calcutta, and each of them was interviewed by the author. Most of the mothers lived in the slums surrounding the health centre and were poor. The incomes of their husbands were less than Rs. I00.00 per month in 525 cases and less than Rs. 200.00 per month in thirteen cases. Only four mothers were working as cooks or maid-servants and the rest were housewives, who stayed at home, looked after the children and did household work. The mothers are grouped according to their education as follows--illiterate, 59.2 per cent; primary school training, 38.6 per cent; and high-school training, 2.2 per cent. Most of the people of the area were Hindu Bengalis. There were a very small number of Mohammedans and a few non-Bengali mothers, who had settled either temporarily or permanently in the area. As their attendance was small and statistically not important they were not included in this report.

BREAST ~'EEDIN G

Nlo,~t of the~e _mother~ \sctc t.~.sophisticated and accept breast-teeding as natural. 'File child ~as put to tile breast ve.'y sooa after birth. But during the first few days when milk flow ~vas not sufficient, plain water or more

.... * From the Department of Pedmtm<s, The All India Institute of Hygiene and Public Health, Calcutta. Received for pubhcatlon on October 6, 1759.

468 Indian Journal oj' Pedialrics

commonly sugar or sugar-candy water was givea. The mothers did not follow any particular time schedule and the child was given a feed when- ever he cried or whenever the mother found time to do so. Not a single mother could state exactly how many times and how often she fed the baby. She did not feed for any definite length of time, but usually stopped feeding as soon as the child ceased to cry or went to sleep. Thus, a child might have been fed many times during the twenty-four hour period. In the clinics too, babies were often seen sucking the breast. The mothers seldom tbllowed any particular routine in the way the breasts were used. The child was fed at the same breast each time he desired a feed and the breast fre- quently given was the left one, due perhaps to the facility of holding the baby with the left hand, the right hand remaining free. Even at night the child slept in the same bed with the mother, lying on a particular side of the mother, and the breast of that side was given whenever heso desired. The mother did not sit up but fed the infant in the lying position. During feeding, it seemed the mother took a much less active part than the baby in the partnership of the feeding process; very seldom a mother sat down quietly to feed her baby. She fad him usually while doing some kind of household work. She fed the baby in whatever posture she was in--sitting, lying, standing and even while walking. These mothers did not take any particular care of the breast or nipple during antenatal or postnatal periods. Most of them who lived in poor slums, did not use breast supports, and more than hatf of them did not use a blouse at home, especially if they were multiparas. They, however, wore loose blouses while attending the clinic. This might be the reason why in this series, breast complications such as engorgement and breast abscess were rare and seen only in two cases (0.3 per cent). JELLIFFE a, on the other hand, found breast complications more common in women in the upper socio-economic groups in Calcutta, and in this series of seventy-eight well-to-do mothers, nipple damage, including cracked nipples, was present in thirteen per cent of cases, one woman having a breast abscess during the puerperium.

It can be seen from Table 1 that 85.4 per cent of the mothers were completely breast-feeding the child at one month, but not more than 19.6 per cent could do so when the child was six months. Even at the end of one month in 1-3 per cent of cases, breast feeding completely failed, and in t3.3 per cent artificial food had to be added. At 6 months, 80"4 per cent of children had artificial food, and in 5.5 per cent breast-feeding had to be completely replaced. But, though breast-feeds had to be supplemented in so many children at an early age, prolonged breast-feeding, though partially, was quite common among those unsophisticated mothers. The cases which were still completely breast-fed at the age of 2 years amounted to 0.8 per cent; and those partially fed 33.0 per cent. Three cases were still breast-fed at the age of 4 years. It was seen that 98.7 per cent of the children were either fully or partially breast-fed at the age of one month; 97.1 per cent at the age of 3 months; 94"5 per cent at the age of 6 months; 84.7 per cent at the age of 9 months; 73.9 per cent at the age of 1 year; 52-0 per cent

Mukherjee--Feeding of Children 469

at the age of 1~ yars; 33.8 pe r cent at the age of 3 years; 11.3 per cent at the age of 2} years; 9.9 per cent at the age of 3 years; and 2-8 per cent at the age of 4 years, whereas there was none at the age of 5 years.

No a t t e m p t was m a d e to find out by means of test-feeding the a m o u n t of mi lk in these cases; ne i the r if the child in p ro longed breas t - fed cases rea l ly got any milk nor i f breas t - feeding worked only as a comfor ter and a subst i tute for a dummy. T h e breas t was given to the chi ldren not only when they were hung ry bu t also every t ime they cr ied, whe ther in pa in or from any other cause, as a solace. T h e au thor has not seen any case of breas t - feeding in this g roup above the of age 4 years. W h e n breas t milk thiled and the mothe r could not feed the baby comple te ly she did not seem to be very much pe r tu rbed and accepted one of the art i f icial feeds.

T A B L E 1

Showing percentage of chil&en on different feeding sche&des at cliff?rent ages

1 3 6 9 1 1~ 2 2�89 3 4 5 Age mth. mths. mths. mths. yr. yrs. yrs. yrs. yrs. yrs. yrs.

Breast-fed 85'4 50'9 19 .6 10.2 4.5 2'2 0.8 . . . .

Breast-fed and artificially fed 13.3 46'2 74'9 74"5 69'4 49'8 33'0 11.3 9'9 2.8 --

Artificially fed 1.3 2"9 5-5 15.3 26"1 48'0 66.2 88.7 90.1 97'2 100

At six months , 374 infants could not be comple te ly breast-fed, and _when the mothers were asked abou t the cause of fai lure the fol lowing reasons were given; In ten instances (2"7 per cent) the mo the r was not well; in three (0.8 pe r cent) the chi ldren were not well; in four (1.1 pe r cent) the mo the r became pregnan t ; in two (0"5 per cent) there were breas t abscesses; and in 355 (94.9 pe r cent) the b reas t milk was insufficient.

I t appea r s from the above tha t the main cause of fai lure of breast - feeding amongs t these mothers was insufficiency of milk, hence the reason for supp lementa t ion . T h e next i m p o r t a n t cause of d iscont inuing hreas t - feeding was ma te rna l illness. T h e r e is a be l ie f a m o n g some of these mothers tha t if they suffer from ac id i ty and hea r t -bu rn , a b d o m i n a l pa in or d i a r r h o e a the child should not have her milk, as the child m a y suffer from the same complaints . Breast compl ica t ions caused the failure of milk supply in two cases, and four mothers s topped breas t - feeding when they became preg~lant. P regnancy is the second commones t cause of the s toppage of breas t - feeding at 1 year o f age, the first be ing an insufficient quan t i t y of milk supply . W h e n e v e r a chi ld deve loped d ia r rhoea , which migh t be hunger d i a r r h o e a or vomi t ing (due to a i r -swal lowing) , the mo the r thought tha t her mi lk was not p rope r and so s topped breast- feeding. Thus, the child

470 Indian Journal of Pedia#ics

was deprived of whatever little supply of milk there was in tile breast. It was difficult at times to discontinue breeast-feeding when necessary, since the infants may start to bite the nipple when older. Even if the child stopped feeds during the day, he cried for it during the night, and this may continue even after another childbirth. Irt those cases, the nipples were sometimes painted with bitter substances like quinine or some herbs.

Most of these mothers came from poor homes where they had to do all the domestic work in the house without help including washing, cleaning, cooking and looking after the children. During pregnancy and lactation none of these mothers except one had milk in the diet, and her food con- sisted mainly of carbohydrates, rice and vegetables with a small quantity of protein available from pulses and rarely from small quantities of fish once weekly. None of the mothers under study used drugs or other means to increase their milk supply except one who drank milk and sago. It is a common belief amongst these people that some type of pulses and green leafy vegetables increase the milk supply. No leaf), vegetables, however, are usually taken during the first two months after childbirth, as it is believed that they may produce colicky abdominal pain in the infant.

It was a common observation that a mother was able to feed her first or second child for a longer period than the subsequent ones, and in subse- quent pregnancies the period during which she could completely breast- feed her child gradually decreased. The genetic factor is also important, some mothers being unable to feed their children with breast milk at all and others only for a short time There were only two such cases in the present series.

Eighty per cent of the children could not get enough milk from the breast, and it had to be supplemented even at the age of six months. During the period they were completely breast-fed, they gained in weight satisfactorily and remained well; but as soon as artificial food was introduced,, the children either lost weight or stopped growing normally. Attacks of diarrhoea and respiratory infections also started during this period.

ARTIFICIAL FEEDING

Table 1 shows that even at the age of one month, 14.6 per cent of the children were having artificial food, 13.3 per cent along with breast milk; whereas there was complete weaning in 1.3 per cent of the children. By 6 months 80.4 per cent of the children had to have artificial food. Thus, contrary to the general belief, unsophisticated mothers in Calcutta have to supplement breast milk at an early period. At 2~- years of age, I00 per cent of the children were having artificial food including solids (11.3 per cent together with breast milk). But what artificial food do these children get ?

Fifty-one children in the study group (10.6 per cent) had dried milk; 134 (27-8 per cent) had cow's milk; eighty-four (17.5 per cent) cow's milk and sago water; sixty-six (13.7 per cent) cow's milk and barley water; twenty-seven (5.6 per cent) sago-water; fifty-three (I 1.0 per cent) barley

Mukherjee--Feeding of Children 471

water only; eleven (2.2 per cent) goat 's milk; six (1-2 pet" cent) arrowroot water; three (0.6 pet" cent) flour mixtures; and forty-slx (9"5 per cent) sugar-candy water.

Most of the mothers realised that if they did not have enough breast milk for the child, they should give him cow's milk; but very few of them could afford it since cow's milk is costly and not available in adequate amounts. On the other hand, carbohydrate gruels are popular since they are very cheap and easily available. Sugar or candy (misri) dissolved in water, and thin watery preparations of barley, sago, arrowroot or sometimes thinly diluted, boiled and strained flour are used as artificial foods in Calcutta, besides cow's or goat 's milk.

I t was found in this survey that 71-9 per cent of the children had milk of all types, and 60.4 per cent of the children had supplements of cheap carbohydrate gruels, either alone or mixed with a small quantity of cow's milk and sugar. These carbohydrate gruels were continued with or without a sufficient quantity of breast milk until the child was a few years old, and were also continued together with solids. In this series it was found that not until two or three years o ~ age did a small percentage of the children have solids alone.

10.6 per cent of the children were having dried tinned milk, but only 6"4 per cent alone or with breast milk, and the rest in addition to barley water (0.4 per cent), sago water (0-9 per cent) or cow's milk (2.9 per cent). The brands which seemed to be most favoured by these mothers were Glaxo, Lactogen, Ostermilk and Eledon. Horlick's milk was also used in two cases. The author noticed that the mothers took pride in the fact that they were using tinned milk. The tinned milk which is available here is the tropical brand and contains three-fourths of the normaI fat content of full cream milk. Most of the children having tinned milk were found to be invariably under-fed; the reason was that both the quanti ty and quality of the milk formulae were unsatisfactory. These were very diluted and the quanti ty given was insufficient. A one-pound tin of milk powder was usually given over a period of three to four weeks.

Though fifty-nine per cent of the children were having cow's milk, the quantity given was very little; on an average not more than four to eight ounces per day diluted with water or with one of the carbohydrate gruels mentioned above. Goat 's milk was given to 2.2 per cent of the children. I t is a belief among these mothers that goat 's milk is efficacious in diarrhoeas and indigestion, and useful when the child cannot tolerate cow's milk. But though the protein content of goat 's milk (4.4 gin. per cent) is higher than that of cow's milk, its fat content is also higher (4"1 gin. per cent); and it seems that it is in no way better in the treatment of diarrhoeas than cow's milk. Buffalo's milk, though often used by adults, is not popular as an infant food in this part of the country.

The artificial food was usually given five or six times a day. A large number of mothers, who still had small quantities of breast milk, gave the children artificial food during the day and breast milk during the night.

472 Indian Journal of Pediatrics

About four to six out~ces were offered at one time. Feeding bottles were

used by these mothers, and in this series it was used by only thir teen mothers

(2"7 per cent); the r emainder used spoons and cups, both usually made of brass. The bottles used were boatshaped; they were not well cleaned a nd the teats were often dirty, soft and used for a very long time. Th i r t een

chi ldren (2"7 per cent) were bottle-fed and 468 (97"3 per cent) were fed with

spoons from cups. I t is interesting to note that only two cases of thrush were seen in this

~urvey, and both were amongst those who were bottle-fed. While feeding

from a cup with a spoon (which had no handle) the fingers of the mother

came into contact with the food. I t was not unt i l the mother started artificial feeding that the child developed diarrhoea.

I n what percentage of cases the diarrhoea is due to the addi t ion of carbohydrates or to infection is not easy to de termine and must be carefully studied before voicing an opinion. W h e n artificial food was given the mother

had to spend a certain t ime away from her rout ine domestic work to feed

TABLE 2

Showing the ages when solids are first introduced into the diet (in percentages)

Age

Breast-fed and artificially fed

Breast-fed and artificially f e d with solids

Breast milk and solids

Solids only

Artificially fed with solids

Artificial[y fed with no solids

1 3 6 9 1 1�89 2 2 } 3 4 5 mth. mths. mths. mths. yr. yrs. yrs. yrs. yrs. yrs. yrs.

13.3 46.2 70.7 57-8 27.6 16.9 3.8 1.6 0.6 -- - -

_ R

1 . 3 2.9

4.3 16.7 28.9 21.6 16.5 7.5 8.0 1.9 -

- - 12.9 11.3 12.7 2.2 1.3 0 . 9 -

- - 3.1 8.8 24.5 37.3 74- I 97.2 100.0

- 1.9 11.8 39.2 41 .7 51 .4 16.0 - -

5.4 13.4 11.2 . . . . . .

the child, and it was not u n c o m m o n to see an older sister, perhaps not

more than 9 or I0 years, feeding the baby when the mother was busy. In Calcutta, nei ther coffee nor tea is given to small children, and in

the present study there was only one child of two years who used to have a

dr ink of tea regularly with her parents. In South Ind ia , coffee is a favourite supplement and is started at 6 months of age; by the age of 3 years seventy-five per cent of the chi ldren dr ink coffee regularly 5.

Solid food: From remote times there is a custom amongst Bengali Hindus known as annaprasan, that is, the ceremony dur ing which solids

(rice) are first in t roduced. This is performed at the age of 6 or 8 months in the case of boys and 7 or 9 months in the case of girls. No solids are given

Mukhe~jee--Feeding of Children 473

be[ore this ceremony and though this is a religious ritual, in practice, solids are not given until the child is one year or 18 months old.

In this series, though solids were started at 6 months in fifteen cases (4.2 per cent), yet the ages during which solids were most frequently started were 1 to 1} years, 62.3 per cent of the children having had their first solid food during this period. By 3 years of age, more than ninety-nine per cent of the children had ah:eady been given solids. The solid foods which are commonly given in the beginning are various preparations of rice (puffed rice, fiat rice and cooked rice) biscuits (a favourite), very small quantities o f boiled vegetables (usually potatoes, green }~ananas and green pawpaws). A small quantity of this is offered to the child usually during lunch time. The mothers strongly believed that the children could not take solids until they had teeth. No efforts were made to provide special preparations, such as pureed vegetables, or to feed the child according to a schedule. The child may have had a special plate or a drinking-glass of his own and was usually fed until the age of 3 years when he started to help himself. The children were rarely given meat or eggs since these articles of diet were rarely bought in many of the households due to economic reasons. Very seldom the child got fish (usually a variety of lean fish) until he attained the age of 3 years because the mothers believed that the child was too young to digest fish. Thus, the child was given solids at a late age in very small quantities and mostly in the form of carbohydrates. Whenever a mother was advised to give solids she usually returned to the clinic with the usual complaint : " I tried, but the child will not swallow it."

Even when the solids were introduced, feeding with other carbohydrate gruels continued until about the age of 4 or 5 years. Though solid foods were started at this age, the children usually did not have much solid food until they became a little older. In this series, even at the age of 2�89 years, over sixty per cent of the children were taking solid foods along with carbo- hydrates, breast milk, cow's milk or all combined (Table 2); and it was not until after the age of 4 years, that the children in this study were completely fed witb solid foods only.

DIscussION

It is very important to know in detail the feeding habits of infants atld children of a particular area of the country to enable physicians to interpret and give correct advice regarding feeding of their young patients and those attending M C H clinics. This knowledge will also help medical workers to understand the etiology of many nutritional deficiencies so commonly seen amongst Indian children. As the feeding habits differ in different parts of India and are so much interrelated with the cultural patterns, socio-economic conditions and education of the parents, it is not possible to generalise from this study regarding the pattern in all areas, and it is essential that pediatricians and general practitioners should have a daorough knowledge of the feeding habits in their own province or district,

474 Indian Journal of Pediatrics

fn d~e majority of the cases of breast failure in western com~tries no obvious cause could be found. 67 A large number of failures were due to local conditions in the breast, constitutional disturbances in the mother and environmental conditions (illegitimacy, etc.). In the author 's series, however, most of the cases (95.3 per cent) of breast failure, either complete or partial, were due to an insufficiency of the breast milk for no obvious cause. However, in Western countries the breast usually fails com- pletely and prolonged partial feeding is not practised; the contrary was found in this series and the children were having breast milk in addition to artificial food and solids for a long time, even up to the of age 4 years in some cases. I t is very doubtful if they were getting enough milk Kom tlle breast. Thus, it seems that these poor underfed malnourished mothers with frequent repeated pregnancies were really not capable of successfully feeding their children on breast milk only for a prolonged period. I t is evident from this investigation that though the mothers who could feed their older children for a longer period a few years ago, could not do so in the case of recent children. The causes may be maternal malnutrit ion during pregnancy and lactation, overwork, lack of rest and fatigue and inadequate breast care. I t is known that breast-feeding is just not a mechanical effort on the par t of the child but includes the active co- operation of the mother also; and the 'let down reflex' which is so very important for successful feeding may not be present if the mother is not psychologically ready for the feeding.

Though this study is of a preliminary nature and does not deal with many other points of importance, especially the relationship of feeding habits and the pat tern of growth and incidence of infection, it is a common observation that the chi!d grows well for the first few months, and as soon as the breast milk becomes insufficient and carbohydrate gruels are started, the child stops growing and gets attacks of nasal discharge, bronchitis and diarrhoea. During this period nutritional marasmus and pro- tein malnutrition are often seen. Some cases start with diarrhoea which may become chronic with secondary infections, and ultimately there is oedema and maligrtant type of protein malnutrition. In a study in India in 1946, ORKNEY 4 found that infection and morbidity in infants were closely rela- ted to the duration and incidence of breast-feeding.

The lesson one learns from this survey is that most of the poor un- sophisticated mothers of Calcutta are incapable of completely breast-feed- ing their children for more than the first few months; the main cause attri- buted to this is insufficiency of milk. I t would not have mattered much if a large quantity of good quality cow's milk was available. But this is unfor- tunately not the case, and whatever is available is beyond the mother 's financial means. What is the solution? Firstly, an at tempt should be made to see whether the mothers can produce larger quantities of breast milk. This may be tried by providing good antenatal care of the breasts--regular massage during the late months of pregnancy, improvement of the diet, and preparation of the mother psychologically regarding the importance

Mukherjee--Feeding of Children 475

of 5reast-feeding. She should also be told about the correct mal~agement and methods of feeding. During the lactation period the value of rest, avoi- dance of fatigue, domestic help and improvement of the diet of the mother (especially increasing the quantity of proteins and water) may be stressed. She should sit in a quiet place and feed her child and should be free from anxieties; she should not feed her child while she is busy with the household work. The another should be toId about the importance of her active co- operation and psychological satisfaction in the feeding process. Whether these methods, whereby the mother becomes conscious of her role in the feeding process, will be more effective in prolonging lactation and increasing supply of breast milk than the present attitude where the mother takes breast-feeding for granted, have to be observed and watched with interest. I f the mother cannot afford to take milk or other animal proteins during lactation, vegetable proteins, such as Bengal gram, should be taken to supplement her protein needs. Tha t extra protein during lactation increases the milk output was shown by GOPALAN 1. An early introduction of soIids to the diets of children, especially protein foods after 6 months of life, should be encouraged if enough breast milk is not present. I f milk and other proteins are not available, vegetable proteins, such as Bengal gram, can be added tO the child's food. An age-old belief amongst these mothers lead them to give carbohydrate gruels at a very early age even when they can afford other foodstuffs and this leads to stunted growth, diarrhoeas and pro- tein malnutri t ion in the children.

HeaIth education regarding correct feeding habits should be cons- tantly impressed upon these mothers in the clinics, out-patient and in-patient departments of the hospitals and at home. Sometimes a demonstration diet kitchen in the clinics and in the hospitals may be of great instructive value to the mothers.

SUMMARY

1. Detailed feeding histories of 538 children between the ages 1 month and 5 years have been collected from an urban population of the lower socio-economie groups in Calcutta and analysed.

2. I t is found that only a small number of mothers is capable of feeding their children at the breast after six months.

3. About sixty per cent of the mothers add carbohydrate gruels as supplementary foods.

4. Solid foods are added mostly at the age of 1 to 1�89 years, and the common solid foods given at this age are carbohydrate in nature.

5. The effects of feeding habits and suggestions for their impro- vement are discussed.

REFERENCES1

~, GOPALAN~ ~.--~ludies on ]&c~&tion in pOOF IDdiall r J . trap, Pedlar., 4: 87. 1958.

476 Indian Journal of Pediatries

2. JELLIFFI~, D. B.--Infant nutrition in the tropics and sub-tropics. W. H. O. Monograph Series No. 29, 1955.

3. JELLIFFE, D. B.--Notes on breast feeding in ~ASest Bengal. Alumni Association Bulletin, All India Institute of Hygiene and Ptlblie Health, Calcutta, 3: 24, 1956.

4. OP`XNE'r JEAN M.--Influence of feeding on infant mortality. Indian med. Gaz., 81 : 150, 1946.

5. Rao, P. T.--Customs of infant feeding in South India. Indian J. Child Hlth., 7 : 347, 1957. 6. ROmNSON, M.--Failing lactat ion--a study of 1100 cases. Lancet, 1 : 67, 1943. 7. Ross, A. I. and HAP.nAN, G.--Breast-feeding in Bristol. Lancet, 1 : 630, 1951. 8. W. H. O. Manual on nutrition, Volume 1, 1952 (unpublished).--Quoted by TROWE~L

and JELLIFFE--Diseases of children in tropics and sub-tropics. Edward Arnold & Co. London, Page 128, 1958.

I am grateful to DR. N. JUNf~AL'C,:ALLA, Director and DR. MUKTHA SEN, Professor of Maternity and Child Welfare, All India Institute of Hygiene and Public Health, Calcutta~ for permission to carry out this investigation and publish the results.