HEALTH AND NUTRITIONAL STATUS AT AGE 0 TO 6 MONTHS AMONG SOME BREASTFED AND BOTTLE-FED INFANTS IN METRO MANILA Evelyn

O. Dela Cruz, BSFN, Celeste C. Tanchoco, Dr. PH, Consuelo L. Orense, MSPH, Noelle Lyn C. Santos, BSND INTRODUCTION The large decline in the number of infants being breastfed beyond 1 to 2 months of age dictates the need to clarify what duration is optimal. Data from the 7th National Nutrition Survey (1) in 2008 conducted by the Food & Nutrition Research Institute, Department of Science & Technology showed that exclusive breastfeeding of 0-5 month old children was only 35.9 %. This means that only more than 1/3 of the children met the WHO recommendation of exclusive breastfeeding for the first 6 months. The same survey also found out that the proportion of ever breastfed children was 89.6 %; out of this ever breastfed, 82.8 % were exclusively breastfed and 89.4 % were given colostrum. The mean duration of exclusive breastfeeding was 2.3 months indicating a significant decrease compared with the 2003 National Nutrition Survey which is 3.0 months. Likewise, the mean duration of ever breastfeeding was slightly lower at 4.9 months in 2008 compared with the 2003 at 5.6 months. There was no significant difference between the two base year. Of the sample children, only 17.1 % were breastfed up to 12-23 months which is far short of the recommended length of breastfeeding by WHO which is up to 2 years of age. Complementary foods to children were introduced between 4-6 months. Mothers attributed the early stopping of breastfeeding to their work as well as inadequate flow of breastmilk. Additionally, the limited understanding of infant growth and maternal nutrition needs has contributed to poor confidence in the nutritional adequacy of human milk. The belief that breastmilk alone is nutritionally insufficient after 3 or 4 months, combined with the fact that weaning foods may be both nutritionally inadequate and contaminated, has contributed to infant morbidity and mortality. The interpretation of infant growth has been controversial for the promotion of breastfeeding beyond 4 months of age. It has been premised that bigger or faster growth is better. The issues on growth faltering among infants exclusively breastfed needs to be addressed. Available data indicates that infant following World Health Organization (WHO) feeding recommendations show a deceleration in both weight and length gains relative to the international WHO/Center for Disease Control (CDC) growth reference from 3 to 12 months with potential catch up there after ( ). However, when the weight data are correlated from maternal height and birth weight, no growth faltering is apparent through the infants first year of life. This newer interpretation of infant growth restores confidence in the nutritional adequacy of breastfeeding infants beyond 4 months of age. The research is needed to define optimal infant growth is based on infant health and development rather than weight in the Philippines. The epidemiologic evidence is now overwhelming that breastfeeding protects infant from gastrointestinal (to a lesser degree) and respiratory infection and that the protection effect enhanced with greater duration and exclusivity of breastfeeding. 1

In the Philippines, there are few in-depth studies on the health and nutritional status at age 0 to 6 months among some breastfed and bottlefed infants in Metro Manila. The main objective of the study is to determine the health and nutritional status at age 0 to 6 months among some breastfed and bottle-fed infants in Metro Manila. Specifically, the research aimed to compare the weight-for-age, height-for-age, and illness patterns of some breastfed and bottle-fed infants at age 0-6 months; to determine the reasons for continued breastfeeding and introduction of bottle-feeding; to describe the complementary foods introduced at aged 4-6 months and the reasons for early giving of other foods to the baby.

Conceptual Framework

Milk Feeding Scheme: - Breastfed - Bottle fed

Nutrient Intake: - from breastmilk - from complementary food

Nutritional Status

Health indicators: - Illness due to fever, cough, colds

Nutritional status and diseases are closely linked. A high incidence of important childhood illnesses (those that have strong associations with nutritional status like measles, diarrhea, acute respiratory infections and malaria) will influence nutritional status. A childs health and nutritional well-being depends on the type of feeding scheme that a child receives. Both quantity and quality of food consumed are important in determining the well-being of an individual. The body requires certain amounts of the various nutrients on a daily basis for proper growth. A limitation in any of these will have negative consequences on an individuals state of nutrition.

METHODOLOGY This project was a descriptive study that collected data on anthropometric measures of babies who were delivered at Jose Fabella Memorial Hospital, Sta. Cruz, Manila. The babies are brought by their mothers to the hospital for regular check-up or consultation. Mothers with babies aged from zero to six months were enjoined to the study with the following inclusion criteria: a.) age of the infants from 0 to 6 months, full term newborns with birth weight greater than or equal to 2,500 grams, gestational age between 38 to 42 weeks, no neonatal abnormalities, and currently breastfed or bottle-fed at the time of recruitment ; b.). non-diabetic mother c.) mother willing to be interviewed on food and health status of the infant A total of 180 mother-infant pairs became participants with 90 pairs per feeding category. To ensure that all age groups were represented, the number of participants was distributed equally per feeding category for breastfeeding and bottlefeeding groups as follows: 02 months, 30 participants, 34 months, 30 participants and 56 months, 30 participants. Breastfed infants were those fed breastmilk direct from the breast or expressed. Bottle-fed infants in this study were those fed infant formula since birth and lasted for about 4 days to 3 weeks; those infants who were breastfed from birth up but pure bottle-feeding at the time of interview were also classified under the bottlefed group. Two sets of questionnaires were used for the interview. Questionnaire A contained questions on weight and length data, age, method of feeding and Questionnaire B which contained information on feeding practices. The questionnaires were pretested among residents in Bicutan Taguig City. Data on birth records, weight and length of the baby were taken from the Medical Records Section and from the Out-Patient Department of the Pediatric Ward of the hospital. For the feeding and illness information, interview was done on the mother at the time of visit to the hospital. The interview with each mother lasted from 30 to 45 minutes. Anthropometric data were analyzed using the software of the WHO Child Growth Standard of 2005. Z-scores were obtained for weight-for-age, height-for-age and weight-for-height for each child. Frequency distributions were generated for data on socio-economic status, foods given, common illnesses and reasons for breast or bottle feeding for describing these variables. Means of birthweight and z-scores of the three anthropometric indices were compared between breast and bottledfed babies at 0-3 and 4-6 months using t-test.

RESULTS AND DISCUSSION Table 1 shows the demographic profile of the mother respondents. They were relatively young, with almost 67.2 % belonging to the 19-29 year old group. Their ages ranged from < 18 to 49 years and mean age was 26.21 years. Most of the mothers had about two live children and 80.0 % of them had normal deliveries. In terms of education, majority of the respondents completed high school/vocational at 63.9 % while 32.2 % had a college degree. Most of the respondents had a monthly family income of P 5001.00-P10, 000.00 representing 43.9 % of the total respondents. The proportion of breastfed infants was lower in families with high monthly income and mothers with high level of education. This finding holds true with the local study done by Ignacio Ma. SE et al in 1980 (2). Results indicate that breastfeeding is the choice of most mothers in the low income group because breastfeeding is economical, convenient and easy to prepare. Apart from being the safest and healthiest infant feeding method, breastfeeding is also the least expensive, thus, economical. For many poor households, the prohibitive cost of breastmilk substitutes put this option completely out of reach. For others, the impact of formula purchases on the household budget can be crippling. This is especially true when the anticipated additional cost of health care for the sick infant take its toll. Table 1. Demographic profile of mother respondents
Type of Feeding Mode Breastfeeding Bottle-feeding (n=90) (n=90) No. % No. % 4 66 20 90 5 62 23 90 21 53 12 4 0 4.4 73.3 22.2 100.0 5.6 68.9 25.6 100.0 23.3 58.9 13.3 4.4 0.0 6 55 29 90 2 53 35 90 19 26 18 11 16 6.7 61.1 32.2 100.0 2.2 58.9 38.9 100.0 21.1 28.9 20.0 12.2 17.8

Factors Age(yrs.) 18 19 29 30 49 Total Educational Level Elementary H.S./Voc. College Total Monthly Family Income < P1,000.00 5,000.00 P5,001.00 10,000.00 P10,001 15,000.00 P15,001 20,000.00 P20,001 - >30,000.00

Total (n=180) No. 10 121 49 180 7 115 58 180 40 79 30 15 16

5.6 67.2 27.2 100.0 3.9 63.9 32.2 100.0 22.2 43.9 16.7 8.3 8.9

Table 2 shows that a total of 180 infant subjects were covered representing 85 males and 95 females. It also showed the mean birthweight (gm) and mean birthlength (cm) of 0-6 month old infants by feeding mode. There were no statistically significant differences in mean birthweight and birthlength between the two types of feeding mode, that is, breastfeeding and bottle-feeding. Table 2. Mean birthweight and birthlength of infants by feeding mode.
Birthweight (gm) Total Birthlength (cm) Total M F Sex M F N 48 42 90 48 42 90 Breastfeeding 2975 3050 3010 292.850 48 48 48.2 1.78292 N 37 53 90 37 53 90 Bottle-feeding 3006 3004 3005 347.7356 48 48 48.0 1.7226 N 85 95 180 85 95 180 48 48 48 1.7130 Total 2991 3027 3017 345.6

Table 3 shows the mean z-scores of weight-for-age, height-for-age and weight-for-height of the babies, whose ages were grouped from 0-3 months and 4-6 months. Using the WHO Child Growth Standard (WHO CGS), z-scores of the infants were below the median for their age. However, using the cut-off of <-2SD to determine malnutrition, the mean measurements of the babies were considered to be within the normal range of weight-for-age, height-for-age and weight-for-height. The differences in the mean values between breastfed and bottlefed infants were not statistically significant in the two age categories. Table 3. Mean z-scores of weight-for-age (WAZ), height-for-age (HAZ) and weight-for-height (WHZ) , 0-3 months and 4-6 month-old infants Age Breastfed Infants (months) Weight- Height- Weightfor-age for-age for sd (n) sd (n) height
sd (n)

Bottlefed Infants Test of Significance Weight- Height- Weightfor-age for-age forWAZ HAZ WHZ sd (n) sd (n) height
-.9316 . 8105 (45) -.4453 . 9812 (40) -.7027 . 9224 (85) -.4490 2.0126 (40) 0.3135 1.3055 (31) -.1161 1.7698 (71) sd (n) -.8270 2.3286 (40) -.6323 1.1142 (31) -.7240 1.8874 (71) F=1.815 ; p=.181 F=.045. p=.833 F=1.244 ; p=.266 F=1.424 ; p=.236 F=.02; p=.889 F=.787; p=.376 F=.137; p=.712 F=.07; p=.792 F=.051; p=.822

0 -3 months 4 -6 months All infants

-.6938 .8630 (45) -.4016 .9057 (44) -.5493 .8915 (89)

.0200 1.5802 (44) .2671 1.3081 (31) .1221 1.4674 (75)

-.9825 1.4597 (44) -.5503 1.3081(31 ) -0.8039 1.4061 (75)

Record of infection (Table 3) from birth to time of interview with the mother respondents showed that purely breastfed infants aged 06 months had less reported incidence of fever, cough and colds compared to bottle-fed infants; however, the association between fever and feeding mode was not evident. For cough and colds, a similar pattern was observed for breastfed and bottlefed infants and no significant association was determined. In a similar study by Meremikwu et al (3) on morbidity and breastfeeding mode among infants, the frequency of dysentery were not significant between the breast or bottlefed infants. Persistent diarrhea was significantly (p < 0.05) less common in breastfeeding infants than in those who had stopped breastfeeding (0.4 % and 1.9 %, respectively). Rubin DH et al (4) used child-months of observation in the risk of gastroenteritis by type of infant feeding, but no significant relationship were obtained. The benefits of breastfeeding particularly on provision of immunity to infections is well documented. However, in some instances, the beneficial effects are not obvious such as that result mentioned by Meremikyu et al and Rubin et al. The same results were obtained from the current study, that common infections were similar for breast and bottlefed infants.

Table 3. Distribution of 06 month old infants with fever, cough and colds by feeding mode. Illnesses Fever No Yes Total No Yes Total No Yes Total Breastfeeding (n = 90) No. % 62 68.9 28 31.1 90 100.0 58 32 90 57 33 90 64.4 35.6 100.0 63.3 36.7 100.0 Bottle-feeding (n = 90) No. % 53 58.9 37 41.1 90 100.0 48 42 90 46 44 90 53.3 46.7 100.0 51.1 48.9 100.0 Total (N = 180) No. % 115 63.9 65 36.1 180 100.0 106 74 180 103 77 180 58.9 41.1 100.0 57.2 42.8 100.0 ChiSquare p

1.541

.214

Cough

1.859

.173

Colds

2.27

.132

In Table 4, it is shown that infants acquired some form of illnesses from age 0-6 months but the observations were small to permit statistical testing. Data shows that exclusive breastfeeders at age 0-2 months did not experience any form of infections or illnesses. but as the purely breastfed infants reached 4 months onwards , the incidence of other infections start to appear together with that for bottle-feeders. This time also it coincides with the introduction of

complementary foods. Improper handling of foods, lack of hygiene and sanitation, and the use of unsafe drinking water may have lowered their resistance to infections and thus made the infants get sick. Bouts of diarrhea were experienced by bottle-feeders at age 36 months. But breast-feeders age 0-6 months were spared of diarrhea. Breastfeeding helps defend against infections, allergies, and protect against a number of chronic conditions. Table 4. Distribution of infants with other illnesses by age group and feeding mode. Age Illnesses Group 0-2 3-4 Allergy, Rashes Pneumonia Measles Difficulty Breathing Diarrhea UTI Allergy, Rashes Sore eyes Pneumonia Diarrhea Breastfeeding (n = 30) No. % Bottlefeeding (n = 30) No. % 1 2 1 1 1 1 1 6.7 3.3 3.3 3 3.3 3.3 3.3 2 2 6.7 6.7 1 10.0 3.3 3.3 Total N = 90 No. 1 2 1 1 3 1 2 1 2 2 % 1.7 3.3 1.7 1.7 5.0 1.7 3.3 1.7 3.3 3.3

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The top reasons (Table 5) cited by mothers for continued breastfeeding was the cleanliness and safety of breastmilk which had the highest number of response from the mothers (274%) . The convenience offered by breastfeeding for the mother and the economical value of breastfeeding (184.4%) was next among the highest response of the mothers. Mothers also value the bonding with her baby whenever she breastfeeds (164%) . Other response for continuing the practice of breastfeeding were advise by doctor and other health professionals, the role of breastfeeding in the prevention of cancer, the relief from pain due to swelling and other reasons.

Table 5. Reasons for continued breastfeeding (Multiple Answers), n = 90.

Reason 1. Breastmilk is nutritious; baby is healthier, stronger, brighter. 2. Breastmilk is clean and safe and offers protection from illness. 3. Breastmilk is convenient and economical. 4. Breastmilk offers emotional bonding between mother and baby. It is preferred by both and baby does not like the bottle. 5. Advise by doctor and other health professionals. 6. Breastmilk is anti breast cancer. 7. Would be wasteful not to use breastmilk because mother has lots of it. 8. Painful when breastmilk is not emptied. 9. No special reason, mother got used to it.

No. 184 247 166 148 75 59 59 49 44

% 96.8 274.4 184.4 164.4 83.3 65.6 65.6 54.4 48.9

Among mothers who bottlefeed, artificial milk was introduced within the first month of the infants life. Respondent mothers cited various reasons for using infant formula (Table 6), the most common of which were: not enough milk/baby not satisfied or no milk secretion; working mother/employment outside the home; cracked nipple/could not tolerate the pain; mother had many household chores; and mother/baby got sick.

Table 6. Reasons for introduction of bottle-feeding (Multiple Answers), n = 90. Reason 1. Not enough milk/ baby not satisfied/ no milk secretion. 2. Working mom/employment outside the home. 3. Cracked nipple/could not tolerate the pain. 4. Many household chores. 5. Mother//baby got sick. No. 61 31 13 6 3 % 67.8 34.4 14.4 6.7 3.3

Table 7 showed the reasons for early giving of other foods to the baby by the mothers. The top reason was that mothers saw that babies tried to get food, hence, they thought it was the right time to give other foods to the baby ( 46.7%). Mothers also acknowledge that baby need additional nutrients for them to grow and gain weight faster (36.7%) . Also mentioned in the same proportion was the insufficient milk as perceived by the mother (36.7%). The top three reasons could be related to each other. Perhaps when the baby was not satisfied with the feeding, she still clamors for more, so that when the perception or smell of food is present, the baby grabs the food and the mother also feels that adding food could help the baby gain weight faster. The role of the significant others can also influence the decision of the mother to maintain or shift to other

feeding methods. Persons who give due influence on the mother could be the health personnel, and relatives such as her husband , parents or in-laws. Table 7. Reasons for early giving of other foods to the baby (Multiple Answers), n = 90 Reason 1. For additional nutrients/for baby to grow and gain weight faster. 2. Baby tries to get food/right age for baby. 3. Insufficient milk. 4. Advise by doctor/husband/parents/in-laws/friends. 5. Alternative to milk/so baby will not be hungry easily. No. 33 42 33 10 4 % 36.7 46.7 36.7 11.1 4.4

Table 8 showed the first types of food usually given to the infant. Instant cereals marketed by a commercial food company was the most common, followed by biscuit, boiled potato, fruit (latundan, ponkan), rice porridge, boiled squash, eggyolk, fruit juice and taho or soybean curd and boiled rice. Other foods less frequently cited were am (thick boiled rice water) and boiled lean chicken. The reasons for continued breastfeeding and the reasons for introduction of bottle-feeding were similar to the local study done by Vega ML et al (5). The same reasons also holds true for the early giving of other foods to the baby and the type of foods given to them in the study done by the same authors.

Table 8. Complementary foods given to the baby by age group and feeding mode, n = 60. Breastfeeding No. Cereal 3 4 months 5 6 months Biscuit 3 4 months 5 6 months Boiled Potato 3 4 months 5 6 months Fruit 3 4 months 5 6 months Rice Porridge 3 4 months 5 6 months Bld. Squash 3 4 months 5 6 months Eggyolk 5 6 months Fruit Juice 3 4 months 5 6 months Taho 5 6 months Boiled Rice 5 6 months Am 3 4 months 5 6 months Boiled Lean Chicken 5 6 months 3 18 0 15 1 17 1 13 0 11 0 11 9 2 10 4 5 0 2 2 % 10.0 60.0 0.0 50 3.3 56.7 3.3 43.3 0.0 36.7 0.0 36.7 30 6.7 33.3 13.3 16.7 0.0 6.7 6.7 Bottle-feeding No. 2 24 1 23 0 11 1 12 1 13 0 10 11 1 7 10 9 0 4 2 % 6.7 80.0 3.3 76.7 0.0 36.7 3.3 40.0 3.3 43.3 0.0 33.3 36.7 3.3 23.3 33.3 30.0 0.0 13.3 6.7 No. 5 42 1 38 1 28 2 25 1 24 0 21 20 3 17 14 14 0 6 4 Total % 8.3 70.0 1.7 63.3 1.7 46.7 3.3 41.7 1.7 40.0 0.0 35 33.3 5.0 28.3 23.3 23.3 0.0 10.0 6.7

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CONCLUSION AND RECOMMENDATION In general, breastfeeding provides ideal nutrition despite of any other social or economic disadvantages that may exist around the child. This reinforces the need to promote breastfeeding and encourage mothers to initiate and continue breastfeeding their infants. Maternal education about the benefits of breastfeeding and familial and government support are recommended to achieve this. It is equally as important to educate not only the babys mother and caregivers but also the household heads about the importance of exclusive breastfeeding for the first six months, the introduction of complementary foods at age 6 months and to instill the importance of continued breastfeeding up to 2 years and beyond, if the situation permits. This can be achieved through the nutrition education and dissemination program of the government.

REFERENCES: 1. Food and Nutrition Research Institute, Department of Science and technology. The State of the Nations Nutrition: 7th National Nutrition Survey, Philippines: 2008. Dietary Survey Component: Infant Feeding Practices. Retrieved from http://www.fnri.dost.gov.ph/nns_results.pdf(application/pdf object. 2. Ignacio, Ma. SE, Ona LN, Azares, FA. (1980). Factors related to mothers choice of infant feeding method. Phil J Nutr. 33(4):209-213, Oct-Dec. 3. Meremikwu MM, Asindi MM, Antia-Obong OE (1997). The influence of breastfeeding on the occurrence of dysentery, persistent diarrhea and malnutrition among Nigerian children with diarrhea. WAJM; 16(1):20-3. 4. Rubin DH, Leventhal JM, et al (1990). Relationships between infant feeding and infectious illness: A prospective study of infants during the first year of life. Pediatrics; 85:464-71. 5. Vega ML et al. (2005). Factors associated with the infant feeding practices among urban poor women. J of the Nutritionist-Dietitians Association of the Philippines, JanDec. 19 (1 & 2): 4-17.

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