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National Institute of Nutrition, Ministry of Health, 48 Tang Bat Ho, Hanoi, Vietnam;
*
Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH, 65726 Eschborn, Germany;
SEAMEO-TROPMED Regional Center for Community Nutrition, University of Indonesia, 10038 Jakarta, Indonesia; and
**
UNICEF, New York, NY
2To whom correspondence should be addressed.
 |
ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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3 mo
exclusively breast-fed group (
2 and Fisher-Exact
Test). Over nearly the whole age range from 1 mo to 4 y, Z-scores
for all indices (weight-for-age, height-for-age and weight-for-height)
of the children who received complementary food were significantly
lower than those of children who were exclusively breast-fed for at
least 3 mo (repeated measures ANOVA, adjusted for sex, family
size, maternal education and family income). These results show a
long-term deterioration of physical growth in infants who received
premature complementary feeding and confirm the importance of exclusive
breast-feeding for infants for at least 3 mo.
KEY WORDS: • breast feeding • preschoolers • acute respiratory infection • diarrhea • growth • Vietnam
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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, Onnela 1997
, WHO 1998a
) as well as the psychosocial
benefits to the infants (Cameron and Hofvander 1993
,
Pipes 1981
) are widely recognized. The early
introduction of nonbreast-milk foods and beverages increases the
risk of nutrient imbalances and infectious diseases. As a result,
WHO (1991a)
recommends exclusive breast-feeding as
the best practice for infants up to the age of 4–6 mo. After this age,
additional food is required to meet the child’s nutrient needs.
In Vietnam, as in other centrally planned economic systems,
breast-feeding rates are relatively high, despite the high rate of
maternal employment. This may be due mainly to the government’s
reinforcement of breast-feeding and the lack of advertising driven
by commercial interests for infant foods during the 1980s. As a result,
most mothers (92%) breast-fed their children up to 9 mo; however,
the rate of exclusive breast-feeding for up to 3 mo was very low
(16%) (Hau et al. 1992
). As in most developing
countries, growth retardation is common in Vietnam; it is therefore
important to investigate to what extent incorrect infant feeding habits
contribute to the widespread phenomenon of growth retardation.
It was the objective of this study to investigate the association between duration of exclusive breast-feeding and growth, morbidity and nutritional status of Vietnamese children up to the age of 4 y using a longitudinal study design. This study was part of a larger study, in which these children are being followed from birth to 18 y.
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SUBJECTS AND METHODS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Since 1981, the National Institute of Nutrition
(NIN)3
of the Ministry of Health has conducted a prospective, longitudinal
study in Hanoi; this study remains in progress. Two out of the four
maternity hospitals in urban Hanoi were chosen randomly for the
recruitment of the children. The newborns from the two selected
maternity hospitals had to meet the following criteria for selection:
gestational age at birth of 38–42 wk; birth weight 2500 g, normal and single birth without physical abnormalities, "Kinh"
ethnic group, mother’s age between 20 and 35 y, and lack of
obvious health problems in the parents. The birth report of the
hospital was used as the information source on the health status of the
newborns. Mothers provided information on the ethnicity and health
status of the parents. Other information such as mother’s education
(years of schooling) and family income [units of 1000 VN dong/(capita
· mo)] was also collected.
In 1981, 1982, 1983 and 1984, newborns were chosen to participate in
the study. In 1981 and 1982, each cohort consisted of 90 newborns; in
the following 2 y (1983 and 1984), 60 newborns were enrolled each
year. Each cohort was followed for the first 4 y of life. The
dropout rates of the children by cohort were 25.6, 22.2 38.3 and
36.7%, respectively. The only reason for dropout was a change in
residence. There was no significant difference in mean birth weight
among cohorts or children who dropped out compared with those who did
not (Table 1
).
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The selected children were followed up at their homes. The home visits
took place 1 mo after birth at monthly intervals up to 12 mo. From the
age of 1 to 3 y, the children’s mothers were questioned every 3
mo, and twice per year for the children older than 36 mo. Information
concerning breast-feeding and feeding practices as well as health
status of children was obtained by interviewing the mothers at each
home visit. Data collection concerning feeding practices was based on
the guidelines of Jelliffe (1977)
and Hofvander and Barvazian (1978)
. Mothers were asked about general feeding
patterns, i.e., exclusive breast-feeding, feeding of liquid,
semisolid and solid foods. Furthermore, the date of introduction, the
kind of complementary food and the date of cessation of
breast-feeding were collected. Infants were classified as being
exclusively breast-fed (only breast milk plus medical drops and
syrups), predominantly breast-fed (water, herbal teas, or fruit
juice in addition to breast milk), partially breast-fed (breast
milk plus other types of milk or food) or fully weaned (WHO 1991b
and 1996
).
Selected infant morbidity data were collected during y 1 on the basis
of the mother’s description of the infant’s symptoms of diarrhea
(frequency and appearance of stools) and acute respiratory infections
(ARI) (suffering from running nose, cough, cold, earache or sore
throat). Children who had a watery stool 4 times/d were
classified as suffering from diarrhea. Mothers were informed about the
occurrence of these disease symptoms during the month previous to the
visit. Mothers received a notebook and were asked to record all
symptoms, date of occurrence of diarrhea and ARI as well as its
duration in the child’s follow-up notebook on a daily basis. The
enumerators collected the information recorded on a monthly basis.
Because practically all mothers attended the child health care service
and prevalent diseases were reported on a health card, this document
was used as the primary information source. In the rare event that
diseases were treated at home and therefore not reported on the health
card, information in the mother’s notebook was used as an additional
information source. Although disease was reported on a daily basis, in
this study period, prevalence of morbidity is expressed on a monthly
basis.
Anthropometry.
Height and weight of the children was measured monthly from birth to 12
mo, every 3 mo from 12 to 36 mo and every 6 mo from 36 to 48 mo. The
standardization procedure for measurement of accuracy and precision for
anthropometric measurements (weight and height) as well as the actual
measurements were based on the recommendation of WHO (1980
and 1983)
and are described in more detail elsewhere (Hop et al. 1997
). The scale was equilibrated every morning with a
known weight (5.00 kg). The date of collection for each child was based
on the child’s birthdate ± 4 d. Anthropometric measurements
were also taken when an infant was ill at the time of the home visit.
Data collectors (staff of NIN) had been trained previously in
interviewing and anthropometric techniques, and regular
standardizations were carried out. The data collectors were rotated
every 6 mo between two districts to avoid systematic errors. Data
collection was under the regular supervision of the principle
researcher.
Children were weighed using a Testut weighing scale (Paris, France) with a precision of 10 g. The scale was calibrated twice daily with a known reference weight (5.00 kg). Subjects were weighed with a minimum of clothing (e.g., undershirt, underpants or diaper). On the basis of the mean weight of 10 sets of minimum clothing, a standard of an age-relevant weight of clothing for each year of age was developed to adjust body weight for clothing. All weights were recorded to the nearest 0.01 kg.
For children up to 24 mo, recumbent length was measured by using the
baby-board (UNICEF, Copenhagen, Denmark). The measurements were
read to the nearest 0.1 cm. A microtoise (UNICEF) was used for
measuring the standing height of children 24 mo. The measurements
were also read to the nearest 0.1 cm. All information was recorded in a
single notebook per child.
Statistical analysis.
Data analysis was carried out by using computer programs EPI-INFO
(version 6.01; Center for Disease Control and Prevention, Atlanta, GA)
and the Statistical Package for Social Science (SPSS PC+, Chicago, IL)
(Norusis 1990
). The anthropometric indicators
weight-for-age (W/A), height-for-age (H/A) and weight-for-height (W/H)
were calculated using the National Center for Health Statistics
reference data (WHO 1983
). Weight and height gains were
used as additional indicators to assess physical growth of the children
(Gibson 1990
).
Data were analyzed statistically according to the description of
Snedecor and Cochran (1980)
. Repeated-measures ANOVA
was used to compare means of Z-scores of two groups with different
duration of exclusive breast-feeding (3 mo and <3 mo). ANOVA was
used for comparison means of birth weight among cohorts. Difference in
prevalence data between groups was tested by the 2 test;
if expected values were <5, Fisher’s Exact Test was used. The
Mann-Whitney U test was used to compare exclusive
breast-feeding duration between two groups. Multiple regression
analyses were used to obtain point estimates and SEM of
weight and height gain adjusted for sex, education of the mother (years
of schooling), family income (unit of 1000 VNdong), family size and
birth weight; P-values were derived by analysis of
covariance (Victora et al. 1998
). The magnitude of the
effects of different feeding patterns on growth was assessed by
multiple linear regression. For example, to examine the effect of
feeding pattern at 3 mo on length gain from 3 to 6 mo, attained length
at 6 mo was regressed on attained length at 3 mo as follows:
 |
where LN is the length in cm and Ex ·
BF-3mo, PRED-3mo, PART and
WEAN-3mo are dummy variables (coded 1 or 0) (Victora et al. 1998
).
Ethical considerations.
The parents of the enrolled children were informed about the purpose of the study and the nature of the research institution before the study was conducted. Assurance was given that cooperation was voluntary and that no negative consequences would result if the parents decided not to participate in the study. The parents of the subjects could skip any questions they did not choose to answer. Before the start of the study, the Ethical Committee of NIN approved the research protocol.
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RESULTS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Table 2
provides information on breast-feeding behavior and feeding
practices during y 1 of life. All but three of the children in the
combined cohorts (98.6%) had received breast milk. The three children
who were never breast-fed were deprived because of illness of the
mother. Including these three infants, 16.5% of all infants were
exclusively breast-fed for <1 mo. At the age of 3 mo, 22.1% of
the infants were exclusively breast-fed and only 3.3% of 4-mo-old
infants were still exclusively breast-fed. The mean duration of
exclusive breast-feeding was 1.6 ± 0.9 mo. However, most of
the mothers (87.1%) continued to breast-feed their children for
>12 mo, and only 3 (1.4%) mothers had completely stopped
breast-feeding their child by 6 mo. The mean duration of
breast-feeding was 12.8 ± 1.8 mo. There was no significant
difference in feeding practices (time of introduction of additional
foods) between children who dropped out and those who remained in the
study. The average duration of exclusive breast-feeding was also
similar in dropouts (1.8 ± 0.7 mo) and those who remained in the
study (1.6 ± 0.9 mo) (P = 0.069, Mann-Whitney
U test). During the first 3 mo after delivery, 35.9% of mothers were
concerned that they might not be producing sufficient quantities of
breast milk, and all of them (100%) introduced other food to their
infants. However, about one third (33.6%) of the mothers who did not
report this concern also introduced supplementary foods to their child
up to the age of 3 mo. There was no significant association between the
breast-feeding pattern (exclusively breast-feeding 3 mo and
<3 mo) and the socioeconomic characteristics of the households. Nearly
all mothers had attended school for at least 6 y (exclusively
breast-feeding 3 mo and <3 mo, 97.9 and 99.4%, respectively)
and most of the households received the drinking water from the public
water supply (exclusively breast-feeding 3 mo and <3mo, 93.3 and
91.5%, respectively). There was also no difference in the
possession of household goods such as color TV (exclusively
breast-feeding 3 mo and <3mo, 36.2 and 34.5%, respectively).
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The crude associations between feeding patterns at the beginning of the
time period and subsequent growth are shown in Tables 3
, 4
, 5
, 6
(excluding mo 1 because the number of infants in the weaned and
partially breast-fed group was too small to test reverse causality,
i.e., at 7 d, there were only 3 weaned and 14 partially
breast-fed infants). These associations are expressed both as mean
growth in each group and as differences in growth between infants
exclusively breast-fed and those who were predominantly or
partially breast-fed. Because only three infants were fully weaned
during the first 3 mo, these three cases were included in the group of
partially breast-fed infants. According to Table 3
, there was no
significant difference in birth weight and length of the infants among
the three groups (exclusive, predominantly and partially breast-fed).
Furthermore, there was no association between feeding pattern at d 15
and length gain in mo 1 of life. However, partially breast-fed and
weaned infants gained weight more slowly than those exclusively or
predominantly breast-fed. In Table 4
, growth from 1 to 3 mo is
examined in relation to the feeding pattern at 1 mo. Exclusively
breast-fed infants grew more quickly in both weight and length
compared with the other groups. The lowest weight and length gains were
observed among partially breast-fed and weaned infants (Table 4)
.
From 3 to 6 mo, as shown in Table 5
, exclusively breast-fed infants
gained more weight than those in the predominantly and partially
breast-fed and weaned groups. However, there was a slight
difference (P = 0.047) in length gain between
exclusively and partially breast-fed infants, and there was no
difference in length gain between exclusively and predominantly
breast-fed groups.
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83.5% of infants (n = 177) were
partially breast-fed or weaned and only 7 (3.3%) were exclusively
breast-fed. In the age category from 6 to 12 mo (Table 6)
,
exclusively and predominantly breast-fed infants were combined into
one group. In this group, infants grew in length more quickly than
those who were partially breast-fed or weaned. However, there was
no difference in weight gain between groups.
Figures 1A
, B
and C
show the H/A, W/H and W/A indices, respectively, from children who had
been breast-fed exclusively during the first 3 mo and from those
who received complementary feeding. Over nearly the whole age range
from 1 mo to 4 y, the Z-scores of all three anthropometric
indices were lower for the children who received complementary food
before 3 mo of age.
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and
Bshow the prevalence of diarrhea and ARI for the
previous month in relation to the duration of exclusive
breast-feeding. Diarrhea among children who were exclusively
breast-fed 3 mo occurred later and the prevalence was relatively
lower than in the group that had been complemented early. At 4 and 5 mo
of age, the prevalence of ARI was significantly higher in infants who
had received other food besides breast milk before reaching the age of
3 mo (P < 0.05; 2 test).
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|
DISCUSSION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Our findings confirm the observation of Hau et al. (1992)
that almost all Vietnamese mothers, even in the urban
area of Hanoi, breast-fed their children for several months unless
the mother was too ill after delivery. The problem arises from the
traditional practice of premature introduction of complementary food,
even among those mothers who did not perceive the quantity of their
breast milk production to be a problem. Many mothers believe that
breast milk alone is insufficient for their infants from the aspect of
quality (Dien and An 1991
), and therefore start to give
additional food.
Exclusive breast-feeding and nutritional status of children.
The benefits of exclusive breast-feeding determined in this study
concerning nutritional status and morbidity during the first 6 mo are
in agreement with other studies (Chandra 1981
,
Kumar et al. 1981
, Rao and Kanade 1992
).
The results of this study showed that there was a long-term effect
of breast-feeding on the nutritional status of children. The means
of Z-scores for all three indices (W/A, H/A and W/H) of children
who were exclusively breast-fed for <3 mo were lower than those of
the children exclusively breast-fed for 3 mo for almost all age
groups (Fig. 1)
. This observation confirms other studies (Adair et al. 1993
, Cohen et al. 1994
, Forman 1990
, Harrison et al. 1992
, Kumar et al. 1981
) and underscores the recommendation of WHO (1998b)
, to breast-feed infants exclusively and discourage
the premature introduction of complementary feeding during the first
months of life.
Exclusive breast-feeding and growth of children.
Exclusively breast-fed infants tended to grow more quickly in both
weight and height during the first 6 mo compared with the partially
breast-fed and weaned groups (Table 3
4
5
6)
, and their height gains
continued to be significantly higher for the following 6 mo of life.
This finding is in agreement with the results of studies by Diaz et al. (1995)
and Piwoz et al. (1995)
,
indicating greater weight gains for exclusively breast-fed infants.
However, partially breast-fed and fully weaned infants in more
affluent societies such as Pelotas, Brazil, grew more quickly in weight
and length during y 1 of life compared with exclusively breast-fed
infants. This could be due to better conditions of supplementary
feeding in these more affluent areas, whereas supplementary feeding
among Vietnamese infants during the 1980s was poor in both quality and
quantity of foods. In these poor communities, exclusive
breast-feeding is an important factor for the growth of the
infants.
Breast-feeding seems to influence growth through two separate pathways
(Adair et al. 1993
). First, growth is influenced through
the provision of energy and essential nutrients in breast milk. Second,
breast-feeding reduces diarrhea morbidity, which in turn affects
the growth of infants. The effects of breast-feeding in reducing
morbidity have been reported in a number of studies (Briend et al. 1988
, Brown et al. 1989
, Eaton-Evans and Dugdale 1987
, Feachem and Koblinsky 1984
,
Nhan and Dien 1986
, Popkin et al. 1990
,
Rao and Kanade 1992
, Rowland et al. 1988
,
Thuan et al. 1986
, Tu 1990
). The results
of the present study show that duration of exclusive breast-feeding
was associated with prevalence of diarrheal diseases and ARI only after
the first few months of life. In particular, diarrhea among the
children who were exclusively breast-fed for <3 mo occurred
earlier and with a greater prevalence than in infants exclusively
breast-fed for >3 mo (Fig. 2a
). The findings of this
study also revealed that duration of diarrhea was negatively correlated
with the growth (both weight and height) of the children during the
period from 3 to 12 mo (Hop 1999
). Diarrhea not only
occurs less frequently in exclusively breast-fed infants, but when
it does occur, it is likely to have fewer negative consequences on the
nutritional status of the children (Brown et al. 1990
).
Diarrheal diseases are important causes of weight loss and impaired
linear growth of children (Allen 1994
, Briend et al. 1988
, Brown et al. 1989
, Butte et al. 1992
, Rowland et al. 1988
, Tu 1990
). The findings of this study show that the feeding
practices during the first 3 mo of life are crucial for later incidence
of infectious diseases such as diarrhea and ARI because of the
long-term effect of early exclusive breast-feeding on the
immune system. On the other hand, early exclusive breast-feeding
may lead to a greater proportion of breast-feeding at later ages
and consequently increased the growth of the children.
The negative consequences of premature complementary feeding for child
development have been recognized internationally. It is argued that
this practice is unnecessary because a healthy infant does not require
extra fluids or feedings, and bottle-feeding may interfere with the
initiation and/or continuation of breast-feeding (WHO 1998c
). The results of this study show that in a developing
country such as Vietnam, improper complementary feeding may cause
long-term deterioration of physical growth and development.
Therefore, efforts are required to ensure that infants are exclusively
breast-fed for at least 3 mo.
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FOOTNOTES |
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3 Abbreviations used: ARI, acute respiratory infection; H/A, height-for-age; NIN, National Institute of Nutrition; W/A, weight-for-age; W/H, weight-for-height.
Manuscript received April 1, 2000. Initial review completed April 24, 2000. Revision accepted July 19, 2000.
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Y. Mistry, M. Freedman, K. Sweeney, and C. Hollenbeck Infant-Feeding Practices of Low-Income Vietnamese American Women J Hum Lact, November 1, 2008; 24(4): 406 - 414. [Abstract] [PDF]
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E. Kamau-Mbuthia, I. Elmadfa, and R. Mwonya The Impact of Maternal HIV Status on Infant Feeding Patterns in Nakuru, Kenya J Hum Lact, February 1, 2008; 24(1): 34 - 41. [Abstract] [PDF]
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P. S. Sawadogo, Y. Martin-Prevel, M. Savy, Y. Kameli, P. Traissac, A. S. Traore, and F. Delpeuch An Infant and Child Feeding Index Is Associated with the Nutritional Status of 6- to 23-Month-Old Children in Rural Burkina Faso J. Nutr., March 1, 2006; 136(3): 656 - 663. [Abstract] [Full Text] [PDF]
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D. J. Hruschka, D. W. Sellen, A. D. Stein, and R. Martorell Delayed Onset of Lactation and Risk of Ending Full Breast-Feeding Early in Rural Guatemala J. Nutr., August 1, 2003; 133(8): 2592 - 2599. [Abstract] [Full Text] [PDF]
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 Growth of healthy infants and the timing, type, and frequency of complementary foods Am. J. Clinical Nutrition, September 1, 2002; 76(3): 620 - 627. [Abstract] [Full Text] [PDF]
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C. L. Eckhardt, J. Rivera, L. S. Adair, and R. Martorell Full Breast-Feeding for at Least Four Months Has Differential Effects on Growth before and after Six Months of Age among Children in a Mexican Community J. Nutr., September 1, 2001; 131(9): 2304 - 2309. [Abstract] [Full Text] [PDF]
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