ANALYSIS OF BREASTFEEDING PATTERNS AND ANTHROPOMETRY OF INFANTS 3–6 MONTHS OLD VISITING PRIMARY HEALTH CARE CENTRES IN LAGOS STATE, RURAL AND URBAN
CHAPTER ONE
INTRODUCTION
The practice of breastfeeding is as old as time itself, yet the usual length of time and level of acceptance varies by community. However, it continues to be advantageous for both the mother and the child.1-3 A major factor in determining an infant’s optimal health, growth, and development is exclusive breastfeeding (EBF) for the first six months of life. EBF is also associated with a decreased risk for many early-life diseases and conditions, including diarrhea, otitis media, respiratory tract infections, and early childhood illnesses.
obesity. 3,4 When compared, EBF infants had more rapid growth, and were healthier than nonEBF infants as shown in a study in Anambra State, Nigeria 5 and a collective analysis of data from 3 countries has also shown that predominantly or entirely breast-fed infants were at considerably less risk of early death than non-breast-fed infants. 6
Early in infancy maybe when the advantages of complete breastfeeding on growth are most obvious.7Infants who were exclusively breastfed doubled their birth weights at 3 months, with the first two months of life seeing the greatest increases in length, weight, and occipitofrontal circumference (OFC). 8 According to the World Health Organisation (WHO), breastfeeding should last up to two years, with the first six months of life requiring just breastmilk. 9 Breastfeeding is seen as the norm, and there are rarely any medical reasons not to.1
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Despite the many benefits attributed to breastfeeding for infant, mother, and society, analysis of the Nigerian Demographic and Health Survey (NDHS) continue to show very low breastfeeding rates with rates for exclusive breastfeeding (EBF) being particularly low .11Even when the infants are exclusively breastfed at birth, the EBF rate declines significantly, for example from 64.9% at birth to 37.3% at 24 weeks of age in a South-eastern Nigerian study.5Also, in another study done in Eastern Nigeria, the proportion of EBF infants 0 to 1 month of age was 26.1%; 18.5% at 2 to 3 months of age and 7.1% at 4 to 5 months of age. A Sydney study noted that only 3% of the children were breastfed exclusively at 6 months 12 and the EBF rates in the 2008 and 2013 NDHS
survey were put at 13% and 17% respectively.11,13
Rural-urban comparison has shown a significantly lower EBF rate for infants less than 6 months among mothers who lived in rural regions (14.7%) compared to those who lived in urban regions (20.7%) in Nigeria. 14 These lower EBF rates in rural areas are usually due more to deep-seated cultural and traditional beliefs rather than scientific reasons. For example, it was observed in the case of the use of Ghutti (local herbal concoction) in rural Gujrat that the elders do not oppose the idea of EBF but justify that Ghutti is beneficial to clear the esophagus of newborn babies.15
Delayed breastfeeding initiation is also an important issue as according to the Demographic and Health Survey done in Pakistan, as many as two-thirds of children were given other things before breast milk initiation.16
Regarding anthropometry, in times past, countries that did not have their reference data had been using the 1977 World Health Organization (WHO) and the National Center for Health Statistics (NCHS) international reference growth charts for growth assessment; however, these charts, developed for height for age, weight for age, and weight for height, were based on children younger than 2 years on a longitudinal study of North American children. Their use in practice showed that because of the original criteria used to select the child population studied, these reference growth charts were not suitable for assessing the growth of breastfed children. The 1977 reference is based on a predominantly formula-fed, child population. The evidence shows that breastfed and artificially fed infants grow differently and that the growth pattern of breastfed children most likely better reflects physiological growth.17
In 1994, based on the accumulated evidence, the WHO started working on new international standards that would be based on a sample of healthy breastfed children. The project, the WHO Multicentre Growth Reference Study (MGRS), was carried out from 1997-2003. It focused on the collection of growth and development data of 8440 children from different ethnic, cultural, and diverse geographical regions: Brazil, Ghana, India, Norway, Oman, and the United States. Weight-for-age, length/height-for-age, weight-for-length/height, and body mass index-for-age percentile, and Z-score values were generated for boys and girls aged 0-60 months and have now become the new reference for these anthropometric values.18
De Onis, coordinator of the Growth Assessment and Surveillance Unit at the World Health Organization (WHO), clearly stated that the new standards demonstrate for the first time that children born in different regions of the world when given the optimum start in life, have the potential to grow and develop to within the same range of height and weight for their age and the breastfed infant is the natural standard for physiological growth.18
PROBLEM STATEMENT
Despite documented evidence, showing many benefits of exclusive breastfeeding, EBF rates in Nigeria continue to fall well below the WHO/UNICEF recommendation of 90% in children less
than 6 months in developing countries.19,20 Apart from classifying infants into those exclusively breastfed or not, there is also a need to properly assess the patterns of their feeding choices as well as the factors that support or deter them in rural and urban areas in Lagos state. It is of great concern that the growth of breastfed infants living under favorable conditions in various geographical areas has been reported to be less than expected based on the current National Center for Health Statistics-World Health Organization (NCHS-WHO) growth reference.21 The first 6 months of life in which rapid growth occurs are the most vulnerable to nutritional insults. Mean weights for infants have been found to start to falter at about 3 months of age and decline rapidly until about 12 months. 22 Further comparison of child growth patterns in 54 countries with WHO standards shows that growth faltering in early childhood is even more pronounced than suggested by previous analyses based on the National Center for Health Statistics reference with the window of opportunity for preventing undernutrition in a child ending at about 2 years of age.23
Sadly, not many studies have been done involving anthropometry in infants less than 6 months among whom mortality is higher than in any other pediatric age group. This has made it difficult to interpret anthropometric measures and guide interventions in this age group. In a study involving children under 3 or 5 years of age, results done excluding 0-5-month-old infants resulted in an overestimation of the prevalence of stunting, wasting, and underweight though the overestimation for wasting was negligible. The regions showing the highest overestimations for stunting and underweight were Asia and sub-Saharan Africa of which Nigeria is a part .24 Though acute malnutrition among infants less than 6 months of age has been assessed using visible signs of wasting and bilateral edema, social criteria such as an absent mother or inadequacy of breastfeeding has also been used to indicate nutritional deficiencies in this age-group.
JUSTIFICATION FOR THE STUDY
The factors that are found to influence breastfeeding practices have been found to vary and may differ in certain urban and rural areas but the anthropometric indices in infants are yet to be compared. Most studies done on anthropometry have been restricted to weight and length/height indices only and there is yet a wide range of measurements that may give more information on other aspects of the nutritional status and the physical development of an infant. Evidence has shown that mid-upper arm circumference (MUAC) is a better predictor of infant mortality and has been suggested as a proxy for anthropometry in resource-poor areas where equipment for weight and length or height may not be readily available. Documentation of the occipitofrontal circumference/length ratio has been suggested to be an effective way to determine if the head circumference is in the normal range for a particular child’s body size: 25 This is important as occipitofrontal circumference can be used as a proxy for adequate brain development. The MUAC and MUAC to OFC ratios are useful for assessing longitudinal growth in preterm infants as it has been found that they do not overestimate the prevalence of malnutrition during periods of apparent protein-calorie sufficiency, unlike weight which likely will. 26 The availability of indicators for body mass index and skinfold thickness is particularly useful for monitoring the growing epidemic of childhood obesity.27 However, these additional measurements are not taken routinely at our primary, secondary, and tertiary health facilities presently and can provide more specific information to improve the overall growth of infants in rural and urban areas in Lagos State.
This study attempts to explore differences in breastfeeding patterns (if any) which may not have been captured in other studies and the differences or similarities in the anthropometric indices of infants aged 3 months to 6 months in these two settings. It has been shown that accurate prevalence data and an understanding of the relative risk for single and multiple anthropometric failures could improve the targeting and design of successful programming.28
The age range selected in this study (three to six months) is because by this age, changes
in breastfeeding patterns have been observed in several studies.5,7,14,15 Also, the measurements mid upper arm circumference(MUAC), Triceps skinfold thickness (TSF) and subscapular skinfold thickness (SSF) which are among the measurements to be taken have WHO reference values from 3 months upwards.19 The upper age limit of 6 months is the time recommended for commencement of complementary feeding the effects of which can affect some anthropometric indices.29Another strength of this study is that the range of anthropometric measurements(weight, length, occipitofrontal circumference, mid-upper arm circumference, Triceps skinfold thickness
and subscapular skinfold thickness) taken go beyond the ones done in most other studies 5,7,12,24 and may reveal specific measurements that could serve as proxies for assessing various aspects of nutritional assessment in this age group.
Research question: Is there a statistically significant difference in the breastfeeding patterns and anthropometric indices of infants three to six months old in rural and urban Local government areas in Lagos State? In this study, children attending the Primary Health Care Centres (PHCs) will be used as a proxy.
This study also hopes to better identify problems or difficulties in the Infant feeding practices of younger infants early as their growth even in later infancy(6-12 months) is significantly associated with their Infant feeding Practices(IFPs) at 1–6 months of age.30
SIGNIFICANCE OF THE STUDY/CONTRIBUTION TO EXISTING KNOWLEDGE
The results of this study will aid public health professionals at all levels in their understanding of the trends and variables that affect breastfeeding. The minimal information that is currently available for infants in this age group will benefit from the anthropometric measurements as well. They will also show if there are any discrepancies in the anthropometric indices between these two groups of children and help identify any early deviations.
The best practices can then be advocated for and turned into policy, improving the environment for breastfeeding, influencing health education, putting a stronger emphasis on breastfeeding advocacy strategies, and designing more specialized programs that are tailored to the needs of mother-infant pairs in Lagos State’s rural and urban communities. This study will assess a variety of anthropometric factors, therefore it will display the results of those measurements and if and to what extent they can serve as proxies to one another.
ANALYSIS OF BREASTFEEDING PATTERNS AND ANTHROPOMETRY OF INFANTS 3–6 MONTHS OLD VISITING PRIMARY HEALTH CARE CENTRES IN LAGOS STATE, RURAL AND URBAN
OBJECTIVES
GENERAL OBJECTIVE
The study aims to assess and compare the breastfeeding patterns and anthropometric indices of infants 3 to 6 months attending primary health care centers in urban and rural local government areas in Lagos State.
SPECIFIC OBJECTIVES
- To determine and compare the breastfeeding patterns of infants aged 3- 6 months attending primary health care centers in urban and rural local government areas in Lagos State.
- To identify and compare the factors influencing these breastfeeding patterns in infants aged 3-6 months attending primary health care centers in urban and rural local government areas in Lagos State.
- To assess and compare the anthropometric indices of infants aged 3 – 6 months attending primary health care centers in urban and rural local government areas in Lagos State.
ANALYSIS OF BREASTFEEDING PATTERNS AND ANTHROPOMETRY OF INFANTS 3–6 MONTHS OLD VISITING PRIMARY HEALTH CARE CENTRES IN LAGOS STATE, RURAL AND URBAN, GET MORE MASTERS PUBLIC HEALTH PROJECT TOPICS AND MATERIALS