Introduction

Ten years ago India had joined many other countries in endorsing the goals set out at the World Summit for Children. These goals ensured a healthy future for its children by bringing down malnutrition.

The official data tells a grim story. Malnutrition among children is a major concern as 47% under the age of three are underweight. These figures have change only marginally during last six years when we compare the data from NFHS- 2¹ with NFHS -1².

These data also show that exclusive breastfeeding is only 19.4% at 6 months and 54.2% at 3 months and only 33% infants provided appropriate complementary foods between 6-9 months, the rates have not changed significantly despite the States commitment and multisectorial efforts including the ICDS and RCH program to promote exclusive breastfeeding and timely complementary feeding and to reduce malnutrition. Major national events more recently have affirmed support to improve infant feeding situation.

This paper examines the reasons and relationship of poor feeding practices and their link with malnutrition and offers possible solutions to reduce malnutrition. This paper also advocates intervention to improve infant feeding practices as an aide to reduce childhood malnutrition, besides addressing larger issues like poverty, health services, household food security and maternal nutrition, which of course influence the nutrition outcome of women and children.

Status of infant feeding practices in India

Exclusive Breastfeeding

Although exclusive breastfeeding is advised till about six months of age, It has not shown a significant improvement over last six and half years as shown by NFHS-2 results. Figure 3 shows that 19.4% are exclusively breastfed at six months and 54.2 % at 3 months of age. It means half the babies born in India are subjected to faulty feeding practices within a short period of three months despite all the efforts made in this direction. Bottle-feeding rate also remains the same 14.5% below 12 months of age

Fig.3: Percentages of exclusively breastfed babies at six months, at three months (NFHS 1 & 2) Fig. 4: Timely complementary fed babies (NFHS 1 & 2) Did you know? Only half of our babies are optimally fed during first three months of life and only one third are given timely complimentary foods between six and nine months?

Optimum feeding practices
A brief review of optimum feeding practices is given here.

1. Initiation of breastfeeding

Putting the baby to breast within half hour of birth is the first and the foremost step to optimal breastfeeding as at this time the baby's suckling reflex is strongest, and the baby is more alert.3,4. Early initiation stimulates breastmilk production through prolactin reflex and also stimulates oxytocin reflex for better milk flow from mother's breast to the baby. It helps to ensure colostrum, which provides the infant with the antibacterial and anti-viral protection, and the crucial nutrition needed at this hour. Early initiation of breastfeeding is associated with fewer breastfeeding problems and better mother-infant relationship5. Babies who are put to breast earlier have been shown to have higher core temperatures and less temperature instability6.

2. Exclusive breastfeeding

Infants who are exclusively breastfed for first six months do not require any other food or drink. In fact giving any thing including non-nutritive fluids would replace breastmilk.7 Exclusively breastfed babies have significantly less gastrointestinal and respiratory illness including ear infections and asthma, than those who are not breastfed8. Exclusive breastfeeding while reduces the risk of diarrhea also contributes to positive impact on nutrition status of child while recovering from diarrhea9. In addition, the breastfeeding mother has a reduced incidence of post-partum bleeding and thus anemia, reduced risk of breast and ovarian cancer, reduced risk of osteoporosis, and other beneficial effects such as increased child spacing due to delayed resumption of ovulation.10

3. Timely and appropriate complementary feeding

After six months, infant's requirements cannot be met with breastmilk alone. This is the time to begin complementary foods, which are of good quality and in adequate amounts. This is necessary to prevent malnutrition including anemia. During this period additional foods and fluids are provided to the baby along with breastmilk. A study 11 has shown that early introduction of complementary food does not result in improved growth velocities or food acceptance. Several other studies have also documented that early start of complementary foods earlier than 6 months, replaces breastmilk intake and does not increase caloric intake and none of these studies reported any benefit of starting these foods earlier than six months12. Replacing breastmilk means losing fats, energy and other micronutrients. It would therefore be important to maintain high levels of breastfeeding along with introduction of complementary foods, which are high nutrition density.

Malnutrition cycle, when it strikes

Malnutrition in children is a major concern in India as about 47% of children under three years are underweight, which number to about 60 million.

Malnutrition runs in an intergenerational cycle. The under weight girl children grow into malnourished adolescent girls who are likely to be malnourished mothers. Percentage of women who are malnourished is very high and they give birth to low birth weight children. It is estimated that 33% of all babies born in India are low birth weight. Look at figure 1 which shows underweight babies at 6 months drops to 15.6% and this drop could entirely be attributed to breastfeeding. If we are able to increase exclusive breastfeeding there is likelihood of seeing this percentage down which could finally effect the nutrition status of the infant and young child.

Fig. 1: When malnutrition strikes

At 6-11 months of age malnutrition to 43%, which could be due to inadequate breastfeeding and inappropriate not exclusive breastfeeding and inappropriate complementary foods and then at two years this percentage goes unto about 63% again could be due to inadequate food or inappropriate practices.

Not much has changed in six and a half years when we compare malnutrition data between NFHS -2 and NFHS -1, it is seen that percentage of children underweight is still extremely high. (Fig 2)

Fig. 2. Underweight children under the age of three. Comparison of NFHS 1 and NFHS 2.

Impact of malnutrition

The World Health Organization estimates that malnutrition was associated with over 55% childhood deaths in developing countries including India. Malnutrition particularly among children and women directly or indirectly causes high morbidity and mortality. The impaired immune functions in these children leads to more severe enteric infections and other infections than those who are not malnourished.

Malnourished children have delayed milestones and impaired cognitive development, and are likely to be handicapped for life if an innovative approach is not adopted. Thus, malnutrition impairs intelligence, strength, energy and productivity. A recent study by the Government of India has established that the annual loss of productivity on account of malnutrition is of the order of more than Rs. 33,000 Crores.

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