Infant and Young Child Feeding Practices among Tribal Population of a Tea Estate in Darjeeling District, West Bengal, India

Introduction:

The concept of child health and nutrition has been an indispensable component of human development since time immemorial. Starting from the old ages to the contemporary era, proper Infant and Young Child Feeding (IYCF) practices has continued to play an instrumental role in the social and in turn the individual aspect of human life. This is because the period from birth up to two years of age is considered the ‘critical period’ for the promotion of good growth, health, behaviour and cognitive development of the child.^[1]

According to the World Health Organization (WHO), optimal breastfeeding practices; including immediate postpartum initiation of breastfeeding, exclusive breastfeeding with no additional fluid or food for 6 months,^[2] and continuation of breastfeeding thereafter up to 24 months and beyond with age appropriate complementary feeding; have great potential to reducing under-five mortality rate.^[3-5] It has been seen that if in 90% of infants, proper IYCF guidelines are implemented, almost 1/5^th of under-five mortality can be avoided.^[6]

Despite this well recognized importance of optimal IYCF practices, the worldwide figures are quite dismal with much room for improvement. As far as breastfeeding practices are concerned, only 38% infants are exclusively breastfed and 36% experience early initiation of breastfeeding globally while for India, the figures are 46.4% (less than six months of age) and 24.5% respectively.^[4]Studies show that sub-optimal breastfeeding accounts for an estimated 800,000 deaths in children under five years annually^[7] and that a non-breastfed child is 14 times more likely to die in the first six months than an exclusively breastfed one.^[1]

These figures may be quite different in tribal populations who inhabit widely varied ecological and geo-climatic conditions and are plagued by various social factors like ignorance, illiteracy, poverty, lack of development in the inaccessible areas and exploitation. In India, the Scheduled Tribes constitute about 8.6% of the total population^[8] which are scattered throughout the country.

In this context, the present study was conducted in a tribal population of northern part of West Bengal exploring the current feeding practices of children as compared to the IYCF guidelines.

Objectives:

To find out the current Infant and Young Child Feeding Practices among tribal children aged 0-23 months residing in a tea garden of Darjeeling district, West Bengal.

To determine the socio-demographic factors associated with age-appropriate feeding practices.

Materials and methods

A community-based cross-sectional descriptive study was undertaken from August to September 2014 in Kiranchandra Tea Estate of Darjeeling district, West Bengal, which falls under the rural field practice area of North Bengal Medical College. The inhabitants of the tea garden comprise of mixed tribe Adivasis with Sadri as the predominant language. The study population consisted of all children aged 0-23 months whose parents are tribals and residing in the study area for more than1 year were considered. Children whose parents refused to give consent and children who were severely ill were excluded

In the absence of any previous study in the area, the proportion of children breastfed within one hour of birth in Darjeeling district as reported in the District Level Household Survey-3 (i.e. 44.3%)^[9] are used for calculating the sample size. Considering 10% absolute precision (L), sample size is computed by using the formula n=4P (1-P)/L^[2]. The yielded sample size comes out to be 99. Considering 10% non-response, the final sample size became 109.

First, line listing of all the children aged 0-23 months who were permanent residents of the tea garden was done by house- to-house visits with the help of the local health worker. A sampling frame was chosen and all the houses were visited during the study period of 2 months to select 109 children by simple random sampling. In the absence of child in a particular house, it was visited for a maximum number of 2 times; after which the child was excluded from the study.

The mothers of the selected children were interviewed at their home with the help of a pre-tested pre-designed schedule and data on age of child, birth weight, gender of child, socio-economic status, educational status and occupation of the mother; feeding history and feeding practices of the study children were collected. Birth weight was also checked from the immunization card and/or discharge certificate from the hospital.

The child's weight was measured using standard guidelines with the help of weighing machine in which reading was obtained by subtracting the mother's weight from the weight of the mother and child combined. The observed weight of the child was then plotted on the WHO growth chart for weight-for-age separately for males and females by a dot.

After data collection, data entry was done in Microsoft Excel. Data was organized and presented by applying principles of descriptive statistics. Further statistical analyses were done using SPSS version 20.

From the responses, the following IYCF indicators were calculated as per definitions formulated by the WHO:^[10][Box 1]

Results:

Discussion:

Infant and young child nutrition has continued to draw the attention of professionals including doctors, health workers and nutrition specialists since long for decades. Infant feeding practices in the form of breastfeeding and complementary feeding have a substantial role in shaping the future health and nutritional status of the child.^[11]

Though breastfeeding was started within one hour of birth in only 22.9% of the children, it was found to be universally practised in the study population. Growing evidence points to the impact of early initiation of breastfeeding on neonatal mortality. A 2006 study in rural Ghana^[5] showed that early initiation within the first hours of birth could prevent 22% of neonatal deaths, and initiation within the first day, 16% of deaths, while a study in Nepal^[12] found that approximately 19.1% and 7.7% of all neo-natal deaths could be avoided with universal initiation of breastfeeding within the first hour and first day of life respectively. The proportion of initiation of breastfeeding within 1 hour of birth for rural West Bengal according to DLHS 4 is 50.4%.^[13]

For infants < 6 months: Breastfeeding was a universal practice in infants aged <6 months and 77.8% of the 0-5 months age group infants were found to breastfed 8 or more times; which was better than 68.8% in a study by Khan et.al in East Delhi^[14] but lower (93.6%) as compared to Bankura^[15].

The practice of giving other food or drinks in this age is completely against the IYCF guidelines. Studies show that about one- fourth of study children who received liquids and solids, along with breastfeeding at 0-6 months of age, remained at risk for infectious diseases and under nutrition.^[4,16]

For children > 6 months: Inspite of the WHO recommendation of starting complementary feeding after 6 months, the age of complementary feeding varies in different studies.^{[15,17,18,19]} The major concerns about complementary feeding throughout the globe are late introduction and deterioration in both quality and quantity of food given to the child.

IYCF indicators:

Very few children (22.9%) were put to breast within one hour of birth. This may be due to the fact that immediately after giving birth, it is not necessarily the mother who decides when the child is put to her chest, but the family members who are influenced by different socio-cultural factors. The corresponding figure was 48.3% in a study done among tribals of Bhatar block of Burdwan district by Mondal et al.^[20] However, a study done among Paroja tribals reported the figure as only 8%.^[21]

Exclusive breastfeeding up to six months of age and breastfeeding up to 12 months was ranked number one among the top 15 preventative child survival interventions in preventing under-five mortality according to the 2003 landmark Lancet Child Survival Series.^[4] The goal is to achieve a target of improvement in exclusive breastfeeding till six months by 50% of the current level in the 12^th year plan.^[23] The present study has shown the proportion of exclusive breastfeeding practices as 84.4% among children less than 6 months and 46.15% among tribals of Bhatar block.^[22]

The proportion of continued breast-feeding at 1 year and 2 years was 100% and 83. 3%. This was comparable to the study done by Sinhababu et al^[16] and lower than the study among Hakkispikkis tribals in Mysore district, Karnataka.^[23]

Coming to the ingredients used to prepare food, 54.7% (in children aged 6-23 months) received food prepared from four or more groups out of the seven food groups as mentioned in the ‘minimum dietary diversity’ indicator of IYCF. Minimum dietary diversity reveals whether the child between 6 and 23 months age is receiving a complete and balanced diet or not. This indicator is quite less in tribals of Bhatar block (30.85%) and is quite good in urban Meerut (79.6%).^[18,20] The discrepancy may be may be the effect of the lower socio-economic conditions of the tribal people as compared to the urban dwellers and also the scarcity of food in the tea gardens which are at a higher altitude than the plains.

After computing the number of meals taken by the children of various age groups, the ‘minimum meal frequency’ was found to be 64.1%. This was more as compared to 43.4% in Meerut^[19] but less than 67% in Delhi^[18] and 95.6% as reported by Chandwaniet al.^[24]

Bottle-feeding is bacteriologically dangerous to the infants and the use of feeding bottles only adds further to the risk of infection as they are difficult to clean properly. The International Code of Marketing of Breast milk Substitutes recommends that Governments enact legislation that will prohibit the advertising and all other forms of promotion of breast milk substitutes, feeding bottles and teats.^[25] Among the 109 study children, only 16.5% have been bottle-fed. This value is less than 28.1% and almost one- fourth (of the total population) as seen in rural West Bengal by Das et.al^[26] and Khan et al in Delhi^[17] respectively. However, in the study by Sinhababu et al, 10.2% of the study children were bottle-fed.^[17]

The proportion of age appropriate feeding practice denotes children aged 0-23 months who receive food according to age. In the present study, only 48 children (44%) received food appropriately according to their age. Appropriate feeding was more prominent in younger age i.e., less than 6 months. This can be explained by the fact that after 6 months of age, it becomes progressively more complex for breastfed infants to meet up their nutrient needs from human milk alone and this may not be possible to provide by these financially weaker families.

In our study, factors influencing the feeding practices were the mother's educational level and the employment of the mothers. The higher educated the mothers were, the more likely they were to practice correctly. Quite understandably, it was seen that the mothers who stayed at home and cared for their children were better in practising age appropriate feeding recommendations.

Income was found to be an important predictor of feeding as children belonging to families with per capita income of Rs. 1000 and above had a greater likelihood of having appropriate feeding practice. This can be explained by the fact that higher per capita income would translate into better accessibility to food.

In the present study, 45.9% of the children were found to be malnourished. The likelihood of malnutrition was found to be significantly more in children with age appropriate feeding practice. Globally, studies have establishedthat inappropriate feeding practices can have adverse consequences on growth, development, and survival of infants and children.^[27,28]

Appropriate feeding during and after illness is important to avoid weight loss and nutrient deficiencies and the cycle of infection and malnutrition can be broken if appropriate feeding is ensured.^[29] Though temporality could not be proven, it was found that children with inappropriate feeding had suffered from illness in the last 15 days. It can be explained by the prevalent practice of giving less food to the sick infant.

Conclusion:

Optimum infant and child feeding practices have a colossal impact on the country's social and economic status as the child population forms the backbone of any nation's future. Amidst the various ethnic and cultural communities, the tribal population studied had quite poor feeding practices which are aggravated by the scarcity of basic amenities and social problems like illiteracy, poverty etc. The feeding practices can be improved to a great extent by extensive IEC efforts and proper education of mothers during their ante-natal visits. It should be remembered that the dissemination of proper knowledge to the mothers and family members can play an enormous role in improving the present feeding practices.