Breastfeeding Practices in Kathmandu

Introduction: In spite of significant evidence on a number of important health benefits of breastfeeding, it has been seen that a vast number of infants in Nepal are not being breastfed appropriately based on standard recommendations. This study was conducted to evaluate the breastfeeding practices prevalent in Kathmandu. Materials and Methods: This was a cross-sectional survey carried out over a period of 24 months from January 2011 to December 2012 on a convenient sample of children aged 6 months to 23 months when they were brought for treatment to Kathmandu Medical College and Teaching Hospital. Breastfeeding was defined according to the recent WHO guidelines and mothers were interviewed as per a structured questionnaire. Results: There were 1250 children enrolled in the study, out of which almost all infants (99.7%, n=1246) received colostrum. Only 62.64% (n=783) babies received breast milk as their first food. Initiation of breastfeeding within one hour of delivery was done by 719 (57.5%) mothers. The median duration of exclusive breastfeeding was 3.8 months. Conclusion: This study reflects that majority of infants in Kathmandu are still not fed in accordance with breastfeeding recommendations and guidelines. More attention should be given to a proper community-based program including subsequent monitoring of its implementation as exclusive breastfeeding has been proved to be one of the most effective ways to improve infant survival.


Introduction
B reas eeding, par cularly exclusive breas eeding, for the ini al six months of life, provides be er health for both infants and mothers 1 .Breast milk gives infants all the nutrients they need for healthy development.Breast milk is aff ordable and readily available.It contains an bodies that help protect infants from common childhood illnesses such as diarrhoea and pneumonia, the two primary causes of child mortality worldwide.Breas ed infants have enhanced immune response and reduced risk for chronic illnesses such as asthma, diabetes and infl ammatory bowel disease 2 .Breas eeding also benefi ts mothers by reducing the risk of breast and ovarian cancer, providing a natural method of birth control and enhancing emo onal health of the mother by the bonding she develops with her infant during breas eeding 3,4 .
Review of evidence has shown that, on a popula on basis, exclusive breas eeding for six months is the op mal way of feeding infants and has been recommended by the World Health Organiza on (WHO) 5 .However, mothers receive infant feeding informa on and advice from a variety of sources 6 and it is o en found in many cultures that this recommenda on of exclusive breas eeding is not followed by many mothers.
The aim of this study was to evaluate the breas eeding prac ces prevalent in Kathmandu.

Materials and Methods
A cross-sec onal survey was carried out over a period of 24 months from January 2011 to December 2012 on a convenient sample of children aged 6 months to 23 months.Mothers of children belonging to this age group who brought them for treatment to Kathmandu Medical College and Teaching Hospital (KMCTH), Sinamangal, Kathmandu, Nepal were interviewed as per a structured ques onnaire.
Breas eeding was defi ned according to the recent WHO guidelines 7 and was categorized as follows: Exclusive breas eeding:The infant had received only breast milk from his/her mother or a wet nurse, or expressed breast milk and no other liquids or solids with the excep on of drops of syrup consis ng of vitamins, mineral supplements or medicines.

Predominant breas eeding:
The infant's predominant source of nourishment had been breast milk.However, the infant may also have received water and water-based drinks like tea and local herbal drops.
Par al breas eeding: When infant's feeding included non-breast milk foods such as animal/ powdered/condensed milk and/or solid/semi-solid food (i.e.cereals, vegetables, fruits, len ls or meat).
Children with delayed developmental milestones, illness during neonatal period, children with specifi c feeding problems secondary to congenital malforma ons and those whose mothers were not accompanying the child during the hospital visit were excluded from the study.

Results
In this study, a total of 1250 mothers of children between the age group of 6 months to 23 months of age were interviewed when they brought the child for treatment to KMCTH.44% of the mothers interviewed were a ending the hospital with their fi rst born child and 56% had more children.
All the women had at least one antenatal checkup during the last pregnancy, but only 18% of them reported to have received informa on on breas eeding during their antenatal visit.Out of all the women, only seven of them said they had their breasts/nipples examined during the antenatal check-up.
The mothers fell between the age range of 19-38 years.477 (38.2%) women were working outside home.The fi rst choice of advice the mother would turn to if her baby had a problem in breas eeding is shown in Figure 1.
Almost all infants (99.7%, n=1246) received colostrum.Only 62.64% (n=783) babies received breast milk as their fi rst food.Remaining, 464 (37.12%) received dried-milk infant formula, two (0.16%) received water and one (0.08%) was given glucose water as represented in Figure 2. Ini a on of breas eeding within one hour of delivery was done by 719 (57.5%) mothers.Addi onally, nearly half of all breas ed infants (48.4%) were supplemented with infant formula during the post-delivery hospital stay.Only 11 mothers (0.88%) reported the need to express breast milk, out of which eight mothers expressed manually and three mothers used breast pumps.
The propor on of exclusive breas ed infants at one month, four months and six months is depicted in Figure 3.The median dura on of exclusive breas eeding was 3.8 months.The commonest reason for star ng other forms of feeding (infant formula/ animal milk/ semi-solid) was the mother's percep on of 'not enough breast milk'.Out of the mothers using dried-milk infant formulae, only 54.6% were using the proper dilu on of formula.92.7% of these mothers used bo le feeding and remaining 7.3% were fed with spoon.
Use of animal milk before the age of six months was found in 427 (34.2%) infants.All of them except four had used cow's milk.

Discussion
American Academy of Pediatrics (AAP) recommends exclusive breas eeding for the fi rst six months with con nued breas eeding past 12 months 8 .In spite of these recommenda ons and proved benefi ts, it has been seen that only one-fourth of children age 6-23 months in Nepal are fed appropriately based on recommended Infant and Young Child Feeding (IYCF) prac ces 9 .
Na onal Demographic Health Survey (NDHS) in 2011 9 states that breas eeding is nearly universal in Nepal, 70% of children less than age six months are exclusively breas ed, and the median dura on of exclusive breas eeding is 4.2 months.However, this study has found a low prevalence of exclusive breas eeding at six months of age (12%) in Kathmandu with a median dura on of exclusive breas eeding being 3.8 months.Similar low prevalence of 9% has been found in a recent study done in Bhaktapur District by Ulak et al 10 .
Almost all infants received colostrum but only about two thirds (62.64%) babies received breast milk as their fi rst food.Some prac ces, including prelacteal feeding and supplemental feeding, which are not recommended by WHO, are s ll common in Kathmandu.Widespread use of infant milk formula, even in the hospital set-up, is observed.Infant formula and/or early introduc on of semi-solid is done and as found in this study it o en occurs when mothers perceive that they have insuffi cient breast milk produc on 11 .
Only 18% women reported to have received informa on on breas eeding during their antenatal check-up.This is sugges ve of how antenatal visit focuses mainly on pregnancy, and there is not much emphasis on breas eeding educa on.Although breas eeding is a social norm and universal prac ce in most communi es, it is also a learned behavior and may be infl uenced by many factors including socio-economic, educa onal level and cultural 12 .The encouragement of breas eeding to families and to the community at large is an important aspect of the paediatrician's profession 13 .

Conclusion
This study on breas eeding prac ces indicate that majority of infants in Kathmandu are not fed in accordance with breas eeding recommenda ons and guidelines.The dura on of exclusive breas eeding is shorter than recommended with only about two thirds babies receiving breast milk as their fi rst food.Prelacteal, supplemental feeding and early introduc on of semisolid feeds s ll seem to be common in Kathmandu.

Recommendations
Important advocacy and advice to encourage breas eeding is lacking in the society.Although mothers tend to adhere to advice from health professionals, they are not likely to ask for help from them when faced with challenges in doing so.There is also need to overcome clinical barriers to help support ini a on of breas eeding within one hour of birth.Breas eeding counseling at antenatal clinics and peer support for exclusive breas eeding should be included as part of breas eeding promo on programs.

Fig 1 :
Fig 1: First Choice for Advice the Mother would approach in case of a Breas eeding Problem Immediate Family Friend Health Professional

Fig 2 :
Fig 2: Various Types of First Food received by the Baby immediately a er birth

Fig 3 :
Fig 3: Propor on of Exclusive Breas ed Infants at 1, 4 and 6 months of age