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African Journal of Food, Agriculture, Nutrition and Development
Rural Outreach Program
ISSN: 1684-5358 EISSN: 1684-5374
Vol. 4, Num. 1, 2004

African Journal of Food Agriculture Nutrition and Development, Vol. 4, No. 1, 2004

INFLUENCE OF COMPLEMENTARY FOODS ON THE GROWTH INDICATORS OF CHILDREN IN GABANE, BOTSWANA

L'INFLUENCE DES ALIMENTS COMPLÉMENTAIRES SUR LES INDICATEURS DE LA CROISSANCE DES ENFANTS A GABANE, BOTSWANA

Nnyepi MS*1, Bond J2 , Johnson N. 3 and L Weatherspoon4

1*Corresponding author Department of Home Economics Education, University of Botswana, Gaborone, Botswana. Email: nnyepima@msu.edu
2 Department of FSHN, 204 Trout FSHN Building, Michigan State University, East Lansing, Michigan 48824. Email: jbond@msu.edu
3 Department of Sociology, 425 Berkey Hall, Michigan State University, East Lansing, MI 48824. Email: johnsonn@msu.edu
4 Department of Sociology, 425 Berkey Hall, Michigan State University, East Lansing, MI 48824. Email: weathe43@msu.edu

Code Number: nd04003

ABSTRACT

This study was conducted to characterise the relationship between complementary foods and the growth of children of ages three to 36 months in Gabane, Botswana. Dietary, anthropometric and socio-demographic data were collected from healthy children attending the monthly Child Welfare Clinic. Most children (92.8%) had adequate birth weights. Ninety-seven percent of children were breastfed. However, exclusive breastfeeding during the first six months of life was rare. Sixty-four point four percent (64.3%) and 44.4% of study children received water and infant formula within their first month of life. The most common complementary foods and fluids in this population were sorghum porridges, ultra high temperature pasteurised (UHT) cow milk, infant formula, tea and other types of milk from domestic animals. Between four and six months of age, sorghum porridges, ultra high temperature pasteurised (UHT) cow milk, and tea were introduced to 78%, 48.7% and 19.7% of children respectively. About 10% of children were introduced to complementary solids between two and three months while 3.4% were introduced to solids after six months of age. Sorghum porridges, which were the most common complementary solids in this population were also associated with lower (p < 0.05) weight-for-age z-scores (WAZ) and weight-for-height z-scores (WHZ). Children of working mothers were more likely (p < 0.001) to receive supplemental infant formula compared to children whose mothers did not have formal employment outside the home. Furthermore, supplementation with infant formula was significantly associated with higher (p < 0.05) WAZ and WHZ. Growth faltering in children became apparent shortly after three months, with the steepest decline in growth occurring between three and 12 months of age. Overall, 9.1%, 12.1%, and 5.3% of children were stunted, underweight, and wasted respectively. The prevalence of stunting, underweight and wasting was comparable in both genders. Children over 24 months of age had poorer (p < 0.05) growth indicators than younger children. Our findings suggest that the choice of complementary foods and fluids significantly influences the child’s WAZ and WHZ, the duration of breastfeeding and the age at which solids are introduced.

Key words: Complementary foods, Sorghum porridge, Growth faltering, Z-scores, Cow milk

Résumé

Cette étude a été effectuée dans le but de caractériser la relation entre les aliments complémentaires et la croissance des enfants âgés de trois à 36 mois à Gabane au Botswana. Des données relatives au régime alimentaire et des données anthropométriques et socio-démographiques ont été collectées chez des enfants en bonne santé présentés chaque mois au Centre médicosocial pédiatrique. La majorité des enfants (92,8%) avaient des poids adéquats à la naissance. Quatre-vingt-dix-sept pour cent (97%) des enfants étaient nourris au sein. Cependant, l'allaitement exclusif pendant les six premiers mois de la vie était rare. Soixante-quatre pour cent (64,3%) et 44,4% des enfants qui ont fait l'objet de cette étude ont reçu de l'eau et du lait maternisé au cours du premier mois de leur vie. Les aliments et fluides complémentaires les plus courants dans cette population étaient des bouillies de sorgho, du lait de vache pasteurisé à une température ultra élevée (TUE), du lait maternisé, du thé et d'autres types de lait d'animaux domestiques. Lorsque les enfants avaient entre quatre et six mois, les bouillies de sorgho, le lait de vache pasteurisé à une température ultra élevée (TUE), et le thé ont été donnés respectivement à 78%, 48,7% et 19,7% des enfants. Près de 10% des enfants ont commencé à recevoir des aliments solides complémentaires entre deux et trois mois tandis que 3,4% ont commencé à les prendre quand ils avaient plus de six mois. Les bouillies de sorgho, qui étaient les aliments solides complémentaires les plus courants dans cette population, étaient également associées à des proportions (z-scores) entre le poids et l'âge (WAZ) moins élevées (p < .05) et à des proportions (z-scores) entre le poids et la taille/hauteur (WHZ). Les enfants des mères qui travaillaient avaient plus de chances (p < .001) de recevoir du lait maternisé supplémentaire par rapport aux enfants dont les mères n'avaient pas d'emploi formel en dehors du domicile. En outre, l'alimentation supplémentaire par du lait maternisé était considérablement associée à des WAZ et WHZ plus élevées (p < .05). Le ralentissement de la croissance chez les enfants est devenu apparent peu après l'âge de trois mois, et la baisse la plus abrupte de la croissance se produisait entre l'âge de trois et 12 mois. En général, 9,1%, 12,1%, et 5,3% des enfants avaient une croissance retardée, avaient un poids insuffisant, et étaient décharnés respectivement. La prévalence du retard de croissance, du poids insuffisant et de la maigreur était comparable chez les garçons et chez les filles. Des enfants âgés de plus de 24 mois avaient des indicateurs d'une croissances plus faible (p < .05) que chez les enfants plus jeunes. Nos résultats suggèrent que le choix des aliments et fluides complémentaires influence considérablement la proportion WAZ et la proportion WHZ de l'enfant, la durée de l'allaitement et l'âge auquel les aliments solides sont introduits.

INTRODUCTION

Growth faltering has been observed in infants three to twelve months of age [1-3]. At this age, most children in developing countries are transitioning from breastfeeding to complementary foods [1, 4-6]. It is currently recommended that complementary foods be introduced at six months [7,8]. However, caregivers’ cultural preferences and access to food often influence the choice of complementary foods more than a child’s nutritional needs. Consequently, impoverished home environments such as those prevailing in developing countries, may limit the child’s access to timely introduction of nutrient-dense and microbially safe complementary foods. Such situations precipitate early growth faltering and subsequent malnutrition in children three to 36 months of age [6]. As in other developing countries, malnutrition in children under five years of age in Botswana appears to start as infants transition from breastfeeding to complementary foods [9,10]. This argument is strengthened by the observation that although most (92.8%) children in Botswana have adequate birth weights, their growth declines sharply between three and twelve months [4,9,10]. The objective of this study was to determine the effects of complementary feeding on the nutritional status of children three to 36 months of age in Gabane.

METHODS

Study Design: A cross-sectional study design was used to address questions raised in this study. Using a systematic sampling procedure with a random start, 132 children of ages 3-36 months were selected from children attending a Child Welfare Clinic in Gabane Village. The enrolment of children was continued for a period of 30 days. Within this 30-day period, clinic attendance was high, with 90% of all children in the clinic registry showing up for their monthly clinic visit. Gabane village is located 15 kilometres from the capital city. The population of Gabane was estimated at 10,000 in the 2001 census data [11].

Data were collected through personal interviews with the primary caregivers. Additional information was also obtained from the Child Welfare Clinic cards. Primary caregivers were defined as adult caregivers who played key roles in preparing food for and serving the study child. Most (60.6%) primary caregivers were mothers of the target children. The variables of interest were household demographic factors, the child’s factors and the mode of feeding that caregivers chose. Household demographic factors that were included were the household size, the head of household and maternal age, education level, and employment. The child’s factors of interest were the child’s birth weight, sex, age, weight, and height. Information on feeding practices such as whether or not the child received breast milk, infant formula, cow milk, other types of milk, tea or water was also collected. In addition, information on the child’s age at the introduction of the different complementary foods, feeding times and the child’s primary complementary food was collected. The primary complementary food was defined as the food most frequently prepared for and given to the child.

The child’s weight and height or length was measured by the first author with the assistance of trained research assistants. Weight was measured using Salter Spring Scales, CMS Weighing Equipment LTD, London, England, while the Harpenden Portable Stadiometer Model VF2M, Holtain LTD, England, was used for height or length measurements. For length measurements, the portable stadiometer was mounted on a measuring board previously used in a UNICEF/Government of Botswana study for children under 2 years of age [10]

Statistical Analysis: SPSS version 9, 1999 was used to analyse most of the data. Epi-Info version 6.04 (Centers for Disease Control/ World Health Organization (CDC/WHO), 1998) was used to calculate z-scores and to estimate the prevalence of stunting, underweight and wasting, which were defined as –2 z-scores of height-for-age, weight-for-age and weight-for height respectively. To further discern differences in the mean weight-for-age (WA), weight-for-height (WH) and height-for-age (HA) z-scores of children in different age groups, One-way Analysis of Variance and Tukey’s post hoc tests were used.

With respect to the influence of complementary foods on growth, the independent sample t-test was used to compare the mean WA, WH, and HA z-scores for children whose primary complementary food was sorghum porridges with those who were fed other foods. The independent sample t-test was also used to examine the effect of the introduction of supplemental infant formula on the child’s WA, WH and HA z-scores, the duration of breastfeeding and the child’s age at the introduction of solids. Finally, a Chi-Square test was used as a test of association between maternal employment outside the home and the use of supplemental infant formula.

RESULTS

Characteristics of Target Children and Caregivers: Subjects were children between the ages three to 36 months with a mean age of 17.8 ± 10.0 months. Girls comprised 48% of the sample (Table 1). Mothers comprised the majority (60.6%) of the primary caregivers.

Household Socio-demographic Characteristics: The average number of siblings in families in Gabane was 2.89 ± 1.89. Each household also had an average of 2.48 ± 2.33 child relatives in residence. Most mothers were literate and about sixty percent (59.1%) had a minimum of secondary school education. Thirty four percent (34.1%) of mothers were employed outside the home. Six percent of mothers were teenagers. The child’s mother and grandparent were reported as the heads of the household in 8.3% and 37.1% households respectively (Table 1).

Child Anthropometric Measurements: The average birth weight for children in Gabane was in the adequate weight range (> 2.5 kg). As shown in Figure 1 and Table 2, the HAZ, WAZ, and WHZ of the sample children deteriorated as the child’s age increased. The steepest decrease in all growth indicators occurred between three and 12 months. The mean HAZ, WAZ and WHZ scores in this population were significantly lower than the WHO reference population. The prevalence rates of stunting, underweight and wasting (defined as -2 standard deviations of the median for height-for-age, weight-for-age and weight-for-height) were 9.1%, 12.1%, and 5.3% respectively. In both genders, however, no child under six months of age was stunted, wasted or underweight. Older children (Table 2) had significantly lower mean HAZ, WAZ, and WHZ scores than younger children. The prevalence of low nutritional status was comparable across the genders and heads of household.

Child Feeding Practices: As depicted in Table 3, breastfeeding was initiated by 97% of mothers. In the four cases where breastfeeding was never initiated, mothers chose not to breastfeed due to their ill health. On average, children were breastfed for 13.4 months.

The common complementary foods and fluids in this population included water, infant formula, ultra high temperature (UHT) pasteurised cow milk, tea, sorghum porridges and commercial baby foods (Table 4). Among children who received water or infant formula, 64.3% and 44.4% received it within the first month of life respectively (Table 3). Among children who received solids, most (84.9%) received them between four and six months. Thus, exclusive breastfeeding for the first six months of life was not practised in this population.

The use of supplemental infant formula was significantly associated with maternal employment outside the home (Table 5). Sixty seven percent of mothers with formal employment routinely fed children infant formula compared to 37% of mothers without formal employment (p < 0.001).

Of all the fluids introduced, water was the most likely to be introduced soon after birth. The introduction of infant formula followed a similar pattern as water although fewer children had been introduced to infant formula compared to those given water. The second most common complementary fluid was ultra high temperature pasteurised cow milk (UHT milk). Contrary to the recommendation that cow milk be introduced after 12 months, 48.7% of the 76 children already introduced to UHT milk had received it between four and six months of age (Table 4). Similarly, 34.6% of children who routinely received other types of milk (milk from household reared goats or cows) had received them between four and six months. Tea (with milk and sugar) was the last of all the complementary fluids to be introduced. Its introduction rate rose from 19.7% at four to six months to 77.3% after six months. Unlike other complementary fluids, which were served ad-libitum, children were served tea only at times when the family had tea.

The Choice and Timing of the Introduction of Solids: Almost seventy percent (68.9%) of study children were primarily fed fermented sorghum porridge (Table 3). Smaller proportions of children were either fed commercial baby foods (8.3%) or a varied combination of foods (9.8%). In this population, complementary foods were frequently served together with milk (41.5%).

A comparison of the growth performance of children fed different complementary foods is displayed in Table 6. Children whose diet was primarily complemented with sorghum porridges had significantly lower WA and WH z-scores (p < 0.05) compared to those for whom breastfeeding was complemented with a variety of foods (mostly commercial baby foods). However, the type of food/fluid given did not significantly affect the mean HA z-scores. Furthermore, children whose primary complementary food was served with cow milk (that is sorghum and milk) had significantly lower WH and WA z-scores than those for whom complementary foods were served together with other foods.

Regarding the effect of the introduction time of complementary foods on physical growth, children under six months of age had better WH z-scores than children over six months regardless of the age at which they were introduced to complementary foods. Initially, early (0-3 months) introduction of mashed food in this population appeared to be associated with better WA z-scores than introduction at four months. However, this association disappeared when the child’s age was factored into the analysis. Significant differences in the progression of complementary feeding and growth outcomes were observed between children receiving infant formula and those who did not. As shown in Table 7, the mean duration of breastfeeding was shorter for children who were supplemented with infant formula. Also, the introduction of solids was significantly earlier (p < 0.05) in children supplemented with infant formula. Supplementation with UHT milk and other types of milk did not confer statistically significant growth advantages to children.

DISCUSSION

Our findings show that the rate of breastfeeding is high in this population, with all but four children having been breastfed for some time in their lifetime. Mixed feeding was very common, with most caregivers introducing other types of milk and fluids before six months of age.

Water and infant formula were the next common fluids after breastmilk, with 64.3% and 44.4 % of children supplemented by these fluids,respectively, receiving them within their first month of life. Solids and UHT-milk were more likely to be introduced between the ages of four to six months, while tea was more likely to be introduced after six months (Table 4). The almost simultaneous introductions of UHT cow milk and solids, against recommendations that cow milk should be introduced after 12 months of age, may have been encouraged by the tendency for caregivers to serve sorghum porridges with UHT cow milk or home produced cow or goat milk.

Our data also showed that the introduction of water, UHT-milk, milk from home-reared cows or goats, tea, and sorghum porridges during the first six months of life did not confer statistically significant physical growth advantages to children. Conversely, supplemental infant formula improved the children’s WA and WH z-scores compared to other supplemental fluids. We also found a highly significant (p < 0.001) relationship between supplemental formula and maternal employment outside the home (Table 5). Although no specific explanations for the high prevalence of supplemental formula feeding among employed mothers were sought, we speculate that the work imposed periods of separation between the mother and the baby may have played a role. In some studies, employment outside the home was associated with the choice of formula-feeding and subsequent cessation of breastfeeding by some mothers [12-14]. Within Botswana, positive associations between maternal employment and supplemental formula feeding have previously been established [9,10,15], with twenty-eight percent (28%) of mothers in Botswana citing work commitments as their number one reason for discontinuing breastfeeding in some studies [9,10,16]. These observations suggest that formula feeding, which may have been meant to provide for the child only in the mother’s absence, eventually became a complete breast milk replacement. In other studies, intake of infant formula, particularly through feeding bottles, was shown to hasten breastfeeding discontinuation by some mothers [12,17].

Sorghum porridges were significantly correlated with lower WA and WH z-scores. Since children cannot tolerate thick porridges that are usually prepared for adults, thinner consistencies were preferred. The thin porridges, locally referred to as motogo, are less nutrient dense compared to thicker porridges and may explain the prevalence of acute and current nutritional stress. Porridge use in complementary feeding is not unique to Botswana. Porridge (maize, sorghum, or millet) use in complementary diets has been reported in several other studies in less developed countries [18-20]. In one of these studies, porridge was preferentially given to children perceived to be young for their age or perceived as unsatisfied by their mother’s milk [18]. Our findings are therefore similar to observations made in other parts of the developing world, although in some studies, porridges were made of maize instead of sorghum [18].

Sorghum is a drought resistant crop and performs better than maize in Botswana, because of the country’s semi-arid climate [21]. Earlier studies also found sorghum and UHT cow milk among the most common complementary foods (and fluids) used in Botswana [10], with 47% and 72% of mothers choosing porridges nationally and in villages respectively. Food availability and access may, therefore, have been a determining factor in what foods were included in the diet of the children.

These findings underscore the central role of appropriate complementary feeding in the growth of children under five years of age. These findings also suggest that the benefits of the high breastfeeding initiation rates and the long duration of breastfeeding are undermined by the nutritionally inadequate complementary foods and fluids offered to children. Caregivers need practical guidance on how to improve the nutrient density of sorghum porridges and to delay the introduction of fluids and foods that offer no growth advantages. Such guidance should focus on aiding caregivers to purposefully feed their children so that they can attain and maintain adequate growth and development.

ACKNOWLEDGEMENT

Funding for this study was provided by the Miriam J. Kelley African Scholarship Grant Program at Michigan State University and Dr. Jenny Bond, professor of Human Nutrition at Michigan State University. Authors also thank women and children who were participants in this study.

Table 1
Characteristics of Target Children and Their Caregivers

Variable

N (%)

Sex

Boys
Girls

69 (52.0)
63 (48.0)

Child's birth weight (from records

<2.5 kg
>2.5 kg

9 (7.1)
117 (92.9)

Primary caregiver

Mother
Grandparent
Other adult relative
Other

80 (60.6)
32 (24.2)
10 (7.6)
10 (7.6)

Proportion of

Teenage mothers (15-19 yrs)
Mothers employed outside home
Fathers employed outside home

8 (6.2)
45 (34.1)
98 (74.2)

Mother's level of formal education

None
Primary
At least secondary

21 (15.9)
33 (25.0)
78 (59.1)

Head of household

Father
Grandparent
Mother
Other

68 (51.5)
49 (37.1)
11 (8.3)
4 (3.0)


Table 2
Age at Introduction of Complementary Food & Fluids

Child's age at introduction of foods (months)

Number (percentage) of children introduced to the following fluids/foods

Water

Infant formula

UHT cow milk

Tea

Other milk

Solids

< 1 Month

81 (64.3)

28 (44.4)

0

0

2 (7.7)

2 (1.7)

2-3 Months

14 (11.1)

19 (30.2)

3 (3.9)

2 (3.0)

2 (7.7)

12 (10.1)

4-6 Months

30 (23.8)

11 (17.5)

37 (48.7)

13 (19.7)

9 (34.6)

101 (84.9)

> 6 Months

1 (0.8)

8 (7.9)

36 (47.4)

51 (77.3)

13 (34.6)

4 (3.4)


Table 3
Feeding Practices

Variable

N (%)

Child ever breastfeed

Yes
No

128 (97.0)
4 (3.0)

Proportion of children whose duration of breastfeeding was1

< 6 months
7-12 months
13-18 months
19-24 months
Over 24 months

15 (23.1)
15 (23.1)
22 (33.8)
12 (18.1)
1 (1.5)

Primary complementary food

Sorghum porridge - regular
Sorghum porridge - fermented
Commercial baby food
Other
None2

91 (68.9)
12 (9.1)
11 (8.3)
13 (9.8)
5 (3.8)

Primary food served

Milk
Milk and sugar
Beans/Vegetables
Variety of foods
Nothing (just by itself)

51 (41.5)
31 (25.2)
12 (9.8)
17 (13.8)
12 (9.8)

1The average duration of breastfeeding for all children was 13.4 months
2Children not introduced to solids

Table 4
ANOVA and Tukey's Post Hoc Comparison of Mean Z-Scores by Child's Age

Growth Index/Age

F-Statistic1

Cell Sizes (N)

Mean Z-score
Subset 1

Mean Z-score
Subset 2

Height-for-age z-scores


>25 months
13-24 months
7-12 months
3-6 months

3.08*

34
47
31
20

-1.14
-0.88
-0.51
--

--
-0.88
-0.51
-02.4

Weight-for-age z-scores


>25 months
13-24 months
7-12 months
3-6 months

9.30**

34
47
31
20

-1.03
-1.00
-0.58
--

--
--
--
0.48

Weight-for-hieght z-scores


>25 months
13-24 months
7-12 months
3-6 months

7.75**

34
47
31
20

-0.61
-0.36
-0.18
--

--
--
--
0.79

1Degrees of Freedom (DF) for the F- statistics are: DF between groups 3, DF within groups 128
*p<.05 **p<.001


Table 5
Effect of Primary Complementary Foods on mean HAZ, WAZ and WHZ

Nutrition Index/Type of Complementary Food

N

Mean

T-Statistic

Height-for-age z-scores


Sorghum
Other foods

Sorghum serverd with milk
Sorghum served with other foods/relishes

103
29

82
50

-0.82
-0.54

-0.85
-0.61

-1.10

-1.11

Weight-for-age z-scores*


Sorghum
Other foods

Sorghum serverd with milk
Sorghum served with other foods/relishes

103
29

82
50

-0.83
-0.17

-0.89
-0.36

-2.60*


-2.41*

Weight-for-hieght z-scores*


Sorghum
Other foods

Sorghum serverd with milk
Sorghum served with other foods/relishes

103
29

82
50

-0.37
0.28

-0.44
-0.11

-2.68*


-2.63*

*p<.05


Table 6
Influence of Supplemental Infant Formula on Z-scores, Breastfeeding Duration and Timing of Solids

Characteristics

With Supplemental Infant Formula

Without Supplemental Infant Formula

Independent Sample
t-test

N

Mean (SE)

N

Mean (SE)

N-13

T-statistics

Weight-for-age z-scores

62

-0.43 (0.17)

70

-0.91 (0.14)*

131

2.21

Weight-for-height z-scores

62

0.02 (0.15)

70

-0.45 (0.14) *

131

2.33

Height-for-age z-scores

62

-0.64 (0.15)

70

-0.87 (0.14)

131

1.07

Breastfeeding duration (months)1

31

10.30 (1.60)

34

16.20 (1.10)*

64

3.10

Age at introduction of solids (months)2

58

4.04 (0.14)

68

4.44 (0.16)*

125

2.00

*p<.05
1Data from mothers who had stopped breastfeeding before the study
2Excludes 5 children who were not introduced to solids
3Degrees of Freedom


Table 7
Infant Formula Use and Employment Status

Variable

Mother Employed N (%)

Yes

No

Infant formula use

Yes
No
Total

30 (67)
15 (33)
45 (100)

32 (37)
55 (63)
87 (100)

Pearson Chi-Square

10.64***

***p<.001

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