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This paper identifies 3 research questions using our experience
with socioeconomic changes in Tunisia as an example.
Tunisia has always adopted the WHO/UNICEF recommendations concerning
children's nutrition, especially breastfeeding and complementary feeding. This paper analyses different studies conducted in Tunisia concerning feeding practices and their effects on growth, morbidity, and mortality in childhood. The results obtained during 2 periods are
presented: the first 20 years after independence (before 1976) and the
second 20-year period (situation in 1996).
Before 1976
Feeding Practices
Most infants were breastfed
84% to 99%,1-3 and
the mean duration was 15 months. The mean length of exclusive
breastfeeding was 6 months. Breastfeeding was less common in urban
communities. This was not explained by mother's occupation but it was
rather because of her ignorance regarding good child feeding practices. Most studies emphasized the lack of complementary feeding starting from
the second semester of life.4 The age of introduction of
the first nutriment was variable according to regions. The first
complementary foods were most commonly (>60%) wheat flour gruels and
watered biscuit. Bread was introduced at 5 months. Legumes were rarely
given. Eggs, meat, and fish were not introduced until 12 months.
Growth
Low birth weight (<2500 g) was present in only 7% to
9%.5,6 Children grew well until the age of 5 to 6 months7,8; then, growth often declined with the
introduction of inadequate complementary foods and continued to decline
until 24 months. According to the Gomez classification, wasting was
common (50%-60%) among children <5 years old, with a peak
prevalence in the second year of life. Kwashiorkor became less frequent
(3.5% in 19698; 1.6% in 19733); mortality
remained high (30%-40%). Mean duration of exclusive breastfeeding
was the same during this period, the decrease in prevalence of severe
malnutrition can be explained by the improvement of the quality of
complementary feeding. In 1969, more than a half of healthy infants 6 to 9 months old had received no complementary foods indicating that
exclusive breastfeeding had fully satisfied their nutritional needs.
Early introduction of complementary foods, which contain potentially
allergenic proteins and may be bacterially contaminated, should be
avoided.
1994
A national and global policy was introduced in the 1970s to
improve the nutritional status of growing children. Weaning food mixes
made from local cereals and legumes were promoted and available throughout the country. The national survey conducted in
19949 evaluated the results and these can be compared with
the "before 1976" figures above.
Feeding Practices
Breastfeeding was still widely practiced (94%). This was little
affected by the educational achievement of the mothers, socioeconomic level, or birth rank but older primiparae breastfed less frequently (80%). The mean duration of breastfeeding was 15 months. It was longer
for women who had never gone to school (18 months) and for mothers
older than 40 (21 months). However, the mean length of exclusive
breastfeeding was 1.6 months only. Before the age of 4 months, 84% of
infants had received water, 66% had received herb tea, 41% had
received water with sugar, 19% had received infant formula, and 19%
had received household foods such as mashed vegetables or wheat flour
gruels (61% of infants had had these by 6 months). Family foods were
received by 48% of the infants at 7 months and by 88% of the infants
at 12 months. Weaning was abrupt in 58% of the infants.
Growth
Wasting was observed in 9% of children <5 years old (2%,
severe). The frequency of wasting was low before the age of 6 months (3.6%), reaching the highest rate between the ages of 6 and 12 months
particularly among whose mothers had not gone to school and with birth
intervals <2 years. Stunting remained frequent (22%, 9% severe). It
increased from 25% at 6 months to 31% between 1 and 2 years and then
declined to 19% at 2 years. Stunting was more frequent in rural
communities than in urban (33% vs 14%). It was more prevalent in
infants from mothers with short birth intervals (<2 years: 30%; >4
years: 17%) reflecting the benefit of family planning. The mothers'
education was a benefit (13% in the children of mothers who had been
to school vs 31% in children whose mothers had never attended school).
A total of 0.8% of children had kwashiorkor. These children were
primarily 1 to 2 years old, lived in rural communities, and their
mothers had not achieved a primary level of education.
Infection
Gastroenteritis with dehydration accounted for 17% to 22% of
hospitalizations during the period 1966-1972 and 24% of these infants
died.3 The action of the national diarrheal disease
control program had led to a reduction of this prevalence. Acute
respiratory infections were the second most frequent infection (18% of
hospitalizations.) They were severe and responsible for a high
mortality3 during the first 20 years. Measles used to be
very frequent and severe. However, since the institution of obligatory
immunization, it is no longer a public health problem. Infant mortality
was 1010/00 during
the period 1970-19749 and had considerably decreased to
350/00 during the
period 1990-1994.
Conclusion
The decrease of morbidity and mortality observed the last years
can be attributed to the several actions conducted in Tunisia to
improve the socioeconomic level, environmental health and hygiene, education, and family planning. Despite the high prevalence of breastfeeding, the mean duration of exclusively breastfeeding does not
exceed 2 months. The lack of exclusive breastfeeding in addition to
inadequate complementary feeding bring threats to infant health. The
growth of children often declines with the introduction of
complementary foods around the age of 6 months and continues to decline
up to 24 months. Public health efforts that focus only on prolonged
breastfeeding in developing countries will not ensure adequate
early childhood growth. Intervention programs can be designed
to promote exclusive breastfeeding, at least for 4 months, and to
enhance the energy and nutrient content of complementary foods by the
use of traditional household mixtures. Such programs and interventions
need to be carefully controlled and evaluated. It is also necessary to
determinate the most important factors affecting the caregivers'
ability to provide complementary feeding and the interactions between
nutrition, growth, and infection in childhood.
Research Questions
- Are there any advantages to complementary feeding before 6 months in developing countries?
- What is the impact of mothers' education on breastfeeding and
the introduction of complementary foods?
- How can the interrelationships between infant growth,
nutrition, and infection be better characterized?
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