ABSTRACT
The study was undertaken to assess the feeding practices, anthropometric indices, vitamin A, zinc and iron status of under-five orphans living in Federal Capital Territory orphanages, Abuja. A cross sectional descriptive study was conducted using 200 orphans (96 males and 104 females) aged between 0-5 years living in ten orphanages. The subjects were purposively selected for the study and 20% of sub-sample was randomly selected for biochemical analysis and weighed food intake assessment. Haemoglobin (Hb) and serum ferritin were used to assess anaemia and iron status, respectively. Serum retinol was used to assess vitamin A status and serum zinc was used to assess zinc status. The subjects were screened for malaria parasites and worm infection to determine their possible impact on anaemia. C-reactive protein (CRP) was used as an indicator for inflammation. Anthropometric information was assessed using height, weight and mid upper arm circumference. Feeding practices and socioeconomic information were assessed using questionnaires. Dietary intake was determined using both food frequency questionnaire and weighed food intake techniques. The values obtained from nutrient intakes were compared with FAO/WHO recommended nutrients intake. Anaemia cut off was Hb < 11.0mg/dl, iron deficiency cut off was serum ferritin levels below 12ug/dl and serum retinol < 20µg/dl showed marginal vitamin A deficiency. Zinc deficiency was defined as a reading bellow 80µg/dl. There was high prevalence of zinc deficiency (60.0%) in relation to 30.0% of iron and 20.0% of vitamin A deficiencies among the under-five children. The prevalence of anaemia was 42.5%. The children met the mean daily energy, protein, calcium, iron, thiamin and riboflavin intake. Zinc, vitamin A, niacin and ascorbate were below the recommended allowance. When dietary iron, zinc and vitamin A intake were correlated with the biochemical status of the children, adequate dietary iron intake significantly (P<0.05) correlated with good ferritin and zinc status of the children. Inadequate dietary zinc intake was significant (P<0.05) and correlated with inadequate zinc and ferritin status of the children. Adequate dietary zinc intake was significant (P<0.05) with serum zinc status. Adequate dietary vitamin A intake reflected significantly (P<0.05) with serum retinol. Inadequate vitamin A intake significantly (P<0.05) correlated with serum zinc. The study recorded a low prevalence (7.5%) of inflammatory disorders. Malaria parasite and worm infestations were also low in the children (12.5% and 10.0%, respectively). Anaemia was significantly associated with helminthes infestation as well as malaria parasite. The study showed that the caregivers practiced a faulty feeding practice. The under-five children were feed infrequently as against the recommended frequency of meal feeds across various age groups. The children were not fed “responsively”. About 45.5% of the children were underweight. About 63.5% of the children were stunted and 47.5% were wasted. These deficiencies were associated with poor feeding practices, low caregiver to child ratio (1:5) and low socio-economic status. The study shows that protein energy malnutrition and micronutrient deficiency are still of public health important in Nigeria.
CHAPTER ONE
1.0 INTRODUCTION
1.1 Background to the study
‘Today’s children are tomorrow’s leaders’. This slogan is raising a massive wave of concern throughout the world. However, children all over the world are deprived of many facilities. Children need various types of support ranging from those things necessary for survival, such as food, adequate nutrition and health care, to those interventions that will provide a better quality of life in the future such as education, psychosocial care and economic self-sufficiency. Ideally, all children should have access to these high quality services. Realistically, this is not the case because most children residing in developing countries, especially orphans are malnourished, sick, without shelter and proper education.
Child malnutrition is the most widely spread disorder in Sub-Sahara Africa. Malnutrition is recognized as a consequence of poverty. It is viewed in the context of violation of child’s human rights. Malnutrition is caused by inadequacy or over-consumption of one or more of the essential nutrients necessary for survival, growth and reproduction (Smith & Haddad, 2000). Under nutrition in all its forms is a significant public health concern. It is the underlying factor in over 50% of the deaths from under five preventable diseases annually (UNICEF, 2001). Poor nutrition severely hinders personal, social and national development. Inmany regions of the world, the onset of stunting is within the first fewmonths of life. Wasting and under nutrition progressivelycontinue through the first two years of life. About one-third of the children less than five years of age are short and underweight for their ages (Jones, Steketee, Black, Bhutta & Morris, 2003). Studies have shown that, this is the peak age for growth faltering, deficiencies of most micronutrients, and common childhood illnesses such as diarrhoea (Martorell,Kettel & Schroeder, 1994). To grow, the children need to consume adequate amounts of energy, protein, calcium, iron, zinc and other nutrients. Failure to provide the extra nutrients precipitates deficiency of essential micronutrients prevalent among children in developing countries, including Nigeria. Under nourished under-fives are unable to learn and this is carried to adult life. The most devastating to under-fives is micronutrient deficiencies of vitamin A, iron and zinc. These combined can cause impaired growth, impaired mental development and learning capacity. The brain, central nervous system and immune systems are all affected when iron and zinc are deficient, other effects includes stunting wasting and underweight.
Nutrition is linked to most of, if not all the Millennium Development Goals (MDG), which are closely interlinked. The right to food and good nutrition for all is fundamental to achieving the MDGs (United Nations, 2002). The first goal (MDG-1) is emphatic on the eradication of extreme hunger and poverty. The prevalence of underweight in under-five children is an indicator for achieving this goal. MDG-4 talks about reduction of child mortality. Malnutrition which is preventable, accounts for up to 53% of all deaths in under-five children and remains the underlying cause of most child mortality. To achieve the Millennium Development Goals (MDG-1) for child survival and the prevention of malnutrition (MDG-4), adequate nutrition and health during the first few years of life is fundamental (United Nation, 2002). Poor feeding practices, coupled with high rates of infectious diseases, are the principal proximate causes of malnutrition during the first few years of life (WHO, 2005).
Infant feeding is a critical aspect of caring for infants and young children. An appropriate feeding practice during infancy and early childhood is fundamental to the development of each child’s full human potential. Economic analysessuggest that the challenge of achieving optimal feeding forinfants and toddlers is often as much related to ignorance aboutfeeding and food choices as to scarcity of food (Global Health Council, 2006). Infant and young child’s feeding practices such as breastfeeding and complementary feeding are major child survival strategies especially in developing world. Improving the quality of infant feeding practices was citedas one of the most cost-effective strategies for improving healthand reducing morbidity and mortality in young children (UNICEF, 2007). Studies indicated that, nearly one-third of child deaths could beprevented by a combination of exclusive breastfeeding for 6months, optimal complementary feeding practices, iron, zinc and vitaminA supplementation (Shrimpton, et al., 2006).
Micronutrients are nutrients required by the body in small amount for proper body functions (Sandstrom, 2001). Micronutrients which include vitamins and minerals play vital roles in body growth and development, reproduction, brain functions and resistance to diseases among others. Vitamin A, iron, iodine and recently zinc are the major micronutrients of public health importance especially in developing country like Nigeria (UNICEF, 2007). This is because of the magnitude and seriousness of their deficiencies and consequences on health, learning capacities and productivity of affected people. Micronutrient deficiencies increase morbidity and mortality rates not only in children under-five years, pregnant and lactating mothers, who are more vulnerable but also to the general populace including vibrant adolescents (Bryce, Boschi-Pinto, Shibuya & Black, 2005). It is generally known that the prevalence of malnutrition and micronutrients deficiency increases rapidly in under-five children because of rapid growth and development, therefore deficiency of these nutrients jeopardises the normal health, growth and development of the child. Children may look healthy and their diets may provide adequate energy and protein but are lacking in micronutrients. This is referred to as “hidden hunger”.
Iron is one of the trace mineral that play a vital role in the body. It is an integral part of many proteins and enzymes that maintain good health. It is an essential component of protein responsible for distributing oxygen throughout the body. It plays a central role in metabolic processes involving oxygen transport and storage as well as oxidative metabolism and cellular growth (Serene, Jack, & James, 2003). Iron deficiency most commonly manifest as anaemia. In Africa iron deficiency occurs more often amongst premature infants, growing children and pregnant women. Studies have shown iron deficiency anaemia to be associated with increased morbidity and mortality rates (UNICEF, 2009).
Anaemia prevalence is high in children and its cause is frequently multifactorial. It has been estimated that about 40% of the world’s population (more than 2 billion individuals) suffer from anaemia with a prevalence of 48% in school-aged children (Shell-Duncan & Mcdade,2005). Anaemia occurs as a result of abnormally low haemoglobin due to pathological conditions. Iron deficiency is one of the most common causes of anaemia, other causes include chronic infections such as malaria, worm infestation, hereditary haemoglobinopathies and other micronutrient deficiency particularly folic acid and vitamin C (WHO, 1999).
Vitamin A is a fat soluble vitamin that is of great significance to the body especially its role as immune booster and for health eye sight. Vitamin A deficiency (VAD) is a major public health problem. The most vulnerable group for VAD includes under-five children and pregnant women in low-income countries. In children, VAD is the leading cause of preventable visual impairment and blindness. Twenty six percent of vitamin A–deficient children live in Africa, with the largest number in Ethiopia (UNICEF, 2009). VAD affects almost 1 in every 3 children in Nigeria (WHO, 2007). World Health Organization has classified Nigeria among 34 countries in the world with serious problem of VAD related nutritional blindness and xerophathalmia (WHO, 2007). VAD significantly increases the risk of severe illness and death from common childhood infections, particularly diarrheal diseases and measles (FAO/WHO, 1992).
Zinc is a trace mineral needed by human body in small quantity but of great importance for child survival. Zinc deficiency is wide spread in developing countries and the most vulnerable groups are infant, children, pregnant women and lactating mothers (ACC/SCN, 2000). It is marked by growth retardation or stunting. In period of rapid growth zinc requirement is normally high and where this demand is not met, problems like growth retardation may arise (Micronutrient Initiative, 1998). Zinc enhances the transport of vitamin A in and out of the cells and its deficiency is thought to have a close link with iron deficiency. Zinc participates in carbohydrate and protein metabolism, DNA and RNA synthesis among other functions (FAO/WHO, 1992).
Globally, nutritional status is considered the best indicator of the well being of young children and a parameter for monitoring progress towards the Millennium Development Goals (MDGs). Nutrition and health status have powerful influence on a child’s learning and how well a child performs in school. The nutritional status of under-five children is of particular concern because, their early years of life are crucial for future growth and development (Prechulek, Aldau & Hasan, 1999). Apart from chronic undernutrition experienced by under-five children, they also suffer from parasitic infections and hunger (SCN, 2000). Hunger is the physiological state that results due to inadequate food to meet the energy needs. Chronic hunger leads to undernutrition, causes growth failure and weakness. Hunger reduces energy and strength; it diminishes concentration, impairs a child’s ability to learn and equally affects the health of the child (Carol, Gaile, Donna & Jacqueline, 2009).
Over 140 million children under the age of 18 in the developing world have lost one or both of their parents. In sub-Saharan Africa alone there are 43 million orphans, representing more than 12% of all children (UNAIDS, UNICEF & USAID, 2004). Sub-Saharan African countries are already struggling to eradicate extreme poverty. This unprecedented burden of orphan populations is further reducing resources within households and communities. As a result, orphans are made vulnerable to a variety of risks, including poverty, school dropout, malnutrition, micronutrient deficiency and other forms of child deprivation. For Nigerian children, the impact of the attendant challenges in the health sector especially HIV/AIDS, education and social welfare has occasioned situations of neglect of basic rights leading to increased vulnerability of over 69 million population under eighteen years in the country (Federal Ministry of Women affaires and Social Development, 2007).
Nigeria like many developing countries in Africa is still far from reducing the rates of infant and under-five mortality. Nigeria is a signatory to the United Nation’s Convention on the Rights of the Child (CRC) and the African Union Charter on Rights and Welfare of Children (AUCRWC). The two declarations emphatically require signatory State Parties to ensure the recognition and enforcement of the rights of children to life, name, home and family environment, adequate nutrition, health, education as well as protection from all forms of abuse, exploitation, inhumane treatment, and the freedom of self expression, privacy and leisure. These rights are extended to all children including the orphans (United Nation, 1986; UNICEF, 2004). Orphans risk losing opportunities for adequate education, health care and proper nutrition. This is because most orphans live without care, love, affection and security available within a family environment. They are exposed to neglect, violence, exploitation and all forms of abuse (John, Lori, Neff & Roland, 2011). Although empirical evidence examining the negative effects of orphanhood is growing, there remains much uncertainty as to how it affects child nutritional status. Only a handful of studies have been published that examined the effect of orphanhood on child nutritional status. One of the major challenges facing governments, international organizations and NGOs in their response to orphanhood is the lack of data on the situation of orphans. This has made it difficult in designing quality interventions tailored at improving the well being of the orphans.
1.2 Statement of the problem
Infants and young children are one of the vulnerable groups in the society. They are more vulnerable when they are denied their rights to proper feeding and good nutrition. Nigeria ranks 14th in global assessment of under-five mortality rate and approximately one million children die annually in Nigeria before their 5th birthday (UNICEF, 2006). Nigeria is among the 20 countries in the world that account for 80% of undernourished children. The causes of this public health problem in Nigeria are complex and multidisciplinary. However, poor quality and quantity of foods given to children play a major role (Bryce, Boschi-Pinto, Shibuya & Black, 2008). There are more orphanages in the country presently than before.
A study of orphanages conducted by the Federal Ministry of Women Affairs & Social Development (FMWA & SD) in 2007 showed that over 150 orphanages exist in Nigeria and the establishment of half of these orphanages occurred over a period of 50 years (1940 – 1990). It took only 15 years (1991-2000) to establish the other half. This indicates that more orphanages were founded in recent times than previously. They are distributed across the thirty six states of the country including the Federal Capital Territory (FMWA & SD, 2007). Basic indicators as indicated by the Nigeria Demographic and Health Survey reveal no significant improvement on the health status of the Nigerian children between 2003 and 2008 (NDHS, 2003; NDHS, 2008).
About 50% of the current 138 deaths per 1000 live births could have been averted if the children were not malnourished. FCT under-five mortality rate is 152 deaths per 1000 lives birth (MICS, 2011). The prevalence of malnutrition among orphans and vulnerable children under-five years of age in Nigeria is as follows: 22 percent of orphans are underweight, 33 percents of them are stunted while 11 percent are wasted (NDHS, 2008). A survey conducted by MICS (2011) showed the prevalence of malnutrition among under-five children in the FCT as follows 46.8% of the children were moderately underweight, while 22.0% of them were severally underweight. 65.1% of the children were moderately stunted while 40.5% of the children were severely stunted. On the other hand, 14.2% of them were moderately wasted while 4.8% of them were severally wasted. From field experience about 35% of children seen in rural communities of the FCT are malnourished.
The prevalence of vitamin A deficiency in the country for under-five children is 29.5%. About 27.5% of children under-five in Nigeria were iron deficient while 20.0% of the under-five children were zinc deficient (Maziya Dixon et al., 2004). It is worthy to note that this survey was conducted on non-orphans. No large scale surveys have been conducted in respect to micronutrient status of orphans in the FCT. Only a few studies have examined the impact of orphan status on child health and nutrition. Children under-five are particularly more vulnerable to the effects of orphan hood because they are undergoing rapid development and require nurturing, proper care, and adequate access to food and health care services.
Inconsistent findings make it difficult to assess if orphans have specific nutritional needs separate from those children that are not orphaned (FMWA & SD, 2007). Out of 37, 532 orphans who participated in a survey conducted by FMWA & SD in 2008, 12.4% of the children assessed went to bed hungry in the four weeks preceding the survey. The reason for this was lack of food. This is the only information reported on nutrition in this National survey. A study conducted by World Bank noted that, orphaned children are more likely to have stunted growth and overall poor health, mainly because of unmet nutritional needs (World Bank, 1997). In Uganda, studies showed that orphans’ health and nutrition status were worse than that of non-orphans (Wakhawenya, 2002). However, there is also some research showing no significant difference in child well-being between orphans and non-orphans (Ainsworth, Martha and Innocent, 2002).
Despite the inconsistencies in these findings, there are compelling reasons to hypothesize that children whose parents are deceased face unique vulnerabilities, including fear, instability, insecurity, lack of basic education, proper care, poor health and nutrition. Information on the nutritional status of orphans in Nigeria is limited and is much more limited in the FCT. There is need for nutritional inputs in intervention programmes for orphans in FCT orphanages and indeed the whole country. It is only an evidenced based data that will propel such interventions. In view of this, a study into the feeding practices of the orphans as well as their nutritional status including micronutrients status becomes pertinent.
1.3 Objectives of the study:
The general objective of the study was to assess the feeding practices, anthropometric, vitamin A, iron and zinc status of the under-five children in the orphanages of Federal Capital Territory.
The specific objectives were to:
- assess the feeding practices of under-five children in FCT orphanages.
- assess the anthropometric status of the under five children in FCT orphanages using weight, height/length and mid upper arm circumference.
- assess vitamin A, iron and zinc status of under-five children in FCT orphanages using biochemical method
- assess the nutrient intake of the under-five children using weighed food intake.
- determine the relationship between the dietary intakes of zinc, vitamin A and iron with the biochemical status of the under-five children
- determine the relationship between anthropometrics indices with biochemical status of the children
- determine factors in the orphanages that influence the nutritional status of the children.
1.4 Significance of the study:
This study would provide information on the nutritional status of the under-five children in the orphanages of FCT as well as their feeding practices. It will provide data on the micronutrients status (vitamin A, iron and zinc) of the under-five children in orphanages of FCT. The generated data and information will be an evidence for strong advocacies to policy makers and stakeholder, which will subsequently inform their decisions on, appropriate nutrition intervention programmes geared towards improvement of the lives of orphans in FCT and Nigeria as a whole. It will also form a based line data for other researchers that would want to work on under-five nutritional status especially among orphans and vulnerable children.
CHAPTER TWO
2.0 LITERATURE REVIEW
2.0 Literature is reviewed under the following main headings:
- Orphans
- Feeding Practices
- Micronutrients
- Assessment of nutritional status
- Factors that influence the nutritional status of the children
2.1 Orphans and Orphanages
An orphan is defined as a child under 18 years who has lost either or both parents and can be further categorized as maternal, paternal or double (both parents deceased) orphan (UNICEF, 2004; FMWA & SD, 2007). Orphanages care for orphans as well as other children who are abandoned but whose parents may be alive. Some orphanages provide care for children whose parents are both alive but could not give sufficient care to their children as a result of poverty (FMWA&SD, 2007).
According to Federal Ministry of Women Affairs & Social Development, categories of vulnerable children include children who have lost one or both parents; children living with ill parents; children on the street/child hawkers; children living with aged or frail grand parents; children who got married before 18 years; neglected children; abandoned children; children infected with HIV; destitute children; internally displaced or separated children; child domestic servant; child sex workers; children with special challenges or disability or whose parents have disability; trafficked children; children who have dropped out of school. Orphans constitute a major category among these vulnerable children in Nigeria (FMWA&SD, 2007).
2.2 Prevalence of orphans and vulnerable children (OVC) in Nigeria
A study conducted by the Federal Ministry of Women Affairs and Social Development on the 2008 situation assessment and analysis on orphans and vulnerable children (OVC) in Nigeria showed that: about a quarter of children in Nigeria are orphans. Considering the fact that about 41% of the 140 million population of Nigeria are children (NPC, 1991; NPC, 2006); their study suggests that up to 14 million children in Nigeria could be classified as orphans. Other studies reported an estimation of 7million orphans in Nigeria as at 2010 with HIV/AIDS epidemic being one of the major contributing factors (UNAIDS, UNICEF & USAID, 2004).
2.3 Causes of orphans and vulnerable children (OVC) in Nigeria
As the HIV/AIDS epidemic progresses, more children become orphaned and vulnerable. One of the outcomes of HIV epidemic has been an increased number of children who have been orphaned or whose social and economic vulnerability has increased due to the serious illness of a parent. In Nigeria 7% of children aged 0-17years are living with neither parent. Studies by UNICEF and other agencies in Nigeria have reported projected/estimated population of different categories of orphans and vulnerable children at different levels (e.g street children, abandoned children, child beggars, street urchins and children orphaned by AIDS) (UNICEF, 2007).
It is estimated that up to 10.7% of estimated 69 million Nigerian children may be categorized as orphans and vulnerable children. By 2010, 8.2 million children are projected to be orphans from all causes (FMW&SD, 2007). Federal Ministry of Health (2006) confirmed the increasing vulnerability of children due to the AIDS epidemic in Sub-Sahara Africa (FMOH. 2006). A 2002 World Bank survey conducted in 12 states in Nigeria highlighted parental death resulting from accidents (42%), ethnic/communal conflicts (22%), maternal mortality (17%) and HIV/AIDS (11%) as causal factors of orphanhood and vulnerability among children.
2.4 Feeding practices
The provision of adequate nutrition during infancy and early childhood is a basic requirement for the development and promotion of optimum growth, health and behaviour of the child. Adequate nutrition is defined as the intake and utilisation of enough energy and nutrients to maintain the child’s well being, health and productivity. The causes of malnutrition in Nigeria are many and complex. The immediate causes of malnutrition in the first two years of life are inappropriate breastfeeding and complementary feeding practices (UNICEF, 2007). The Federal Ministry of Health (FMOH), recommends that all mothers shall be encouraged to exclusively breastfeed their babies on demand until the age of 6 months, (with no water or other liquids including breastmilk substitutes). Complementary feeding should commence when the infant is six months old. Infants are particularly vulnerable during this transition period when new foods are introduced. Therefore mothers and care-givers should be encouraged to practice responsive feeding using the principle of psycho-social care (FMOH, 2007).
FMOH also recommended that for the motherless/adopted infants and young children, re-lactation of a foster mother or caregiver who is HIV negative shall be encouraged such foster mothers or caregivers shall remain HIV negative throughout the period of breastfeeding. Caregivers shall be supported to feed the infants on breastmilk substitute from birth to six months, if the child is not breastfeeding. Caregivers shall be counselled to introduce locally sourced complementary foods from the age of six months in addition to milk feeds and subsequently introduction of family foods at eight months as the case may be (FMOH, 2007).
Feeding practices during infancy are critical for the growth, development and health of a child during the first two years of life. The linear growth retardation acquired early in infancy cannot be easily reversed after the second year of life. In this context, providing infants with optimal feeding should be the key objective of a global strategy to guarantee the nutrition safety of a population. This is very important for the early prevention of chronic degenerative diseases. Progress in improving infant and young child feeding practices in the developing world is remarkably slow (Ruel et al, 2003). Under-five children are fed according to their age, as they grow their food intake increases as well as type of food. Their feeding practices includes; breastfeeding, replacement feeding, complementary feeding and family food.
2.5 Breastfeeding
Breastfeeding is the act of giving infant breast milk while exclusive breastfeeding can be defined as giving infant only breast milk for six months including expressed breast milk. With the exception of drops or syrups consisting of vitamins, mineral supplements, or drugs,no food or drink other than breast milk not even water is allowed (FMOH, 2007). The 1990 innocenti Declaration empowers all women to breastfeed their babies exclusively for six months and continue breastfeeding with appropriate complementary feeding practices for two years and beyond. This will help reduce infant and young child morbidity and mortality rate including malnutrition (WHO, 2000).
Surveys have shown that exclusive breastfeeding for six months is the best way of feeding infants for optimal growth and development (Nduati, John & Mbori-Ngala 2000). Infants who were never breastfed during the first two months are more likely to die than those who were breastfed especially for a longer duration. Longer duration of breastfeeding, leads to increased chances of child survival (FGN/UNICEF, 2007). Breast milk contains white blood cells, and a number of anti infective factors, which help to protect a baby against many infections. Breastfeeding protects babies against diarrhoeal and respiratory illness and also ear infections, meningitis and urinary infections. Colostrums the special milk produced within few days after delivery contains immunoglobulin IgA which is protective against bacteria especially E. coli (Nduati, John & Mbori-Ngala, 2000).
Human milk promotes the growth of acid forming bacteria flora in the intestinal tract. The growth of this acid forming bacteria creates a hostile environment for some pathogenic bacteria and parasites. Lactoferrin a protein found in human milk prevents the growth of some pathogenic bacteria by denying them iron. Breast milk contains 35% casein protein and 65% whey protein which is easily digestible by the baby. It has amino acids (cystine and taurine) and essential fatty acids that promote brain development. Breast milk prevents allergy, overweight, obesity, diabetes and some cancers in children (WHO, 2000). Woman known to be HIV negative can breastfed a baby that is not hers. This is also applicable in the events when the mother is temporary unavailable or death of mother as in the case of orphans. On the other hand, breast milk could be expressed and heat-treated under pressure to 62.5 oC for 30 minutes for each feed and allowed to cool. The baby is then fed using clean cup, within 1 hour of boiling. All of these allow the baby to enjoy the benefit of breastfeeding even if the biological mother in unavailable (FMOH, 2007).
2.5.1 Composition of breast milk
2.5.1.1 Colostrum
This is the special breast milk that women produce in the first few days after delivery. It is thick, and yellowish in colour. It contains a lot of antibodies that offer protection to the baby. Its composition is very different from the mature milk which is produced at the end of the first week of lactation. Colostrum contains five times more protein than the mature milk, 20% of which is casein (FMOH, 2007). The majority of the other 80% of protein is secretory immunoglobulin A (IgA). The rest is other whey proteins such as lactoferrin and lysozyme. Lactoferrin is an iron-binding protein which helps iron absorption from the gut. Lysozyme inhibits bacterial growth in the gut. There is les fat and carbohydrate in colostrums than in mature milk. Colostrum contains all of the known vitamins. The trace elements present are bound to protein to form parts of enzymes (FMOH, 2011).
2.5.1.2 Mature milk
Mature milk is of two types; the foremilk and hindmilk.Foremilk is the thinner milk that is produced early in a feed. It is produced in large amounts and provides plenty of protein, lactose, water and other nutrients while hindmilkis the whiter milk that is produced later in a feed. It contains more fat than foremilk which is why it looks whiter. The fat provides much of the energy from breast milk. The protein content is les than colostrum; it is predominantly soluble whey proteins and contains immunoglobulins A, G and M (IgA, IgG, IgM) as well as lysozyme and lactoferrin. It is important for a baby to have both foremilk and hindmilk. To get the complete nutrient the baby needs to empty one breast before switching over to other breast. There is no sudden change from ‘fore’ to ‘hind’ milk. The fat content increases gradually from the beginning to the end of a feed (UNICEF, 2007).
2.6 Replacement feeding
When a child is not receiving any breast milk, replacement infant feeding option is used. As the name implies, it is a way of feeding an infant who is not receiving any breast milk with a diet that provides the entire child’s need during the first six months of life until the child can receive complementary foods or family food. This is done with a suitable breast milk substitute or infant formula. Infant formula is a special food for infants, suitable as a complete or partial substitute for human milk. The milk is gotten from cow or goat but cow’s milk is the common infant formula because of its acceptability and availability. The major advantage of breastfeeding is provision of antibodies that impart immune protection to the infant which is not found in the cow’s milk. Cow’s milk contains 80% casein protein and 20% whey protein. Casein forms thick, indigestible curds in a baby’s stomach resulting to milk intolerance (FMOH, 2007).
In developing countries, the replacement of breastfeeding with bottle feeding often leads to an increase in infant mortality. This is due to poor handling of feeding utensils which predisposes the infant to many diseases like diarrheoa. This subsequently, leads to an increase in incidence of malnutrition and death (Prechulek, Aldena & Hasan, 1999). Replacement feeding requires clean water, clean utensils and clean environment for proper preparation of formula. There has to be optimal hygiene practices for babies to survive and thrive on infant formula (FMOH, 2007). Infant formula could be Commercial Infant Formula or Home Modified Animal milk.
