Infant feeding and infant illness in a Micronesian village

01607987/X0/0201-0033102.00/0

INFANT

FEEDING AND INFANT ILLNESS A MICRONESIAN VILLAGE LESLIE B.

College of Nursing

and Department

IN

MARWAU.

of Physiology

and Biophysics.

The University of Iowa.

Iowa City. IA 52242. U.S.A. and MAC Department

of Anthropology.

MARS~~AL~

The University

of Iowa.

Iowa City. IA 52242. U.S.A.

Abstract-The 41 mothers of 49 infants resident in Peniyesene village, Truk. Micronesia. in 1976. were interviewed regarding their infant feeding practices and the types of illness their infants had experienced in the previous 2 years. Four-fifths of the infants received at least occasional bottlefeeding and nearly half of the infants were completely weaned from the breast before 6 months of age. Most mothers introduced semisolid foods in the first 6 months. The medical records for outpatient clinic visits and for admissions to the local hospital for these infants were also examined. and the occurrence of illness serious enough to warrant hospitalization was found to be associated with exclusive bottlefeeding in the first year of life.

Relationships between infant feeding habits and patterns of infectious disease in the first years of life have been examined in many areas of the world in devel-

preliminary evidence that bottlefeeding of infants as practiced there had an adverse effect on child health.

oping and industrialized nations. in temperate and tropical climates [l-7]. The role of bottlefeeding of infants in promoting the occurrence of infectious disease has been of particular concern in most of these studies and the importance of that role in various environments remains the subject of much debate [4.7,8]. Although the birth rate in Truk District of Micronesia is one of the highest in the world (4.5% per annum) and children two years of age or under made up 1I.472 of the total district population in 1973 [lo], the relationship between infant feeding and infant illness has not been investigated in this region. In the more than 20 years since the last detailed account of infant feeding practices in Truk was prepared as part of a larger survey [I 11, there has been a substantial increase in affluence, educational opportunity. and availability of wage employment-all of which have been demonstrated to affect infant feeding practices in other parts of the world [12-141. Two surveys of diet and nutritional status among various age groups in Truk were conducted in the early 1970s [15, 161, but both were concerned with dietary intake rather than with customs of feeding. None of the earlier studies dealt with the occurrence of serious childhood illness. The present study was undertaken first, to describe current infant feeding practices in Truk and second, to determine what influence such practices have on infant morbidity. Unlike the earlier studies of diet and nutrition in Truk, which surveyed a random sample of families resident on several islands, this study reports observations on all children born during a ?-year period in a single community and provides

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requests

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Peniyesene village, the community in which this study was conducted is located approximately five miles from the urban port town on Moen Island, Truk, in the Pastern Caroline Islands of Micronesia. Moen, an island of seven square miles, serves as the governmental, educational, recreational and commercial center for Truk, one of the four states that comprise the Federated States of Micronesia (formerly part of the United States Trust Territory of the Pacific Islands). Most of Peniyesene is arrayed along one side of a deep bay that cuts into the northern side of Moen Island. From the head of the bay, the rest of the village continues up the valley of the Wiichen River. Other than private homes, Peniyesene consists only of a single movie theater, a pool hall, a church building, and three small village stores. Peniyesene is linked to the downtown area by an unpaved road which allows its populace easy access to the wide variety of imported goods available in town and frequent exposure to the customs of visitors from industrialized countries. Peniyesene has no health care facility of its own and its inhabitants must rely on the new hospital in town for all but traditional medical care, which is still actively practiced by a number of persons in the village. Because the village is situated outside the hot, overcrowded downtown area of the island, many residents characterized it as a particularly healthy place for children. In March, 1976, the indigenous population of Peniyesene was 468 persons. 70% of the village population was under age 30 and 17% was under age five. Census data collected by the authors revealed that a wide variety of occupations, average family incomes, and educational levels were represented in the community. Regardless of income, all Peniyesene persons

B. Mar-

33

LESLIE B. MARSHALLand MAC MARSHALL

34

lived in extended family households, typically consisting of three to four generations. Child care and food preparation tasks were widely shared within the households. Most households had someone involved in wage work, and a few had as many as four or five regular incomes on which to draw. Even so, Peniyesene residents continued to consume traditional foods, such as breadfruit, taro, bananas, coconuts and fish. Several families subsisted almost entirely in the traditional manner, having no one employed for regular wages and deriving their limited cash from the sale of copra and other crops. Every family consumed at least some purchased rice and canned fish. Those with higher incomes supplemented their diet with a wide range of additional foods, e.g. canned corned beef, flour. sugar, cooking oil, and soy sauce from the larger stores downtown. The general level of sanitation in Peniyesene was poor by Western standards.
The study population consisted of the 47 children born between January, 1974, and March, 1976, to 39 women resident in Peniyesene. both at the time of the child’s birth and during the month of March, 1976. These children all had been raised in Peniyesene, with occasional short stays in other villages on Moen. In addition. two other children who had been adopted and raised by two women resident in Peniyesene from 1974 to 1976 were included in the study, even though these children were born elsewhere on Moen. Each mother was interviewed by the authors in Trukese without aid of an interpreter. In addition to routine census information, the mothers were asked a Table

RESULTS In their first year of life, only 9 of the 49 infants were breastfed exclusively, i.e. had no other source of milk (Table 1). 20 infants were given only supplementary bottles for most of their first year, usually during the day when the mother was working. For 5 of these 20 children, the supplementary feedings were initiated after their third month, and for one child, exclusive breastfeeding was resumed after a few months. The other 20 children were weaned completely from breast to bottle at some time in the first 6 months, 5 of them within the first few days of life. Table 2 indicates the ages at which major changes in feeding of the infants occurred. About half of the 30 children already weaned from the breast at the time of the study were weaned before 6 months of age, while the other half were not weaned until near the end of the first year. Of the 14 women still breastfeeding at the time of the interview, 3 had done so for over a year and another 6 had done so for at least 8 months. 20 of the infants in the study were no longer receiving any milk, and all of these had been given milk for at least 10 months. One-third of the children still given milk were over a year old. Very few of the mothers intended to give their children any milk after the second year. 40 of the 49 children had been or would be introduced to semisolid foods in the first 6 months. Two of the three mothers who deIayed the introduction of semisolids for 12 months had offered their children only breast milk for their first year of life. Commercially jarred baby food-usually pureed banana or banana and tapioca-was offered to 20 of the 49 infants in’their first 6 months of life. 16 of these 20 infants were introduced to jarred semisolids between 3 and 4 months of age. The jarred foods were given to

I. Source of milk fed to infants during first year of life Mode

of milk feeding

Exclusively* breastfed Breastfed with supplementary Breastfed with supplementary then bottlefed only Exclusively* bottlefed Total

standard set of questions regarding the mode and schedule of feeding, the feeding of semisolids, the care of bottles and formula preparation, the persons involved in care of their infant, and the health history of each of their children under age two. Follow-up questions were asked of some of the women during informal encounters in the village. Although the interviews were conducted in March and April, 1976, the observations of feeding practices and general sanitation on which this paper is based were made over a 6-month period. Formal permission was obtained from each mother to inspect the hospital records of each child. All comments written by the attending medical officer for outpatient clinic visits and for hospital admissions were noted.

Number 9

bottlefeeding for I2 months bottles for l-6 months.

20 1.5 5 49

* Refers to mode of milk feeding only. Most of these infants received solid food supplements in the latter half of their first year.

Infant feeding and infant illness in a Micronesian village Table 2. Major changes in feeding by age of infant Wean from

breast

Discontinue all milk

Introduce

(months) 1-3 4-6 7-P lo-12 13-18 19-24

6 8 0 12 3 f

0 0 0 I2 6 2

18 22 4 3 0 0

30*

2O‘r

47t

Age

Totals

solids

*Of the remaining 19 infants. 14 were not yet weaned and 5 had been exclusively bottfefed. t The remaining 29 infants were continuing to drink milk at the time of the interview. $ No data on introduction of solid foods were obtained for 2 of the infants.

2 of the 9 exclusively breastfed infants, to 2 of the 5 exclusively bottlefed infants, and to 16 of the 35 breast-and-bottlefed infants-eight of whom were no longer receiving any breast milk. A few mothers also gave jarred pureed meats when the infant was older. Of the more traditional weaning foods, mashed banana was the first to be introduced and was occasionally followed by mashed papaya or mango if available. Soft boiled rice and/or mashed cooked breadfruit mixed with water followed quickly upon the fruits. Fish was introduced much later, usually by the end of the first year. A few mothers mentioned other foods which they considered acceptable for infants, such as taro (prepared as for breadfruit), soft bread, flour soup, mashed sweet potato, and coconut sauce. By early in the second year, the child was usually eating a normal adult diet. When questioned about bottle care, most women stated that they knew how to use soap and water to clean the bottles and nipples and to use boiled water to mix with the powdered formula. Many mentioned using boiiing (or boiled) water as a final rinse for the bottles. Only one woman actually reported using unboiled water whenever that was more convenient. In many houses, the clean bottles and nipples were kept covered and boiled water was stored’in a teakettle, ready for use. Fewer than half of the mothers said that the formula was made up fresh for each feeding;

35

others prepared a certain amount and used it for several feedings. Since only three of the 32 women who bottlefed their infants had regular access to a refrigerator, bottles of formula frequently were kept at room temperature [80”-!9O%J for 6-12 hr. Uncapped nursing bottles of water were occasionally noted on the window sills and sleeping mats in houses where formula was prepared with great care. In large social gatherings, older siblings were observed playing with the bottles of formula being offered to infants. Most mothers reported learning how to clean bottles and prepare formula from members of the nursing staff soon after they had delivered in the hospital. Others said that they had been instructed in proper bottle care by two of the hospital nurses who resided in the village. Sources of information on formula preparation cited only occasionally include: public school classes, manufacturer’s instructions on the tins of powdered formula, radio announcements, female relatives, and missionaries. The various ailments that were reported in the medical records of our sample are listed in descending order of frequency in Table 3. Most of the health problems can be grouped into three major categories: respiratory disorders (ear. nose and throat), gastrointestinal disorders and skin disorders In addition to describing the symptoms of these problems when discussing their offsprings’ health history, the village mothers reported a condition called mi mwiing which could afflict newborns as well as toddlers. This condition, associated with flaccid muscles, fever, crying, constipation and anuria was said to be treatable only by a type of massage known to a few Trukese. It was not described as life-threatening. All Trukese readily make use of both traditional and Western medicine, applying pragmatic standards to each: if it works, it will be sought again in similar circumstances. Only a few of the disorders listed in Table 3 were deemed serious or ~~e-t~~ten~g enough to warrant hospi~~~on. Most other iiinesses were treated by h~pi~-pr~~ medication or by simple home remedies, e.g. increased Ruids, tidbits of preferred foods, or poultices when appropriate. Traditional Trukese medicine was reserved for certain conditions, such as mi mwiing, or certain situations, such as an illness which did not respond readily to the hospital prescriptions or an illness which occurred when relatives were violating taboos.

Table 3. Health problems reported in hospital records for Peniyesene children in the first year of life (April f974-April.1976) Respiratory C&l-It “Runny nose”t Sore throat Otitis media Pneumonia* Thrush Wheezing Adenitis

Gastrointestinal

Dermatological

Diarrhea due to: unspecified cause*+ amoeba* worms* viral gastroenteritis; Vomiting, Dehydration* Abdominal pain

* Ailments for which hospitalization t More than 25 reports.

was required.

Other

Fever? Impetigo Conjunctivitis Scabies Chicken pox Skin lesions Unidentified rash Boils Mumps Hives Pitariasis Skin fungus

LESLIE B. MARSHALL and MAC MARSHALL

36 Table 4. Incidence

of hospitalization

during

first year of life according

to type of milk feeding

Number of infants < 1 y’ear old*

Number of infants in sample

Number of infants > I year old*

Type of milk feeding Breastfed exclusively from birth until age 1 year Breast plus supplementary bottle for first year

Total

Total

Hospitalized

Total

Hospitalized

8

I

I

0

9

I

IO

I

10

0

20

I

7

1t

8

3:

15

4

3

2g

2

2

5

4

21

5

49

IO

Breast plus supplementary bottle for 1-6 months. then bottle only Bottlefed exclusively from birth Totals

Hospitalized

28

5

* Age at time of examination of medical record. t Hospitalization occurred after child was weaned to bottle only. 2 Two of the children were hospitalized after weaning to bottle only. one when supplementary bottle was used. 9:One of these 2 children was hospitalized 3 times for different problems between 5 and 8 months of life.

According to hospital records and parental reports, almost all. of the children in the sample had experienced minor ailments at least occasionally during their first year of life. There were no accounts of illness for only rwo of the infants. Table 4 shows the number of children in the sample who required hospitalization for serious illness for more than 1 day during their first year of life. Data

for those children who had reached their first birthday at the time of the medical record search are reported separately from data for those who were not yet 1 yr old and were. therefore, still at risk of becoming seriously ill in their first year. Because of the small sample size, no test of statistical significance can be made. However, it is apparent that a much higher

proportion of infants were seriously ill when exclusively bottlefed than when exclusively breastfed. The one child in the bottlefed group who did not become seriously ill was born with a bilateral cleft palate and took milk only from a spoon until the defect waS

repaired at 4 months of age. The ages at which these 10 infants were hospitalized are given in Table 5. Because one of the 10 was hospitalized on three different occasions (at 5 months, 6 months. and 7 months of age), a total of 12 hospitalizations is indicated. Both of the major types of serious illness. respiratory and gastrointestinal, Table

5. Ages

at

which

hospitalization*

occurred in infants under 3 months as well as in those over 5 months of age. All of those children who became seriously ill after 4 months of age had been introduced to semisolid foods at least 2 months prior

to their hospitalization. Only one of these children had been given commercially jarred foods regularly. DISCUSSION

This report differs from earlier, survey-type studies of the influences of infant feeding practices on patterns of infant illness in that it presents observations of all members of a certain segment of a single community over a period of several months. This has the disadvantage of examining only a small number of subjects. However, it has the advantage of providing repeated observations of the study population in a variety of situations-formal interviews in homes, casual interviews while sharing a taxi, and observations of daily village activities-all of which were cross-checked and further verified against medical records and census data. Compared with the 1953 dietary survey of Truk District [ll], our data on Peniyesene village in the 1970s indicate a much higher frequency of bottle feeding (supplementary or exclusive), a lower age for weaning from the breast for a substantial proportion

occurred

according

to

type

of milk

feeding

when

hospitalized Type of milk

feeding Breast only Supplemented breast Bottle only Total

c I month

2 months

0 0 I I

0 2 2 4

Ages of children 3-4 months 5-6 months 0 0 0 0

It 0 2t 3

7-8 months

0 0 4: 4

Total

I 2 9 I2

* Seven cases of gastroenteritis. 3 cases of pneumonia, and 2 cases of combined gastrointestinal and respiratory distress. t These children had been receiving semisolid foods in addition to milk since 3 months of age. : These children had been receiving semisolid foods in addition to milk since 3-5 months of age.

Infant feeding and infant illness in a Micronesian village

37

of infants, and a lower age for introduction of soft pital care in the unlikely event that the mothers were foods. However, it should be noted that this study reluctant. and the 1953 survey deah with related but not identiOur data from Truk, like those of Cunningham [6] cal populations. The survey included residents both of and Larsen and Homer [7-J on middle class United the urban center and of the more traditional and isoStates populations, suggest an association between mode of feeding and occurrence of serious or lifelated neighboring islands where breastfeeding remains threatening illness (that which required at least overa much more common practice. Thus, the different results reported in the two studies may be due to night hospitalization). Four out of five exclusively bottlefed infants required hospitalization in their first differences in setting as well as time. A historical analysis of infant feeding practices in Peniyesene over a 8 months of life, one of them on three separate occasions, while there was only one case of serious illness thirty year period (1945-1976), however, has indicated a decreased reliance on breast milk and increased use in the eight infants who received no bottlefeeding in of commercial formula and semisolid food for their first year. It is extremely unlikely that a life-threatening illness children under 6 months of age [17]. The traditional pattern of offering the breast until the child could among the breastfed group went unreported or that a walk and withholding all other food until the child bottlefed infant was hospitalized for a minor illness. had teeth was practiced by fewer than one-fourth of The four outcomes of serious illness are that Western medicine (provided by the hospital) ameliorates the our sample of Peniyesene mothers. Most Peniyesene women who bottlefed their problem, that traditional Trukese medicine ameliorchildren knew how to care for the bottles and the ates the problem, that the patient recovers without milk properly. However, it was often difficult or im- any treatment, or that the patient dies. According to possible for them to do so. Even in the tidiest homes, our detailed census and interview data, there were no flies and roaches were common. Older siblings and deaths or cases of “miraculous recovery” among the other relatives, who were less aware of the importance infants in our population during the period studied. Accounts of the two situations in our study in which of proper sanitation or correct measurement when preparing the bottle, were frequently responsible for Trukese medicine was said to have cured health probthe actual feeding of the infant. Refrigerators were too lems considered out of the ordinary by our inforexpensive for most families, it was inconvenient to mants were also to be found in the hospital recordsmix up fresh formula for a small infant on a demand one had been hospitalized for gastroenteritis and dehydration, the other had been treated as an outschedule (especially at night), and it was impossible to patient for recurrent otitis media and diarrhea. keep other young children away from the bottlesAccording to the nurses’ daily reports on the inpatient which contained milk, water, sweet tea, or carbonated charts, the infants in our study who were actually beverages. Thus, even milk that was made with boiled admitted to the pediatrics ward were in need of immewater in well-washed bottles could quickly become diate professional care for breathing difficulties or contaminated. dehydration. The incidence of the minor illnesses which occurred It is possible that the hospitalized infants in this in the Peniyesene infant population is not reported in study were more likely to have been exposed to this study. The willingness of different parents to take pathogenic organisms or to have had lowered resisttheir children to the hospital outpatient clinic for ance to such organisms for reasons other than their minor ailments varied considerably, so that the mode of milk feeding. Factors which might have innumber of recorded visits to the clinic cannot be used fluenced the occurrence of serious ilmess include genas an accurate estimate of the number of episodes of eral sanitation and child care practices, numbers of illness or their duration. When interviewed, mothers other children in the household, and the introduction were able to recall that a child experienced, for of semisolid foods. General cleanliness and sanitary example. several coughs, an occasional fever, and no practices (window screens, covered water drums. diarrhea, but could specify neither frequency nor swept ‘floors, screened cabinets, hand soap, etc.) varied duration of these minor complaints. Life-threatening from household to household. However, households serious ailments, on the other hand, were recognized where infants had been bottlefed or hospitalized did as such by Trukese parents, were treated during duly not differ systematically from other households in this recorded admissions to the hospital pediatric section, regard. The number of children living in any Peniyeand were recalled in some detail by the parents. sene household changed frequently and it was exIt should be noted here that breastfeeding mothers tremely rare that only one child would be found in were no more reluctant to use the hospital facilities any household. All except one of the infants in this than were mothers who had begun to use infant forstudy lived in households with at least two other mulas. Although hospital records (of birth, inpatient young children. Since half of the seriously ill children admissions. or outpatient visits) existed for five out of had no foods other than milk at the time of their five exclusively bottlefed infants but for only six out of hospitalization, ingestion of contaminated semisolids nine breastfed infants. hospital records existed for cannot explain all cases of serious illness. Birthproportionately fewer of the infants who had received weights of the hospitalized infants were similar to the supplementary bottle feeding (19 out of 35) than of birthweights of the entire sample. the infants who were exclusively breastfed. FurtherThe mothers of two of the five bottlefed infants more. the three breastfed individuals without hospital were regularly employed in the wage economy and records lived in extended family households in which other female relatives in the extended household sick children had been taken to the hospital in the cared for their infants during the day. The mothers of recent past. The mothers of these infants would have all of the nine breastfed infants had primarybeen urged by close relatives to seek any needed hos-

38

LE.XIEB. MARSHALLand

although not exclusive-responsibility for their children’s care. However, similar proportions of the infants whose mothers were (3 out of 13) or were not (7 out of 36) regularly employed outside the home were hospitalized. Thus, full-time wage employment of the mother was not related to increased incidence of hospitalization in this study. Since reliance on both breast and bottle has become commonplace in Peniyesene, as in other parts of the world, it is important to consider the influence of the supplemen~ry bottle on infant health. Several investigators have reported that infants given even occasional suppIementary bottles of commercial formula had altered gastrointestinal flora [2, 181 and higher incidence of gastrointestinal and respiratory disease [Z]. Plank and Milanesi [l] found that mortality in infants given a supplementary bottle was as high as in infants fed exclusively by bottle. Our data, however, suggest that the incidence of serious illness is lower in those infants offered the breast as well as the bottle than in those offered the bottle alone. A final point to consider is the age at which serious illness occurred in the Peniyesene infants. Ail those chiidren hospitalized within eight weeks of birth had experienced either supplementary or complete bottlefeeding. Thus, the use of any bottle may put the very young at greater risk. Acknowledgemenrs-The research upon which this report is based was supported by a grant from the American Philosophical Society (Johnson Fund) and a Faculty Research Assinnment from The University of Iowa to MM. The auth&s wish to thank Kiosi An&i, Director of Truk Hosuital. the staff of the Medical Records Division and the peoble of Peniyesene village for their kind assistance.

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Mhc

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