Infectious diseases

8
INTRODUCTION
Breastfeeding is important for the health of the young child. Its role for the
optimal growth and development of the infant has been well documented in the
past few decades. The biological properties of human milk as a nourishing and
protective agent are astonishing. (Butte NF et al 1984)
Various studies have shown that breastfeeding reduces the relative risk of
morbidity and mortality not only from diarrheal diseases but also from otitis
media, neonatal sepsis and possible respiratory tract infection (Faechem RG
1994). The problem of various false beliefs in our society interferes with the
feeding of infants. A new born is fed water arq, ghutti, honey and sugar water as
a prelacteal feed for the first 2-3 days while the mothers colostrum is believed to
be stale and discarded. The practice of exclusive breast feeding is very limited
and various types of parlacteal fededs are started right from the first day like
bottle feeding, gripe water, ghutti, honey, arq and tea. Some mothers do not like
to breast feed with the belief that their milk is bad as the insects are killed when
dropped in expressed milk (Bashir A 1993). These breast milk deprivation
practices predispose the infants to various types of morbidity and ultimately to
mortaitly which is 84/100 (UNICEF 2001)

9
The purpose of this study is to highlight the morbidity patterns of infants who are
on mix feeding or bottle feeding and comparison with the infants on
breastfeeding. The objectives are
1. To determine the patterns of infectious diseases in non-breastfed
infants admitted in hospital.
2. To compare the patterns patterns of infectious diseases in breastfed
and non-breastfed infants admitted in hospital.

11
REVIEW OF LITERATURE
FEEDING AND MORBIDITY
The neonate does not have innate defense to protect himself against the highly
contaminated environment which he enters from the sterile environment of
uterus. Breastfeeding is effective in minimizing the infection in infants by
decreasing the exposure to pathogens that may contaminate other milks. The
breast milk has various unique protective factors. Breast milk IgA has antitoxin
activity against enterotoxin of E coli. In studies by Gotherfors (1975) it was shown
that E coli isolated from stool of breast fed infants differed from the strains found
in formula fed infants. These were more sensitive to bactericidal effect of human
serum. Specimen of human colosturms has been found to contain neutralizing
activity against respiratory syncytial virus. Statistically significant data collected by
Downham (1996) showed that few breastfed babies (8 of 115) were among the
infants hospitalized for respiratory syncytial virus infections, compared with
controls who were non breastfed (46 of 167). Karmar MS 1988 suggested that
the predispostion of bottle fed infants to purulent otitis media as compared to
breastfed infants may be due to IgA immunity in breast milk. Beauregard WG
1971 described the relation to the mechanism of bottle feeding May JT (1984)
reported that in human milk bile salts stimulated lipase has been found to the
major factor for inactivating portozoans. Human milk protects against many
intestinal and respiratory pathogens with the evidence of inflammation. Goldman

12
And colleagues 1986 hypothesize that human milk is poor in initation and
mediation of infriammation but rich in anti inflammatory agents.

13
Mondal SK et al 1996 did a comparative study of morbidity and mortality of
breastfed and bottle-fed infants. It was found that there is higher incidence of
diarrhea mong mixed fed infants 75.54%, bottlefed infants 73.53% and 35.39%
in breastfed infants. This lower incidence of dirrhoea may be related to the
crucial role of immunologic protection. Ravlomanana et al 1995 showed that only
absence of breastfeeding was associated with higher risk of dying, mortality rate
was 16% in the study. It was concluded that breastfeeding protects severely
malnourished children against death from diarrhea.
Lopez-Alareon-M 1997 studied 170 healthy new born to determine, if
breastfeeding protects against acute respiratory infection (ARI) as it does against
diarrhea. Incidence and prevalence of ARI were significantly lower in fully
breastfed infants than in formula fed infants. From birth up to four months
incidents of ARI was negatively associated with duration of breast feeding.
Infants that were never breastfed and that had more sibling, were more likely to
have episode of ARI than those fully breastfed for at least one month. These
results demonstrate protection against ARI as a result of breastfeeding similar to
that of diarrhea i.e. lower incidence and percentage of days of illness and
episodes of shorter duration.
IL lopez Bravo et at, 1984 studied 207 Chilean children (who were born at the
San Francisco DeBorja Hospital) in Santiago. About of the study infants
received artificial milk during their first month of life, either alone or as a
supplement to their mother's milk by the third month. This proportion had risen

14
to 43% by the 6th
month, it had risen to 64% and by the 12th
month it had
reached 91%. The results of the study are tabulated:
Percentage feeding practices of infants in "Ilse LopezBravo" study.
Age Breastfed Mixed feeding Bottle fed Total number
1 Month 78.2 6.8 1.4 207
2 71.1 15.0 5.8 207
3 57.0 18.8 10.1 207
4 47.4 27.5 15.5 207
5 42.9 30.9 21.7 207
6 35.9 30.9 26.2 207
7 34.5 27.7 36.4 206
8 26.7 26.7 38.8 206
9 25.2 22.3 51.0 206
10 15.5 20.9 53.0 206
11 14.6 20.9 63.6 206
12 08.9 15.7 64.5 206

15
Kukai-R al of Kenya 1995 studied immune response in breast fed and non
breastfed children presenting with diarrhea, 69% of whom were breastfed
which tended to have a shorter duration of diarrhea than either mixed fed or
bottle feed.
Millaat-WA et al 1995 of India worked on diarrhea and showed that males
accounted for higher percentage of all diarrheal cases, their mothers mostly
had low education. Bottle fed children showed higher proportion (53.1%) of
diarrhea than other types of feeding, suggesting the feco oral route of infection
and the effect of poor sanitation.
Mitra AK & Rabbani F 1995 of Bangladesh showed the importance of
breastfeeding in minimizing mortality and morbidity from diarrheal disease.
Studies have shown that the duration of benefits of breastfeeding in diarrhea
can range from a few months to several years. However breastfeeding is not
consistently protective in all types of diarrhea. For example there is evidence
of increased risk of rota virus diarrhea in breastfeeding children compared to
non breastfeeding children after certain age.
Khaldi-F et all 1995 it is recognized as a major cause of morbidity and mortality
in developing world, 69 percent of children were breastfeeding and 82 percent
were bottle fed before 12 months of age. The results showed that among usual

16
risk factors of persistent diarrhea (PD) bottle feeding, diet errors and history of
acute diarrhea seems to be particularly frequent in this Tunisian population.
Kuba-K, Novak-A 1992 studied a group of 4210 children. They showed that
there were less frequency of illness in girls and infants breastfed for more than
four months and had significantly fewer spells of illnesses. These results were
influenced by sex and birth order.
Brito-Hernaindez-ML etal 1995 carried out a study sample of 300 infants and
found that breastfeeding was maintained during first 4 months of life in 58
percent of infants. In addition acute diarrheal and respiration diseases were
found to be more frequent in there infants whose breastfeeding period was
shorter.
Hamid-M 996' studied 100 cases of pneumonia. Seventy-four were under one
year and out of all only 6 mothers have practiced exclusive breastfeeding. Low
socio-economic status, illiteracy and malnutrition were the other risk factors.
Van Derslice-J et al 1 994 showed that breastfeeding protects infants by
decreasing their exposure to water and food borne pathogens and by
improving their resistance to infection. As a result breastfeeding becomes
more important if the sanitation barrio is not in place. Breastfeeding
provides significant protection against diarrhea for infants in all
environments. Even small portions of contaminated water to fully breastfed
infants nearly double their risk of diarrhea. Mixed fed and weaned infants

17
consume greater quantity of supplement liquids, and as a result, the
protective effect of full breastfeeding is greater when drinking water is
contaminated. Similarly full breastfed has stronger protective effects among
infants living in crowded, highly contaminated settings.
Sheard-NF 1993 in a recent study provided strong evidence that exclusive
breastfeeding for at least 4 months decreases the incidence of otitis media in
the first year of life.
Pelton-SI 1996 studied risk factors for recurrent Otitis media which include
bottle feeding, day care attendance exposure to cigarette smoke and
immaturity.
Mary Jeanowen et al 1992 in their study concluded that a shorter duration of
breastfeeding was associated with more Otitis Media with effusion (OME)
during the first six months of life but not with earlier age at on set of OME. The
magnitude of effect was calculated and it was found that breast fed infants for
the first six months of life had a 10 percent decrease in amount of OME during
this period compared with infants who were not breastfed at all.
Azizi-BH et al 1995 studied the protective effect of breastfeeding on
respiratory infections in hospitalized children. Out of other factors studied

18
breastfed for at least one month was confirmed as an independent protective
factor.
Victora-CG et al 1992 studied 227 infants who presented diarrhea and in 75% of
these diarrhea was considered to be the underlying cause of death. Acute
diarrhea accounted for 28%, persistent diarrhea for sixty two percent and
dysentery for 10%. A comparison with neighborhood control showed that breast
milk provided protection against deaths due to acute or persistent diarrhea.
John-D Clemenus et al 1986 studied the children with Shigellosis. It was
concluded that a substantial degree of protection against severe Shigellosis was
evident for breast fed children.
Wystepowanie-J et al 1995 studied the protective effect of breastfed on viral
respiratory infections in 114 cases. Viral etiology was established. Out of all viral
infections, respiratory syncitial virus was predominant para influenza type 3 virus
was rare mixed and adenovirus infections were more frequent. The breastfed
children were statistically more rarely infected by these respiratory viruses that
artificially fed ones.
Anaansson G et al 1995 analyzed the effect of breastfeeding on the frequency of
acute otitis media (AOM). By one year of age 85 (21%) children had experienced
AOM episodes. The AOM frequency was significantly lower in the breastfed than
in non-breastfeed children (P<0.05). First episode of AOM occurred significantly
earlier in children who were weaned before six months of age. The frequency of

19
upper respiratory infections was increased in children with AOM but significantly
reduced in the breastfeeding group.
Meremikwu MM et al 1997 reported the influence of breastfeeding on the
occurrence of dysentery, persistent diarrhea and malnutrition. The proportion of
the children with persistent diarrhea or underweight was significantly lower
among currently breastfeeding children than the age matched non breastfeeding
counter parts.
Wan C et al 1999 made randomized trial of different rates of feeding in acute
diarrhea and concluded that breastfeeding is preferred method of feeding
infants with acute diarrhea.
Dewey KG et al in 1995 determined whether breastfeeding is protective
against infection. They showed that in first year of life the incidence of
diarrheal illness among breastfeed infants was half that of formula feeding
infants and with prolonged episodes more than 10 days & was 80% lower in
breastfeeding compared with formula feeding infants. There were no
significant differences in rates of ARI. These results indicate that reduction in
morbidity associated with breastfeeding is of sufficient magnitude to be of
public health significance.
Davies Adetugbo AA 1997 described that breastfeeding promotion is an
important intervention for the control of infant diarrhea. The study group

20
received individual focused breastfeeding counseling with the controls had
routine advice for diarrhea. The result showed marked early decrease of
diarrhea in breastfeeding as compared to control.
Golding J et at 1977 reviewed literature in regard to possible relationship
between breastfeeding and diarrhea. It is mentioned that breastfeeding has
protection role in developed and developing world in the 4-6 month age
infants.
Banajeh SM '1999 reported the effect of breastfeeding on serum electrolytes of
children admitted with severe dehydration due to diarrhea. Breastfeeding
significantly reduces case fatality and likelihood of electrolyte disturbances
among infants hospitalized with serum dehydrating diarrhea.
Hanson LA 1999 described that breastfeeding has significant protection against
diarrhea, respiratory tract infection, otitis media, bactermia, bacterial meningitis,
botulism, UTI, and necrotizing enterocolitis. There is also good protection for HI
type infection and wheezing bronchitis.
Ball TM 1999 studied the cost of health care services for three diseases
Respiratory tract infection, gastro-intestinal illness and otitis media in the
infancy. The estimated cost for health came services was 331-475 US dollars
for the never breastfed infants during the first year of life.

21
HUMAN MILK AND PROTECTION FOR MORBIDITY
Over the last few decades more evidence has become available regarding the
protective factors in human milk. In 1961 the major immunoglobulin in the
human milk was isolated and characterized (Hanson 1961, Hanson and
Johansson 1962).
This immunoglobulin is now called secretory IgA (SigA), being a part of the
mucosal immune system (Hanson and Brandtzaeg 1989). The SigA antibodies
in the milk are directed against a wide range of bacterial, viral, parasitic and
fungal antigens (Hanson et al 1979). The SigA antibodies in the human milk
reflect the intestinal exposure of the mother for the corresponding antigens.
When an antigen is presented to intestinal epithelium it is taken up by the
Peyer's patches in the gut. The antigen-stimulated lymphoid cells leave the gut
and travel, or 'home', via the blood to the exorcrine glands, including the
mammary gland where they produce SigA. This homing is called the
'
enteromammaric pathway and explains how the infant via the milk is reached
by the antibodies initiated in the mother's gut (Goldblum et al 1975, Ahlstedt et
al 1977, Hanson et al 1983). Thus, the human milk contains antibodies against
a wide variety of Escheridchia coli, Salmonella (Ahlstedt et al 1977), Shigella
(Ahlstedt et al 1977, Hayani t al 1992), streptococci (Hanson and Johansson
1962), polioviruses, Coxsackie, ECHO viruses (Hodes et al 1964, Michaels
1965) and Rota virus (American Medical Association, 1987). Antibodies

22
against respiratory syncytial virus have been isolated from the maternal milk
after pulmonary infection of the mother, suggesting a bronchomammaric
pathway (Theodore et al 1982). A main function of SigA is to bind antigens and
to prevent their attachment to the mucosal surfaces (Kenny et al 1967),
svanborg et at 1986, Hanson ad Brandtzaeg 1989). Thus they also provide
antiadherence for the microbes (Svanborg et al 1979, Davis et al 1982) and
neutralize toxins (Galss et at 1983, Cruz et al 1988) and viruses (Taylor and
Dimmock 1985).
Small quantities of IgM and IgG are present in the colostrums and even less in
mature milk (McClelland et al 1978).
Leukocytes are normally found in human milk, especially in the colostrums.
Approximately 90% of these are macrophages and 10% are lymphocytes
(Lawrence 1989). The precise function of the macrophages in the human milk
has not been fully explored. It has been suggested that they transport
immunoglobulins (Pittard et al 1977). They can participate in antibody-
dependent cell-mediated cytotoxicity to herpes simplex type I virus infected
tissue culture cells (Ogra nad Ogra 1988). The biosynthetic and excretory
activities of the milk macropages include production of lactoferrin, lysozyme,
components of complement, properdin factor B, epithelial growth factors), T
lymphocyte suppressive factor(s) and IgA B cell helper factor(s) (Ogra 1988). It
is also suggested that macrophages may be important in the regulation of T-
cell function (Losonsky and Ogra 1981). Macrophages in milk also possess
phagocytic activity against E. coli and Candida albicans (Ho and Lawton 1978).

23
The functions of the T cells are not known, but some data imply that the
maternal cellular products or soluble mediators of cellular reactivity may be
transferred passively via the process of breastfeeding (Ogra et at 1977)
Breastfeeding significantly enhance cell mediated response to BCG vaccine
given at birth, but had no significant effect if vaccine was given after one
month. Enhanced general cell mediated immunity is found in breast fed babies
at 6 days and 6 weeks but not beyond this age (Pabst Henry-F et al, 1989).
The role of B cells in human milk is not well known although after EBV
transformation of the milk B cells they could be shown to produce IgA and IgM
antibodies (Hanson et al 1985).
Lactoferrin is the iron binding protein in the milk and has a bacteriostatic
function (Bullen et al 1972). Other potentially protective factors in human milk
are lysozyme (Goldman et al 1982), unsaturated B12 binding protein (Guilber
1973), bifidus factor (Gyorgy 1971), receptoractive oligosaccharides which
prevent adherence of Haemophilus influenzae and pneumococci to epithelial
cells (Andersson et al 1986). Human milk also has the property of blocking
hemagglutination by Vibrio cholerae, E. coli and binding of enterotoxins from
these microbes (Holmgren et al 1981, Holmgren et al 1983).
Many researchers have documented that breastfeeding protects against
infections. There is evidence that breastfed infants have a lower firsk of

24
diarrhea (Feachem and Koblinsky 1984; Lopez-Alarcon-M et al, 1997) and
respiratory tract infections Lepez Alarcon-M et al, 1997) as compared to non
breastfed infants. Otitis media (Dewey-KG; et al, 1995) necrotizing
enterocolitis urinary tract infections, bacteremia and meningitis are also less in
breastfed infants Cochi et at 1986).
An association is suggested between bottle feeding and disorders of the
immune system e.g. lymphoid hypertrophy and autoimmune disease, Boat et
at 1975). Bottle feeding is suggested to increase the risk of Crhoh's disease
(Whorwell et at 1979) and insulin dependent diabetes (Mayer et at 1988) to
mention some. However, these connections must be further studied to be
confirmed.
Recent reports also suggest that the mortality risk in artificially fed infants is 3-
5 times higher as compared to breastfed infants. Most of these deaths are due
to diarrhea (de Macedo 1988). The non breastfed infants have an increased
risk of deaths due to respiratory infections (Victora et al 1989). In the
industrialized countries the impact of breastfeeding is associated with reduced
mortality in technically advanced countries as well (Mandeley et al 1986. Infant
botulism which has been considered to be one cause of sudden death in
infancy also occurs primarily in bottle fed infants (Arnon et al 1982).
Whether formula or breast feeding influences the functional activity of
compliment system from birth to three months of age has been studied.
Bactericidal and hemolytic capacity of serum from Breastfeeding activity infant

25
of 1-3 month of age was significantly greater than of serum from formula fed
infants (Barriga-C et al 1995).
Based on recent evidence that Cytokines in human milk might be important in
host defence, prevention of autoimmunity and immunological development of
digestive system, quantitative analysis of colostrums, transitional and mature
milk was carried out. Women's delivering preterm had lower level of several
cytokines in colostrums that women delivering at term. Yet, cytokine levels
remained high months to years with lactation, providing immunological benefits
to the breastfed infant/child (Srivastava M.D. et al 1996).
Regarding thymus size in formula fed and breastfed infants in Denmark, the
author concluded that thymus was considerably larger in breastfed than in
formula fed infants at the age of 4 month. The cause of this effect was
proposed to be immune modulating factors contained in human milk
(Hasselbalch H, 1996).
Ahiadeke-C 2000 studied the protective effects of breastfeeding in poorest
sanitation conditions. It was found that risk of diarrhea among mixed fed
infants in the poor sanitation areas tends to be high and minimal for breastfed
infants in the same area.
Newburg DS 1999 mentioned that breastfed infants have lower incidence of
diarrhea, respiratory disease and otitis media. The neutral glyco sphingolipid

26
antipathogenic agents and milk glyco conjugates oligosaccharides may be
novel source of protection of breastfed infants.
Honorio France Ac et al 1997 described that colostrum mononuclear
phagocytes are able to kill entero pathogenic E-coli (EPEC) opsonized with
colostral 1gA. It was proposed that clostral phagocyte killing of EPEC may
represent an additional mechanism of breastfeeding protection against
infections during the first week of life.

27
BREASTFEEDING AND WATER SUPPLEMENTATION
A majority of neonates in Africa, Asia and Latin America are breastfed.
However, exclusive breastfeeding is rare. In Peru, for example where 99% of
infants were breastfed at one month of age 83% were given water in addition
to breast milk (WHO 1991). In a study population in India 80% of the 1-4
month old infants were given additional water (Sachdev et al 1991). In Lahore,
Pakistan about 50% of one month old infants were given water in addition to
maternal milk (Hanson et al 1986). According to a recent anthropological
survey conducted in Pakistan, the mothers and the health providers strongly
believe that water should be given as supplement to maternal milk, especially
during the summer (National Breastfeeding Steering Committee 1991). It is a
common observation that water is given to a vast majority of newborns in the
maternity hospitals locally and this practice has been reported from the
maternity wards elsewhere as well Nylander et al 1991). It is believed that
water, herb water and teas given to young infants quench thirst, prevent colic,
treat cold and sooth fretfulness (WHO 1991).
Giving water supplements to breastfed infants may have certain
disadvantages. For example, diarrhea (Feachem and Kiblinsky 1884) and
respiratory tract infections (Brown et al 1989) are less prevalent in exclusively
breastfed infants than in partially breastfed. Water may be contaminated by

28
enteric pathogens Khalil et al 1993a). Furthermore, it is a common
observation that the feeding utensils are often not optimally cleaned in
situations with poor hygiene and environmental sanitation. These factors may
be the cause of diarrhea which is highly prevalent in this region (Government
of Pakistan 1984). Maternal milk output may decrease when breastfed infants
are given supplements (Howie et al 1981) and the reduced output may end up
in premature termination of breastfeeding. The infants given water
supplements probably ingest fewer calories Sachdev et al 1991). This may
affect the nutritional status of the infants. In a population with a high
prevalence of malnutrition (Government of Pakistan 1988) this practice can
have undesirable effects.
Growth in exclusively breastfed infants has been studied by various
researchers Khan 1984, Salmanpera 1985), the definitions of exclusive
breastfeeding in most of these studies allow additional water as supplements.
Under adequate living conditions, in the developed world this practice may not
influence growth. In contrast, in developing countries with inadequate
hygiene, ignorance, poverty and compromised living conditions, this practice
may have a negative influence on growth in early infancy. The water
requirements of individuals depend on the concentration of the feeds, the
energy consumption, the environments of a healthy infant range from 80-100
ml/kg during the first week of life to 140-160 ml kg between three and six
months of age. If the infant consume less, then the osmolarity of serum and
urine increase and the infant is dehydrated (WHO 1991). Human milk has a

29
low solute load as the concentration of nitrogen, sodium, chloride and
potassium is relatively low compared to cow's milk. Therefore, a relatively
small amount of water is required for excretion of the waste products (Almroth
1978). With the available amount of water to a 4-6 month old breastfed infant
the urine osmolality will be 216 mosm/L (Almroth 1978). Therefore, in
theoryexclusively breastfed infants can safely manage without additional water
even in the hot season.
The national and regional surveys from Pakistan indicate that breastfeeding is
prevalent to the extent of 85-98% (Government of Pakistan 1978,
When breastfeeding is so prevalent (85-98%), the high morbidity and mortality
due to diarrhea and infections in infants is not easily understandable. Is it that
breastfeeding does not protect in this high risk population? Or could other
factors like the definitions of breastfeeding and the method of data collection in
some of the previous studies have masked the real feeding patterns (Jalil et al
1990).

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BREASTFEEDING PATTERNS
Colostrum is the secretion of breast during the later part of pregnancy and
for 2-4 days after delivery. Previous studies have shown that more than half
the new born receive the first breast feed as late as the third day. Gupta A
and Gupta R (1992) studied 100 mothers with babies below 4 months of
age. They showed that 5% of mothers started breast feeding within 2 hours
of birth, 19% within 2-12 hours, 27% within 12-24 hours and 49% after 24
hours. Reasons given for late initiation included family customs and belief
that milk comes in only after 2nd
or 3rd
day of birth. Breast milk was the first
feed in 2% of infants, honey in 90%, glucose water in 5% sugar-salt
with/plain water in 1%.
J.B. Ghosh 1992 studied 65 mothers at B.S Medical College Hospital, Bankura
(India). Out of 65 mothers 30 (46.1%) had received no education, 32 (49.%)
were educated till primary level and 3(4.6%) were graduate. Type of first feed
was plain water in 46 (70.8%), colostrums in 15 (23.1%) and artificial mil in
4(6.1%) babies.
Prelacteal feeds were used in 76.9% babies and 23.1% babies were not given
any prelacteal feed.
Kulsoom-U; Saeed-A 1997 studied 52 infants during their first year of life,
98% mothers started breastfeeding within first week and 54.3% continued
until 12 months. Breastfeeding was initated within 47.4 hours after birth and
prelacteal feeds were given to 94% infants. In 65.4% colostrums was not

31
given, water was given. Water was considered essential from the very first
day in 55.4% cases, 48% babies were put on bottle feeding during the first
week and by 5 months of age 97% were bottle fed. The most common reason
for starting bottle feeding was received insufficiency of breast milk in 71% of
cases. Breastfeeding was stopped earlier by mothers who were illiterate and
have female children. The mean age for initiating supplemental feeding with
semi solid food was 4.4 months. Weaning occurred earlier in literate mothers.
Health education interventions are needed to promote use of colostrums
exclusive breastfeeding and appropriate complimentary feeding practices.
Banapurmath-CR 1996 studied 1050 infants and showed the timely first
supplement rate was 0.3%. All the infants received prelacteal feeds.
Colostrum was rejected by 29% of mothers, 35% babies were not breastfed
even at 48 hours of birth. Exclusive breastfeeding was noted in 94% at one
month, 83.5% at two month, 72.5% at three month 61.2% at four month
43.4% at five month and 26.8% at six month age. Timely weaning feeding rate
was 57.3% among infants from 6 at 10 month of age continued breastfeeding
rate was 99.7% at one year. The bottle feeding rate was 49.4% below one
year age. The ever breastfed rate was 97%.
Sahidullah-M 1994. showed that it is not the duration of total breastfeeding but
the duration of un-supplemented breastfeeding which increases child survival.
Un-supplemented breastfeeding appears as such as crucial determinant of

32
early infant mortality that its effect could not be attenuated even in worst
possible environment.
Chirmulay-O; Misal-R 1993 showed that exclusive breastfeeding was
beneficial only upto six months of age. After this age it lost its advantage. This
exclusiveness although protect against infection but had a high prevalence of
malnutrition. No other factor like sex of the child, parental literacy past history
of illnesses had any significant effect.
Beaudri-M et al 1995 concluded the protective effect of breastfeeding on
respiratory illness, on Gasterointestinal illness and on other illnesses during
the first six months of life.
Akram-Ds et al 1997 studied the effects of intervention on promotion of
exclusive breast feeding, 67 mothers were registered in the intervention
group and 53 in the control group, 66% mothers in the control group gave
prelacteals as compared to 31% in the intervention group. Colostrum was
given by 97% mothers in intervention group and 3% in control. Majority of
study groups 94% continued exclusive breastfeeding till four months against
7% in control. It was concluded that health education programs in the
antenatal period as well as after birth can promote exclusive breastfeeding
practices.

33
Badruddin SH et al 1997 studied 100 infants in Karachi Pakistan from births to
16 weeks. Eighty seven infants received prelacteal feeds of honey 16 received
ghutti for "cleansing of stomach". Other prelacteal feeds were given as
substitute of breastfeeding. Supplemental water was given to 53 major
reason being mother perception of thirst. Supplemental milk was given to 24
infants.
Victora-CG et al 1997 studied 650 mother and infants. It was shown that
pacifier use was common with 85% of users at one month. Children who used
the pacifiers with four times more likely to stop breastfeeding by six moth of
age than non users. Users also had fewer daily breast feedings those non
users.
Butt M.A et al 1998 studied 200 infants in relation to morbidity and mortality
with breastfeeding and non breastfeeding and narrated that the breastfed
infants had 98 episodes of illnesses as compared to bottle fed infants who
have 323 episodes of illnesses.

35
METHODOLOGY:
STUDY DESIGN:
This is a retrospective descriptive study. The study has been conducted to
study retrospective feeding practices of infants from birth up to the age of 6
months resulting severe illness and thus admitted in hospital for
management. The variables sex, weight, place of delivery, mode of delivery,
person conducting delivery, first feed given, feeding practices in first, second,
third, fourth, fifth & six months of age (where applicable) have been selected
to find possible relationship for the sickness leading to hospital admission.
SAMPLE RECRUITMENT:
The study sample is an area sample which had been selected from the area
of encatchment of the Children's Hospital & the Institute of Child Health,
Lahore (CH&ICH). See appendices for detail. The Children's Hospital is a
350-bedded hospital and has an OPD load of more than 1,000 patients and
Emergency and Indoor of 200 patients daily belonging to medical and
surgical departments. The area of encatchment of CH&ICH is of two types,
the posh area which includes Gulberg, Model Town, Garden Town, Town
Ship, Faisal Town, Defence and Officer Colony and the poor slum area which
includes the people residing along with the railway track and the area
surrounding the Kot Lakhpat Jail. The names of these poor slum areas are
Nawaz Sharif Colony, Gull Bahar Colony, Qainchi Amarsidhu, Chungi
Amarsidhu, Phatakee, Gulstan Colony, Youhana Abad, Peer Colony and Al-

36
Noor Town. A consecutive sample of 100 infants belonging to above
mentioned area of encatchment admitted in the medical emergency / ward
SELECTION CRITERIA:
SAMPLE CHARACTERISTICS:

38
RESEARCH INSTRUMENT AND DATA COLLECTION:
A especially design pre-tested questionnaire was used to record the
information by personal interview from the mothers of Infants admitted in
emergency/medical ward. See appendix for questionnaire.
DATA PROCESSING:
The data collected on the questionnaire was processed In SPSS software
computer program after coding and decoding of variables. Initially simple
frequencies of variables were taken to find some error in data feeding.
After the correction of errors cross tabulations and multiple response
tables were analyzed. For details regarding coding and spreadsheet see
appendices.
STATISTICAL METHODS:
The following formulae and terminology was used for statistical analysis of
results.
1. Number (N):
It represents the number of observations.
2. Arithmetic Mean:
It was a single value, which represented the average of all
the individual values and was calculated as follows.

39
X EX / N
Where
EX is equal to sum of individual
observations. N is number of
observations.
2 1/2
is equal to individual observations.
X is equal to mean of all observations.
is equal to difference from mean.
2
is equal to sum of differences squared.

44
Exclusive Breastfeeding:
It is the practice of breastfeeding in which infant gets only and only mothers
milk and no water, ghutti, arq, gripe water, honey etc.
Partial Breastfeeding:
It is the practice of breast feeding in which infant gets mothers milk along with
administration of water arq, ghutti, honey, gripe water etc.
Mixed Feeding:
It is the practice of infant feeding in which along with mother milk bottle
feeding is also given.
Feeding

46
RESULTS
Age wise distribution of 100 infants selected for the study is shown in table 1. As
the sample is of 100 infants the number and percentage is equal. Eleven
percent of infants were neonate, 21% were of two months age, 16% of three
months, 17% of four months, 18% of five months and 17% of six months.
The mean age is 3.61, mode is 2, median is 4 and standard deviation is
1.651.
Table I Age Wise Distribution of Infants
Age in months No. Percent Cumulative %
1 11 11.0 11
2 21 21.0 32
3 16 16.0 48
4 17 17.0 65
5 18 18.0 83
6 17 17.0 100
Total 100. 100.0

48
Table 2 shows the distribution of infants according to the sex. There were
65% male infants and 35% female infants admitted to the medical
ward/emergency of the CH & ICH, Lahore during the period of study.
Table 2 Sex of Infants
Sex No. Percent
Male 65 65.0
Female 35 35.0
Total: 100 100.0

50
Table 3 shows the weight of infant in percentiles at the time of admission in
hospital out of 100 infants, 75 % of infants were having weight less than 5th
percentile, 10% infants were at 10th
percentile, 4% at 25th
, 5% at 50th
, 4% at 75th
and 2% at the 90th
percentile.
Table 3 Weight of Infants
Weight in percentile No. Percent
> 5th 75 75.0
10th
10 10.0
25th
4 40.
50th
5 5.0
75th 4 4.0
90th
2 2.0
Total 100 100.0

51
Table 4 describes the educational status of infant's parents, there were 55
mothers and 39 fathers having education nil. The education level of parents for
primary middle, matric, F.A. graduation and postgraduate level is shown in
table:
Table 4 Education of Parents
Education Father Mother
No. % No. %
Nil 39 39.0 55 55.0
Primary 12 12.0 12 12.0
Middle 16 16.0 5 5.0
Matric 20 20.0 21 21.0
F.A. 9 9.0 2 2.0
Graduate 1 1.0 5 5.0
Postgraduate 3 3.0 0 0.0
Total: 100 100.0 100 100.0

53
Table 5 shows the place of delivery of infants in the present study. There were
46% infants delivered at home, 37% at hospitals and 17% at private clinics.
Table 5 Infants Place of Delivery
Place No. Percent
Hospital 37 37.0
Private clinic 17 17.0
Home. 46 46.0
Total: 100 100.0

55
Table six shows the distribution of persons whom conducted the delivery of
infants. In the present study traditional birth attendants (TBA) conducted 41%
deliveries, doctors 48% and LHV/Midwife 11°A.
Table 6 Person Conducted Delivery
Person No. Percent
TBA 41 41.0
LHV/Midwife 11 11.0
Doctor 48 48.0
Total: 100 100.0

57
Table 7 shows the distribution of infants according to the first feed given. There
were only 13% infants who received mother milk as the first feed, honey was
given to 33%, sugar and ghee 20%, Arq 16%, Ghutti 9%, sugar water 7% and
Tea, salt water 1°/0 each
Table 7 First Feed Given To Infants
First feed given No. Percent
Mother milk 13 13.0
Ghutti 9 9.0
Honey 33 33.0
Sugar water 7 7.0
Arq 16 16.0
Sugar and Ghee 20 20.0
Tea 1 1.0
Salt water 1 1.0
Total: 100 100.0

59
Table 8 shows the person conducted delivery and first feed given to the infants.
As already mentioned in Table 6, 41 deliveries were conducted by TBA, 11 by
LHV and 48 by doctors.
In the group of infants delivered by TBA N=41. Only 3 (7.3%) got mother milk as
first feed 9 (21.9%) honey arq and sugar ghee each, 7 (17%) ghutti 2 (4.8)
sugar water and 2 (4.8) tea + salt water.
LHV delivered 11 infants out of these only 1 (9.1%) received mother milk as first
feed. The remaining 5 (45.5%) received sugar and ghee, 3 (27.3%) sugar water
and 2 (18.2%) honey.
Doctors delivered 48 infants and out of these 9 (18.7) received mother milk as
first feed, 22 (45.8%) honey, 7 (14.6%) arq, 2 (4.2%) sugar water 6 (12.5%)
sugar and ghee and 2 (4.2%) ghutti.

62
Table 9 shows the morbidity (clinical diagnosis) of infants admitted to the
medical emergency/medical ward of CH & ICH Lahore. The persistent diarrhea
was diagnosed in 31% of infants, acute diarrhea 27%, chest infection 15%,
septicemia 14% pyomeningitis 9% and SOM with complication 4%.
Table 9 Distribution of Infants According To Morbidity
Morbidity No. Percent
Acute diarrhea 27 27.0
Chest infection 15 15.0
Pyomeniningitis 9 9.0
SOM with complication 4 4.0
Persistent diarrhea 31 31.0
Septicemia 14 14.0
Total: 100 100.0

64
Table 10 shows the infants weight and morbidity pattern. In the group of
infants having weight less than 5th
centile there were 75 infants.
Out of these 28 (37.3%) were having persistent diarrhea 17 (22.6%) acute
diarrhea 12 (16%) septicemia 8(10.6%) chest infection 7 (9.3%) pyomeningitis
and 3 (4%) SOM with complication.
In the group of infants having weight at 10th
centile there were 10 infants out of
these 6 suffered from acute diarrhea 2 chest infection and 1 pyomengitis and
persistent diarrhea each.
In the group of 25th
centile there were 4 infants 2 were having persistent
diarrhea 1 septicemia and chest infection each.
In the group of infants having weight at the 50th
centile there were 5 infants, 2
were having acute diarrhea, chest infection each and 1 was having SOM with
complication
In the group of infants having the weight at 75th
centile there were only 4
infants 2 having acute diarrhea and 1 having pyomeningitis and septicemia
each.
In the group of 90th
centile there were 2 infants and both were suffering from
chest infection.

65
This table clearly shows that persistent diarrhea more in the infants having
weight less than 5th
centile and infants who were overweight and are at 90th
centile were having severe chest infection leading to hospital admission.

68
Table 11 shows the age of infant at admission in hospital and morbidity pattern.
In the age group of one month there were 11 infants, out of these 7 (63.6%) were
having septicemia, 2(18.2%) chest infection and 1 (9.1%) having acute diarrhea
and pyomeningitis each.
In the age group of 2 months of there were 21 infant and out of these 6 (28.6%)
were having acute diarrhea, 4 (19%) having chest infection, pyomeningitis,
persistent diarrhea each. Three infants (14.3%) having septicemia.
In the age group of three months there were 16 infants and out of these 5
(31.2%) were having acute diarrhea, 6 (37.5%) persistent diarrhea, 2(12.5%)
septicemia and 1 (6.2%) chest infection pyomeningitis and SOM with
complication each.
In the age group of four months there were 17 infants and out of these 7 (41.2%)
were having acute diarrhea, 6(35.3%) persistent diarrhea, 3 (17.6%) chest
infection and 1 (5.8%) pyomeningitis.
In the age group of five months there were 18 infants and 7 (38.8%) were having
acute dirrrhoea and persistent diarrhea each. 2 (11.2%) septicemia and 1 (5.5%)
chest infection.
In the age group of six months there were 17 infants in these 8 (47%) were
having persistent diarrhea 4 (23.5%) chest infection, 2 (11.76%) pyomeningitis
and SOM with complication each.

71
Table 12 shows the feeding patterns of all infants at different ages. At the age of
one month, all the infants i.e. 100, only 9% were on exclusive breastfeeding,
36% on mixed feeding, 34% on partial feeding and 21% on bottle feeding.
At the age of 2 months there were 89 infants i.e. 100-11 *=89 * 11 infants were at
the age of 1 month.
Out of these infants 36 (40.4%) were on mixed feeding, 27 (30.4%) on bottle
feeding 21 (23.6) on partial breastfeeding and only 5 (5.6%) on exclusive
breastfeeding.
In the age group of three months there were 68 infants i.e. 89-21*=68 21* infants
were at the age of 2 months.
In this group of infants 28 (41.2%) were on bottle feeding 26 (38.2%) on mixed
feeding 12 (17.6%) on partial breastfeeding and only 2 (3%) on exclusive
breastfeeding.
At the age of 4 months there were 52 infants i.e. 68-16*=52 *16 infants at the age
of three months.
In this group of infants 28 (53.8%) were on bottle feeding 18 (34.6%) on mixed
feeding 6 (11.5%) on partial breastfeeding. No infant was on exclusive
breastfeeding in this age group.
At the age of 5 months there were 35 infants i.e. 52-17*=35 *17 infants at the age
of 4 months.

72
Out of these 18 (51.4%) were on bottle feeding 12 (34.3%) on mixed feeding and
5 (14.3%) on partial breastfeeding and no infant on exclusive breastfeeding.
In the age group of six months there were 17 infants i.e. 35-18*=17 *18 infants in
the age of 5 months.
In this group 9 (52.9%) were on bottle feeding 6 (35.3%) were on mixed feeding
and 2 (11.8%) on partial breastfeeding.
The graphic representation of these values in various months clearly shows how
breastfeeding decreases by the age of infant and mixed feeding and bottle
feeding increases.

75
Table 13 shows the month wise feeding practices of infants at the age of one
month there were 11 infants out of these 6 (54.5%) were on mixed feeding
4(36.4%) on bottle feeding and 1 (9%) on exclusive breastfeeding.
At the age of two months there were 21 infants and in these infants 9 (42.8%)
were on bottle feeding 5(23.8%) on partial breastfeeding and mixed feeding
each. There were 2 infants on exclusive breastfeeding.
At the age of three months there were 16 infants and out of these 5 (31.2%)
were on mixed and bottle feeding each 4 (25%) on partial breastfeeding and
2(12.5%) on exclusive breastfeeding.
In the age of 4 months there were 17 infants out of these 11 (64.8%) were on
bottle feeding 4 (23.5%) on mixed feeding and 2 (11.7%) on partial
breastfeeding. No infant was on exclusive breastfeeding.
At the age of 5 months there were 18 infants out of these 9 (50%) were on
bottle feeding 6(33.3%) on mixed feeding and 3 (16.6%) on partial
breastfeeding.
At the age of 6 months there were 17 infants. Out of these 9 (53.0%) were on
bottle feeding 6 (35.3%) on mixed feeding 2 (11.7%) on partial breast feeding.

78
Table 14 shows the feeding patterns of infants at different ages in this table
exclusive breastfeeding and partial breastfeeding is labeled as breastfed and
mixed feeding or bottle feeding is labeled as non breastfed.
In the age group of one month there were 11 infants and out of these 1 (9%) was
breastfed and 10 (91%) non breastfed.
At the age of two months out of 21 infants 7 (33.3%) were breastfed and 14
(4.3%) non breastfed.
At the age of three months there were 16 infants and out of these 6 (37.5%) were
breastfed and 10 (6.5%) non breastfed.
At the age of 4 months there were 17 infants and out of these 2 (11.8%) were

79
Table 14 Feeding Patterns of Infants
Age & No.
of infants
Breastfed Non Breastfed
No. % N o . %
M1
N=1
1 9.0 10 91.0
M2
N=2
7 33.3 14 66.3
M3
N=16
6 37.5 10 62.5
M4
N=17
2 11.8 15 88.2
M5
N=18
3 16.6 15 83.3
M6
N=1
2 11.8 15 88.2

81
Table 15 shows the morbidity patterns of breastfed and non breastfed infants. In
the age of 1 month there were 11 infants 1 breastfed and 10 non breastfed. The
only breastfed infant was suffering from pyomeningitis in the non breastfed
infants 7 (63.%) having septicemia, 1 (9%) acute diarrhea, chest infection and
pyomeningitis each.
In the age group of 2 months there were 21 infants 7 breastfed and 14 non
breastfed. In the breastfed infants 3 (14.3%) were having pyomeningitis 2(9.2%)
having chest infection and acute diarrhea each.
In the age group of 3 months there were 16 infants 6 breastfed and 10 non
breastfed. In breastfed infants 2 (12.5%) suffered from acute diarrhea 1 (6.2%)
chest infection, pyomeningitis, persistent diarrhea and septicemia each. In non
breastfed infants 5 (31.2%) were having persistent diarrhea 3 (18.7%) acute
diarrhea and 2 (12.5%) septicemia.
In the age group of infants 4 months there were 17 infants 2 breastfed and 15
non breastfed. The morbidity pattern of breastfed infants were 1 (5.9%) chest
infection and pyomeningitis each. In non breastfed infants the morbidity patterns
was 7 (41%) acute diarrhea 6 (35.3%) persistent diarrhea and 1 (5.9%) chest
infection and pyomeningitis each.

82
In the age group of infants 5 months there were 18 infants 3 breastfed and 15
non breastfed. The morbidity pattern in breastfed infants were acute diarrhea 2
(11.1%) chest infection 1 (5.5%). In non breastfed infants the morbidity patterns
was 7 (38.8%) persistent diarrhea 5 (27.7%) acute diarrhea and 2(11.1%) SOM
with complication and 1 (5.5%) septicemia.
In the age group of infants of 6 months age there were 17 infants 2 breastfed and
15 non breastfed. The morbidity patterns in breastfed infants were chest infection
and complicated SOM 1 (5.9%) each while in non breastfed infants 8 (47%)
persistent diarrhea 5 (29.4%) chest infection and 1 (5.9%) acute diarrhea and
SOM with complication each.

85
Table 16 shows the morbidity patterns of breastfed and non breastfed
infants. The admission of non breastfed was almost 4 times more as
compared to breastfed infants.
Out of 100 infants in breastfed infants of present study 21% infants were
breastfed and morbidity patterns was acute diarrhea chest infection and
pyomeningitis 6% each SOM with complications persistent diarrhea and
septicemia 1% each.
While in non breastfed infants persistent diarrhea was 30% acute diarrhea
21% septicemia 13% chest infection 9% pyomeningitis and SOM with
complication 3% each.

87
Chinf
An understanding of the determinant of morbidity is of critical
importance in the developing countries. Morbidity patterns with breastfeeding and
bottle-feeding varies widely both between and within countries. Educational level
of the parents was found to be a significant factor of morbidity during infancy. In
the present study more than half of mothers and 2/5th
of fathers had no education
at all and 118th
of the parents had education of primary level. This shows that
illiteracy of parents and especially of mothers had more negative impact on
infant's health. The results correlate with the findings of Alam and Cleland (1984).
They described those children of educated women experience lower morbidity at
all ages than those mothers having no schooling. Similarly results have been
reported by Irian (1996).
The person conducted delivery, the place and mode of delivery do
have important role in infant morbidity especially in the early infancy. In the
present study 46% of the infants were delivered at home, TBA's conducted 41%
of the deliveries. This preference of home delivery could be attributed to
our social and cultural trends that women and their families prefer.
In our society it is a custom to give prelacteal contaminated
feedings like honey, Arq, Ghutti etc and most of the babies are devoid of the
beneficial role of colostrum as described by Hanson LA et al (1983). In the

88
present study the similar customary pattern of prelacteal feeding is reflected i.e.,
honey (33%), sugar and ghee (20%), sugar water (7%), Arq (16%) & the
colostrum was given only to 13% of the infants.
Early initiation and maintenance of exclusive breastfeeding are
important factors for child's survival strategies. In a traditional society like ours
various studies have shown that use of prelacteal as well as paralecteal
feedings and family custom have crucial role in lactation failure and then
administration of unhygienic milk in bottle leading to various serious morbidity
patterns. (Bashir A et al 1993). In Lahore (Pakistan) 50% of the infants at one
month of age were getting water in addition to breastfeeding. (Hanson et al
1996). It is believed that water, herb water (Arq) and tea given to young infants
quench thirst, prevent colic, treat cold and sooth fruitfulness (WHO 1991). This
non-exclusiveness of the breastfeeding may be the cause of diarrhea which is
highly prevalent in this region (Government of Pakistan 1984).
Extensive research on the biology of human milk and the health
outcome associated with breastfeeding has established that breastfeeding is
more beneficial. In the present study non-breastfed infants were four times more
admitted in the hospital for the management of ailment as compared to the
breastfed infants. Allan S Cunninghan (1997) showed in his study that there is
about 2 fold increase in episodes of illnesses in the bottle fed infants as
compared to breastfed which are statistically significant difference (P<0.05). Allan
also showed that the protection provided by the breast milk differ at different ages

89
at one year. The morbidity increases nearly 2 fold and at four months the
difference was 4 fold and during the first two months & artificial feeding can
increased morbidity upto 16 fold. In the present study breastfeeding was 43% at 3
months and 20% at six months. The figl4res quoted by Allan are 15% and 19%
respectively in these age groups. In the present study of 100 infants acute
diarrhea was 6% in breastfed and 21% in non breastfed infants, chest infection
6% breastfed and 9% in non breastfed infants, SOM with complication 1% in
breastfed and 3% non breastfed infants, persistent diarrhea 1% in breastfed and
30% in non breastfed infants, septicemia 1% in breastfed and 13% in non
breastfed infants. These results show that the resistance to infectious diseases is
more in breastfed infants because human milk contains abundance of factors that
are active against pathogenic micro-organisms. Since the infant's immune system
is fully matured until about two years of age the transfer of these protective
factors through human milk provides a distinct advantage that bottle-fed infants
do not experience. Specifically human milk contains immunologic agents and
other compounds such as secretory antibodies, leukocytes and complex
carbohydrates that are active against viruses, bacteria and parasites. The
findings of the present study for breastfed infants, lower number of patients
admitted in hospital with diarrhea, chest infection, otitis media are similar to other
studies by (Beaudry M et at 1995), (Howie et al 1990), (Duncan B et al 1993).
Breastfed infants compared to non-breastfed infants produced enhanced immune
responses for day to day common infection. This is due to anti-inflammatory
factors in human milk that regulate the response of immune system against

90
infection (Goldman AS 1993). Protection against infection is strengthens during
the first second months of life who are breastfed exclusively (Scariati et at 1997).
The administration of prelacteal feed instead of colostrums is being practiced
even in the hospitals and private clinics, which are supervised by the trained
health professionals. The practices of exclusive breastfeeding is limited and in the
present study of 100 infants, only 9% infants were on exclusive breastfeeding in
the first month and 5% in the second month and 3% in the third month. This
changing pattern of feeding leads to deprivation of infection protection, decreased
immunity and thus morbidity leading to hospital admission for management and
saving the life.

92
CONCLUSION:
The present study indicates that instead of breast feeding
prelacteal feeds are give to 87% infants. Thus avoiding the use of colostrum
which was replaced by potentially contaminated fluids. The prevalence of
exclusive breastfeeding is very low, there is high prevalence of partial
breastfeeding and mixed feeding and gradually leading to bottle-feeding. This
leads to increased risk of morbidity. With non-exclusive breastfeeding the
protective effect is dilated as far as morbidity is concerned. We can reduce
infant morbidity in Pakistan Four times by targeting exclusive breast-feeding.
There is a need for action as slogans could not be a substitute for the real
work. It is pity to say that in-spite of huge campaign for the promotion of
breastfeeding even still now health professionals are ignorant and are not
practicing exclusive breastfeeding in infants.

93
SUGGESTIONS:
The health of the infant is more dependant upon the health of
the mother because she Is both the seed and soil. The women must be
recognized as the foundation of nation and accorded due status. Infant
morbidity will fall with education and health awareness of mothers. There
should be no discrimination of sex. The breast-feeding promotional
activities need re-implementation. The girls should be provided health
education in child-care, in their curriculum. Advantages of breastfeeding
and disadvantages of bottle-feeding should be explored in the print and
electronic media.
Lactation management clinics should be launched in every
hospital and there should be trained supervisor available to supervise the
activity. This will need the regular training/refresher courses to the health care
providers In the hospitals & TBAs in the community, The
obstetrician/lady doctors should be involved, so that they can rectify and
manage the breastfeeding supportive activities in the antenatal period.
These activities should be extended to the rural and pad urban areas.

95
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110
LIST OF ABBREVIATIONS
Abbreviation Meanings
% Percent
< Less than
> More than
ACDIA Acute Diarrhea
AOM Acute otitis Media
ARI Acute Respiratory Tract Infection
BCG Bascillus Calmutt Gurinne
B.F.I Breast fed at the age of one month
BF2 Breast fed at the age of two month
B.F.3 Breast fed at the age of three month
BF4 Breast fed at the age of four month
B.F.5 Breast fed at the age of five month
BF6 Breast fed at the age of six month
Bottle feed Bottle feeding
Chest inf Chest infection
Cond Condition
E.Coli Escherichia Coli
EPEC Entero Pathogenic Ecoli
Exbf Exclusive breast feeding
Fatedu Father's education
FFG First Feed Given
GOP Government of Pakistan
GH Ghee
HI Hemophilus Infuelanzae
IgA Immunoglobulin A
LHV Lady Health Visitor
M-1 One month age
M-2 Two month age
M-3 Three month age
M-4 Four month age
M-5 Five month age

111
NBF2 Non breast fed at the age of two month
NBF3 Non breast fed at the age of three month
NBF4 Non breast fed at the age of four month
NBF5 Non breast fed at the age of five month
NBF6 Non breast fed at the age of six month
OME Otitiis Media with Effusion
Parbf Partial breast feeding
Pcd Person conducted delivery
PD Persistant diarrhea
Per Dia Persistant diarrhea
Pld Place of delivery
Pvt. Clinic Private clinic
Pyo Pyomeningitis
Sig A Secretary immunoglobulin A
Som Supportive Otitis media
Sug Sugar
SVD Spontaneous Vaginal Delivery
TBA Traditional Birth attendant
UTI Urinary Tract Infection
Wa Water
WHO World Health Organization
Wt Weight
LIST OF ABBREVIATIONS
Abbreviation Meanings
M-6 Six month age
Mid Midwife
Mix feed Mixed feeding
Mod Mode of delivery
Moedu Mother's education
Morb Morbidity
N Number
NBF1 Non breast fed at the age of one month

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