the nutritional status of - Health Systems Trust

4.3.7 BREASTFEEDING AND WEANING PRACTICES
The growth pattern of children from disadvantaged communities (Molteno et al., 1991; Delport & Bergh, 1994; Tables
1-7) clearly indicates that undernutrition often develops at the time of weaning. Tables 78 to 83, which describe
dietary patterns, show that breastfeeding and weaning practices in many groups are far from optimal. The studies
of Krynauw et al. (1983), Lazarus & Bhana (1984), Househam & Elliot (1985), Molteno & Kibel (1989) and Sive et al.
(1993) all identified insufficient breastfeeding and inappropriate weaning practices as major contributors to
undernutrition in South African children. The risks of unhygienic bottle feeding, infections and diarrhoea with
consequent undernutrition in deprived communities are well known.
Whitehead (1994) recently pointed out that textbook dietary recommendations for young babies overestimate energy
requirements. New research from the Dunn Clinical Nutrition Centre in the UK indicates that an infant of 1 month
needs 483 kJ/kg daily, at 4 months 399 kJ/kg and at 6 months 357 kJ/kg. Accepting that human milk output peaks
around 850 mL/day, breastfeeding would cover energy needs of a child growing along the 50th weight percentile
until 4 months. For a typically developing (3rd) world child tracking the 25th percentile, exclusive breastfeeding
would be sufficient for 6 months. However, infections would increase energy needs. Brink & Boshoff (1984)
reported that in urban blacks, supplementary feeding of some babies started at 1 month and is common at 3 to 6
months, confirmed by Cleaton-Jones (1991). Zöllner & Carlier (1993) found that 60 % of rural black mothers in their
study introduced solid foods before 3 months. Both Gericke et al. (1987) and Odendaal (1988) reported that urban
black children are less breastfed and weaned earlier than rural controls. Richter (1994) inteviewed 100 urban black
mothers and their babies and mentions that the early introduction of supplementary food could be due to a
perception that crying infants are hungry.
4.3.8 EDUCATION, IGNORANCE AND PSYCHOLOGICAL FACTORS
The impact of education status and/or knowledge of nutrition of the mother or care givers (child minder) of children,
has been examined in some studies. Lack of education and ignorance were found by Molteno & Kibel (1989),
Howard (1990) and Sive et al. (1993) to be risk factors. In other studies (Fincham, 1982; Krynauw et al., 1983)
education did not appear to be a significant variable, especially in rural circumstances. However, Lazarus & Bhana
(1984) describe ignorance and lack of nutritional knowledge, exchange of misconceptions by housewives and
passing on of harmful traditions as part of a vicious circle of poor nutritional practices in rural communities,
leading to undernutrition. Richter (1993) found that “emotional unavailability” of stressed care givers, together with
socio-political inequalities and physical deprivation, plays an important role in the development of protein-energy
malnutrition and disruption of the “life ecology” of young children.
4.3.9 PARASITIC INFECTIONS
Helmintic infections can affect health and nutritional status. Rapid urbanisation and increases in population
density in informal settlements with inadequate sanitation increase the risk of parasitic infections (Fincham et al.,
1996; 1996(a)). Walker & Walker (1994) reviewed the burden and prevalence of these infections in South African
populations, particularly in schoolchildren. Approximately 1 000 million people world-wide suffer from ascariasis,
900 million from hookworm, 750 million from trichuriasis, 400 million from amoebiasis and about 200 million
from schistosomiasis (Walker & Walker, 1994). It is estimated that 4 million people in South Africa may suffer from
schistosomiasis infection (Schutte et al., 1995). From Table 76 it can be seen that high prevalences of infections
have been observed in certain areas. Unfortunately, the contribution of a particular infection to loss of appetite and
food intake, nutrient losses (blood loss), undernutrition, growth, intelligence, and physical activity is not well described
(Walker & Walker, 1994). Fincham et al. (1996) showed that whipworm (Trichuria trihiuria) infection was associated
with anaemia and iron depletion in children. They also showed that antihelminthic treatment, without extra food,
resulted in improved growth and less anaemia in these children. Haycock & Schutte (1983) examined 834 children
in KwaZulu and 1 219 in Tongaland and found that children infected with schistosoma haematobium showed
slower progress through school. From the available literature, it is clear that treatment of heavily infected children
improves appetite, growth, general health and physical fitness.
Because parasitic infestation is associated with poverty and substandard hygienic practices, reinfection is a constant
hazard (Schutte, 1994). Therefore, long-term control of helminthic infections has proven to be practically impossible
(Schutte, 1994). For example, when whipworm infestation is predominant, treatment should be continued for 3
years at intervals of 4 months (Fincham et al., 1996a). It is advised that treatment should be targeted at areas with
prevalences > 30 % and that it should be coupled to improvements in sanitation, water supply, waste disposal and
education to improve hygienic practices.
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